Walking through the sliding glass doors at 10:55pm on a Monday, I found myself wondering if it would be a good shift or a bad shift. In Emergency Medicine a “good shift” has to strike many delicate balances. It can’t be too busy, but it also can’t be too Q-Word-That-Must-Not-Be-Named. It should have some high acuity patients, but not so many that care becomes unmanageable. The staff and residents should be fun but should also work efficiently. On reflection, a “good shift” seemed to rely on many factors all of which were outside my control.
After years of feeling at the mercy of all the external factors that determined how my shift went, I realized my thinking needed to change. The philosopher William James famously said: “I don’t sing because I’m happy, I’m happy because I sing.” I needed to learn to sing.
To understand how to create good shifts irrespective of external factors, I turned to the ancient philosophy of Stoicism. One of its core tenets is that we must focus on what is within our control.
“Happiness and freedom begin with a clear understanding of one principle: Some things are within our control, and some things are not. It is only after you have faced up to this fundamental rule and learned to distinguish between what you can and can’t control that inner tranquility and outer effectiveness become possible.”Epictetus
Too often we ignore his admonitions and we focus our efforts on things that our outside our control while paradoxically relinquishing control of things that are within our control. Things within our control, per the Stoics, are our own thoughts, emotions, and actions. We relinquish control of them by allowing our emotions to be unduly affected by external things. “That person said something that made me upset,” or “I’m angry because I couldn’t get something I needed.” On the other hand, we try to control things that are outside our circle of control, such as other people’s actions or opinions, politics, coronavirus, or even the weather. We try to control them in our minds by resisting their presence, continuously wishing them away, or perseverating that they should be different. In order to have the inner tranquility and outer effectiveness Epictetus encouraged, we must give up the fiction that we can control things outside ourselves and maintain better control of ourselves.
Here are three practical steps:
1. Maintain agency over what you do have control over. Agency means taking rather than abdicating responsibility for your thoughts and emotions. You can also think of agency as power. If you prime individuals to feel powerful they show greater “executive functioning, optimism, creativity, authenticity, the ability to self-regulate, and performance.”(1) When you give up control of your own thoughts and feelings, you are giving up your own power. By claiming ownership over your own thoughts and feelings, you are accepting that whether you have a good shift or not is entirely up to you, not external things.
He is most powerful who has power over himself.Seneca
2. Even out your standard deviation and raise your mean. Imagine a graph of your personal shift quality vs time. Some shifts are truly terrible. Others are fantastic. Most shifts, however, fall within 2 standard deviations of our mean. By choosing to make most shifts a ‘good’ one, it does not mean artificially trying to like the terrible shifts. Instead, it means smoothing out the variation, and raising the mean itself.
3. Change your own mind. Shifts are difficult. They often consist of an 8 or 12-hour exercise in tolerating a continuous stream of small frustrations, insults, barriers, and setbacks. The Stoics have many provocative things to say about enduring hardships. Marcus Aurelius wrote: “Ask: What is so unbearable about this situation? Why can’t you endure it? You will be embarrassed to answer.” The only way to be able to decide to have a good shift is by changing our own minds.
To bear trials with a calm mind robs misfortune of its strength and burden.Seneca
We can change our minds by employing a practice the Stoics called meditation, which is similar to cognitive therapy.(2, 3, 4) Stoic meditation consists of becoming actively aware of one’s thoughts, analyzing them, selecting the thoughts we wish to entertain, and rejecting futile thoughts. At 2am when I am unable to get a patient a ride back to her nursing facility, the thought “I should be able to get the patient home” is futile and leads only to frustration. The thought “this should have been fixed already” is useful only if it leads us to action to fix it, but on its own is a waste of precious cognitive bandwidth. Entertaining futile thoughts leads to a sense of learned helplessness that reduces our ability to think creatively and solve problems.
Perhaps the most shocking of Aurelius’s statements on enduring hardships is this one:
If it’s endurable, then endure it. If it’s not endurable, then stop complaining. Your destruction will mean its end as well.Marcus Aurelius
The ED, the challenges of providing healthcare within a broken system, and patients in need of help will be here long after each of us. We must endure the challenges while we also work to remedy the problems.
The mind adapts and converts to its own purposes the obstacle to our acting. The impediment to action advances action. What stands in the way becomes the way.Marcus Aurelius
When we work to overcome a challenge, we gain the inner tranquility and outer effectiveness that were the things we needed most in the first place. By managing our minds, we can repurpose obstacles into opportunities to build strength.
This is my challenge to you: Maintain ownership over the things that are in your control. Choose your thoughts intentionally. Raise your mean and decide to measure the goodness of a shift not by the external circumstances you face but by your attitude in the face of those circumstances. Then, and only then, will a good shift be something you create, not something you hope for.
This article was first published on KevinMD.