When we talk about the idea of work life balance, the question that always comes into my head is where is the line between an appropriate amount of work and an excessive amount of work? Both ends of the spectrum are evident. I bet that we all could identify characteristics of someone who is too lazy and someone who is a workaholic. But finding the line that separates these two extremes in the middle is a much more challenging affair.
This becomes an even more difficult question to answer as we consider generational differences regarding attitudes towards work. It almost goes without saying that millennials have a different view of the primacy of work than older generations. Older generations place great value in a career and the long, brutal hours required to advance to the pinnacle of success. While millennials don't disregard the need for hard work, they tend to place a greater value on developing personal interests and leisure activities. They see boomers and X'rs as focusing too much on the grind and not on the other things that make life beautiful and meaningful.
But if you ask the same question to my boomer and older Gen X colleagues, they would claim that the millennials are soft and lazy. That they are unwilling to make the sacrifices necessary to make medical practice or corporation successful. The accusation is that millennials and Gen Z'rs have inherited a comfortable life on the backs of the hard work of boomers and X'rs and don't appreciate the hard work that is necessary to make a leisure happen.
As in all things, the reality probably lives somewhere in the middle. As I have progressed through my career, I have felt the tension between my desires for life and the requirements of work. I’ve spent time, thinking about this dichotomy between work and life and have routinely asked myself the question - where is the line between a good day's work and overwork? And how do we keep ourselves from overwork?
The Importance of Work
A conversation like this begins with understanding the nature of work and why it is important. Work has always been a part of the human experience. Whether you are talking about a subsistence farmer in the ancient fertile crescent or a modern executive in some numbered office suite overlooking downtown New York, work has always been a means of providing for our basic and material needs. While the products of our labors may appear different, at the end of the day, work puts food on our tables, clothes on our backs, a roof over our heads and provides some degree of material security for those to whom we are responsible.
The value of our work is not just limited to ourselves. Humans are a social species. Throughout the pages of history, we can see a meta-narrative that spans across civilizations. Social interaction breeds interdependence and occupational specialization. The result is increased efficiency and technological advances. On a macro level, our work contributes to a robust, functioning economy. And on a micro level, our work is an opportunity for us to use our talents and unique ability to serve those around us.
While work meets our material needs and the material needs of those around us, it also provides us with meaning and purpose. When we have a job to do, we have a role to fill. It is part of the answer to the age-old question of why I am here. And on the contrary, people who are unemployed or don't work tend to have greater rates of depression and negative emotions. While work cannot be the ultimate source of our happiness, it does greatly contribute to our overall wellbeing.
Consequences of Overwork
As physicians, we are a highly motivated bunch. This begins with a degree of self-selection. The process of medical education is a daunting affair. And only those who think they have the stamina and desire will succeed. Then add to it the early mornings and late nights memorizing the Krebs cycle along with every muscle, bone, and nerve. But this drive also has a tendency to work against us. We have a hard time finding the off switch. This is problematic because overwork carries with it a number of negative consequences.
The first, and most obvious consequence is that overwork stresses our relationships, children in particular. I recently ran across a post on twitter extolling the virtues of a hyper-focus on devoting vast quantities of time to work, claiming that children will learn to value the parent's devotion to making for them a good life. Nothing could be further from the truth. I have never had any of my children ask for me to spend more time at work.
Overwork also tends to have unfortunate health consequences. A 2015 study in the Lancet reported that people who work long hours have a 1.13 times higher risk for coronary artery disease and 1.3 times higher risk of stroke than those who work 35-40 hours per week. The paper hypothesizes that this is due to a chronic stress response and physical inactivity to which I would add poor nutrition and sleep. Lack of attention to the basic tenants of health result in decreased exercise tolerance, weight gain, and unbalanced consumption of macromolecules. Hypertension and insulin resistance follow. The rest is predictable.
Finally, overwork is one of the contributors to burnout. The golden handcuffs can keep someone on the workplace treadmill. The latest Medscape survey on physician burnout reported that 53% of physicians overall are burned out. That means, when you see your doctor, there is a better than coin-flip's chance that he or she is not in a healthy headspace. And unfortunately, physicians who suffer burnout have impaired motivation, impaired empathy, and impaired physical ability to perform their jobs.
Rest
Thom Mayer in his book Battling Healthcare Burnout likens a doctor to an elite athlete (I'll take it). In order to maintain peak performance, an elite athlete needs to follow a cycle of work, recovery, and rest. A game is followed by a to retreat to the locker room for ice baths and stretching. Off days are spent focusing on sleep, nutrition, and training.
