Shallow versus Deep. Prolific versus Profound.

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

We see work and rest as binaries. Even more problematic, we think of rest as simply the absence of work, not as something that stands on its own or has its own qualities. Rest is merely a negative space in a life defined by toil and ambition and accomplishment. When we define ourselves by our work, by our dedication and effectiveness and willingness to go the extra mile, then it’s easy to see rest as the negation of all those things. If your work is your self, when you cease to work, you cease to exist.

What fraction of doctors (and miscellaneous business workaholics) do you think still believe rest is for the weak and that the ability to slog and hustle is not just good but truly enviable?

Second, most scientists assumed that long hours were necessary to produce great work and that “an avalanche of lectures, articles, and books” would loosen some profound insight. This was one reason they willingly accepted a world of faster science: they believed it would make their own science better. But this was a style of work, Ramón y Cajal argued, that led to asking only shallow, easily answered questions rather than hard, fundamental ones. It created the appearance of profundity and feelings of productivity but did not lead to substantial discoveries. Choosing to be prolific, he contended, meant closing off the possibility of doing great work.

Just like many jobs are bullshit jobs, much of our research is bullshit research. If we reward volume, we disincentive depth.

As Vinay Prasad was quoted in the Atlantic, “Many papers serve no purpose, advance no agenda, may not be correct, make no sense, and are poorly read. But they are required for promotion.”

When we treat workaholics as heroes, we express a belief that labor rather than contemplation is the wellspring of great ideas and that the success of individuals and companies is a measure of their long hours.

And this is one of the tough parts about almost everything written about deep work, rest, the power of no, when to say yes, and everything else in the modern business/productivity/self-improvement genre. The approaches just don’t apply very well out-of-the-box to service workers.

Doctors are primarily service workers. If we work more hours, we see more patients. While there is almost certainly a diminishing return in terms of quality care, there is no diminishing return for billing. A doctor generates more RVUs when they have more clinical hours, and that means more profits for their handlers (until someone burns out and quits).

William Osler advised students that “four or five hours daily it is not much to ask” to devote to their studies, “but one day must tell another, one week certify another, one month bear witness to another of the same story.” A few hours haphazardly spent and giant bursts of effort were both equally fruitless; it was necessary to combine focus and routine. (He lived what he preached: one fellow student recalled that in his habits Osler was “more regular and systematic than words can say.”)

Cramming is bad. Overwork is bad. A reasonable concerted effort over a long period of time is good.

Studying 4-5 hours a day was apparently a reasonable amount to Osler’s sensibility. Olser, if you recall, founded the first residency training program at Johns Hopkins.

Do you remember when the heads of the NBME and FSMB suggested in 2019 that a pass/fail USMLE Step 1 would be bad because students might take the decreased pressure as an opportunity to watch Netflix? Because I do.

Focus on the drive, not the distraction

NYT Columnist David Brooks writing about “The Art of Focus” back in 2014:

If you want to win the war for attention, don’t try to say ‘no’ to the trivial distractions you find on the information smorgasbord; try to say ‘yes’ to the subject that arouses a terrifying longing, and let the terrifying longing crowd out everything else.

There are whole books written about The Power of No, but I wouldn’t discount how our environments shape our behavior. Whether or not willpower is muscle or decision fatigue is real, there are plenty of data to show that making suboptimal activities harder improves outcomes in a variety of contexts.

I can tell you, for example, that the proximity of a Panera to one of the imaging centers I work at is not helping me make good lunch choices (bread bowls are my kryptonite).

But Brooks does reframe the classic “If you do what you love, you’ll never work a day in your life” adage to make it more approachable.

I think “find your passion” is generally terrible meaningless advice in most circumstances. If you have one, great. But if you don’t, it’s not exactly straightforward to meditate for a few minutes, analyze your innermost desires, and manifest your calling.

However, there’s also no denying that having a “pull” to do something (say, teaching others or writing) is the antidote to other less impactful activities. If you are drawn to something that matches your desired identity and goals, then it automatically makes it easier to avoid the “trivial distractions.”

As in, it’s easier to focus when you don’t want to escape the thing you’re trying to do.

Residency and the Craftsman Mentality

From Cal Newport’s excellent Deep Work: Rules for Focused Success in a Distracted World:

Whether you’re a writer, marketer, consultant, or lawyer: Your work is craft, and if you hone your ability and apply it with respect and care, then like the skilled wheelwright you can generate meaning in the daily efforts of your professional life.

You don’t need a rarified job; you need instead a rarified approach to your work.

Let’s add “physician” to Newport’s list.

One of the more disheartening aspects of medical school is the siloing of medical specialties such that different breeds of doctors appear to compete in the hospital and medical students come away with the idea that one specialty should spark passion in their hearts (and that they will be professionally unhappy if they then don’t match into that one specialty).

It doesn’t have to be this way.

The satisfaction of professional growth and a job well done can transcend specialty choice. If the results of the match weren’t what you wanted, apply yourself to developing a craftsmen’s mentality. Get good at what you do, take pride in it, and passion can follow.

 

 

The One Thing

From The ONE Thing: The Surprisingly Simple Truth Behind Extraordinary Results:

When everything feels urgent and important, everything seems equal. We become active and busy, but this doesn’t actually move us any closer to success. Activity is often unrelated to productivity, and busyness rarely takes care of business.

You can become successful with less discipline than you think, for one simple reason: success is about doing the right thing, not about doing everything right.

Maybe a collection of bland truisms, but…it’s amazing how enticing the pull of doing urgent but unimportant things can be.

 

Scheduling Slack

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.