Ally Istl is a senior General Surgery resident at Western University
The concept of Wellness in the professional medical arena has become a contemporary Gargantua that we are perpetually seeking to satisfy, but never able to sate. As other disciplines seek to make their trainees ‘Well’, wellness has also become a growing subject of exploration in surgical disciplines.
Wellness means different things to different people and formal definitions provide no clarity in the context of the medical profession: ‘the state of being in good health, especially as an actively pursued goal’ only provokes more nuanced questions about the meaning of health and what pursuit of health looks like. Attempts to articulate a more pragmatic definition have led to a cookie-cutter concept of Wellness as a routine of strict punch-out times and sporadic meditation. This is not attainable in surgery.
And maybe it doesn’t need to be.
Defining Wellness in a surgical career deserves more than an examination of what Wellness is or is not; it requires an understanding of what it means to be a surgeon. Opinions on the most integral characteristics of a surgeon may vary, but what is common to all who choose this vocation is that it becomes entrenched in our lives. Surgery is not just a job or a career; it is part of who we are.
Training to be a surgeon means surrendering personal priorities. It means relinquishing the mentality of self-precedence. Committing to a life where you no longer come first is something most people only do once or twice in their life: for their partner, and for their children. As surgeons, we do it a third time. It is an enormous commitment, the responsibility is immense, and – if you are dedicated to your patients’ outcomes and self-improvement – it never releases you. But you make that commitment with certainty, devotion, and excitement. You mean it. It takes years before you fully understand what living that commitment looks like, how it rewards you, and what it robs you of.
Wellness is finding a way to keep meaning it; to stay certain and devoted and excited despite the things that surgery takes from you. Central to this is the conceptualization (and internalization) of surgery as a vocation rather than a job. What distinguishes a surgeon from a technician are the visceral experiences of the enormity of the problems you are trying to fix, the scars that remind you what failure looks like, and embracing the weight of your patients’ suffering. The emotional investment is unavoidable. There are many inescapable experiences that surgeons and surgical trainees report after any significant length of work experience: exhaustion, discouragement, nihilism, hollowness, conflict – but these are not just derived from long hours; they are hazards of an emotionally and physically taxing vocation. Finishing an unending workload at home under the guise of satisfying work-hour restrictions doesn’t make you Well. Wreaking fresh hell on your circadian rhythm by changing from a thirty-six hour stint every fourth day to night shifts doesn’t make you Well. You can’t achieve Wellness just by working fewer hours or leaving at five o’clock. It is the inherent character of surgical training itself that gnaws at Wellness: having the life and death conversations, making the decisions that change people’s lives and bodies, bearing the heavy responsibility of the consequences of those decisions – it is draining and consuming. But it is inextricably part of the vocation we chose. If your goal is to leave the building once you’ve logged your requisite hours, you will be constantly disappointed. More importantly, you won’t be the surgeon your patients need.
The way we are trying to make medicine ‘less demanding’ on physicians and trainees runs in direct opposition to the culture of patient-centered care we are trying to cultivate. You cannot adequately address the medical and emotional needs of your patients if you have a daily expectation of clocking out at five. The current climate of medical education suggests that Wellness is something achieved through occasional meditation and timely departure from work. It is no surprise that with such unrealistic expectations of what it means to take care of sick people, trainees may become disillusioned with their career.
We don’t have to reconcile being a surgeon with the ‘Wellness’ recommendations for protected meditation time and surrendered responsibility that journals and hopeful leaders are prescribing. But we do have to find a way to be Well beneath the weight of our responsibilities and the consequences of the care we provide. When we experience that weight in solitude and silence, we condemn ourselves. We become our own persecutors and, as a result, when things go wrong, one of the most common and overpowering experiences in surgical training is that of feeling alone. In a profession where every incredible and terrible thing we experience has been experienced by the people surrounding us, how do we feel isolated? Everyone has been there. We all know the grief of mistakes made. We know the shudder of a patient’s story hitting too close to home. We know the loss of time with our families. But we are a family to each other. We chose the hard road because it means something; it is fulfilling and rewarding. We see that in the faces of our cancer-free patients, in the eyes of our trauma patients’ parents, and in the calm of our palliative patients who die with dignity. We chose the hard road because we see the value of a compassionate and committed surgical practice through the trees of exhaustion and sacrifice.
We need to strive for the reawakening of surgery as a team sport, not only in the context of provision of care, but in the creation of a climate where we are reminded by each other that we are not alone. Wellness isn’t creating opportunities to escape; it is creating opportunities to carry each other. Wellness isn’t found in hour restrictions and meditation; it lies in the comradery and support of the people with us in the trenches. In the face of exhaustion, in the face of loss, Wellness is being reminded of the value of your sacrifice by someone who knows that sacrifice. We are in this together. And we need to make sure we are showing it.