Editorials

A call to renew

Doctors who feel ground down can renew their spirits and their values

See also p   1633

Why do so many physicians wallow in woe? Why do so few resist imposed yet ill advised policies, regulations, and practices? Why is there reluctance to band together with each other and patients to make suggestions and take action? Physicians list several reasons. Some find that the pleasures of the practice of medicine outweigh the problems, so they choose to disregard the problems. Others report that clinical ambiguities can lead to professional paralysis. A recent issue of the BMJ, for example, highlighted the shortcomings of available science: we do not know how to prevent deaths caused by mentally ill people,¹ the best surgeons to operate on patients with pituitary tumours,² or the explanation of chronic pelvic pain in men.³ Minerva reported the difficulty of performing much vaunted meta-analyses.⁴ Since uncertainties far outnumber certainties in science, medicine, and life, slow brownian motionkeeping a low profileseems less upsetting and risky than thrusting forward.

Other reasons given for moaning instead of moving ahead include: "We were brainwashed during training," "Authorities don't respond, so why bother?" "Our values differ from business and administrative values and the green eye shade types win every time," "I don't want to lose my job," "If we lie low, maybe someone else will get the hit," "I am numb. I can't feel my own needs or my family's needs," "It is too hard to change," and "Too tired."

If these are our chief complaints the diagnosis is clearly located deeper than behaviour, deeper than courage or combativeness. The diagnosis is that our spirit, our morale, has drained away. A neurosurgeon recently said, "We have forgotten that taking care of people is the greatest honour we could have." How can we replenish our souls? How can we restore the enthusiasm and resilience of earlier years? This is the question of renewal.

Values

While developing programmes to address the angst that many feel today, I have listened to hundreds of physicians and other health professionals who are reviewing their values as part of the process of renewing their energy and goals. Several touchstones recur: excellence, kindness, integrity, and loving and giving relationships. Altruism, devotion, and respect for others also recur. Perhaps during these perilous times, each of us should have our own laminated "values card" to carry and to consult whenever important decisions are made (especially regarding finances). Assuredly, there are risks to talking about values. Statesman John W Gardner has noted that only to a very limited degree do we strengthen values by talking about them: values live or die in everyday action. Yet a profession without values, without values at work, is worthless, and sometimes we need reminding of that.

Knowing and living our own values can help us understand the purpose in our lives. Values are one's bedrock, the principles on which one will not yield. They are the basis of our judgments about what is good and bad, right and wrong. Values are not quantifiable yet they are beacons in the darkness. Learning to understand and act on one's values is the key to renewaland thinking about renewal is a fitting way to begin a new century for physicians who feel burdened.

In this era when evidence based medicine and medical education demand measurement,⁵ values and meaning may seem outdated. But they are as new as today and as necessary as our heartbeat. They are our spirit's fuel, our stamina. They become our motivation and our commitments. They enable us to reach our goals and to oppose odious pronouncements and measures.

Physicians who are bucking the flow towards meltdown do not propose quick or easy solutions. They do have several recommendations that can help contend with forces that conflict with values. These also enhance the opportunity to revitalise, rebuild, and, in short, renew.

Learning

Learning is high on the list, whether new professional skills, communication techniques, or outside interests. Healthy sleeping, reading, and exercise are popular approaches to renewal, as is spending substantial, pleasant time with friends and family. Indeed, one outstanding physician, a doctor's doctor who has survived cancer, reported a new definition of "success." It does not relate to accomplishments, honours, or even receiving thanks. He defines success as the number of people who will pray for you when you need it. That is renewing.

Other boosters to renewal include curiosity, a sense of humour, camaraderie, seeing or hearing beautiful things, regular spiritual practices, mentors, appreciation from others, and the time to savour professional challenges. Time away from work is essential. Having a goal on which to focus is also essential. Novelist Edith Wharton noted several routes to renewal: "One can remain alive long past the usual date of disintegration if one is unafraid of change, insatiable in intellectual curiosity, interested in big things, and happy in small ways."⁶

We are finding that physicians can refresh themselves. It takes time and work. It can be a solo or family mission or take place during confidential conversations among a group of physicians who tell their stories, sharing their wisdom and compassion. A deep reservoir of strength and capability is available to us. As we revisit values and heal, we develop a brighter vision and firmer step. We can resist pessimism and passivity. We can take action on behalf of patients and for our own satisfaction. We can renew.

Linda Hawes Clever, chair. 

Department of Occupational Health, California Pacific Medical Center, San Francisco, CA 94120-7999, USA

Acknowledgments

Some of LHC's work on renewal has been funded by grants and speaking fees from trusts and not-for-profit organisations.