Preserving Career Longevity in a World Not Built for You

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IT’S A WILD WORLD: HOW TO WORK WELL IN AN UNJUST SOCIETY

So many of us work in organizations or regularly interface with institutions that were simply not built with us in mind. The resultant friction poses an obstacle to our career longevity.

A Calling

I have this vivid memory from the year 2000, when I was an intern. It is Saturday early morning and the inpatient medicine ward is full of the hustle and bustle of rounding teams. I am the psychiatry resident doing my obligatory rotation in internal medicine. I am post call, still in scrubs, have barely slept, and my stomach is fueled only with greasy cafeteria food.

As I enter orders into a chart, I spot a psychiatry attending doing C/L rounds. He appears to be in his early 70s, tall, slim with a shock of white hair. I watch him move with confidence and poise as he speaks with nurses, residents, and then family members. He exudes a calming wisdom that has me hypnotized.

“I want to be him someday, as long as my brain and body is cooperating. I want to be that doctor, in the hospital on a Saturday rounding. Still teaching, still being of service in my 70s,” I found myself thinking.

In that moment, I was struck by the depth of my love for my profession and overwhelmed by how privileged I was to be a doctor. This was my calling, my path to fulfillment, and a way to do something valuable in the world. Furthermore, this notion of practicing psychiatry well into your 70s and even 80s was not far-fetched. During my years as a resident and junior attending, I would meet many clinicians (typically men) who were doing just that.

When I look back, I still believe that moment, experienced by my 24-year-old younger self, was true and pure. It was rooted in my core belief that medicine was a vocation. I was not naive but what I was grossly underestimating was how my future longevity in this field would be determined by many factors that I barely understood at the time. My commitment to service and the doctor-patient relationship would not be enough.

I am sad to say it is highly unlikely I will ever realize that vision I had for my 70-year-old self. When I look around at many of my mentors, mentees, and colleagues, my guess is they would probably say the same. If they had a choice, they would not want to be practicing in their 70s.

The new question becomes this: how do we ensure we work well and do good for as long as we possibly can, and when the time comes to retire from clinical practice we walk off the field, not limp off?

Work Stress: Macro Issues

No doubt, there are a myriad of ways the practice of medicine has changed unfavorably over the last 25 years. Some of the major issues that spring to my mind include: the increasing amounts of time clinicians spend doing data entry in electronic medical records; hurdles dealing with insurance companies and declining reimbursement; crippling medical trainee debt; top heavy, bulky health systems that disempower frontline clinicians; and the never-ending overregulation of our professional lives.

For much of my career I have navigated this shifting landscape with a “change is the only constant” mindset that required me to adapt and pivot to meet new demands and also stay creative in how to navigate these challenges in a way that stayed true to my professional self and my patients.

If I am honest, I have noticed a tangible loss of momentum in my ability to adapt to change in recent years. As I reflect on why this is, it becomes very apparent to me that I have become bogged down by this fact: the very personal qualities that were deemed essential and deliberately accentuated during my years of medical training often work against me in the current medical environment.

I know I am not alone. When I think of the hundreds of clinicians I have met over my career—teachers, mentors, peers, colleagues, and students—many of them have several traits in common: they trend toward the nerdy side (ie, love science, data and have an insatiable mental curiosity); are perfectionistic; they are not naturally disruptive (ie, generally accepting of hierarchy); have grit, stamina, and focus, a huge capacity for delaying gratification; and are typically pragmatic and very adaptable. Most of all they have humility and care deeply about being of service and doing work that is meaningful. Finally, they are generally not power or money hungry because, let’s face it, there are lots of easier ways for smart individuals to accrue money and power in this world than becoming a health care professional.

The sad fact is many of these character traits work against us (or are taken advantage of) when we work in organizations or regularly interface with institutions that are built to put profit and processes over patients and people.

