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Not what we have, but what we enjoy constitutes our abundance.

– Epicurus

In the previous chapter on physician burnout, we warn you of problems you will encounter during your training and while you are practicing so you can be aware and respond appropriately. In this chapter, we remind you of the fun and joy to be found in the practice of medicine. Despite the sometimes intolerable work load, long hours of study, and personal and social responsibilities, we want to remind you how important it is to enjoy the pleasures and relish the intellectual stimulation and camaraderie you experience each day.

There is a joy, a pure pleasure that comes with the practice of medicine. There are many ways you experience this happiness: it may be the enjoyment of a personal relationship with your patient, the ecstasy of saving a life, the exhilaration of making a difficult diagnosis, the satisfaction of completing a difficult procedure or surgery, or just the wholesome fun of working with bright, committed, intelligent colleagues and team members to care for patients, complete a surgery, or solve a problem. Practicing medicine is a lot of fun, spiritually rewarding, and intellectually and emotionally satisfying.

Working in any intensive care unit is about as demanding, difficult, and emotionally draining as medicine can be. For example, in the NICU, parents have invested time and effort, physically and emotionally preparing for the baby’s arrival, and they expect their babies to be healthy. When the baby is premature or ill, it can be a dreadful, nightmarish experience. The neonatal care team is empathetic to that anguish and concern; they feel it 24/7 until the crisis is over. Yet over shared experiences of teamwork, the entire healthcare team, often from diverse backgrounds, develop respect and are protective of each other and their families. In any successfully run medical or surgical specialty unit, patients and families often share in the unit comradeship. There are so many stories of families hugging and kissing their thanks and expressing their admiration for lives saved and prolonged.

One feels a special gratification when your name is called out by a seeming stranger in a mall or restaurant and says, “I was critically ill in your unit, and I just wanted to say thank you.” Or perhaps they are visiting you in your office for the first follow-up after a critical illness and they bring a thank you gift and want to take a selfie. These are some of the rewards that can only come from solving a life-and-death problem through your skill, knowledge, and training, and because you are part of a well-functioning team.

We have included in this book a number of biographies of famous and outstanding physicians. Appreciate how many have continued to contribute into their eighth and ninth decades. Examples include Shigeaki Hinohara who was seeing patient when he was over 100, Nanette Wenger who sees patients at 90, Helen Taussig, Eugene Braunwald, and Louis Sullivan who are and were active in their 80s.

A favorite example of a lifetime enthusiasm for the practice of medicine is Michael DeBakey, the renowned Baylor heart surgeon, who at age 88 was asked to consult on Russia’s first president, Boris Yeltsin. Yeltsin had experienced a heart attack and was felt to need coronary artery surgery. His Russian physicians were convinced he could not survive the surgery, so Yeltsin consulted Dr. DeBakey who had a favorable opinion concerning coronary artery surgery. The successful result probably saved the Russian President. The story goes that after spending some time in Russia, Dr. DeBakey complained he had to return to Texas before his patients forgot him.

DeBakey had an appreciation for the profession: “In medicine, helping others while solving complex intellectual puzzles is our special reward.” In the book Medicine: Preserving the Passion in the 21st Century [1], the editors Phil Manning and Lois DeBakey have compiled the personal reflections of 24 renowned physicians concerning their passion for medicine. Included in this collection was the late Phillip Tumulty, former Professor Emeritus at Johns Hopkins University who expressed the feelings of many doctors when he wrote:

Because each day that medicine is practiced properly, I find a full measure of those fulfillments for which we all strive: intellectual enhancement, stimulation, and excitement; an opportunity to increase and expand the best qualities of mind and spirit; a chance to feel the thrill of bringing relief to fellow human beings through the best use of one’s intellectual and personal endowments; and finally the daily experience of seeing and understanding more clearly the depths of human nature, with its intense complexities and eccentricities, its good and bad, its sublimity and depravity, its victories and defeats. A clinician is not merely a bystander looking at life as it flows by him; he is an active participant in it, at some of its most crucial stages involving his fellow human beings.

We noted in the burnout chapter that it is not uncommon for students, residents, and fellows to feel they are being criticized for lapses in medical care, for practicing physicians to feel the criticisms at tumor conference or case presentations, and how difficult that can be when the effort and commitment is so great. But there is another side to practice where you are treated with respect in informal meetings and social occasions by patients and other healthcare workers for your skills and devotion to service, and where you are constantly learning characteristics of the human condition that cannot be taught in the classroom.

