Finding Enduring Happiness in Medicine

A question was asked to Harvard MBA students. The question was, “how can you ensure that your career will be an enduring source of happiness?” That question really was thought provoking to me, and I'd ask you this question as you're reading this. How can you ensure that your career is going to be an enduring source of happiness for you, especially if you are new in your career? How can you ensure that your job as a physician assistant or nurse practitioner is going to be an enduring source of happiness, going to really keep you satisfied for a long time, because burn out is very real, especially in emergency medicine.

One of the real gifts, I think of being a physician assistant and nurse practitioner is that we can change fields pretty dramatically. It’s more liberal as a physician assistant, yet we both have mobility. Now I've met a number of board certified ER docs that are bitter. They became bitter and burned out, and this is my theory. (It doesn't mean this is right, but this is what I believe.) I believe that they're relatively young college professionals that go through medical school, and they decide, "I'm going to go to emergency medicine," and they join that curriculum before a lot of them really know if they like it. Next thing you know, they're a couple years into the residency program, and still they haven't evaluated it from a quality of life perspective. They're so deep doing it, that they haven't evaluated how it's going to be for their family, and then when they finally get into clinical practice, they get out of the residency to become an attending, next thing you know, they're making good money. They're living a good life. They get the house, the car, they get all the luxuries of that revenue, that income, and then they get bitter, and then they can't go anywhere.

Good thing is as physician assistants and nurse practitioners, we don't typically fall on that as we can more easily change not only jobs, but areas of medicine. Now, how can we ensure our job, as a physician assistant or nurse practitioner, will be an enduring source of happiness? Now, I love my job as a PA. I love being a PA, but I had bad times too. I had a lot of bad times. I had bad cases, but I got fired from my first job. My first job I was asked to leave. If you said, "John, why were you asked to leave? What was the real core, root problem?"

Often in life, we scratch around the surface of a rationalizing what happens to us, but I put a lot of time into thinking about it, and I know exactly why I was fired, because I had an I:E ratio mismatch. Whoa, whoa, what's that, John? What's an I:E ratio mismatch? I:E ratio mismatch is the “intelligence to ego ratio.” Let me explain, if you have a really high intelligence and you have a really big ego, will you do well in medicine? The answer is yeah, you'll be fine. You'll just be a pain in the ass to work with, okay? If you have a really low ego and a really low intelligence level, how will you do? The answer is you'll be okay, you'll be okay, because you won't know what to do, but you'll always ask for help. "I have no idea what to do. Can you help me again?" You just don't get in trouble that way, and a lot of times the bedside manner's good.

It's when you have too much ego for your intelligence, and that's when you get into big trouble. I'm speaking from experience, okay? Back to the root question, how can you ensure that your career is going to be an enduring source of happiness? I can tell you that I love my job, and I know exactly why, and this is the answer I have for you.

So, how would you ensure your career is an enduring source of happiness? For me, here's the answer. It’s simple. There's only one answer. Become clinically excellent. Become so good at your job that everybody wants to work with you. Do not settle for what a physician assistant or nurse practitioner thinks is “their level.” Don't settle for, "Oh, I know enough to get by." No, no, no, no, go to mastery of that.

If you work urgent care medicine, you need to become the smartest person on the planet when it comes to sore throats. You need to become way smarter than your supervising doc. You need to not just study the strep throat and mono, you need to look at all the weird zebras that could possibly be in the throat, and become the throat expert. Keep studying until you know your stuff so well, and then if something happens that's new, you haven't seen it before, you research the crap out of it, YouTube it. You seek it out.

Rashes, okay guess what? Don't just be someone who puts Benadryl or Lotrisone on everything. Learn your rashes like the back of your hand, and keep knocking these things off. Become so good at your job that everybody wants to work with you, and that means you've got to be really good with the nursing staff. I mean, good medicine is so much about getting commitment and engagement from others, like the nursing staff, and the respiratory therapist, and the x-ray tech, and the CT scan and the radiologist, getting all these people to kind of get onboard to help you.

My experience is when your ego gets in the way, you hurt relationships, and people don't want to help you. They'll kind of let you hang yourself. This means staying out of trouble with patients, and medical legal cases, and not getting patient complaints. I am very, very thankful for my career, and I work autonomous in emergency medicine, and I've earned the respect of the docs that hirer me, and my documentation, my clinical judgment is sound, and very rarely do I get any feedback that says anything other. I also understand how important the nursing staff are. I've gone through my ups and downs.

I will never forget Deb from 3300 at Park Ridge Hospital. I wish I still had contact with her, but she was the nurse that taught me respiratory medicine at night. When I was a night time hospitalist, and I had to cover respiratory floor, 3300, there's a lot I didn't know. I just didn't know, and I had to rely on Deb to guide me. "Deb, what do you think I should do here?" She was wonderful, so some of the greatest things I ever learned in my life was from nurses. I also know that nurses can turn. Nurses quickly go from nurturing to neutering if you're not practicing with enthusiasm and humility, okay? I'm really speaking from experience.

