By the time physicians arrive at the Center for Professional Well-Being, many are on the verge of complete despair. Some are considering dropping out of a profession they once entered with passion and commitment, and one that's required an investment of many years and thousands of dollars. It's our job to help physicians recapture the joy of practicing medicine. Take, for example, the weary 50-year-old doctor who recently arrived in our office. His frustrations may sound familiar:

• A constantly fluctuating schedule of patient appointments;

• Competing demands for his time and attention from patients, other physicians and his staff;

• Information overload;

• Endless paperwork;

• Insufficient time to spend with his family;

• Insufficient time for his hobby (fly-fishing);

• A general lack of enjoyment in his life and with his profession.

What did he love about practicing medicine? He couldn't readily recall, but he could identify elements of his job that still energized him:

• A challenging case;

• The opportunity to connect with people, including some long-time patients he knew truly appreciated him;

• Collegial relationships with his partners and opportunities to collaborate with them;

• A supportive staff that tried to “run interference” for him as often as possible;

• Learning through CME.

As he articulated this list, he was surprised by how much he could identify.

Getting started

It's almost impossible to recapture something in our lives when we can no longer even conceptualize it. For example, feelings of joy are, at best, a mental construct for many physicians who seek our help. Although some may have felt it briefly from time to time, an ongoing state of joy is about as foreign to most physicians as bloodletting is to modern medicine. Can you recall recent periods of joyfulness? If not, you may need assistance to recover from burnout and to recapture the joy of practicing family medicine. (For information about organizations that offer help with professional renewal, see “Resources for physician wellness.”)

Overstressed physicians need to pinpoint aspects of their professional and personal lives where they still find joy. Ask yourself, “What rewarding experiences am I currently involved in that make me feel complete as a person?” This exercise helps doctors realize that joy isn't a totally foreign emotion. Once you've identified what parts of your work still energize you, move to a more tangible level and make some easy-to-implement improvements in your work flow. It's usually best to focus on things that you've already identified as frustrations (see “Common physician frustrations” for some examples from other doctors). The goal is to find what's draining your energy and minimize the time you spend on these tasks so that you have more time to invest in the work that's most rewarding.

If this doesn't provide adequate relief, you might want to explore transition options — options that are based on the aspects of your life you've identified as sources of joy and that take into account your phase of life. For example, ask yourself what vision you have for yourself, your family or your practice. Then identify the skills or talents you need to acquire to realize this vision. Your answers will help direct your efforts to find joy and reduce the likelihood that you will consider a quick fix for your frustrations.

The quick fix

Some have already decided on a quick fix by the time we see them. If they're getting close to retirement, they're usually thinking about it. Some are examining the possibility of taking stress-disability leave. Others are looking for alternatives that allow them to continue to use their medical background but in less stressful environments.

While eventually it may be important to look at retiring or changing professions, dropping out is just a quick fix. It'll take you out of your present pain without fixing the problem. Quick fixes come in all forms. We've seen physicians cope with stress by overworking. Their burnout and chronic fatigue are attempts to adapt to their decreased satisfaction about their lives and profession. Some have had extramarital affairs. Others have looked for satisfaction in a new BMW roadster or a new house.

No one reaches the point of dropping out of the profession without needing significant emotional and spiritual healing. If the healing isn't done, physicians who drop out may find themselves unable to experience joy in whatever new setting they've chosen. Even with lots of time to spend on the golf course or traveling, the dissatisfaction usually recurs. One physician confided to us that he had become involved with a much younger nurse, left his 25-year marriage, bought a new Porsche and a new house, and traveled all over the world — only to find himself with the same dissatisfaction five years later.

The quick fix can be addictive. We feel better for a short while and then look for temporary relief from other sources. While the quick fix gives us the illusion that things are better, it's like using a Band-Aid to control hemorrhaging. Without going through the healing process, you'll continue to lose your lifeblood.

To find joy, acknowledge pain

From the first day of medical school onward, you've most likely felt behind. Practicing medicine can be like racing through life on a treadmill that's always picking up speed. Exhausted, many physicians begin to question whether they can keep up the pace. But most feel forced to continue on the treadmill, regardless of the personal toll, because of commitments they've made. First they work to pay off medical school loans. Then they work so they can afford the expensive lifestyle they've created — sometimes to appease family members for their constant absences. If they don't want their children to start professional life with the burden of debt, they may keep up a fast pace to help pay for college or professional school.

