There are these two young fish swimming along, and they happen to meet an older fish swimming the other way, who nods at them and says, “Morning, boys, how’s the water?” And the two young fish swim on for a bit, and then eventually one of them looks over at the other and goes, “What the hell is water?”
David Foster Wallace began his 2005 commencement speech at Kenyon College with this parable, and went on to deliver one of the greatest commencement speeches of all time (in my humble opinion).
He goes on to remark that the point of the fish story is merely that the most obvious, important realities are often the ones that are hardest to see and talk about.
Lunch
I bumped into a colleague a few years ago on my way to lunch. We exchanged pleasantries and chatted for a few minutes about how the practice had changed in the last decade or so. The changes were many, but the one that irritated me the most at the time was the loss of a real “lunch hour”. Don’t get me wrong, I still eat lunch. I have to, as it is the time of day my body needs food the most, but lunchtime has changed.
When I started, we had protected time for lunch. It was an oasis in the middle of a moderately busy day. I enjoyed my lunches, chatting with the gaggle of physicians who happened to be in the doctor’s lounge. Afterwards I would meander back to the radiology department and finish the day. Most days I felt recharged in the afternoon.
Something changed though. It was a slow progression, but the peaceful 30-45 minutes or so morphed into a hurried 15-20 minutes (actual eating time was closer to 5-10) so I could get back to the list and hopefully have it under control near the end of the day. As the workload slowly increased over the years, something had to give. I certainly became more efficient during the day, trying to shave a few seconds off each case and in between. I developed systems and refined my algorithms from how I looked at each type of study and which keyboard shortcuts to use, but eventually it was just about impossible to be done at the end of the day AND have a leisurely lunch.
The obvious solution would be to just take a longer lunch and stay a bit later, but the side effect of becoming more efficient and going faster is a higher level of fatigue at the end of a shift. I didn’t want to stay later because I was tired after going full speed for the whole day. Adding another 20-30 minutes at the end of the day felt about 17 times more painful than the first 20-30 minutes of the morning. If I was going to go all out like this, I just wanted to walk out the door at a reasonable hour. The only solution was to chip away at lunch. Don’t get me wrong; I don’t mind working hard, but I miss the lunch hour.
As I told a variation of this story to my colleague she looked at me with a puzzled blank stare and said:
“What kind of doctor has the time to sit and eat lunch?!?”
She was truly confused and horrified. I guess she didn’t eat lunch. I don’t think she meant to be mean spirited, but in her reaction was implied that I was somehow lazy or weak for actually wanting a few minutes to eat my lunch in peace rather than trying to dictate chest x-rays and CT scans while stuffing a few bites of food in my mouth between cases and hoping the transcription came out reasonably audible. She was the young fish, unable to see the water around her. For her, it was normal to never take a break during the day, but to charge forward full speed until the end. It had not occurred to her that maybe we should try and build a short time to eat into our workday. I briefly wondered if she ever considered using a catheter during the day so she didn’t waste time using the rest room…
We chatted for a few more minutes, but of course had to get back to work (the talk was over the already shortened lunch and precious seconds were ticking away). But this encounter stuck with me. Why don’t we make time for something as simple and pleasant as lunch? I mean, we are in complete control of our practice. We could hire another radiologist to decompress the work, or even better, ancillary staff to make us more efficient. We could even hire people to bring us lunch and massage our shoulders if we wanted. We could make each day quite pleasant. But we don’t. We don’t see the water around us.
Making The Schedule Work For You
On the opposite end of the spectrum is good friend from medical school. He scheduled two hour lunches at times so he could go play basketball for an hour or so. He was a morning person, so he had very early morning hours. He was often home early to see his family. He set up his practice to suit his lifestyle, and he loved what he did. He made his job work for him rather than be its slave. He was the wise old fish.
At the end of the day it comes down to money (as it usually does). Radiology and most physician practices do not scale well (unless you own equipment, real estate or other ancillary businesses). After practice expenses are paid, there is a linear relationship between work and remuneration. It is very highly compensated assembly line work. The faster, harder and longer you work, the more money you make.
We make more money by reading through our lunch hour and not hiring more people to do the work. We do not make changes unless everyone is on the precipice of burning out, and even then some resist. We don’t see the water even when we start to drown in it…and from talking to many other physicians, their practices are the same.
