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There Is More to Life than Lifestyle¹

¹ From the Department of Radiology, Indiana University School of Medicine, 702 Barnhill Dr, Room 1053, Indianapolis, IN 46202-5200. Received March 11, 2005; accepted March 18. Address correspondence to R.B.G. (e-mail: rbgunder{at}iupui.edu).

One of the most important professional misconceptions afoot in radiology today concerns the relationship between lifestyle and service. In considering the lifestyle aspects of a new job, we often think of the number of hours worked per week, the intensity of the workload, the flexibility of scheduling, and compensation. As a result, we find ourselves speaking of lifestyle as a primarily self-centered issue—the more we are able to increase our compensation and vacation, and the less effort required to achieve these goals, the better our lifestyle.

Such an understanding of lifestyle omits a vital source of professional and personal satisfaction—service. If we do not believe that we are making a real contribution to the lives of others, we are unlikely to experience genuine fulfillment. This article explores the concepts of lifestyle and service and the vital connection between them and provides insights into how we can create and take advantage of service opportunities to enhance our lives both professionally and personally.

	LIFESTYLE AND CHOICE OF SPECIALTY

TOP INTRODUCTION LIFESTYLE AND CHOICE OF... THE CALL OF SERVICE WHAT KIND OF LIFE... RECOVERING THE SELF RECHARGING EMOTIONAL BATTERIES RESTORING SATISFACTION WHY NOT MORE SERVICE? THE ULTIMATE LIFESTYLE ISSUE References

 
In past years, the relative attractiveness of radiology as a career choice of medical students has increased steadily. The number one factor that contributes to this general trend is the perception of a controllable lifestyle, which includes fewer work hours and fewer night calls (1). This perception may indicate that students put family and leisure at the top of their priority lists, if one assumes that less time at work means more time for family and leisure activities. Another explanation may relate to the emphasis of medical school admissions committees on attracting students with diverse interests. Although academic achievement has always been a requirement for admission, how many of today's medical students are heavily committed to extracurricular activities, such as raising a family, participating in athletics, involving themselves in performance arts such as music and dance, and playing an active role in civic and professional organizations? If time off from work is a high priority, it is no wonder that graduating seniors are choosing careers that they believe will permit them to pursue such outside interests.

Of course, lifestyle means more than fewer work hours and fewer night calls. The growth in the number of applicants to radiology training programs has paralleled the increase in the number of radiology job openings and the levels of compensation for radiologists. As jobs have become available and salaries have risen, more medical students have applied to radiology residencies (2). One factor may be the rising indebtedness of medical students. At an average debt of $115 000 for the class of 2004 (3), students are compelled to consider the economic implications of their career choices. They may judge that the average full-time radiologist's annual compensation of more than $350 000 would give them the opportunity not only to pay off educational debts but also to lead economically advantaged lives (4).

	THE CALL OF SERVICE

TOP INTRODUCTION LIFESTYLE AND CHOICE OF... THE CALL OF SERVICE WHAT KIND OF LIFE... RECOVERING THE SELF RECHARGING EMOTIONAL BATTERIES RESTORING SATISFACTION WHY NOT MORE SERVICE? THE ULTIMATE LIFESTYLE ISSUE References

 
People who pursue a career in medicine as a route to wealth are probably making a mistake. In the time it takes to complete medical training, a college graduate could obtain a master of business administration degree and march far up the corporate ladder or achieve substantial financial success as an entrepreneur. Most people who choose medicine as a career are not motivated merely by money. Many of us also want to help people. Most people regard medicine as a service profession, and many who enter it do so, at least in part, out of a desire to serve others.

