If You Don’t Know What You Want, Start Here

“I don’t even know what I want anymore.” You may have had this thought during fleeting moments of frustration in your career, or, if you’re experiencing burnout, this may be a track stuck on repeat in your mind. You may have a strong impulse to quit your job but struggle to act on it because you have no idea what you’d do instead, or you may fantasize about careers that have nothing to do with your training or skill set, like being a truck driver or a park ranger. 

It can be daunting to try to decide on a next step when you’re overwhelmed, but there’s a framework called self-determination theory, developed by Edward Deci and Richard Ryan, that I like to use as a prompt when starting to tease apart which of your current challenges at work are causing the majority of your dissatisfaction. In this article, we’ll discuss the three components of this theory, which I consider essential for a fulfilling career as a physician, and how you can use them to identify what needs to change. 

Autonomy

In his book The E-Myth Revisited, Michael Gerber introduced me to a concept that changed the way I think about my place in medicine. He explained the roles involved in running a business: the Entrepreneur who serves as the visionary for the direction of the organization, the Manager who plans and organizes the more detailed aspects of business operation, and the Technician - the one who actually does the work. Until the moment I read that, I had never realized that I, in my role as a clinician, was a technician, not much unlike a plumber or an electrician.

Technicians are obviously crucial to the operation of any business, but this was a recognition for me that as an employed physician, I didn’t actually have much control over my work. This isn’t to say that full-time clinicians always face burnout, and some of you in academic or leadership roles may also wear the hats of Entrepreneur and Manager and still face your own unique frustrations. However, there are many elements of your job that can influence how much autonomy you feel, from taking less call so you can prioritize your personal life, to being able to limit or broaden your scope of practice to fit with your personal preferences and professional goals. Consider what aspects of your practice feel most out of your control and see if there are opportunities to negotiate. 

Competence

For physicians, I think of competence as efficacy and the satisfaction we feel in being able to do our work to the best of our abilities. It can be helpful to break it down into two different buckets: individual competence and institutional competence. On an individual level, the greatest threat I see to physician competence isn’t a lack of knowledge or skill, as it might seem - it’s actually burnout. Reduced efficacy is one of the three hallmarks of burnout, along with cynicism and emotional exhaustion. The feeling that you’re offering substandard care to patients can lead to guilt and self-loathing that spiral into a vicious, self-perpetuating cycle. 

Institutional incompetence is one of the main drivers of burnout and is often mistaken for individual incompetence. If you can’t thoroughly address uncontrolled diabetes, hypertension, and depression along with an oh-by-the-way complaint of chest pain all in the span of 15 minutes, are you an incompetent physician? We know this is an unreasonable system, but we’re often the ones left holding the bag. In addition to organizational-level problems like inadequate time with patients and a lack of reliable support staff, in the United States we have widespread financial barriers to care that can also impact our ability to help our patients. Think about which of these limitations is most bothersome to you. Would a direct-care or cash-pay practice eliminate your frustration with insurance companies? Could you stay at your current job and see fewer patients for less pay if it meant higher personal satisfaction and greater career longevity?

Connection

Connection is another component that I like to divide into two parts. We’ll start with connection to a greater purpose. This doesn’t mean that you need to be religious or even spiritual, and you don’t need to know the meaning of life. However, in order to feel that your work is worthwhile, it can be helpful to think about how it aligns with your values. Are you someone who prioritizes success and status? Or do you strive to be of service and want to feel that you’re making the world a better place? There’s no right or wrong answer here - your work just needs to make sense in light of what’s important to you. It needs to be connected. 

The other aspect of connection is connecting with others. For a variety of reasons, physicians have learned to suffer in silence. During my own experience with burnout, I had an unshakeable feeling that my burnout was the result of some personal failure and that no one else was experiencing what I was feeling. By finding a community where we can share and be vulnerable, we can combat shame through the normalization of our experiences. Then we can become empowered to take ownership of and transform our lives. 

Conclusion

Self-determination theory identifies three elements that I believe physicians need in order to find balance, satisfaction, and meaning in their careers. Autonomy is having control over the work you do, Competence is how you feel when you’re doing it, and Connection is how your work fits into your broader view of life. If you’re ready to identify the areas in your practice that need to change, or if you’re not sure where to start and are looking for a supportive community of like-minded physicians, please join us today.