I recognise this conversation well. I lived it. But I think the framing misses a crucial cause.
Early cynicism in medicine is not a failure of vocation or an overcorrection toward leisure. It is learned behaviour. It emerges when trainees realise that the “Medical System” is not abstract but hierarchical, opaque, and uneven in how it distributes protection, credibility, and consequence.
The essay implies that prioritising life outside medicine risks hollowing out patient care. My experience suggests the greater danger runs the other way: demanding unlimited sacrifice while denying clinicians dignity, procedural fairness, and psychological safety produces moral injury, not meaning. When bullying is reframed as resilience, when harm is quietly managed rather than openly disclosed, and when glossy recruitment narratives collapse on contact with reality, idealism does not mature. It erodes.
In that context, protecting one’s life outside the hospital is not a retreat from purpose. It is often the only remaining space of agency.
Medicine will always be hard. What breaks people is not the work itself, but the absence of reciprocity. Meaning does not disappear because young doctors want balance. It disappears when institutions expect devotion without honouring their side of the covenant.
Until that is addressed, cynicism is not a moral failure. It is an adaptive response.
This piece puts its finger on a real tension, but from a Cognitive Transformational Mindfulness (CTM) (a framework for mindfulness I recently completed and just started sharing here on substack) perspective, the issue isn’t that work and life should be fused, nor that balance is naïve — it’s how meaning and coherence are organized. When work becomes the sole axis of identity, joy, and worth, the system may feel unified for a while, but it often does so by narrowing rather than integrating the person.
CTM agrees that framing work as the enemy is corrosive. Where it diverges is in the claim that fulfillment requires “living to work.” CTM understands medicine — like art, teaching, or caregiving — as meaningful precisely because it can be held within a coherent life, not because it replaces one. Joy that crowds out rest, relationship, and inner variability isn’t depth; it’s rigidity wearing purpose as armor.
What trainees are often reacting to isn’t laziness or misplaced priorities — it’s early detection of fragmentation in the system they’re entering. CTM would say the task isn’t to suppress that signal, nor to dilute medicine with leisure, but to reorganize the relationship between vocation, identity, and care so meaning doesn’t demand self-erasure. When awareness, values, and limits are aligned, medicine doesn’t compete with life — it becomes one expression of it, without consuming the whole.
I'm 87 and retired 10 years ago because I became a snowbird. In my career I experienced 2 ways to practice. I did my residency at SFGH and then worked for a county medical system for a few years in a 40 hour/week job. Loads of time to knock around in San Francisco but not very satisfying. Then moved back to small city Pennsylvania and went solo private practice. Fortunately had a nest egg, some chip in from my wife and no med school debt (not that hard to do in those days - early 60's). Took me about 5 years to be going full blast during which time there were no days off. Building a practice on your own requires availability. The satisfaction was like night and day. Independent medical practice in the days before the third parties started controlling everything was a blast.
This is a great piece. Thank you for writing it. I think what you’re talking about is, if you will, the “Serenity Prayer of Medicine” — the goal being to accept that things you cannot control (EHRs, long hours, “the system”) and to lean into the areas where you do (the joy of caring for human beings, the satisfaction of making a difference, the intellectual stimulation of critical thinking on matters of life and death) — and to know the difference. The latter is where wisdom lies. It’s wonderful to see you have it already!
Apologize in advance for the rambling, but this subject is extremely non-scientific, as all the participants are quite diverse and there is mean or average or ideal physician. I would not have made it to medical school now! I did no research in college, I worked in the hospital, I got married, and we both worked evenings in surgery and recovery room. I didn't make it into medical school until I proved myself in graduate school and knocked on lots of doors. I worked in medical school and did no research. I was able to start in the neurosurgery program, as there weren't many students wanting the life of treating brain trauma and glioblastoma. I had no interest in an academic career. I feel so blessed to have shared "Life" and "Death" with so many people. I have often thought,"I wish I could gift this patient a week or a month of good health," at a critical point of their life. I have taken "life" to work!; in my tux with my young daughter sitting on the nurses counter in the emergency room, much more commonly my young son on rounds Sat. or Sun. They have fond memories, as do I. When confronted by another physician complaining about our work load through my career, I asked a simple question,"If you could get the same compensation and work 8 hours a day, would you take out the garbage or sweep the floors, or worse clean up after our messes?" I never got any takers! One more related comment: When an intern in 1982(before the song was written, and Garth Brooks made it famous), I coined the term "friends in low places." Friends means you get to know them, and friends are always ready to help one get things done. Always ready to help my "friends in all places" Now in retirement I have friends in all places! I couldn't have "not planned" it better(retirement LIFE). I worry about our selection processes(medical school and post graduate training). I think the general plan to every accepted medical student until graduation is faulty. We should accept more students than can graduate. The same people who plan out every part of their medical school career to prepare for the most prestigious positions in post graduate training, I think will not be satisfied with The Physician Life.
