“I'd come home from work and lie down on the floor — literally,” says Christopher J. Keenan, MD, MPH, reflecting on his years as a resident in Worcester, Mass. “I think my peers and mentors thought, ‘Oh, he's a good doctor and a good resident.’ And professionally I was fine, but as a partner for my wife, Susan, I was a wreck. I was drinking too much. I was a basket case.”

That was six years ago. Today, Keenan is living in Colorado, has two young daughters and recently celebrated his 10th wedding anniversary with Susan. He's usually out of bed before dawn to watch the sun come up so he “can appreciate being alive.” And he loves being a physician. “It's a real privilege to be in this profession,” he says about being an associate residency director at the University of Colorado School of Medicine and his work at Clinica Campesina Family Health Services, caring for the working poor. So what happened to the doctor who candidly describes his earlier difficulties as the result of being “too involved in me”?

“I decided to start seeking a balance and start dealing with my issues,” Keenan says. “When you've been trained, rewarded and indoctrinated into not being balanced, it's difficult to start being balanced,” he says. But a series of self-described wake-up calls jarred Keenan. He sought counseling and began to examine his life.

“A book I really like, Stephen Covey's Seven Habits of Highly Effective People [New York: Simon & Schuster, 1989], helped me a lot,” he says. “Covey talks about emotional bank accounts and how, if you have a relationship with someone whose withdrawals exceed his or her deposits, you need to close that account. In my relationship with my wife I needed to put some more deposits in. That meant time. When I used to have a day off I'd go running in the mountains and it was glorious. But the cost of that was that I would be asleep when she got home and I wouldn't be there for her. I've stopped running so much. To me, how you spend your time is a manifestation of your principles and your values.”

Keenan also developed a personal mission statement and uses a computer to guide him daily. “I can make a large to-do list on my computer, prioritize it with regard to my principles and that helps me acknowledge my inability to do everything I want to do,” he says.

Effort counts

Keenan is the first to acknowledge that “rightly, my colleagues don't view me as the most balanced person.” But he tries. In his residency program, the residents work hard, but receive weekends off and have a maximum of seven on-call nights per month. “I think we've tried very hard to allow people to have the balance,” he says, “and I think we've created a very humane residency.” While Keenan isn't sure whether his residents recognize his efforts to instill balance in them, he says it doesn't matter. “When they eventually have to deal with a less-balanced peer, I hope they'll have the insight to think, ‘Why are you hat way?’ It's disappointing to me to see so many physicians complaining.”

It's his patients who could complain, he says. Many are uninsured, single parents working more than one job. “Take my problems, multiply them by 10 and that's what they have to deal with,” he says. Keenan views caring for them as a collaborative effort. “I've got problems. You've got problems. Let's try to identify ones to work on.” His clinic recently received praise for a diabetes collaborative care project that used this simple approach. “I'm a doctor so I get excited about the medicine, but that might not be what's concerning my patients,” he says. “So we go from there.

I want to work on what my patients want to work on.”

And while he used to think the path to hell was paved with good intentions, Keenan now realizes that good intentions actually mean a lot. “What I tell my patients is that the effort is what counts. Whether you're successful or not isn't measured at the end of your life, but right now. You know it's kind of like what Socrates said: The unexamined life is not worth living. Well, the unaware life is not worth living. Ronald Epstein, MD, wrote a wonderful piece on awareness in JAMA earlier this year. It's worth reading.”¹

The article Keenan refers to shows how self-reflection can enable physicians to refine their technical skills, make evidence-based decisions and clarify their values.

Keenan jokes about the fact that he's balding, can't see well without glasses and is 15 pounds overweight but, he says, he considers himself successful. “My patients give me a lot. We live in a beautiful place, and our kids seem to be good people. I'm not an excellent example of a balanced person, but I'm confident that I'll be more balanced five years from now and next year. It's the effort that matters.”