Laws of Nature
Gresham’s law states that bad money drives out good money. It basically means that if there are two types of money in circulation, and both possess similar value by law, the one that is less valuable will be used for payment and the more valuable one will be hoarded and at some point, it will disappear from circulation completely. In other words, when there are two currencies, people will spend the one they perceive to be of lesser value, and stockpile the good stuff. If you live in Venezuela, you spend the crappy government currency which will be worth a small fraction of what it was a few months from now, and hoard more valuable monies such as dollars, gold, bitcoin, etc.
I propose a corollary to this which is The Happy Philosopher’s law: Horrible work schedules eventually drive out reasonable work schedules. It doesn’t matter if the organization is a democracy or authoritarian dictatorship run by evil corporate overlords. All organizations will eventually be dominated by sociopaths people who want to make more money, so they will organize around making employees (and themselves if necessary) work harder and more efficient. The optimal level of pain is low-level misery that slowly builds over time (so the frog can get used to the boiling water). It is just terrible enough to make you unhappy, but not too terrible that it kills you or sends you into a crippling depression where you become less efficient. Obviously many medical schools and residency programs really care about this, as sometimes their students and interns leap to their deaths from the upper stories of the hospital to escape the pain of their miserable existences. No matter though, there is an endless supply of willing and able volunteers.
Now, of course this doesn’t apply to everyone. Working to the edge of what is possible may make sense, especially those with a low paying job, after all there is a certain amount of money people need to live, and although I understand it intellectually, I haven’t experienced real poverty in a meaningful way (Related: The Messy Truth About Privilege), but physicians are not poor. By any meaningful metric we are incredibly rich. Yeah, we may have a lot of student loans or work in lower paying primary care or live in a high cost of living area or whatever other complainy-pants excuse we want to use, but most of us don’t really need any more income to be perfectly happy.
Margins
Life happens on the margins. When people make economic decisions, they usually don’t take into account the marginal utility of money, marginal tax rates or their marginal quality of mental and physical health. Quality of life matters. At some point less money and more quality makes sense. Working a few more years in a pleasant work environment (with lunches and seeing your kids before they go to bed for instance) may be a better trade than going full steam, burning out and dying of a heart attack at 55.
Unfortunately, you may not have this luxury. Maybe you feel obligated to slow down a bit, spend an extra few minutes with patients to solve their problems rather than figuring out the quickest way to bill for a higher level exam in a completely toxic EMR without adding an ounce of value to the universe. Perhaps you are not the fastest physician in your group which makes your day more stressful and longer than your partners. This seems like a good time to remind you that whatever system you are working in, it is not designed with your well-being in mind. Nobody cares about your happiness. Nobody cares if you work yourself to death. If you are unhappy with your job, and are living on the financial edge, stop and reflect before you squander your freedom on that new car smell or extra 3000 square feet of house you never get to enjoy. Time, money, freedom; they are all a balancing act. Usually we must give up one to increase the other.
Buy your freedom first.
This is water.
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Welcome back, man. I’ve missed your writing.
I completely agree with the sentiment outlined in this post. I want to cut back to full time (that wasn’t a typo) but the work load for our department is ever increasing and we aren’t hiring fast enough to keep up. Many of us are burning out as we hope the Calvary is coming.
What’s the point in all of this if life passes you by and you rarely get to enjoy the life you actually want to live. “Someday” never comes.
As the Dalai Lama says about the mystery of man, “Man. Because he sacrifices his health in order to make money. Then he sacrifices money to recuperate his health. And then he is so anxious about the future that he does not enjoy the present; the result being that he does not live in the present or the future; he lives as if he is never going to die, and then dies having never really lived.”
TPP
Thanks TPP. Feels good to be writing again. Seems like every physician in every specialty I’ve talked to is busier than ever, and the baby boomer wave is just starting. Unless AI starts doing our jobs there will be no shortages or work to do anytime soon.
great Easter pun Calvary vs Cavalry
@TPP – your actual typo made me smile! “Cavalry” are soldiers who fight from horseback and can swoop in and save the day. “Calvary” is the hill where Christ was crucified – May represent salvation but probably not what you meant. 🙂
And “Calgary” is a city in Canada FWIW.
Great to see you writing more!
I love my midday breaks. They are increasingly rare among physicians. Even ten years ago when we hired a new partner we would bring lunch to primary care doctors’ offices. We felt a bit like a drug rep. But it was a great way to introduce a new doctor and get to know a potential referral source. The PCPs seemed to enjoy the introduction, discussion, and lunch.