One of the things I stress and teach to younger clinicians is something that I do often. When I'm working in a new facility, new ER, and the nurses are feeling me out, I'm feeling them out, and once we get through that initial formalities, I'll announce this question. I said, "You know what the job of a good ER nurse is?" Right away you get people look at me and go, "Huh, what is the job of a good ER nurse?" Then I'll say, "It's the job of a good ER nurse to make a moderate PA like me look extraordinary." I say, "It's your job that if I don't do something I'm supposed to do, you're supposed to remind me of that, and if I'm going to do something I shouldn't do, it's your job to tell me I shouldn't do it." That normally gets them a little bit going, "I kind of like this guy," and then I'll say, "Quite frankly, if I make any mistakes this shift, it's your fault." Then they laugh and then I get serious and say, "No, I really want your feedback. I want your input. This is, we're here as a team, and I need you." That's especially important where I work at critical access hospitals.     

How can you ensure that your career will be an enduring source of happiness? Guys, you've got to be so good at your job, clinically, with patients, and with the nursing staff, that everybody wants to work with you. Everybody wants to work with you, and you know what happens when that happens? You can go anywhere, and therefore you don't have to tolerate situations that don't suit you well.

Now, understand this, guys. I'm an entrepreneur. I own three different businesses that have done quite well. We've been on the Inc. 5000 list two years in a row. I'm confident we're going to make it again this year, so I'm a hardcore entrepreneur, and I'm constantly going to business conferences, and I'm very involved with entrepreneurial education, and core values are very real. Core values are what a business is. It's not an aspirational vision. It's who we are right now. Core values, in medical practice, are very rarely really uncovered, so if you go to a job and you say, "What are your core values? How often to you live by them? Is this how you process your thinking by them? Is this how you hire and fire?" Most hospitals and most ER groups, most urgent care groups, medical groups, they don't have core values, but they're there. You need to align with their core values. If you don't align with the core values, you won't fit.

Now you can think, "Oh humility, humility's a core value." A lot of times it's not. I worked cardiothoracic surgery, and the core value is you kind of have to kiss up to the surgeon. You have to be on the good side of the surgeon. Don't get me wrong, politics are politics, and that's a good idea anyways, but it wasn't about good medicine. It was being on the good side of the staff. Just their core values didn't really align with how I practice medicine. I'm a pretty autonomous guy, so I was not a good fit there.

I have found that there are some places I've worked that I align clearly with the core values, and clinically, I was competent and I fit in, and they thought I was the greatest PA they've ever seen. Also worked in places where I just didn't align with their core values, and it will be the same thing with you, but the good news is, because of my clinical background, I can go really anywhere. I can go to many different ERs, any urgent care.

If you're new in medicine, here's the deal. How do you become so good at your job, clinically, that your skills, everybody wants them? You have to become a pit bull learning. You have to be a lifelong learner. I know that's stressed in PA school, and I'm sure it's encouraged in nurse practitioner school, but medicine is always evolving, and you have to practice with metacognition. Now there was a study done that asked a question, where's mastery really come from? Mastery is not a skill, where do you gain mastery from? The study looked at three different factors. They looked at where did you go to school, experience, or what they called, domain specific training, special classes like ACLS or CME programs. They found which one of those determined mastery, and the answer was yes, all of those contribute, but what ultimately determined mastery was a concept called, deliberate practice, also known as metacognition.

It's thinking about your own thinking. It's thinking about where are you weak at your job? It's thinking about what goals you need to set to hit the level that you want to hit, documenting them, writing them down. Guys, a really weak clinician will be bad at EKGs and not even know it. I've taught way too many classes where people thought they were okay at EKGs. Turns out they were really bad because number one, they never got burned yet, and number two is they got by with the computer read. They kind of thought, "Well, if it's something bad, I'll be able to just pick it up or the computer will tell me." There are people that are way worse at EKGs than they even know because they've gotten lucky. They just haven't been burned yet. Metacognition, I would challenge you to YouTube, and search out, Goggle that term, metacognition, also known as deliberate practice.

Someone who practices that way, they're very hard on themselves. They're very realistic. They're always looking at their behavior, but they're setting goals. They're very motivated, and they know that it all depends on them. They are in control of their learning is completely on them. That means you seek out CME programs that really fulfill your goals of what you need to learn. If you're weak on radiology, fix it. If you're weak in neurology, fix it. If you see a patient that really trips you up, get angry about that. Come home and study up on it. Go to work and have questions. That's how you're going to have an enduring source of happiness for your career.

Jumping jobs is not infrequent as an advanced practitioner. Options are what's important, and if you're clinically excellent, if everybody wants to work with you, if you're politically smart, and you have the emotional intelligence to really get along with people, everybody's going to want to work with you when you cap that with extraordinary clinical skills.

Thank you for reading.

Good luck, and God bless. 

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