I’m a big believer in coaching. Having coaches – both formal and informal – has been invaluable to me over years; at their best, coaches are thoughtful observers who can ask us the right questions to elicit our coming up with our own right answers. I remember an “aha” moment with a talented executive coach about ten years ago. He was asking me about my motivators as a doctor – the things that, deep down, drive why I do what I do – and his questions led me to an insight that still resonates deeply. It goes without saying that altruism and compassion are paramount drivers for all doctors. But beyond these self-evident motivators, two other drivers are also fundamental – the desire to achieve mastery over challenge and the desire to make a favorable impact. Furthermore, based on discussions I’ve had with dozens of colleagues over the years, I believe that these drivers are also universal. In unpacking each, it seems clear that seeking mastery over challenge – the desire to accomplish something that is hard to do and to be really good at it – and craving impact – wanting to do good for other peoples’ lives – have profound implications for how doctors’ careers unfold and the choices we make.
Seeking impact is the simpler of the two drivers to understand. What doctor wouldn’t say that wanting to make a favorable difference in others’ lives is among the greatest privileges we all enjoy? That seeking impact is a fundamental driver for physicians is pretty obvious to me now (though it wasn’t evident to me until my coach probed). Furthermore, the appetite for impact never goes away, though the type of impact we want may evolve over a career. Certainly, from the first day of medical school, every doctor wants to make their patients better. Practicing medicine is an intimate one-on-one interaction in which doctors help patients one at a time. Later in some careers, as some doctors take on leadership roles, they often cite an appetite for an impact that goes beyond one-on-one. Leaders aspire to do good over a broader organizational canvas in order to multiply their impact.
The second driver – mastery over challenge – is more nuanced, I believe. To be clear, mastery is elusive. Like a Sisyphean task or something akin to Xeno’s paradox – despite intense effort, we never quite get there. Indeed, acquiring skill in pursuit of mastery has a slope to it. The slope is steep at the beginning and flattens with deliberate effort and experience. Put differently, the rate with which we acquire skill in pursuit of mastery approaches an asymptote as one’s proficiency increases. Consider the challenge of becoming a doctor; medical school isn’t easy and isn’t supposed to be. But we graduate and learn how to think, talk, and act like a doctor. Then comes graduate medical training – for me internal medicine and then pulmonary/critical care medicine. Again, not easy but exhilarating by virtue of being fascinating, having impact, and being hard to accomplish. And staying good at it, as great doctors do, is also hard. Indeed, staying good at being a doctor requires discipline and a continuous commitment to acquire new knowledge and skills. Still, the slope of the challenge flattens with experience. I think it’s easier to continue to get better later in one’s career than it was to get good at being a doctor in the first place.
Consider another example of what I mean by “reaching an asymptote” in pursuit of mastery. When I first learned to do bronchoscopy (before we had simulators), my progress case-by-case was steep and evident. Within a couple of cases, I was able to traverse the vocal cords by myself – unaided by my attending. Then, within a few more cases, I stopped bruising the bronchial walls with the scope, and then, with more experience, I could slickly intubate all the bronchopulmonary segments, etc. Later in my career, when I was a better bronchoscopist, my progress case by case was slower. Any progress milestones were fewer and spread out further over time. Actually, in keeping with the appetite for mastery over challenge, later milestones were about learning new bronchoscopic techniques, precisely because I had reached a personal proficiency asymptote on the more basic bronchoscopic skills. I submit that it is this very need to acquire new skills and to take on new challenges that keeps doctors energized.
Now consider what happens when one reaches an asymptote and there is no new challenge on the other side. A state of professional “ennui” can ensue – listlessness arising from lack of excitement. Again, discussions with dozens of colleagues suggest that experiencing professional “ennui” is also pretty common at some moment over the course of a career. In fact, what prompted me to write this reflection was that I myself was the unsuspecting victim of ennui when – about 15 years into my faculty career – I felt that had “ticked the boxes” on some academic challenges. Twenty five years earlier, these same challenges seemed distant and unobtainable. I became overcome by the feeling that the attainment of these goals was, in many ways, less satisfying than their pursuit. This personal brush with ennui was powerfully unsettling for me because I didn’t see it coming and could have never even imagined the possibility. In what I now recognize as post-traumatic growth, my experience of what we might call the “mastery cycle” (challenge – asymptote – ennui – new challenge) ultimately helped me discover a new and exciting pathway in my career.