Renewing the Passion

Sometimes you feel you are in a rut, no new challenges, the fun seems lost, the passion diminished. To find the joy and experience the fun, you may need to reinvent yourself. This can include developing a special expertise, altering your practice pattern, or volunteering to teach or engage in clinical research. In our own careers, we have at different times developed special knowledge on a variety of subjects ranging from expertise in ventilation physiology, pharmacologic treatments in late pregnancy, ICU workflow efficiency, causes and treatment of syncope, hypertension, and special expertise in dysautonomia. These projects, while infrequently resulting in published studies, meant we would often be asked by partners and colleagues to consult on difficult and complicated patients and issues associated with these problems. These requests are validation of the extra time spent on developing these interests and provide gratification for a service unique to our medical community.

Working for our community professionally and the general community welfare is especially rewarding. We have worked actively in the local medical association and our professional societies. We volunteer at our public and not-for-profit hospitals and we teach at local seminars and to medical students in the clinics. These experiences provide stimulating, pleasurable, and gratifying change from our routine daily clinical practice.

Such activities and challenges, whether niche clinical care, clinical research, or administration, provide experiences unique to each individual role and present problem-solving opportunities in aspects of medicine other than those in the daily routine. They also provide engagement with colleagues outside of our immediate community, resulting in long-term friendships, and interactions with patients from a wide stratum of society. This last is critical to providing the physician the full panorama of life that cannot help but result in a well-rounded and more fully educated member of society at large.

Clinical Research Is Fulfilling

Clinical research can be especially rewarding. Dr. Mary Ellen Avery, recipient of the Presidential Medal for her work in developing lung surfactant, was famous for her aphorism, “All significant medical research begins at the bedside.” Someday a patient will come to you with a baffling array of symptoms, or a surgical technique will not turn out as expected, or a patient will tell you he has started some daily routine and serendipitously a troublesome symptom disappeared. Be alert for these moments, and be on the lookout for clinical studies that investigate or treat the condition you want to investigate. It is an entirely different facet of medicine, and while many studies lead nowhere some may lead to an important discovery. We participated in almost every clinical trial of inotropic drugs for heart failure. All were dismal failures; then we were part of a major beta-blocker trial for heart failure that was transforming, a true breakthrough that has saved countless lives. That was truly thrilling.

In 1977, we took the unexpected opportunity to study with the pediatric cardiologist, Dr. Norman Gootman, who taught us how to do cardiac ECHOs on the newborn when the technique was still in its infancy (pun intended). This led to a number of clinical studies. While we did not publish those studies, they did serve to educate us and our colleagues on many aspects of our patient’s progress. On another occasion, we had a patient with recurrent ventricular tachycardia and episodes of near sudden cardiac death. The medical student reported this condition was being treated in Europe with a drug Amiodarone, a drug not available in this country. We found that the FDA would allow us to obtain a special use permit as an investigator if we did not charge patients. We were able to provide the medication that was life saving for this patient and helped many more patients before it was available by prescription.

There were many more occasions, some serendipitous, some we had to work for, and some, in retrospect, we let blow past us. But by staying alert and receptive to the opportunities, you will find exciting episodes in your careers. If nothing else, it will lead down a path to self-discovery and knowledge.

A Medical Degree Opens Many Nonclinical Career Choices

Many physicians feel like they are one trick ponies. They were trained to care for patients and with that training there is nothing else they can do. They are trapped. Not true. Your medical degree gives you opportunities no other degree can confer. Having finished medical school you are a proven performer in the sciences, you know how to be a team player, you have developed critical skills, you know certain management techniques, you are an excellent learner and most likely a competent teacher, you know how to use logic to solve problems and advance ideas, and you do not shy away from making critical decisions.

You are a trained observer. You know how to work under pressure, meet deadlines, and think outside the box. You may not know it, but you have been collecting stories and writing narratives since you started your clinical years. You can actually make this into a new career. Take some creative writing courses, or if you prefer, you can serve as an editor or content provider for online or print medical journals or for lay consumption.

Insurance companies, healthcare companies, and hospitals are always in the market for well-educated administrators. Take a starter position in a healthcare company or a hospital and get your MBA or a masters in healthcare administration. It will be a far less grueling schedule than your current one, and the starting salary will probably be a lot higher. Those 5 or more years of residency and fellowship you thought you wanted to complete can turn into a 3-year advanced degree, and you can have a career you enjoy rather than suffer through one you resent. The knowledge, skills, and techniques you learned in medical school and whatever level of training or years of practice you completed are valued in every area of business, science, management, and administration.

Elements of a Successful Career

A successful, satisfying medical career, wherein you will find joy in using your intellect and skills to help the sick and the helpless, requires tenacity and effort coupled with resolve and purposefulness, continuous learning, and maintaining your skills. However, you cannot achieve happiness in medicine isolated and alone. It is essential to maintain friendships with some and collegiality with others, to support your colleagues and maintain rapport with your staff, nurses, and administrators.