The impulse to serve, however, does not always persist and grow throughout a medical career. In some cases, the pressures of medicine lead medical students and physicians to begin to think more about their own survival and prosperity than about the welfare of patients and the needs of the community. This perspective is captured in the burlesque medical novel The House of God by pseudonymous author Samuel Shem. This book portrays the disillusionment that can develop over the long and difficult course of medical training. Although fiction, it conveys important half-truths through one of its main characters, the worldly wise Fat Man, who opines:

The whole pattern of medical education is backwards: by the time we realize we're not going to be like the doctors on TV, we've invested too much to quit. The whole sequence of training should be reversed. [We should first let physicians see what their daily clinical life will be like.] Then—then and only then—let the ones who still have the stomach for it start on the preclinical years (5).

The altruistic impulse is subject to the harsh lessons of reality. Along the way, many of us discover that our initial aspirations to save the world were somewhat impractical. We sense that we cannot conquer disease and, in some cases, that we cannot even relieve our patients' suffering. We cease to be idealists and instead become realists. Unfortunately, this momentum may carry us even further, from realism to cynicism. Soon we may end up feeling that we cannot save anyone else and decide that we should spend all our energies on saving ourselves.

The realization that we cannot save the world need not dampen our impulse to help others. In the words of the great English poet William Blake, goodness is frequently achieved not through grand heroic conquests but "in minutely organized particulars" (6). We may not save the world, but we can certainly make it a better place for some of the people who inhabit it by performing one good deed at a time.

	WHAT KIND OF LIFE DO WE WANT?

TOP INTRODUCTION LIFESTYLE AND CHOICE OF... THE CALL OF SERVICE WHAT KIND OF LIFE... RECOVERING THE SELF RECHARGING EMOTIONAL BATTERIES RESTORING SATISFACTION WHY NOT MORE SERVICE? THE ULTIMATE LIFESTYLE ISSUE References

 
Some medical students seem to think that radiologists work relatively short hours in relatively comfortable conditions for relatively high wages. If this is their vision of a satisfying career, they may suppose that radiologists must be among the most satisfied of all medical specialists. In one large survey of female physicians, however, women radiologists were more likely to think they were overworked, reported longer work hours, and reported that they had less control over their work and less career satisfaction than did women in other medical fields (7). Results of one study that included a survey of 3000 diagnostic radiologists, radiation oncologists, and nuclear medicine specialists revealed that only about half would recommend a career in radiology to a college-age adult (8). In the same study, it was also reported that 41% of radiologists surveyed said they liked working in the field less than they did 5 years ago, whereas only 22% said they liked it more. If radiology offers such a great lifestyle, why are radiologists not happier with their careers, and why would we not encourage more young people to enter the field?

To answer these questions, it is important to consider burnout. Why are physicians, particularly radiologists, dissatisfied with their careers, and what specific factors contribute to this demotivation (9)? Through a better understanding of the nature of burnout, what causes it, and what can be done to prevent or ameliorate it, we can help to restore a genuine sense of fulfillment and satisfaction to the careers of radiologists at risk.

Broadly speaking, three factors contribute to burnout: depersonalization, emotional exhaustion, and loss of personal satisfaction (10). To reinvigorate radiologists, we need to find the means to get back in touch with our best selves, recharge our emotional batteries, and rediscover the sources of personal satisfaction in our professional lives.

	RECOVERING THE SELF

TOP INTRODUCTION LIFESTYLE AND CHOICE OF... THE CALL OF SERVICE WHAT KIND OF LIFE... RECOVERING THE SELF RECHARGING EMOTIONAL BATTERIES RESTORING SATISFACTION WHY NOT MORE SERVICE? THE ULTIMATE LIFESTYLE ISSUE References

 
Why might radiologists experience a sense of depersonalization? Part of the answer lies in the nature of radiology itself, which tends to distance the physician from the patient. In many cases, radiologists do not meet the patients whose diagnostic images they are interpreting. What we see is not the whole patient but pieces of the patient's internal anatomy on a computer monitor. All imaging modalities are associated with the tendency to objectify the patient, with removal of the subjectivity of biography and personality from the human being to whom the images correspond.

