Ally Istl is a senior General Surgery resident at Western University
Sarah Jones is a Pediatric Surgeon at Western University
The concept of Wellness in the professional medical arena has become a contemporary Gargantua that we are perpetually seeking to satisfy, but never able to sate. As other disciplines seek to make their trainees ‘Well’, wellness has also become a growing subject of exploration in surgical disciplines.
Wellness means different things to different people and formal definitions provide no clarity in the context of the medical profession: ‘the state of being in good health, especially as an actively pursued goal’ only provokes more nuanced questions about the meaning of health and what pursuit of health looks like. Attempts to articulate a more pragmatic definition have led to a cookie-cutter concept of Wellness as a routine of strict punch-out times and sporadic meditation. This is not attainable in surgery.
And maybe it doesn’t need to be.
Defining Wellness in a surgical career deserves more than an examination of what Wellness is or is not; it requires an understanding of what it means to be a surgeon. Opinions on the most integral characteristics of a surgeon may vary, but what is common to all who choose this vocation is that it becomes entrenched in our lives. Surgery is not just a job or a career; it is part of who we are.
Training to be a surgeon means surrendering personal priorities. It means relinquishing the mentality of self-precedence. Committing to a life where you no longer come first is something most people only do once or twice in their life: for their partner, and for their children. As surgeons, we do it a third time. It is an enormous commitment, the responsibility is immense, and – if you are dedicated to your patients’ outcomes and self-improvement – it never releases you. But you make that commitment with certainty, devotion, and excitement. You mean it. It takes years before you fully understand what living that commitment looks like, how it rewards you, and what it robs you of.
Wellness is finding a way to keep meaning it; to stay certain and devoted and excited despite the things that surgery takes from you. Central to this is the conceptualization (and internalization) of surgery as a vocation rather than a job. What distinguishes a surgeon from a technician are the visceral experiences of the enormity of the problems you are trying to fix, the scars that remind you what failure looks like, and embracing the weight of your patients’ suffering. The emotional investment is unavoidable. There are many inescapable experiences that surgeons and surgical trainees report after any significant length of work experience: exhaustion, discouragement, nihilism, hollowness, conflict – but these are not just derived from long hours; they are hazards of an emotionally and physically taxing vocation. Finishing an unending workload at home under the guise of satisfying work-hour restrictions doesn’t make you Well. Wreaking fresh hell on your circadian rhythm by changing from a thirty-six hour stint every fourth day to night shifts doesn’t make you Well. You can’t achieve Wellness just by working fewer hours or leaving at five o’clock. It is the inherent character of surgical training itself that gnaws at Wellness: having the life and death conversations, making the decisions that change people’s lives and bodies, bearing the heavy responsibility of the consequences of those decisions – it is draining and consuming. But it is inextricably part of the vocation we chose. If your goal is to leave the building once you’ve logged your requisite hours, you will be constantly disappointed. More importantly, you won’t be the surgeon your patients need.
The way we are trying to make medicine ‘less demanding’ on physicians and trainees runs in direct opposition to the culture of patient-centered care we are trying to cultivate. You cannot adequately address the medical and emotional needs of your patients if you have a daily expectation of clocking out at five. The current climate of medical education suggests that Wellness is something achieved through occasional meditation and timely departure from work. It is no surprise that with such unrealistic expectations of what it means to take care of sick people, trainees may become disillusioned with their career.
We don’t have to reconcile being a surgeon with the ‘Wellness’ recommendations for protected meditation time and surrendered responsibility that journals and hopeful leaders are prescribing. But we do have to find a way to be Well beneath the weight of our responsibilities and the consequences of the care we provide. When we experience that weight in solitude and silence, we condemn ourselves. We become our own persecutors and, as a result, when things go wrong, one of the most common and overpowering experiences in surgical training is that of feeling alone. In a profession where every incredible and terrible thing we experience has been experienced by the people surrounding us, how do we feel isolated? Everyone has been there. We all know the grief of mistakes made. We know the shudder of a patient’s story hitting too close to home. We know the loss of time with our families. But we are a family to each other. We chose the hard road because it means something; it is fulfilling and rewarding. We see that in the faces of our cancer-free patients, in the eyes of our trauma patients’ parents, and in the calm of our palliative patients who die with dignity. We chose the hard road because we see the value of a compassionate and committed surgical practice through the trees of exhaustion and sacrifice.
