From Alan’s Weiss’ classic Getting Started in Consulting:

Medical consultants advise doctors never to schedule wall-to-wall appointments during the day, because inevitably there are emergencies, late patients, complications on routine exams, and so forth. These create a domino effect by day’s end, and some very unhappy scheduled patients. Instead, they advise some built-in slack time that can absorb the contingencies. If not needed, slack time provides valuable respite.

Ha.

I read this book years ago when I was a resident and came across this passage when reviewing my Kindle highlights the other day.

Perhaps there are consultants in real-life operating as Dr. Weiss suggests, but this common-sense approach to sustainable medical practice is not what many large health systems employ.

In my wife’s old outpatient academic practice, lunchtime wasn’t respite. It was an overbook slot, and her schedule was so jam-packed that there were always patients clamoring to squeeze in.

In order to make that all work, the average doctor spends 1-2 hours charting at home per day.

Contrast that with her current solo practice where she has complete autonomy: her patients aren’t scheduled wall to wall, and she has time for the inevitable emergencies, hospitalizations, collateral phone calls, prior auths, and the other vagaries of modern medical practice.

I’m proud of the practice she’s built–during a pandemic no less!–but it’s crazy that even academic medicine has become so corporatized in its paradigm that it was easier to craft her own business in order to practice on anything approaching the terms that would best serve her patients and herself.

A few separate passages I’ve combined from Dr. Ronald Epstein’s Attending: Medicine, Mindfulness, and Humanity:

Altogether, I saw too much harshness, mindlessness, and inhumanity. Medical school was dominated by facts, pathways, and mechanisms; residency was about learning to diagnose, treat, and do procedures, framed by a pit-of-the-stomach dread that you might kill someone by missing something or not knowing enough.

Good doctors need to be self-aware to practice at their best; self-awareness needs to be in the moment, not just Monday-morning quarterbacking; and no one had a road map.

The great physician-teacher William Osler once said, “We miss more by not seeing than by not knowing.”

The fast pace of clinical practice—accelerated by electronic records—requires juggling multiple tasks seemingly simultaneously. Although commonly thought of as multitasking, multitasking is a misnomer—we actually alternate among tasks. Each time we switch tasks we need time to recover and, during the recovery period, we are less effective. Psychologists call this interruption recovery failure, which sounds a bit like those computer error messages we all dread. We increasingly feel as if we are victims of distractions rather than in control of them.

Outside of the OR (and not always even then), it’s rare to find an environment that promotes the space for deep focus and self-awareness. Mindfulness, insofar as a daily approach to medical practice, is something that goes against the grain of one’s surroundings.

Good doctors need to be self-aware to practice at their best; self-awareness needs to be in the moment, not just Monday-morning quarterbacking.

I like that. Medicine is generally ripe for Monday-morning quarterbacking (and radiology in particular due to the permanent, accessible, and objective nature of the imaging record).

But doctors don’t work in vacuums. We are humans.

Consider for a moment the discipline of human factors engineering:

Human factors engineering is the discipline that attempts to identify and address these issues. It is the discipline that takes into account human strengths and limitations in the design of interactive systems that involve people, tools and technology, and work environments to ensure safety, effectiveness, and ease of use. A human factors engineer examines a particular activity in terms of its component tasks, and then assesses the physical demands, skill demands, mental workload, team dynamics, aspects of the work environment (e.g., adequate lighting, limited noise, or other distractions), and device design required to complete the task optimally. In essence, human factors engineering focuses on how systems work in actual practice, with real—and fallible—human beings at the controls, and attempts to design systems that optimize safety and minimize the risk of error in complex environments.

(I first found that passage plagiarized on page 8 of the American Board of Radiology’s Non-interpretive Skills Guide.)

Despite the rise of checklists and evidence-based medicine, humans have been almost designed out of healthcare entirely. Rarely is anything in the system–from the overburdened schedules, administrative tasks, constant messaging, system-wide emails, the cluttered EMR, or the byzantine billing/coding game–designed to help humans take the time and mental space to sit in front of a patient (or an imaging study, for that matter) and fully be, in that moment, a doctor.

From Rest: Why You Get More Done When You Work Less:

Neurosurgeon Wilder Penfield, for example, warned medical students that unless they cultivated other interests, “your specializing will expose you to an insidious disease that can shut you away from all but your occupational associates” and “imprison you in lonely solitude.” Penfield’s mentor, William Osler, warned that without care, “good men are ruined by success in practice,” and that “ever-increasing demands” can leave even the most curious person “worn out, yet not able to rest.” It was essential to develop “some intellectual pastime which may serve to keep you in touch with the world of art, of science, or of letters.”

These statements came from an era when residents literally lived in the hospital and Osler’s famous surgical colleague William Halstead’s work ethic was fueled by cocaine.

And even they thought it was important for doctors to be well-rounded, have hobbies, and get a life.

Honestly, I’m more interested in what you do for you than what boxes you’re just checking to impress me.

From Insider’s Pre-Med Guidebook: Advice from admissions faculty at America’s top medical schools:

Every year, hundreds of thousands of students pursue premedical studies at four-year universities across the United States and the world, and they, too, want to become physicians for a myriad of reasons. Many will find their reasons to be mature and well-reasoned. These students will find the motivation and strength to succeed as pre-med students, medical students, and physicians, and they will live happy and productive lives. Others will pursue medicine for reasons that are immature, underdeveloped, or untested. For these students, there are two major possibilities: they will struggle through their pre-medical studies and drop out, or they will end up dissatisfied with their life-long careers as doctors.

Before you pursue medicine as a career, you must be sure medicine is a good fit for you. If your motivations are poor or false, you will not have the drive to succeed during the long and difficult road ahead. You will lose time, money, and the opportunity to pursue whatever your passion truly is. If your motivations are genuine and well-developed, you will find this path to be easier and infinitely more rewarding. Not only that, but your passion will shine through the activities you pursue. Medicine is a pursuit that is simply too long, too difficult, too costly, and too important to pursue for the wrong reasons.

I would like to call bullshit on these bland truisms.

Someone show me some data.

I think there are plenty of folks who choose medicine for the “right” reasons and then get burned and churned through the medical training gauntlet. It’s hard, and the difficulty varies for different people for different reasons. It’s specious to argue that unhappiness with a medical career stems from flawed motivation as opposed to, say, a toxic training paradigm or a flawed healthcare system.

And, I think there are lots of folks who choose medicine because it’s a challenging well-compensated job where you generally have a meaningful positive impact on other humans on a daily basis.

Your pure soul can be exclusively motivated by humanistic altruism but actually have zero idea what it’s actually like to be a doctor day in and day out. Because shadowing isn’t the same as doing it for years.

You can be passionate about “medicine as a career” for all the “right” reasons even though the “career” you’ve chosen is actually a broad umbrella under which there lies a huge variety of professions from diagnostic radiology to general surgery to psychiatry?

I’ve never been convinced by the idea that good successful doctors are mostly a bunch of 18-year-olds who have a singular understanding of their lifelong “passion” let alone a meaningful understanding of medicine.

I’ve known wonderful failed pre-meds who would’ve made excellent physicians but didn’t make it through the gauntlet, and I’ve met plenty of self-satisfied doctors who got through but probably shouldn’t have.

Show me some data that the process selects for the right reasons and not just the right boxes checked.