A tremendous number of physicians have compassion fatigue; that is, they give to patients to the point where it hurts too much to give any more. Some have alienated their families. One physician we worked with overheard his child ask, “What's a daddy?” If the physician's marriage is still intact, it often needs healing, too. To start healing, it's necessary to admit that there's been a lot of pain. Along with it, there's likely to have been a lot of frustration, anger, sadness, loss and even fear.

Admitting that we have these feelings is one key to recapturing joy. When we suppress pain, frustration, anger and fear, we simultaneously incapacitate our ability to experience peace, love, excitement, enthusiasm and joy. Because our emotions are integrally related, it's impossible to disable some without handicapping them all. No body parts exist without function (even though there are some we can survive without). Our emotions are the same. Paralyzed emotions are just as dangerous to our health as an atrophied limb.

Realize that you have options

Once you begin to see that you can feel joy, introducing it into your daily life becomes largely a state of mind. If you plan to continue to work in the same environment, you'll need to understand that you have options about your practice life; this will help you derive more satisfaction from your work. Start by developing a vision of how you want to practice. You might reflect about colleagues who seem to relish their work and stay joyful in spite of all the changes and craziness around them. Here are six traits that people like this often share, as well as tips for developing them in yourself.

1. Humor

One often-mentioned trait is the ability to find levity in even the most humorless situations. Exercise your sense of humor; chances are it's shriveled up in the pressure cooker of your work. (For more information, see “Physician, Laugh at Thyself,” September 1998.) Seek out those who have a lighter approach to their work, both to learn from them and to help you rekindle your spirit. Misery loves company, but whining sessions with other colleagues will focus your attention on the half-empty glass rather than the one that's half full. Participating in these sessions won't bring you the relief you're seeking; realizing this should give you the incentive to excuse yourself for higher-spirited circles.

2. Strong support

Another trait of more-satisfied physicians is their ability to receive support from others. This requires openness and a willingness to give up some control, and for many physicians these are skills that must be learned. If there is a support group for physicians in your area, consider joining; if one isn't available, consider joining with other frustrated physicians to form one. Meetings should be times for identifying and sharing recurrent problems and then exploring the options available. Maintaining this focus helps keep the sessions from becoming another venue for whining.

While these groups are valuable as sources of possible solutions, the personal support they offer is also very important. For example, in one session a physician parent reported a lesson she had learned about making time for family members. Pleased with herself for finally setting time aside, she asked the family member, “What would you like to do today?” Feeling long forgotten, the family member instead asked her, “Why weren't you there when I needed you?” Recapturing the joy of medicine often means confronting the pain of past actions, accepting mistakes and disappointments, and moving forward. A support group can help you find the courage to make this journey. (For more information, see “Physician Support Groups: A Place to Turn,” October 1995.)

Of course, support isn't limited to support groups. Whenever people share heartfelt stories or concerns, it's important to listen and let them know you appreciate their honesty. Take the time to recognize and even celebrate an accomplishment, a professional milestone or the achievement of a personal goal — yours or someone else's. It makes everyone involved feel good. The most important gifts we can give our peers usually cost little more than an acknowledgment and some flexibility. Sending a card or rearranging the call schedule so a colleague can celebrate an achievement can create an ongoing connection between you. Staff members also appreciate this type of recognition. The joy you bring to others brings you joy as well.

3. Clear values

Doctors who are healthy in their work are keenly aware of what's most important to them — and they act on that awareness.

When your work environment requires you to behave in ways that conflict with your values, it's natural to feel stressed. And in the pressure cooker of modern medicine, it's easy to fall into a reactive mode. Instead of choosing how to act within our value systems, we tend to adapt to new rules, which may even directly conflict with our values. To identify the parameters within which you're comfortable practicing medicine, ask yourself questions to clarify your values:

• What is sacrosanct?

• Violation of what principles makes me really angry?

• What specific difference do I want to make as a physician?

Taking time to reflect on your professional values may seem highly impractical in clinical practice; after all, you're overextended as it is. Reflection can be seen as unprofessional or somehow incongruous with the persona of a super-busy doctor. Yet, when rules, regulations or contract provisions intrude on the covenants of practice, you can achieve excellence in clinical care only through reflection and discussion with peers. Articulating a values-congruent yet workable definition of family practice helps you be proactive about how you approach your work. Once you can articulate this definition, you'll be better equipped to engage in dialogue with those whose interests lie in following the rules and contract provisions. Through that dialogue, you'll be better able to meet the demands of the changing health care system and work comfortably within your own value system.

