Radiology is in turmoil. Hospitals are operating at near zero margins and many are predicted to close within the next 5 years. At the same time, radiology has moved from a profit center with abundant capital support to a cost center with inadequate service levels, poor alignment with hospital leadership and questionable stipend support of the radiologists. Many groups are having difficulty meeting the current environment that demands 24/7 final reads, around the clock IR coverage, subspecialty expertise, and more stringent service level requirements for quality, turnaround time and physician outreach metrics. Many leaders within the ACR have written extensively on these topics and have offered meaningful and practical solutions to these challenges. It is clear that the fate of our profession depends in a large part to how radiologists react to these pressures over the next few years. What is not so evident is the critical relationship between professional success and personal happiness. We have been taught that success (material or academic) will lead to happiness. So if we focus on achieving more money, more titles, and more accolades, we will become happier. The equation, however, is actually reversed: Happiness is a better predictor of success than success is to happiness. Therefore if we understand and apply the evidence-based and time tested principles that can increase personal happiness, we will also ensure more professional satisfaction. So as we prepare for a future of value based payment models and increased competition for the reimbursement dollar, let’s focus on preparing ourselves first.
We all want to flourish. We want to live lives of meaning. We want to raise good kids who will be better off than we are. We want to have some fun. We long for the care free days of our youth and wonder where the time has gone. We want to be more present and in the moment. We are all searching and often struggling to find the path forward. We know the path that we (and most others) are on, often, simply does not feel right. Most of us have a growing sense of a deep unrealized potential. Unlocking this potential in order to live a more authentic, joyful and meaningful life can become our life’s work. We can stop sleepwalking through life and fully experience each moment. We can stop getting what we want and start wanting what we have. We can stop accumulating and start giving. We can stop living by society’s default value system of moderate hedonism and start living a principled life of integrity, gratitude and service. These concerns and self-reflection are not new for mankind. They are not the result of modern culture, the internet or terrorism. These questions were asked and answered by Stoic philosophers over 2000 years ago. Fortunately for us, their answers and approach to life have profound implications for each one of us.
Stoicism has changed my life. It has impacted the way I interact with other people (especially my kids), how I view successes and failures, and how I view my place in this world. After reading Marcus Aurelius’ Meditations, I realized that we are all philosophers or at least that we all should be. The word philosopher is literally translated as a “lover of wisdom” from the Greek words philos “loving” + sophos “wise, a sage”. Wisdom in this context refers to the knowledge of life. So philosophers are people who are in love with learning how to live. Philosophy offers us a very practical guide to living well. In the days of ancient Greece, parents carefully chose schools of philosophy for their children in much the same way we choose colleges today. Parents recognized the importance of philosophy in order to develop a sort of “personal operating system” or code to live the good life. Stoicism was the dominant philosophy of the Western world for several hundreds of years but lost its prominence when the emperor Constantine declared Christianity the official religion of the Roman Empire in the 4th century. At this point, religion largely supplanted philosophy as a moral compass and means to living a purposeful life. Philosophy then went from a very useful practical guide for optimal living to esoteric academic principles discussed only among University professors. If we entered a bookstore in ancient Greece, the philosophy section would be completely different than it is today. Titles such as Of Love, Of Human Life, Of Just Dealing by Epicurus or On Anger, On Leisure, Moral Letters by Seneca and Proofs that Pleasure is Not the Good by Chrysippus would be displayed prominently. Philosophers in those days asked and answered meaningful questions that offered a path for all to follow. We must return philosophy to its roots and utilize its timeless principles to allow us to learn how to live in this life and in the right way. We must all become philosophers in order for ourselves, our children, our profession and our society to truly flourish.
For the stoics, tranquility or equanimity (one of my favorite words) was available to everyone to achieve. It was not, however, easy to attain and required daily and deliberate practice in areas of reason/logic, mindfulness, self-awareness and self-control. A modern interpretation of the main virtues in Stoic theory would be that, in all circumstances, when needed, we must act with self-restraint, we must choose our activities carefully and carry them out wisely, we must be fair to others and we must face difficult circumstances with courage. If we can live this way and only if we live this way, can we live well. Nothing else is needed for our ability to fully flourish.
Socrates said “To know good is to do good” but for most of us this simply is not true. On a personal level, we all know that we should eat more vegetables, exercise more, spend more quality time with our family, worry less about what others think, remain calm to events out of our control, and watch less TV. On a professional level, we all know that we should be spending more time with referring physicians and patients, pursuing value based initiatives like Imaging appropriateness and service line support, and in general become better integrated into the fabric of the hospital or health system. Putting what we know into practice is difficult and requires us to develop rituals and habits. One of the concepts that we can borrow from most religious practices is the use of rituals. Each service within a specific religion follows a routine so that each time you go to mass; you essentially repeat the same sequence of prayers. A daily practice by our Chief medical officer is to visit the ED three times per day – first thing in the morning to assess how we performed overnight, at lunch time and before leaving at the end of the day. In doing this, he is showing the ED docs that we are interested in how we are serving the emergency room and their patients. This concept of physician outreach has become a ritual for him and for others in our group that have followed this advice.