These days the doctors “don’t take a lunch.” They gobble something at their desk while charting in the EMR. So we don’t have an opportunity to get to know them. The lounge in our hospital is a ghost town during the day. We have lost some of the enjoyment and sense of community among physicians.
My office staff are used to me blocking our a “lunch hour.” I talk with staff, catch my breath, check e-mails, and enjoy some good nutrition. At times I stroll outside to get some sun and fresh air. Those breaks strengthen my resiliency when stress comes my way.
When I spend an entire day in the O.R. I also carve out a lunch hour. That gives me time to stretch, get rehydrated, eat lunch, and catch up on charting. Otherwise I would have to do all that at 6 pm and I would feel run down in the afternoon, rather than refreshed. The whole concept is hard on the nursing and scheduling people since the whole “lunch break” concept is beyond them. They keep offering to call the last patient in early to “fill the gap.” Efficiency above all. But there is a big price to pay for that efficiency.
I have certainly noticed a changing feel of the doctors lounge in the past 5 years or so. Everyone is busier. There are fewer smiles and meaningful conversations. Sadly I don’t see it changing anytime soon.
As a fellow radiologist, I hear you. I have a great group, but they have been slowly ramping up production year after year. We used to have lunch together a few times a month. Now, we eat at the reading station. We track productivity and keep our staffing the same despite adding more and more sites. We track MIPS indicators and increase the documentation burden every year. As the job demands more and my burnout increases, I’m choosing to increase my family time. I’m leaving my practice in 15 months to start doing locums. I plan on working 7-8 months a year and traveling with my family the rest of the time.
I appreciate your insight and hope that you continue writing and advocating for change
Sounds familiar. Now that everything can be tracked and measured…everything is. Good luck on your transition to locums.
Wish you would write more, glad you don’t. I’d rather read quality posts that come sporadically then twice a week posts that feel forced.
I imagine you enjoy writing in such a unscheduled fashion as well.
Thanks for keeping it real.
Thank you for the comment. I wish I had the combination of motivation/skill/desire/creativity to write more, because I know there are people out there that want to hear what I have to say. I hope to write a little more this year, but I refuse to force something just to publish.
Great piece, as usual. I have seen the same trend throughout my career. In the old days, lunch in the Doctor’s Lounge was a great way to connect with clinical colleagues, learn about their concerns and how you can help them, build relationships, and was a high point of the day. Now, it’s a quick duck-in and grab-and-go, very unsatisfying.
I think that “efficiency” and “productivity” have become the holy grails of radiology, and medical practice, more generally, and striving for both increases the tendency toward burnout. No one gets up at a group meeting and says that lunch should be abolished, but I did have partners in the past who would, in private, “lunch shame” their colleagues. Is taking a break for lunch a sign of weakness?
It would be an interesting service to provide teleradiology midday lunch coverage for radiology groups allowing people to get a break in the middle of the day. I live in the central time zone and imagine being able to work 10A through 3P, covering practices in all four US time zones, starting with 11A on the east coast and ending at 1P on the west coast. Could be a sweet gig.
At any rate, hit me up when you start a lifestyle-oriented Rad practice (and have enough staffing for it) because I will want to join.
Lunch shaming is a real thing. I’m not sure it is even intentional half the time, but I have seen it many times.
I’m quite sure any big telerad company would be more than happy to cover a practice during daytime hours. Any group could turn this function on in a matter of days, but no one does it. Outsourcing reads is money not kept in house. It is also an unknown. There is variable quality in outsourced reads, and there is limited control over who reads your studies.
I like my practice. Unless something catastrophic happens, this will be my last (and only) radiology job.
I had exactly the same lament as you, except that I began to eat out of a vending machine between OR cases. There came a time when I rejected that de-humanization and returned to the physicians lunch room, only to find that it had been largely abandoned by my peers. I started eating there alone, reading the paper and/or working on my laptop. An occasional worried/lost appearing soul would rush through, grab a cup of coffee and blast out the door again. The medical staff began offering free soup and salad in an attempt to get doctors meeting and talking again. More people showed up, most of them to load a plate and hustle back to where-ever they did their charting.