We need to strive for the reawakening of surgery as a team sport, not only in the context of provision of care, but in the creation of a climate where we are reminded by each other that we are not alone. Wellness isn’t creating opportunities to escape; it is creating opportunities to carry each other. Wellness isn’t found in hour restrictions and meditation; it lies in the comradery and support of the people with us in the trenches. In the face of exhaustion, in the face of loss, Wellness is being reminded of the value of your sacrifice by someone who knows that sacrifice. We are in this together. And we need to make sure we are showing it.
Ally, I applaud you identifying what I also believe are important factors in preventing burnout. You are right that you have to believe that the service you have been chosen for is of utmost worth, and that you need your community to support you in the weight of this often very painful service to humanity. I am a “missionary” surgeon, so arguably I understand a vocation as well as any and better than most, and I do have a fairly supportive community. Having completed not so long ago a stretch where being on call 2 out of 3 nights was a “good” week, I eventually did experience significant burn out. We are whole people; you can only abuse your body so long before your mind and soul can no longer make up the difference.
So I think the reality is that cultivating resilience is comprised of a complicated set of societal, institutional and personal factors which will never be the same for any one surgeon. We are foolish if we neglect any of them. We must do our best to ensure that our society and institutions also support our colleagues in their own efforts to cultivate resilience for the sake of the vulnerable in our society. There are few more vulnerable than an anesthetized patient on an operating table.
I agree with you that thinking of your career as a vocation or a purpose rather than a job can lead to a greater sense of well-being, but it also sets many future physicians up for disappointment. As medical students we are repeatedly told to choose the specialty that: we love, we can’t imagine not doing, work 80 hours a week in, that we’ll be excited to get woken up at 3 am for. What happens to physicians that find their specialty isn’t everything they built it up to be in their heads?
Our medical education system has done a great disservice to students by repeatedly them they will LOVE their future careers and that it is what will bring them fulfillment and a purpose in life. We are setting these future physicians up for burn out. It is completely unfair to expect every physician to reach this unrealistic standard. We are not robots whose sole purpose is to work and sleep, we are humans with interests and passions outside of medicine. Older physicians may not like to hear this, but at the end of the day being a doctor is a job. There is nothing wrong with being truly fulfilled by your job, but this will not be the case for a large portion of physicians.
We need to stop blaming individuals for not being resilient enough to avoid burn out and look at the system that is promoting it. To improve well-being among the profession, the system needs to allow physicians to reduce their hours working so they can spend time on other aspects of their lives, or with friends and family. We should encourage students to choose a specialty based on how much enjoyment it will enable them to have in all aspects of their life – not just at work.
I agree completely. It took me too long to be able to achieve that balance in my career.
I empathize with a lot of that. Been there, done that, had the good team experiences, the long nights and the long days and the weekends when I ended up constipated because I literally could not get peace to poo. Sorry, not being facetious, just realistic. And yet, there is the huge danger of government, tax-payers, departments of health, employers, even colleagues, just using us because we are dedicated. Because we see our jobs as vocations. To my mind, the institutionalized exploitation of our vocational ethos has been a constant, a given for the nearly five decades since I headed off to medical school. If our health service was adequately funded and efficiently managed, would it be necessary for any of us to work our butts off? As so many of us have done for so many years? Would our horrific suicide rate go down if we could all work reasonable hours?
John(y) Van Aerde (Chief-editor CJPL.ca)
Many aspects of this blog refer to servant-leadership.
Dr Donald Prior
Yes, I understand. However, change in that forum has been necessary for over 50 years, with little improvement! I congratulate a resident to see for himself what is necessary and be able to implement change for himself when that time occurs. He is more likely to accomplish change in that environment.
What he has said needs to be said, but unfortunately,
the egos of his preceptors will find it difficult to accept.
Thank you for correcting my error on gender.
Dr Donald Prior
Ally. Your blog clearly defines the nature of a surgeon who embraces his “vocation” in a way that will be truly satisfying for you and your patients over the life of your career. When I look back at my orthopaedic surgical career and were asked what is the most stressful aspect of your daily life, it would be the “loneliness” that you identified. It was the inability to discuss the failures and tragedies of life that you could not change, with your peers, colleagues, friends, and family.
I encourage you to engage in a process that allows you and your colleagues to share the above in an empathetic and supportive forum and in addition to engage them in your free time get-togethers that do not discuss “work issues” as a prerequisite. A regular discussion time that is scheduled would ensure that these take place.
Identifying your fears and wanting to do something about them is an excellent sign that you will enjoy a rewarding surgical career that allows you to get up in the morning and “want” to go to work