I think the problem is not so much the work-life balance but rather the changes in the work part that have nothing to do with the practice of medicine and bring about disillusionment and burn-out. We didn't take up medicine to become clerks or corporate employees.
I teach a course on burnout to physicians, and I have been making this point for years. I have noticed some of the happiest physicians are those who work well beyond typical retirement, because they find "joy" in their work. I share a slide that X's out the word "Work" in "Work-Life Balance". It is all LIFE balance and for each of us the role work plays in that may vary. But if you find meaning in your work, it will definitely play a bigger part in the joy of your life.
Well said! Important too. Our whole notion of what "balance' should like like is already a corruption of a deeper understanding of our lives. And it feels commoditized.
There is idealism here that is refreshing and age-appropriate (it would be troubling if he was already cynical at this early stage). It would be interesting to sample his perspective in 10/20/30 years to determine how it has shifted, if at all.
But in my experience with trainees over the years (mostly residents and fellows), the focus on “balance” and “lifestyle” has generally increased, compared to my age cohort (let alone my predecessors) (but my training era was still from the “shame-based learning” days where “duty hours” did not exist).
I would also say, in one’s early/mid 20’s, there generally isn’t much that needs balancing. Marriage/kids/family has a way of bringing that balance into sharper focus.
An interesting youthful take, that I think contrasts with the sense of "burnout" that emerges mid-career. As our careers evolve, one sees how other parties (administrators, hospitals, insurance companies, regulators, politicians etc.) take complete advantage of our patient-centered idealism. The patient care we want to deliver is diluted by the noise created by these entities, who absorb the value of your time "given". We don't necessarily see that aspect in medical school.
Also, as you age, your "free time" isn't just yours, but belongs to your spouse, kids, aging parents and other family as well. Thus, the trade-off between work and life becomes much steeper as you age. Choosing to go out to the bar vs doing extra question banks in med school, is a much different trade-off than sacrificing being there for your kid vs. performing useless clicks on EPIC. The "cost" of your free time increases substantially.
Personally, I have found that those doctors that more quickly master the "work-life" balance and are happy, ironically deliver better patient care and last longer to deliver that care, rather than burning out into early retirement or career changes.
Wise beyond his years. I'm an old physician, been practicing over 50 years and still practicing. First of all I'm a physician. I bring my laptop on my vacations and do telemedicine when visiting my daughter in Vienna. I always had a work life balance. I worked 24 seven but I also took my family to Europe for six weeks at one time and four weeks for another and made the same income those years by just working harder before and after. You can do it all. I will grant you in today's world of documentation compliance. You're going to burn out early. I survived it and now I'm in the fortunate position to totally ignore documentation and compliance and just take care of my patients.
Maybe part of the problem is the term "work-life" balance, as if work is not part of life. Work is a part of one's life, and one is lucky if their vocation is something they enjoy doing. Maybe it needs to be phrased as work-play balance :)
I see the attitudinal change in younger doctors and I totally understand the motivation. I also see changes in my profession over my 30 year career that make me very sad. However, I will also point out that I have never seen anyone in a comparably highly compensated career who does not work long, stressful hours - including working while on “vacation”. They may be out there, but it is rare. I certainly am able earn much more money than any of my girlfriends in whatever they do. So we do need to remember this simple fact of life.
I would like to suggest an alternative approach to the separation of your life as a physician from your own personal life. Growing up, I had a very active social life in high school, college and even medical school. We had a number of friends that we interacted with on a regular basis. My surgical residency kept me in the hospital or on call for what I now recognize as an inordinate amount of time. It came a point during the end of my residency when I realized I could no longer have conversations with our friends who were not in the medical field. I was weirdly socially awkward at this point. I recognized if you allow it, medicine will consume you. And for some, this is a reasonable life to live. But for most I think we would like to have something more in our life. When I lecture medical students and residents, I encourage them to get a life that is separate from their medical career. This doesn’t obviate your dedication to being a physician, but does allow you to experience the joy of things beyond being a physician. And there is a whole wonderful world things to enjoy outside of medicine.
Well written. Sending to my second year med student dtr. I hope she can find joy and meaning in a career in medicine. Working inpatient for almost 30 years now (not as an MD), there have definitely been challenges as a parent (missing holidays, school events etc). But I look back on my career and do cherish the privilege ive had to help people.
I recognise this conversation well. I lived it. But I think the framing misses a crucial cause.