Then I exercised my ultimate vote over the circumstance…I quit. I left in disgust and utter exasperation and emotional exhaustion over watching our profession and fraternity being brutalized and devalued in the workplace we had created.
Now I eat when I want to. I have 3 independent but related businesses that capture pieces of what I used to do under one tax ID number. The difference is that I now own every bit of what I’m doing, rather than accept conditions meted out to me by the anonymous someone else. The rest of my colleagues still work in that place where the rules been wrested from their grasp and placed in the hands of an administocracy. I’m sad for them, mourn the loss of a lost fraternity, but I am much more at peace, now that I’m not struggling to understand what is(was) happening to me. I know what is happening to me, because I set the rules and the pace. I traded a reduction in income, but I work in a plaid shirt, denims and sandals, rather than the doctor’s business casual uniform. My personal office and lab is only paces from my back door. My clinic is 10 minutes drive, in the place of my choosing. I drink a lot of coffee with friends, co-workers and new colleagues. There are things I miss about the old days, but not the destruction of our culture. I went into medicine to deliver service to persons who needed my skills and to have the luxury of autonomy in how I practiced. I have it again. The price was abandoning the hospital culture, and abandoning conventional expectations about how i would earn a living and how much I would earn in order to preserve command and control over my work
Nicely done. Freedom has the ability to bring much joy to our profession.
Very powerful article. As a fellow radiologist I know exactly what you mean. I like to work fast and efficient and because of that I do want to get out on time. I don’t let the practice get the best of both worlds and have have me do quick turnarounds and longer hours.
I have almost lost my lunch hour as I stay in my office and read studies as they come while eating. Only just recently I started not answering my phone and even locking my office door because it seems that other doctors on their lunch break use it to try and discuss a case with me (in the past many a time I would be eating lunch and in the 5-10 min I do so a doc would walk in and I would either have to stop eating or eat while they are there (which I hate). So lock door and voicemail it is
I like the idea of protected and undisturbed time, even if only for 5-10 minutes. Not ideal, but better than nothing.
Great post! Most days I do a 30 minute swim, run or elliptical workout at lunch. (This is in addition to an early morning workout – normally CrossFit or weights.) I find the lunch time work out is so important for my productivity and really breaks up my day. Clears my head. I know I’m lucky to have the ability to do this, but I also think we as physicians have the ability to set the culture in our work environments to some extent. We are the leaders, we can influence the culture. And lead by example that fitness and safe guarding one’s mental health is an important priority!
Nicely done. We certainly can influence the culture, however I feel there are so many physicians pushing the other way the culture has become no lunch by default. I understand it, but do not like it.
Ah man. Wise words. I loved my first practice because there was a doctor’s lounge with fairly inexpensive meals ($3 for vegetarian and $5 for meat, all you can eat dishes). We would go down there for an hour a day and enjoy ourselves. At my last job I would go to the gym at lunch. Sometimes it was rushed but getting out was nice. As you said, change of scenery and improved mood. Now onto my third job. The workload is fine, but I have not found the balance for lunch time. On the other hand, I get home everyday at a reasonable hour and my call never really requires me to go in at night.
I am with you, go slow, earn a little less, but enjoy life/family/leisure now and hopefully have a long and fruitful career.
Giving up lunch was kinda reasonable when the end of the day was predictable (within a reasonable variance). It was a calculated choice. Most days now are both lacking in much time for lunch AND working past the “shift”. Some would say this is a good problem to have, and in a way they are right from a job security standpoint.
“Life happens on the margins.”
Interesting point, most impactful.
Happiness can have a narrow therapeutic window of +/- 2 shifts.
The unintended consequences of seemingly minor decisions (“I’ve accepted another committee appointment at my chair’s behest, and will miss one more dinner at home a week to attend the meeting”) might be enough to determine whether one’s marriage succeeds or fails, whether one’s kid feels presence or absence of parental involvement.
Medicine tends to camouflage such implicit decision-making, hiding its consequences by lumping it into our expectation of the nebulous and all-consuming job. Instead of explicit choices (“You will be going solo to all kid-related events this year”) we have implicit decisions for which we deny accountability (“We never abandoned lunch. The job just got busier.”).
I’ve observed that academics disproportionately rewards the pathologies you describe, which is not to say that all academics are pathological, just that many who thrive in an inhumane system are able to do so because of an ability to neglect human needs – be it their own (sleep) or those of others (note again the frequent linear relationship between level of tenure and number of spouses).