To add insult to injury, in the digital age, it can sometimes feel that patients require clinicians to compete with the internet, where apparently everyone is an expert and increasing amounts of our time are spent undoing the harms of widespread disinformation. Again, all those years spent devoted to deep thinking and embracing the complexity in learning may feel diminished in a world that has limited patience for these ways of being.

Practicing medicine, under such conditions, equates to mental friction and on bad days, it can feel like one is being set up to fail.

Work Stress: Micro Issues

A couple of years before the pandemic, I realized something was amiss. At work, I frequently felt stressed and overwhelmed yet was struggling to identify why. Of course, there were the macro issues I have already alluded to, but I was aware of their influence, felt I had accounted for them, and had safeguards in place to minimize their negative impact on my practice. Overall, my professional life was healthy with no major reason for discontent or disappointment. There were many demands on my time, and I was always busy with the all the roles and responsibilities I had shouldered but these were all by choice and, moreover, I was also doing all I was supposed to be doing to manage any related stress. My regular routine consistently included meditation, decent quality sleep, time for recuperation, and leisure with friends and family. I avoided unhealthy ways of coping, and, after many years of persistence, I was finally on a path where I was consistently eating healthfully and exercising regularly—better than at any other time in my life. For all these reasons I was baffled by how stressed and overwhelmed I was by minor incidents that seemed to crop up on a daily basis:

• How do I delegate to an employee who does not accept my authority as a woman leader?
• Why does this trainee, whom I have never met, assume they may address me by my first name on an initial email communication?
• How should I respond to a patient who refuses to have me as their doctor because of the color of my skin?
• Why does my colleague of 10 years keep mistaking me for the new doctor—who also happens to be a woman of color—on this conference call?

I became aware of a daily mental calculus I was doing when dealing with these micro stresses: weighing up which battles I should pick, what I should let go, which situation required patience and kindness, and which required me to prioritize my own sense of self-respect. The juggle left me feeling mentally exhausted. And while such incidents, in isolation, were not significant what I was finding was that, over time, they were taking an insidious toll on me, sucking my energy and dulling my zeal for work.

Faced with the conundrum of unrelenting stress, I did what I have always done in such situations: look to my colleagues to see if they were having a similar experience and what they were doing to manage such micro stresses.

On one extreme, there was the no grit, no grind, no greatness brigade. They leaned into the notion that work equals stress. They dealt with such experiences by compartmentalizing, denying, and deflecting them. They embraced toxic positivity, a notion you could positive think yourself out of pretty much any stressful situation, specifically by quashing emotions like anger or sadness. From my viewpoint, the problem with this approach was that it involved a disturbing form of self-negation as well as a neglect to their self-respect, and they were surviving such experiences by wearing, what I call, a Teflon Skin. This Teflon strategy rendered them inert to inappropriate behavior, unaltered by hate or injustice with any related comments sliding right off them, never sticking. Furthermore, they had a very high heat tolerance which meant it would take a lot to damage them. While this strategy works well for kitchenware, I have always had grave concerns about the long-term consequences of this approach on human well-being. Indeed, as the year have passed, I have seen the toll such a strategy has taken on their mental wellness, physical health, and quality of their interpersonal relationships.

On the other hand, there were those colleagues that prioritized their own mental wellness, did not shy away from showing their vulnerabilities, and were vocal advocates for themselves in situations when they felt they had been invalidated, insulted, or ignored. They were always ready to hold the world accountable for its actions against them. Unfortunately, this group was not without its issues either. Too often they seemed held hostage to a series of perceived slights and too quick to play the blame game, and this approach left them less effective as clinicians, stuck as health care leaders, and stalled as innovators. I was in search of a middle path and a more comprehensive solution to the challenges of dealing with these day-to-day micro stresses at work.