Radiologists may also, from the patient's point of view, seem impersonal. Many patients never see the radiologist who interprets their imaging examinations. Many patients may not know the difference between a radiologist and a radiologic technologist. Of course, radiologists and patients often do interact face to face, such as in the performance of fluoroscopic or interventional procedures, yet many radiologists are less likely than physicians in other fields to see patients and to witness directly the difference that their care makes in the lives of their patients.

How can we radiologists recover our best selves and the altruistic motives that led many of us to choose careers in medicine in the first place? For many, one of the best answers may lie in philanthropic service: the use of time, talent, and treasure to enrich the lives of others. In his book The Call of Service, Pulitzer Prize-winning physician-scholar Robert Coles describes the many "satisfactions" that come from serving others (11). He posits a universal human need to believe that we are making a difference in the lives of others.

We need to know that other people have benefited from our existence and our hard work. "There is no question," Coles writes, "that for many volunteers [there is] considerable satisfaction that goes with making a connection with a fellow human being" (11). Radiologists, perhaps more than others, face special challenges in finding such rewards in their daily work and, therefore, need to look extra hard for opportunities to connect. We need, in other words, to look extra hard for opportunities to serve.

	RECHARGING EMOTIONAL BATTERIES

TOP INTRODUCTION LIFESTYLE AND CHOICE OF... THE CALL OF SERVICE WHAT KIND OF LIFE... RECOVERING THE SELF RECHARGING EMOTIONAL BATTERIES RESTORING SATISFACTION WHY NOT MORE SERVICE? THE ULTIMATE LIFESTYLE ISSUE References

 
Another source of job burnout is emotional exhaustion. This exhaustion may stem from overwork, information overload, a constant stream of interruptions, the increasing prevalence of managed care, and loss of professional autonomy, among a host of other sources. It has been suggested that the fear and uncertainty of managed care had "a significant and deteriorative influence on the satisfaction of radiologists during the middle 1990s" (8). Results of studies of job motivation and satisfaction clearly indicate that radiologists must enjoy a sense of control over their work environment and the nature of the work they do if they are to believe that they are engaged and invigorated by it (12).

By participating in service, we can reduce uncertainty. Service is an activity in which we choose to participate of our own free will, not something others tell us to do, and it provides special opportunities for each of us "to define a flexible, self-directed, and meaningful agenda" (13). What one considers meaningful "must also be defined by the individual if [the service] is to be therapeutic or rewarding" (14). In service, this definition is up to us. We play a huge role in shaping how rewarding and therapeutic the service activity will prove to be. We, not others, decide when, where, how much, and with whom to share what we have to offer in energy and compassion. The benefits of this increased sense of autonomy and effectiveness extend beyond professional life to the personal realm.

We should not simply assume that radiologists lead less demanding, more comfortable lives than other medical specialists. Mere distance from patients and their physical and emotional conditions is not necessarily protective, and such human distance is often purchased at a price. We, too, may become emotionally exhausted. Consider this excerpt, quoted by Coles, from Anton Chekhov's short story "Gooseberries":

I saw a happy man, one whose cherished dream had so obviously come true, who had attained his goal in life, who had got what he wanted, who was satisfied with his lot and with himself. Obviously, the happy man is happy only because the unhappy ones bear their burden in silence. It is general hypnosis. Behind the door of every contented, happy man there ought to be someone standing with a little hammer and continually reminding him with a knock that there are unhappy people, that however happy he may be, life will sooner or later show him its claws, and trouble will come to him, but there is no man with a hammer (15, p 196).

Chekhov warns us that true happiness lies not in obliviousness to the plight of others but in answering a call of service to others. Coles, in turn, invites us to look within ourselves to try to find the hammer to which Chekhov alludes. Our human mission is not to sleepwalk through life in a state of anesthesia, oblivious to life's vicissitudes, but to recognize and respond with compassion when we see opportunities to help others.