Early cynicism in medicine is not a failure of vocation or an overcorrection toward leisure. It is learned behaviour. It emerges when trainees realise that the “Medical System” is not abstract but hierarchical, opaque, and uneven in how it distributes protection, credibility, and consequence.
The essay implies that prioritising life outside medicine risks hollowing out patient care. My experience suggests the greater danger runs the other way: demanding unlimited sacrifice while denying clinicians dignity, procedural fairness, and psychological safety produces moral injury, not meaning. When bullying is reframed as resilience, when harm is quietly managed rather than openly disclosed, and when glossy recruitment narratives collapse on contact with reality, idealism does not mature. It erodes.
In that context, protecting one’s life outside the hospital is not a retreat from purpose. It is often the only remaining space of agency.
Medicine will always be hard. What breaks people is not the work itself, but the absence of reciprocity. Meaning does not disappear because young doctors want balance. It disappears when institutions expect devotion without honouring their side of the covenant.
Until that is addressed, cynicism is not a moral failure. It is an adaptive response.
This piece puts its finger on a real tension, but from a Cognitive Transformational Mindfulness (CTM) (a framework for mindfulness I recently completed and just started sharing here on substack) perspective, the issue isn’t that work and life should be fused, nor that balance is naïve — it’s how meaning and coherence are organized. When work becomes the sole axis of identity, joy, and worth, the system may feel unified for a while, but it often does so by narrowing rather than integrating the person.
CTM agrees that framing work as the enemy is corrosive. Where it diverges is in the claim that fulfillment requires “living to work.” CTM understands medicine — like art, teaching, or caregiving — as meaningful precisely because it can be held within a coherent life, not because it replaces one. Joy that crowds out rest, relationship, and inner variability isn’t depth; it’s rigidity wearing purpose as armor.
What trainees are often reacting to isn’t laziness or misplaced priorities — it’s early detection of fragmentation in the system they’re entering. CTM would say the task isn’t to suppress that signal, nor to dilute medicine with leisure, but to reorganize the relationship between vocation, identity, and care so meaning doesn’t demand self-erasure. When awareness, values, and limits are aligned, medicine doesn’t compete with life — it becomes one expression of it, without consuming the whole.
I'm 87 and retired 10 years ago because I became a snowbird. In my career I experienced 2 ways to practice. I did my residency at SFGH and then worked for a county medical system for a few years in a 40 hour/week job. Loads of time to knock around in San Francisco but not very satisfying. Then moved back to small city Pennsylvania and went solo private practice. Fortunately had a nest egg, some chip in from my wife and no med school debt (not that hard to do in those days - early 60's). Took me about 5 years to be going full blast during which time there were no days off. Building a practice on your own requires availability. The satisfaction was like night and day. Independent medical practice in the days before the third parties started controlling everything was a blast.
Great article, reminds me of the Naval quote, ‘The only real test of intelligence is if you get what you want out of life.’
Docs should understand why they throw themselves into this wild career that doesn’t always love them back.
The stubborn mastery is a meaningful pursuit.
Pain becomes a pleasure.
Ref: Paul Bloom’s book The Sweet Spot
This is a great piece. Thank you for writing it. I think what you’re talking about is, if you will, the “Serenity Prayer of Medicine” — the goal being to accept that things you cannot control (EHRs, long hours, “the system”) and to lean into the areas where you do (the joy of caring for human beings, the satisfaction of making a difference, the intellectual stimulation of critical thinking on matters of life and death) — and to know the difference. The latter is where wisdom lies. It’s wonderful to see you have it already!
Apologize in advance for the rambling, but this subject is extremely non-scientific, as all the participants are quite diverse and there is mean or average or ideal physician. I would not have made it to medical school now! I did no research in college, I worked in the hospital, I got married, and we both worked evenings in surgery and recovery room. I didn't make it into medical school until I proved myself in graduate school and knocked on lots of doors. I worked in medical school and did no research. I was able to start in the neurosurgery program, as there weren't many students wanting the life of treating brain trauma and glioblastoma. I had no interest in an academic career. I feel so blessed to have shared "Life" and "Death" with so many people. I have often thought,"I wish I could gift this patient a week or a month of good health," at a critical point of their life. I have taken "life" to work!; in my tux with my young daughter sitting on the nurses counter in the emergency room, much more commonly my young son on rounds Sat. or Sun. They have fond memories, as do I. When confronted by another physician complaining about our work load through my career, I asked a simple question,"If you could get the same compensation and work 8 hours a day, would you take out the garbage or sweep the floors, or worse clean up after our messes?" I never got any takers! One more related comment: When an intern in 1982(before the song was written, and Garth Brooks made it famous), I coined the term "friends in low places." Friends means you get to know them, and friends are always ready to help one get things done. Always ready to help my "friends in all places" Now in retirement I have friends in all places! I couldn't have "not planned" it better(retirement LIFE). I worry about our selection processes(medical school and post graduate training). I think the general plan to every accepted medical student until graduation is faulty. We should accept more students than can graduate. The same people who plan out every part of their medical school career to prepare for the most prestigious positions in post graduate training, I think will not be satisfied with The Physician Life.