Stressful Experiences vs Stressful Experiences Rooted in Injustice: A Crucial Distinction

So many of us work in organizations or regularly interface with institutions that were simply not built with us in mind. In fact, in recent years, there have been growing calls from mental health professionals and scholars to acknowledge how entrenched social constructs embedded in our man-made world, such as racism, sexism, and heterosexism, continue to seep into our modern lives.¹ When they do, they manifest as potently stressful. Such stressors may be ubiquitous and frequent in the daily lives of clinicians. This situation is further complicated by our lives that have been quickened and intensified in the digital era. Collectively, these stressors present a series of bombardments where real-time resolution is often unrealistic, impractical, or impossible.

Effective workplace stress management strategies, in such instances, require an acknowledgment of the traumatic social constructs that are baked into the structures and communities we inhabit and how their toxic remnants continue to wear us down emotionally and mentally. Today, as a society, we are generally more attuned to understanding social justice issues and their relationships to mental health and are more comfortable with accepting that hate can cause psychological injuries. Yet the sad fact remains that it is hit or miss on how this understanding is incorporated into stress management strategies for the individual.

My experience as a posttraumatic stress disorder (PTSD) specialist and trauma scientist has led me to believe that, just as human-made trauma is potently more traumatizing, and hence more likely to lead to PTSD, than trauma attributable to “an act of God,” stressful experiences rooted in injustice are much more toxic and damaging than regular stressful experiences. In my view, the under-acknowledgement of this phenomenon is stymieing our efforts to put a dent in the chronic stress many of us face in the workplace.

How to Work Well in an Unjust World

“God, grant me the Serenity to accept the things I cannot change. The courage to change the things I can, and the wisdom to know the difference.”

If I am honest, the macro sources of stress in my work life currently feel unsurmountable to me, but that does not mean I have given up. I continue to hold the line and advocate for the primacy of patient welfare. I am somewhat heartened by the wider recognition and growing urgency that health care must change if it does not want to lose more clinicians, but I fear I am unlikely to see much tangible difference on the frontlines in my professional lifetime. More importantly, if there are some sweeping heroic changes that can fix our broken health care systems when, and in what form, they will make their appearance is something I have no control over.

That said, I feel I do feel more empowered to tackle the micro stresses encountered in my daily work life. I have much hope that by attending to the day-to-day friction caused by this ubiquitous stress, in a thoughtful and comprehensive way, I can undo some of the associated harm and thus contribute to my longevity as a clinician.

I am presenting the following suggestions, not as a solution, but as a start. A way to take small steps on a path toward ensuring career longevity and prosperity in our wild world.

1. Accept that stressful experiences rooted in injustice are potentially more harmful than regular stressful experiences. This is, in part, because real-time resolution in clinical settings is often unrealistic, impractical, inappropriate, or impossible.

2. Strategies such as “letting it go,” “taking the higher road,” “killing them with kindness,” or “giving the benefit of the doubt” may become ineffective for combatting chronic stressful experiences rooted in injustice.

3. Learn to differentiate between the two. This “name it to tame it” strategy can, in of itself, be empowering and healing.

4. Target your self-care and stress management resources toward stressful experiences rooted in injustice for more overall impact.

Dr Jain is a board certified psychiatrist, with specialty expertise in PTSD, primary and mental health integrated care, and women’s health psychiatry. She is a former health services researcher, affiliated with the National Center for PTSD, and from 2012-2020, she served as Medical Director for Integrated Care at the VA Palo Alto Healthcare System. She is an adjunct clinical professor of Psychiatry and Behavioral Sciences at the Stanford University School of Medicine and a distinguished fellow of the American Psychiatric Association and the author of The Unspeakable Mind: Stories of Trauma and Healing from the Frontlines of PTSD Science (Harper, 2019).

Disclaimer

The views expressed are those of the author and do not necessarily reflect the official policy or position of the organizations with which she is affiliated.

Reference

1. Holmes SC, Facemire VC, DaFonseca AM. Expanding criterion A for posttraumatic stress disorder: considering the deleterious impact of oppression. Traumatology. 2016;22(4):314-321.