When it comes to genuine human happiness, detachment is not our friend but our enemy. If we become emotionally and humanly disconnected, like the protagonist of The House of God, then we, too, will discover that "all the shadows have been taken from [our] sun" (5). If our daily work lives promote such detachment, then it is incumbent on us to seek out opportunities to reconnect.

	RESTORING SATISFACTION

TOP INTRODUCTION LIFESTYLE AND CHOICE OF... THE CALL OF SERVICE WHAT KIND OF LIFE... RECOVERING THE SELF RECHARGING EMOTIONAL BATTERIES RESTORING SATISFACTION WHY NOT MORE SERVICE? THE ULTIMATE LIFESTYLE ISSUE References

 
From one perspective, satisfaction has narcissistic connotations. I satisfy myself by getting what I want. Helping other people get what they need or want seems counterproductive, for I am no longer doing what I want but what someone else wants, and at the cost of time and energy I could spend on myself. Undoubtedly, the ambition for personal happiness and the impulse to look out for "number one" are universal tendencies in human nature.

Selfishness, however, is not the whole story. In an interview with Coles, a college student, who volunteers as a tutor in one of the more disadvantaged neighborhoods in his city, commented:

This work I do will help me, I sometimes think, more than it will help the kids. I guess I ought to say that the work will give a boost to my success, and that I know it, and that when you ask me about the satisfactions I get from this kind of work—well, if I left that out, I'd be leaving out something that's part of the picture (11, p 93).

To be sure, the student expects to benefit in some way from what he is doing. There is a difference, however, between pursuing our own satisfaction to the exclusion of the claims of others and finding satisfaction through service to others. Although such students would not engage in such service if it did not provide a certain degree of satisfaction, "still, the work has its own worth, most of these ambitious, able young men and women remembered, and their tutees would agree"(11, p 94).

Some might respond that medicine, too, "has its own worth"(11, p 94). This might lead to the objection that physicians are already acting as servants in everything they do for their patients, and therefore they need not look for additional opportunities to serve. There is an important psychological and moral difference, however, between service that generates income and service that is uncompensated.

When we are getting paid, we do not experience the same purity of motive as we do in service without compensation. In the latter context, we can see more clearly why we are serving, because it is less mixed up with self-interest. When compensation never enters the picture, we enjoy our most fruitful opportunity to appreciate the beauty of service for its own sake; that is, we appreciate the beauty of the service for the benefit of the person and the community we are serving. The intangible yet deeply real nature of caring becomes more apparent, and we are able to see our lives as serving a purpose larger than ourselves.

Again and again, we hear it said that medicine is becoming less like a service and more like a business. Of course, most physicians have always earned their livelihood through their craft, yet medicine is now, perhaps more than at any time in living memory, driven by the need to generate revenue. This need is good in some ways. The incorporation of sound business practices has certainly helped us to improve the efficiency and effectiveness of health care, yet if physicians regard patients merely as customers and the practice of medicine merely as a means of paying the bills, we will become what Socrates refers to in Plato's Republic as "mere moneymakers" (16).

How much money do we need to be happy? There is a point at which additional monetary returns are no longer worth the time and energy they require, at least not where human fulfillment is concerned. We must be on guard lest our appetite for higher income undermine our profession's core commitment to service.

	WHY NOT MORE SERVICE?

TOP INTRODUCTION LIFESTYLE AND CHOICE OF... THE CALL OF SERVICE WHAT KIND OF LIFE... RECOVERING THE SELF RECHARGING EMOTIONAL BATTERIES RESTORING SATISFACTION WHY NOT MORE SERVICE? THE ULTIMATE LIFESTYLE ISSUE References

 
If service is so important to us both psychologically and morally, why are more radiologists not involved in service activities? A recent survey of more than 10 000 female physicians suggested that radiologists are less likely than other medical specialists to engage in philanthropy and voluntary service (17). In general, the study found that service activity was more prevalent among physicians who are not primary care physicians and physicians earning higher than average incomes. The behavior of radiologists, however, contradicted this general rule.