After you've identified your professional values, it's natural to examine your personal values. For example, you may decide that a more balanced life is important to you and that you want to take more time off for yourself and to nurture relationships with loved ones. Taking time to identify your personal values and evaluate how closely your life reflects them can help you pinpoint discrepancies.

4. Openness to patients' gifts

In a busy practice, it's easy to concentrate on giving and to forget that your patients are a wonderful source of spiritual replenishment. One way to reconnect with the joy of practicing medicine is to take time to receive your patients' gifts. As you learn to experience your emotions, you'll begin to relish the love, appreciation and respect that many patients want to share with you.

Allowing yourself a moment to bask in the glow of your patients' appreciation will help to relieve the boredom of some aspects of practice and the inequities you may sense in today's health care environment. Moments when you make a diagnostic or procedural difference — or provide tremendous comfort — can be inspiring and uplifting when shared with trusted peers. Recalling the appreciation of someone who needed a house call or the joy of a patient to whom you gave good news can lighten the days when you're feeling overextended. Even something as simple as recognizing the value of reassuring someone in a time of need can help bolster your lagging spirits.

5. Collegiality

Another component of joyful practice is collegiality. Do you often feel a lack of support or commitment from your staff? Perhaps you need to encourage more collaboration. To foster this type of work environment, ensure that all staff members feel their input will be valued and respected. Begin by listening to your staff members, acknowledging and implementing their suggestions and creating an atmosphere in which they feel safe sharing ideas and observations. (For one approach, see “Finding Diamonds in the Trenches With the Nominal Group Process,” May 1999.) Work together to create a shared vision that includes an understanding that mistakes and conflicts are expected, and that conflict resolution is valued.

A shared vision requires input from everyone in the practice, including your patients. It also requires patience. But it's worth the effort. It creates a more positive work environment where people feel valued and have the attitude that “all of us can win in the long run, but each of us needs to be involved to make it work.” Ultimately, people who feel valued work harder and get more accomplished.

To create a more joyful practice environment, you'll also need to confront colleagues who won't collaborate or who are disruptive (see “Managing the Unmanageable: The Disruptive Physician,” November/December 1997). Moreover, you'll need to do it sooner rather than later so negativity doesn't fester and so appropriate help can be offered. Depending on the situation, you could offer a listening ear or a referral to a mentor, interpersonal-skill adviser or mental health professional. Confronting uncooperative colleagues isn't a matter of pointing fingers but of working to solve problems. When you do so, focus on what's happening in the here and now, not on what happened months or years ago. In a healthy practice, all staff members should be free to say what they feel and think (with courtesy, of course); no individual should be able to intimidate others. Diverse ideas and feelings must be respected and accepted.

6. Awareness of your needs

While it's critical to the healing process to address the underlying issues blocking your ability to feel joy, it's also essential to discover what you need in order to replenish your energy and enthusiasm. For example, over the years we've worked with several male physicians who readily accepted their female colleagues' need for family-friendly schedules or sabbaticals. But while they could recognize the needs of other colleagues, none could identify what they needed themselves. Freedom to enjoy your practice will come only after you recognize your needs and start working toward fulfilling them.

One of our physician clients was exhausted by her practice; medical record keeping was particularly draining. We suggested that she hire a scribe, familiar with the language of medicine, to shadow her. The physician approved or edited the scribe's work as part of her medical record keeping. The physician seemed to lighten up just realizing that there was a potential solution to her problem.

Another physician was frustrated by not having enough time to provide adequate education, especially for patients with chronic conditions. After some discussion, we realized that he had several patients who needed similar information. We suggested that he schedule monthly group education sessions for patients with similar conditions, giving him the time to cover the material more thoroughly than he could by repeating the same information to each patient individually. The doctor was excited by the prospect of teaching these sessions and being able to offer much more detail in his explanations. He also surmised that his patients would have tips to share with one another and might even teach him a thing or two. Had he not been so excited about teaching these sessions, we might have explored another alternative: To delegate his patient education to qualified staff members but stay in the loop by asking patients and staff members to give him periodic feedback.

You can do it

When you're exhausted, reclaiming the joy of practicing medicine may seem like a distant goal or an impossible dream, but it needn't be. All that's required is your commitment to learning new ways of approaching frustrating situations, your willingness to consider the alternatives that others have found worthwhile and your courage to keep trying and not to fall back into your old habits. While you may initially find this uncomfortable, it will almost certainly give you greater satisfaction with your profession and your life, as well as a renewed vigor to meet the challenges that lie ahead.