Finding physician fulfillment.

Unlike previous eras in medicine where physicians stayed on one relatively constant career course, physicians today are exploring a host of ways to run their professional lives. Some are seeking changes due to stress. Others are simply searching for something that connects more deeply with their talents and passions.

Consider these two scenarios:

1: A 46-year-old female married physician heads up a small group practice that she started. She enjoys the practice of medicine, but finds herself in an administrative role dealing with the myriad logistics of running a practice. Increasingly, she is dissatisfied. Practice revenue is decreasing and expenses are increasing. Staff is bickering and her physician partners and employees are threatening to leave the practice if their salaries are not increased. She is feeling fatigued and weary and the stress is having an impact on the health of her marriage.

2: A 37-year-old male specialist in ENT enjoys a busy practice within a multispecialty clinic. He faces the usual gamut of stresses--heavy workload and call schedule, insurance and regulatory issues, some difficult patients, some staff conflicts, etc.--but has been managing these in stride. It's not so much worklife distress that prompts him to consider a different job or career direction; rather, he wonders if there's something that's missing, some kind of work other than his career that he would find more fulfilling. He has considered medical missionary work where he feels his special skills are greatly needed and would be greatly appreciated. On the other hand, he has entertained the entrepreneurial thought of starting a free-standing ENT clinic with associated hearing-related diagnostic and treatment services.

Whether you are a physician who is grappling with career transition questions or a physician coach trying to help others, understanding the difference in the plights that these two physicians face is critical.

All job and career modification implies movement. Remember physics and the law of force vectors? "The sum total of forces acting on a body determines its forward movement. The sum total of forces acting against a body determines its resistance to forward movement."

Likewise for a physician's career "movement."

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So, what are these change drivers and resisting forces?

The change force is actually comprised of two distinctly different types of drivers. Those that push one out of, away from, the present situation--these are the pain drivers. And those that attract one to a new state--these are the longing forces.

Pain relief?

Stress in the practice of medicine (and it seems in society in general) is at an all-time high and shows no signs of plateauing.

Physicians face huge workloads, grueling practice and call schedules, rising costs, concerns about litigation, increasing government intrusion, etc. Add to these the challenge of simply running a business--having partners, managing staff, staying and growing in business and, perhaps more importantly, interacting with the real people who are patients.

As stress continues, and as the stress issues are unaddressed and unmanaged, pain ensues.

Pain is perhaps the greatest motivator for change. In the context of a physician's job or career dissatisfaction, you will hear "I can't stand this any longer," and "This isn't working for me."

So, pain pushes us toward change. Pain is the "propeller" of worklife transition. It moves us forward.

Longing

It is a fundamental manifestation of our maturing psyches that we want to do well in all that we pursue. We want to follow our interests, use our skills, live our values and achieve certain goals. These goals may be financial, intellectual and social.

We strive to find means to achieve an expression of skills, interests, values and goals in work that meshes with our personality style. Over time, we've learned not to fit the round cylinder of ourselves into the square hole of work.

If we are outgoing and creatively flexible, we look for an environment that fosters that. If we are more introverted and analytical, we seek a setting that enables us to best be who we are.

Finding yourself in an environment that is not favorable to your personality style is like trying to plant palm trees in Alaska. They just don't do well there. (And you may have noticed, igloos don't do particularly well in Florida either.)

When we find that work fails to enable us to use and develop our skills, capture our interests, live our values or meet our goals, there is a disconnect. We are "out of sorts," and long for something that will bring us fulfillment.

So, we begin to imagine and explore other career possibilities. This change force is "longing."

Longing compels us. It attracts, and pulls us forward. So, there are two dynamics or vectors that drive us toward change: Pain pushes us and longing pulls us. And physicians vary in the proportions of each dynamic.

Increasingly, many are motivated predominantly by pain (actually, significant numbers of physicians are downright miserable, regretting their career choice and discouraging their children from pursuing medicine).

Others are motivated more by longing, wanting to find a better career fit and not propelled so much by dissatisfaction and pain.

So, if this dynamic is like a physics equation with physicians being pushed by pain and/or pulled by longing, why don't they change? What's holding them back?

Great question. This may seem tautological, but what's holding them back is resistance.

I believe the resistance driver is, in fact, composed of two different dynamics: real world considerations and internal myths.

Let's say you've been miserable in your practice (pain), or that you're just not getting the charge out of your work that you want and it's not meeting your needs (longing).

Imagine for a moment that "the world is your oyster" and you could re-craft your career in any way you wanted. What's holding you back?

Here's an example of the strength of resistance:

A physician says she wants to do more humanitarian work, perhaps as a medical missionary in Africa. "What's holding you back?" I ask.

She replies, "My husband doesn't want to come with me...." "The educational opportunities for my kids seem inadequate...." "It's a huge cut in pay--I'm not sure I, or we, are ready to adjust our lifestyle...." "I can't break my practice contract; it has two more years...." "Truth be told, I'm afraid of contracting HIV or some tropical illness...." "I'm afraid I won't be good enough or know how to respond in such dramatically different circumstances...."