When we as physicians show up to work, we are expected to perform at a high level cognitively. We are supposed to listen to and examine a patient, interpret vast quantities of subjective and objective data, and come up with the right diagnosis and treatment plan multiple times per day, managing the delivery of care and navigating through an increasingly complex healthcare infrastructure of administrators, payers, and pharmacies. Early mornings, long days, call, and overnight shifts make this job exhausting. Yet, we often fail to complete the triad. We neglect our recovery and rest.
The Judeo-Christian calendar is built around weekly periods of rest. When I was a medical student, I decided to follow this pattern. I set aside Sunday as my no study day. Every other day of the week I was up early and studied until late in the night - Saturdays included. But Sunday was my day to set all that aside and rest.
In the books, Reset by David Murray and The Common Rule by Justin Whitmel Earley, both authors open the books with accounts of their experience with serious medical conditions that arrested their attention from a frenetic pace of work and caused them to implement habits that forced a reorientation of priorities and adoption of periods of rest. As busy physicians, I think that we would benefit from doing the same.
The Doctor's Prescription
When I was young, my parents had a house on a lake in central Wisconsin. This was likely influenced by my Dad's boyhood experience growing up in northern Minnesota going to a lake cabin in the summers. For us, this place was a retreat. It gave us the opportunity to unplug from daily life and enjoy the simple pleasures of being on or near the water. Near the front door they had a rock painted with the inscription, "Rest that you may run." This rock served as a reminder for us and the myriad of other families that used the cabin of its purpose. A lifestyle of leisure is not to be our ultimate reality. But periods of rest allow us to regain perspective, align our values and priorities, and prepare ourselves for the work ahead of us. So, absent a literal lake cabin, how can we as busy physicians rest? Here are a few ideas.
Get adequate sleep
Resting appropriately starts with the basics. Get good sleep. Every aspect of health, wellness, and productivity is profoundly affected by our sleep. We are creatures whose existence is marked by finiteness. We are not made to be infinite. Yet, all too often the story of our sleep conveys the message that we are attempting to be just a little bit more infinite. In his book, Why We Sleep, Dr. Matthew Walker discusses the physiology of sleep, and the role sleep plays in our overall health. Lack of sleep not only impairs our cognitive performance, but it also increases our risk for hypertension, diabetes, heart disease and cancer. Sound familiar? Start with the easiest, low hanging fruit. Get some sleep.
Sabbath
As human beings, we are limited in our abilities and our importance. No, I don't mean that your existence doesn't have real meaning and value. I mean that in our patterns of work we act as if we can plow through any limitation because the product of our labor is from us and about us. But a simple step back and view of our place in the arc of human history reminds us that the world does not depend on us, nor can we do everything. Just as our body needs rest, our soul needs rest too. 20th century Jewish Rabbi, Abraham Heschel said, "A man who works with his mind should sabbath with his hand, and a man who works with his hands should sabbath with his mind." As physicians, we spend a great deal of time talking with patients, analyzing journal articles, completing charts, return calls and emails, and a myriad of other tasks. Step 2 is to make an intentional time to disconnect from work. This doesn't mean you need to sit on our couch at home and ponder the color of the walls. But you should make time to engage in activities that are restorative, exercise, take up a hobby, go on a vacation.
Keep the main thing, the main thing!
In our work we tend to get hyper-focused on what we are doing. This state of flow and the resultant productivity can be a euphoric experience. I remember when I was in medical school, I would get into a cognitive state where my mind was so engaged with the material that time seemed to vanish. But the same quest for flow that can enhance our productivity can also distort our sense of what is of importance. From time-to-time we need to step back and reevaluate our priorities. What and who is most important in our lives. Does our pattern of work reflect that? When viewed from a wholistic perspective, our relationships (with God, our spouse, our kids) are likely the things that we categorize as the top priorities. So, does our work reflect these values? Do I set aside time to put myself in right orientation with God? Do I make regular time for my wife? Do I regularly engage in the lives of my kids? When our cognitive abilities fade and our physical abilities deteriorate, these are the things that will remain.
Conclusion
Getting back to the original question, where is the line between underwork and overwork? If you were hoping for someone to finally reveal a magical epiphany, sorry. I have no clue! But, as I have thought about this issue, I am currently of the mind that there is no fixed line. It is different for every person and every situation. But wherever the line happens to fall in your life, we all would benefit from an intentional and purposeful focus on rest.
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