Do not despair if you feel you are not up to the challenges; the admissions committee members know what they are doing. Or that it is your fault when something goes sideways with one of your patients; not every outcome is perfect. Burnout is most likely to occur in those students who start medical school as the most caring, dedicated, and determined to excel, but are then faced with sleep deprivation, social isolation, impossible schedules, as well as upsetting personal events that tilt an already delicate balance of coping.

Later, during the clinical years and into residency, trainees are frustrated when caring for seriously ill individuals whose problems transcend their diseases: individuals with illnesses related to poverty and societal structural issues causing harm no medicine can ameliorate. Some of these challenges you will be able to confront, and some you will not. Not all of the outcomes depend on your knowledge and dedication. In many cases, a less-than-satisfactory result is due to a number of factors, not least of which are the capabilities of the institution you serve.

You may find you do not enjoy caring for patients, or that the strenuous schedule you are experiencing now will continue if you take a career path in surgery or obstetrics. Be aware that the hours you work as a trainee are much greater and the stress of pleasing everyone from the patient to the attending to your family is much greater during the training years than they are when you are in practice. That said, there are strains and tensions, just of a different nature, and you may feel the passion you had for medicine is still there, but caring for patients is just not your thing.

Do a self-assessment. Decide what it is you like best about medicine. Focus on those factors, for therein lies the joy. Medicine offers many specialties that do not involve direct patient care. Maybe you do not like surgery, but would like forensic pathology. Consider a career in public health, environmental studies, medical engineering if you have the background, pharmacology patient trials, or journalism. But if you want to make a clean break, then you have proven you are smart, motivated, and willing to work hard. You will be able to parlay that into a new career you will enjoy.

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Permission for photo and biography: International Department St. Luke’s International Hospital and the family of Shigeaki Hinohara from Kaori Wakamatsu

Shigeaki Hinohara

A Humanist Known for His Caring Spirit

Dr. Hinohara continued seeing patients until months before his death at age 105 and frequently offered advice on how to live well. Described by his colleagues as Japan’s national treasure, he headed five foundations in addition to being the president of St Luke’s International Hospital in Tokyo. He began working during World War Two, as a doctor at St Luke’s in the 1940s. During the war, he helped to treat victims of the firebombing that destroyed large parts of the Japanese capital. A great music lover, Dr. Hinohara, at the age of 88, wrote a script for a Japanese musical entitled The Fall of Freddie the Leaf. The show was first performed in 2000 and Dr. Hinohara also acted in the production, dancing with children. Dr. Hinohara frequently appeared on Japanese television, urging audiences to have more fun in their lives and to ward off illness by always giving themselves something to look forward to. On TV and through a best-selling anthology of essays called How to Live Well, he encouraged others to do away with strict rules on when to eat and sleep. One of his last pieces of advice was: always take the stairs and keep up your strength by carrying your own bags. “We all remember how as children, when we were having fun, we often forgot to eat or sleep,” he once said. “I believe we can keep that attitude as adults—it is best not to tire the body with too many rules such as lunchtime and bedtime.” His contributions to healthcare in Japan include introducing Japan’s system of comprehensive annual medical check-ups—called “human dry-dock”—which have been credited with greatly contributing to the country’s longevity. He was also a strong advocate of maintaining an active social life into old age. Dr. Hinohara became director of St Luke’s in the early 1990s and had oxygen tubes installed throughout the building in 1994 to prepare for mass casualties if an earthquake struck the capital. The next year, a sarin gas attack on Tokyo’s metro by members of a cult killed at least 12 and injured thousands, but the hospital was able to cope with the number of patients because of Dr. Hinohara’s preparations. A most energetic person, many tributes have been paid to Dr. Hinohara, including by The Japan Times journalist Judit Kawaguchi, who knew him well.

She told the BBC World Service World Update that he had amazing energy and drive. “I met him when he was already in his 90s and I would say he drastically changed my mind about ageing because even then he was working 18 hours, 7 days a week, and he was the most energetic person I’ve ever met,” she said. “He believed that life is all about contribution, so he had this incredible drive to help people, to wake up early in the morning and do something wonderful for other people. This is what was driving him and what kept him living.” She added. “He always had today’s goals, tomorrow’s and the next 5 years. He was just an amazing, amazing person and everybody who met him was transformed because of him” [2, 3].

Study Guide

  1. 1.

    There is much joy in medicine. Where do you find that joy?

  2. 2.

    Name five aspects of medicine that bring you the most pleasure or fun or satisfaction.