I think the problem is not so much the work-life balance but rather the changes in the work part that have nothing to do with the practice of medicine and bring about disillusionment and burn-out. We didn't take up medicine to become clerks or corporate employees.
I teach a course on burnout to physicians, and I have been making this point for years. I have noticed some of the happiest physicians are those who work well beyond typical retirement, because they find "joy" in their work. I share a slide that X's out the word "Work" in "Work-Life Balance". It is all LIFE balance and for each of us the role work plays in that may vary. But if you find meaning in your work, it will definitely play a bigger part in the joy of your life.
Well said! Important too. Our whole notion of what "balance' should like like is already a corruption of a deeper understanding of our lives. And it feels commoditized.
There is idealism here that is refreshing and age-appropriate (it would be troubling if he was already cynical at this early stage). It would be interesting to sample his perspective in 10/20/30 years to determine how it has shifted, if at all.
But in my experience with trainees over the years (mostly residents and fellows), the focus on “balance” and “lifestyle” has generally increased, compared to my age cohort (let alone my predecessors) (but my training era was still from the “shame-based learning” days where “duty hours” did not exist).
I would also say, in one’s early/mid 20’s, there generally isn’t much that needs balancing. Marriage/kids/family has a way of bringing that balance into sharper focus.
An interesting youthful take, that I think contrasts with the sense of "burnout" that emerges mid-career. As our careers evolve, one sees how other parties (administrators, hospitals, insurance companies, regulators, politicians etc.) take complete advantage of our patient-centered idealism. The patient care we want to deliver is diluted by the noise created by these entities, who absorb the value of your time "given". We don't necessarily see that aspect in medical school.
Also, as you age, your "free time" isn't just yours, but belongs to your spouse, kids, aging parents and other family as well. Thus, the trade-off between work and life becomes much steeper as you age. Choosing to go out to the bar vs doing extra question banks in med school, is a much different trade-off than sacrificing being there for your kid vs. performing useless clicks on EPIC. The "cost" of your free time increases substantially.
Personally, I have found that those doctors that more quickly master the "work-life" balance and are happy, ironically deliver better patient care and last longer to deliver that care, rather than burning out into early retirement or career changes.
Wise beyond his years. I'm an old physician, been practicing over 50 years and still practicing. First of all I'm a physician. I bring my laptop on my vacations and do telemedicine when visiting my daughter in Vienna. I always had a work life balance. I worked 24 seven but I also took my family to Europe for six weeks at one time and four weeks for another and made the same income those years by just working harder before and after. You can do it all. I will grant you in today's world of documentation compliance. You're going to burn out early. I survived it and now I'm in the fortunate position to totally ignore documentation and compliance and just take care of my patients.
Nicely written.
Maybe part of the problem is the term "work-life" balance, as if work is not part of life. Work is a part of one's life, and one is lucky if their vocation is something they enjoy doing. Maybe it needs to be phrased as work-play balance :)
I see the attitudinal change in younger doctors and I totally understand the motivation. I also see changes in my profession over my 30 year career that make me very sad. However, I will also point out that I have never seen anyone in a comparably highly compensated career who does not work long, stressful hours - including working while on “vacation”. They may be out there, but it is rare. I certainly am able earn much more money than any of my girlfriends in whatever they do. So we do need to remember this simple fact of life.
I would like to suggest an alternative approach to the separation of your life as a physician from your own personal life. Growing up, I had a very active social life in high school, college and even medical school. We had a number of friends that we interacted with on a regular basis. My surgical residency kept me in the hospital or on call for what I now recognize as an inordinate amount of time. It came a point during the end of my residency when I realized I could no longer have conversations with our friends who were not in the medical field. I was weirdly socially awkward at this point. I recognized if you allow it, medicine will consume you. And for some, this is a reasonable life to live. But for most I think we would like to have something more in our life. When I lecture medical students and residents, I encourage them to get a life that is separate from their medical career. This doesn’t obviate your dedication to being a physician, but does allow you to experience the joy of things beyond being a physician. And there is a whole wonderful world things to enjoy outside of medicine.
Well written. Sending to my second year med student dtr. I hope she can find joy and meaning in a career in medicine. Working inpatient for almost 30 years now (not as an MD), there have definitely been challenges as a parent (missing holidays, school events etc). But I look back on my career and do cherish the privilege ive had to help people.