Perhaps obstacles stand in the way of radiologists who wish to serve. Consider, for example, radiologists' ability to provide pro bono patient service. Most of the charges for radiologic procedures are outside the radiologist's control and, therefore, cannot be waived by fiat. When computed tomography or magnetic resonance imaging is performed, only a relatively small percentage of the charge is directly attributable to the radiologist. A large percentage of the total charge is attributable to technical fees imposed by the hospital, and most radiologists have little direct control over these technical fees.

Other factors also limit the ability of radiologists to waive their professional charges. Medicare and Medicaid ask how radiologists can fairly apply the full professional charges for some patients and waive them for others. The physicians most likely to engage in pro bono care are those who work in solo, two-physician, and rural settings. Many radiologists work in hospital-based practices. Therefore, the average radiologist likely has more administrative hurdles to overcome than other physicians to provide pro bono care. Another problem with pro bono work for radiologists is the fact that most of their clinical practice is based on referrals. Patients do not ordinarily present initially to radiologists for care. Thus, it is generally more difficult for radiologists to set up or staff a free clinic in the community.

Radiologists, however, are not just radiologists; they are also physicians, and there may be medical work they are qualified to do that is not of a specifically radiologic nature. For example, radiologists possess other clinical skills that might be useful in caring for the poor, and such care can provide them an opportunity to develop and maintain their skills in history taking and physical examination.

Radiologists are not merely less likely to do pro bono work. They also are less likely than physicians in many other specialties to engage in service of any type, such as coaching a youth sports team, teaching Sunday school, or volunteering time to serve the poor. Why are more of us not engaged in volunteer community service that does not rely on our medical expertise? Why are radiologists not leading the way in hospitals and academic medical centers in both practicing and promoting voluntary service?

Perhaps part of the answer lies in the relative dearth of role models. Some of us may not know a radiologist who is a leader in service. Another reason may lie in the nature of radiology training programs, which frequently pay service little heed. While residents in specialties such as family practice or pediatrics are being encouraged to participate in service activities, radiology residents feel compelled to focus their energies on passing the board examinations. We need to foster greater esteem for service among radiologists at every stage of professional life, but especially in the earliest and most formative years of their careers.

	THE ULTIMATE LIFESTYLE ISSUE

TOP INTRODUCTION LIFESTYLE AND CHOICE OF... THE CALL OF SERVICE WHAT KIND OF LIFE... RECOVERING THE SELF RECHARGING EMOTIONAL BATTERIES RESTORING SATISFACTION WHY NOT MORE SERVICE? THE ULTIMATE LIFESTYLE ISSUE References

 
A life devoid of service is less worth living. It is time for radiologists to devote more time and attention to their service contributions. We should highlight service activities in our professional meetings and publications. We should incorporate service into our training programs. All of us should seek out more opportunities to serve.

We should guard against the temptation, to which many departments and professional organizations succumb, to extol the service activities of members only when they directly benefit the departments or organizations in question. Such activities are important and need to be cultivated, but the service that we most need to highlight is that which is directed beyond the profession to the benefit of our communities.

If we follow this prescription to serve, we enable medical students to choose a career in radiology for the very finest of reasons. We will help radiology residents and practicing radiologists reconnect with their highest and best selves, including the aspirations that drew them into medical careers in the first place. We will enhance our opportunities truly to make a difference in the lives of others. And we will know with refreshing clarity the deep fulfillment that only service can bring.

	References

TOP INTRODUCTION LIFESTYLE AND CHOICE OF... THE CALL OF SERVICE WHAT KIND OF LIFE... RECOVERING THE SELF RECHARGING EMOTIONAL BATTERIES RESTORING SATISFACTION WHY NOT MORE SERVICE? THE ULTIMATE LIFESTYLE ISSUE References

 

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