What happened? Having been unexpectedly affected, I became keenly interested in understanding how ennui could take hold in a person who prided himself on being highly intrinsically motivated, focused, and energetic about career. As I again talked to colleagues and coaches about what I was feeling and my obsession to understand it, I was referred to another coach, a professor of organizational development (OD, even though I didn’t know what OD was then). That conversation had two profound effects on me: 1. It convinced me that my experience of the mastery cycle wasn’t atypical and wasn’t unsuspected; in fact, it was predictable, and 2. The conversation stimulated a deep curiosity about OD that prompted graduate work and a keen interest in sharing this reflection (which prompted my writing this piece). My new challenge – which had the collateral benefit of also completely restoring my clinical and academic passions – became understanding the trajectories of medical careers and seeking opportunities to help colleagues find their ideal career pathways. The unintended consequence was the invitation to serve in roles that were never previously on my radar. I came to appreciate the quote from the famed 19th century Danish philosopher, Soren Kierkegaard, that “Life can only be understood backwards; but it must be lived forwards.”
Now, a closer look at the mastery cycle invites consideration of its half-life in medical careers. Of course, as experts in expertise like Ericsson and Pool remind us (1), the pathway to mastery requires deliberate practice – practice that has specific goals, is focused, and includes coaching feedback. Mastery is not about time spent, whether 10,000 hours or otherwise. Comments from Vince Lombardi, famed Green Bay Packers coach, resonate here: “Practice doesn’t make perfect, perfect practice makes perfect.”
I’ve come to believe that the mastery cycle in medicine occurs in 5 – 12 year epochs. From medical school to the end of residency generally ranges from 7 to 12 years, depending on school and specialty. Adding subspecialty training augments the cycle by another 3 – 7 years. The median time to complete a PhD in the biomedical sciences varies from 4.88 to 5.73 years (2); only 42% of candidates complete their doctorate in genetics/genomics in < 6 years (2). As another example, most would say that the learning curve for newly minted faculty to hit stride in their clinical and academic skills is especially steep for 5 – 12 years. All these 5 – 12 year epochs exemplify mastery cycles. I believe that we doctors should be paying more attention to the periodicity of our careers.
So, what takeaways might I offer about what drives doctors and the impact of these drivers? First, it is important to be aware of the periodicity of careers and that these drivers exist and are common – the appetites for mastery and to have impact. Second, awareness of the drivers and of their impact helps us to recognize and to “name the emotion” when, as I believe, the asymptote periods inevitably come. Understanding that we are at risk for ennui can inoculate us against its unsettling and sometimes dysfunctional effects. Finally, following Kierkegaard’s observation, senior colleagues have an opportunity to coach junior colleagues about their careers. We must talk about the slope of careers in medicine. In the end, constantly seeking new challenges, always hungering for impact, and pursuing mastery endlessly are the stuff of which ideal careers and great medicine are made.
References
- Ericsson A, Pool R. Peak: Secrets from the New Science of Expertise. Mariner Books, Houghton Mifflin Harcourt. Boston, New York, 2016.
- Research-Doctorate Programs in the Biomedical Sciences: Selected findings from the NRC Assessment. https://www.ncbi.nlm.nih.gov/books/NBK82480/. Accessed May 22, 2020.
Professor James Stoller
James K. Stoller, MD, MS serves as Professor and Chairman of the Education Institute at Cleveland Clinic, where he has been a pulmonary physician for 34 years. He holds the Jean Wall Bennett Chair and the Samson Global Leadership academy Endowed Chair at Cleveland Clinic. He holds a Master’s degree in Organizational Development and is Adjunct Professor of Organizational Behavior at the Weatherhead School of Management of Case Western Reserve University and Honorary Visiting Professor at the Cass School of Business, City University of London. He has a longstanding interest in developing physician leaders and currently serves as the Associate Director of Physician Leadership Development in the Cleveland Clinic’s Mandel Global Leadership and Learning Institute and as Co-Director of the Clinic’s Samson Global Leadership Academy.
Declaration of interests
I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.