As you can see, she has a plethora of resistances (and probably more not yet stated). If, in fact, she wants to move to Africa to do medical missionary work, she must sufficiently address each and every one of her resistances.

To help her sort it out, she should divide the variety of identified resistances into two columns that exist along a continuum.

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The next challenge is to carefully examine each of these to determine how real or mythological they are. If real, what is she going to do about them? If mythological, how is she going to dismantle them so they're not continuing to get in her way?

After all, if it is self-myths that are holding you back, then you are not able to meet your heart's desire. And if it is real world considerations, there may be ways to address or work around these.

It's important to note that some resistances that are initially listed as real world considerations may in fact have an internal myth component to them. They need to be assessed for their factual basis and elements of distortion.

Likewise, some elements of the internal myths may be real world considerations--such as it is quite possible to have a higher risk of contracting certain diseases when you are more in proximity to them.

Too often, physicians, who are customarily bright, patient and thoughtfully analytical, tend to act impulsively in matters of their career happiness. With increasing but unexamined professional dissatisfaction (read "pain"), and with unexplored longing, they may say "This isn't working for me" and impulsively jump into something else, sometimes something radically different. "I'll open a pro shop." "I'll run a restaurant."

While infrequently these shot-in-the-dark career moves can work (attribute these successes to the wisdom of intuition and the goodness of grace), more often they simply result in the physician jumping from one stew pot into another or worse, from the proverbial pan into the fire.

What emerges from all this is a "four quadrant" model of physician worklife transition to help systematically explore the essential elements contributing to professional well-being.

When you have undertaken a thorough and thoughtful exploration of your unique four quadrants--perhaps because of your clearer vision, perhaps because of your stating your intention to the world--optimal opportunity makes itself more apparent to you.

If physicians want to find worklife happiness, they've got to do some systematic exploration. But if they don't do the reflective work, they're sure to stay stuck or make an ill-considered transition.

For physicians who are dissatisfied or unsettled in their careers, now is the time to map out your path to professional fulfillment.

Kernan Manion, MD, is a career development coach and organizational consultant on "people issues" in health care. He may be reached through his website at www.WorkLifeDesign.org or [e-mail].

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By Kernan Manion, MD

RELATED ARTICLE: Dr. Smith Takes a Risk, Forms Her Own Practice

(The following story is fictionalized in part to protect the client's confidentiality)

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Dr. Sarah Smith, a pediatrician in her early 40's working in a mid-size single specialty group, sought coaching to examine her current career dissatisfaction. She had been practicing with her current group for about 10 years but found that communication with the senior partner/founder had become strained, especially around compensation issues.

Additionally, there were a number of issues causing interpersonal strain between her and some of her colleagues and her staff. Her dissatisfaction was showing up as weariness and irritability and it was also having a negative impact on her married and family life.

She felt hopelessly stuck, unclear about whether she should stay in this group, in pediatrics in general, go for fellowship training in a subspecialty or perhaps switch specialties altogether.

And part of her wanted to get out of practice for good and be a full-time mom. But she felt guilty about contemplating this, and besides, she also worried that the financial impact of this would be more than she and her husband could endure.

She periodically thought about starting her own solo practice, but feared being over-whelmed by the challenges of setting it up and, perhaps worse, the specter of nightly call.

Coach approach

In coaching Smith, we focused on first learning more about her career journey--how did she choose this specialty, this locale, this group? What have been the highlights of her career? What have been the low points? Each question helped get a better idea of the multiple components of each of the change dynamics.

It's important to realize that this exploratory coaching process using the four quadrant model is necessarily an interactive and reflective one. You simply can't gather all the information in the first meeting or in one comprehensive exercise.

Over a series of eight sessions and using a variety of focused homework exercises, we looked at the multiple sources of her worklife unhappiness, her longing and vision for the future and her "hold backs."

Early on, we learned that there were a variety of non-essential administrative leadership positions that Smith could easily drop and afford herself considerably more emotional space and, with that, more resiliency.

We also systematically explored her longings. Smith realized that she really longed to focus her practice on a few select disease states, in essence being seen as the community specialist for childhood asthma and dermatology conditions.

As we spoke about her starting her own practice, and whether it should be solo or a small group, she was flooded with concerns:

* "What do I need to do first?"

* "It's too complicated."

* "What will call be like?"

* "I don't have the energy to do this."

* "I can barely cope now."

* "What will my colleagues think of me?"

* "Where will the patients come from?"

* "I feel like I'm abandoning the group."

Each of these concerns needed to be aired and thoroughly explored. While some were real world concerns, others are much more of a "self-myth" nature. Without exploring each of these resistances in full, it's quite likely she would be stuck at impasse.

Using the four quadrant model in a distance coaching format helped Smith make a fully informed and well-reasoned decision to leave her pediatric group and set up her own practice.

She decided to initially open a solo practice but had immediate plans for sharing call with existing colleagues and had an eye toward recruiting a part- or full-time clinician as the practice established its identity.

Now, less than one year later, Smith's enjoying a thriving small group practice, one where she has specifically marketed for and is treating the types of patients and conditions she wants to treat.

Most importantly, Smith's doing work that she loves and her patients love her for it.