Enjoyed this one.
Fondly,
CD
Good points. It is a slippery slope. I just didn’t wake up one day and lose my lunch hour. It was gradual. It happened to everyone, and most days we didn’t notice. It just became the new normal.
Great story. I had the same experience. I liked to take a little break in the middle of the day. I soon found I was the only doc in the doctors lounge. Then one day it was closed. I inquired about this only to find the hospital had re-designated the room to be a diabetic teaching room. Just like that, the doctor’s lounge was gone. I also had three day call weekends. I started taking the Monday afterward off for my sanity. Other’s could not understand me not booking a full day a patients. I had enough to do from the weekend to keep me busy and needed a hole in the schedule to handle it. I’m planning to put this story in Fawcett’s Favorites this week.
Thanks,
Dr. Cory S. Fawcett
Prescription for Financial Success
Thanks Cory.
and, the “doctor’s lounge” has become the “administrator/CRNA/PA/ANP” lounge…..
At least it is being used 🙂
You make a good point; I feel that the character of our doctors’ lounge changed when it became at least 50% PAs and NPs. Yes, of course they deserve a break, but it creates a totally different atmosphere that is not as relaxing.
I’m retired now, but at the hospital they started serving free food in the Drs lounge at breakfast and lunch years ago, and maintained a Doctors’ dining room in the cafeteria, where one could purchase a meal and go eat in a quiet place – needless to say, the Drs dining room went the way of the dinosaur and I think it was a sad loss. It was a nice refuge in the middle of a busy day, but as mentioned in the column, productivity became the utmost priority of our corporate overseers. Glad to be gone.
It is quite sad to hear that professionals are less and less able to take breaks. I don’t have the highest income in the world, but I take a lunch everyday and most days get to enjoy it with my wife. Bring back the lunch break. cd :O)
It would be interesting to study that correlated length of lunch break with things like overall job satisfaction, efficiency, medical error rates, etc.Maybe if there was good data showing the benefits of protected lunch time it would be mandated.
I’m so glad you wrote again. I was so excited to see it in my inbox.
I’m in higher ed, not the medical profession, but experienced much the same thing. It seems that in many areas there is deliberately more work than time for a normal person to do the work. At the small colleges that I’ve worked there was just no way to ever hire enough people that were needed to cover the amount of work that existed, but not doing something was not an option.
For a long time I worked through lunch or just wolfed down something quick. I got to the point where I realized just what kind of negative toll it was taking on my health. The remuneration was just not worth it. I’m more of an early person so I’d get to work early and put in the extra then, but there was always work that was coming home with me too.
I figured that no matter what, I was working more at both ends of the day, so I was going to take a decent lunch break. When the weather was nice I’d take a walk outside. For awhile I’d exercise at the college gym. Sometimes I’d just spend time getting to know my colleagues.
It was worth it. I recognized quickly how much more productive I could be in the afternoon when I had that solid break in the middle of the day. Soon after that I’d get on my staff when they would work through breaks and lunch. I’d say that I was being selfish by making them take breaks because then they’d be more productive for me. Hopefully it was a win-win.
Thanks again for posting. It’s good to hear your thoughts.
Thanks for the comment 🙂
A great post. I have been following your blog in the shadows, and I am a fan. I recently stumbled on to David Foster Wallace’s commencement speech myself and felt uplifted and inspired…until further research led me to learning he committed suicide three years later. I guess feelings of self-focused isolation and despair are part of the process that depression wreaks, but I have a hard time reconciling the wonderful words of secular wisdom in that speech and his final act in this world.
Yeah, depression can be terrible and his suicide was tragic.
Hi Happy philosopher,
I also have got 30 mn to have lunch and it s very short indeed. Here in France, things have also went wrong for this part of the work day
Fortunately, i ll be part time 4days a week on 2022.
I do agree for the lunch shaming.
Anyway, i cultivate happiness whch is the main goal for me now at 47 years old.
Thank you.
Take care.
[…] to keep up our productivity? The Happy Philosopher has a few things to say about this in his post Water and Fish. You won’t want to miss this […]
[…] Can you find time for lunch? The Happy Philosopher stepped away from the PACS system to grab a bite and share his views on lunch and how this meal or lack thereof contributes to the physician burnout epidemic. From the man who brought us Alligators and Kittens, here’s Water and Fish. […]