The Stoic philosophers Seneca, Epictetus and Marcus Aurelius walked their walk when it came to the practice and application of their principles to daily living. Marcus Aurelius awoke each day and said to himself;
“When you wake up in the morning, tell yourself: The people I deal with today will be meddling, ungrateful, arrogant, dishonest, jealous, and surly. They are like this because they can’t tell good from evil. But I have seen the beauty of good, and the ugliness of evil, and have recognized that the wrongdoer has a nature related to my own – not of the same blood or birth, but the same mind, and possessing a share of the divine. And so none of them can hurt me. No one can implicate me in ugliness.”
Here was the Emperor of Rome, arguably the most powerful man on earth, expressing daily reminders of compassion and service. He believed that we are all connected with each other and with the Universe and that each of us has a duty to live our lives to the best of our ability in the service of others and to the larger Cosmic order.
Seneca claimed to have daily practice of recounting the day’s events and judging his actions according to his own virtues. We can do a similar practice by keeping a daily journal recalling the events of the days in detail from the moment you wake up to the present moment. Remember every interaction, every response and how you performed according to your best self – your virtuous self. Write it all down and visualize how you would act differently next time. This journal practice has dramatically affected my life – I have been able to ruminate less about things that I wish I had handled differently. By writing down these events and visualizing them positively, I have also gained clarity and a small sense of space between the stimulus (event) and my (optimal) response. So the next time, you have an less than favorable interaction with your spouse, child, colleague, hospital administrator or technologist, write it down and visualize how you would handle it next time (for there will always be a next time).
Another practice that I stole from both Marcus Aurelius and Epictetus is negative visualization. Following the principle of hedonic adaptation, we quickly adapt and take for granted the positive events or people in our lives. One way to avoid this adaptation is to think and really visualize how you would feel if you no longer had a job or if your wife had left, or your child was sick. How would I feel if I found out that I had cancer or that this was the last day of my life? Would I care about the minor inconveniences of life or would I smile and make sure that those I cared about knew how I felt? Are the kids running around screaming and yelling – imagine if they were no longer living with you or were not healthy enough to play. I believe that negative visualization is the antidote to hedonic adaptation and to the entitlement mindset that is so pervasive in our society. Many radiologists assume that simply by having board certification, they should have a generous amount of imaging volume flowing to them and earn several hundred thousand dollars per year while spending as little time as possible on non-RVU generating activities. Imagine if you lost your hospital contract or if you had to live on half of what you made last year? Really visualize your group and your job imploding and having to look for another job. Contrary to what may seem like a morose practice, visualizing yourself without all of the good things in your life brings both gratitude and mindfulness that are key components of happiness.
Finally a third Stoic exercise is to accept each moment as if it were meant to happen. This is based on the Stoic belief in fatalistic determinism – that things are predestined according to the Universal order. Without getting into the merits of that argument, this concept of active acceptance of each moment is very powerful. It does not imply that things happen for the best but it does allow us to make the best of what is happening in the moment. Eckhart Tolle elaborates on this concept in his book The Power of Now where he advises us to act as if we had chosen the event to happen exactly as it has and then to choose our best response. A mantra that I have used is “I chose this moment and I will choose my optimal response.” So when my daughter is having a melt down at the end of the day, instead of yelling back at her (which still does happen), I can act as if I chose her meltdown to happen. It doesn’t make the meltdown go away but it does create a tiny space before my instinctual angry response. This space allows me to better act according to my own nature – thru the use of reason and with virtue. We can apply this exercise to an interruption by a technologist or referring physician that disrupts our workflow during a busy day or toward difficult contract negotiations with hospital leadership. Let us accept and then act well rather than complain and act out.
As the Stoics taught, the key to living a good life depends on our ability to focus on what we can control. We cannot control reimbursement changes but we can develop different reading processes designed to make us more efficient. We cannot control public awareness of radiation exposure from imaging but we can serve as leaders in proactive radiation dose management for patients. We cannot control excessive costs in imaging from self-referral but we can act as imaging consultants at the time of the physician-patient interaction. We cannot control future payment models but we can act as patient advocates rather than passive consumers of imaging revenue. By focusing on things that we can control – our actions, values, goals, and opinions, we can replace the pessimistic doom and gloom that pervades so many radiology departments with a learned optimism toward a changing but much improved profession and more importantly, an improved self.