Achieving work-work balance

Work-life balance is important, but it’s talked about plenty. How about your work-work balance?

To elaborate:

Once you’ve finished your initial training in medicine, and achieved the basic competence needed to do your day-to-day job, you may wonder what’s next. Probably you should keep learning and honing your knowledge and skills, but after your core training, this becomes a mostly self-guided process. So the question remains: where should you devote your time? And for any one area, what’s “enough”?

As a jaded adult, you likely understand the practical reality that you cannot be an expert at everything. Your time, interest, and mental capacity are limited. Whatever the size of the cognitive vessel into which you pour medicine (hopefully large), it is still finite. At some point, devoting more time, interest, training, and specialization to one area means giving less to another. How should you apportion the coin of your skill?

Here’s one approach: aim to be a lumpy plateau.

A what?

A lumpy plateau. Like this:

There are two things happening here.

First, you have broad competence across all relevant domains. You can select an antibiotic regimen, titrate the ventilator, read a chest x-ray, place a central line. For any patient who presents to your ICU, you can safely and appropriately manage their problems, and reliably provide the standard of care.

Then, you have individual areas of specialization. For a few narrow areas of your job, you have chosen to rise above that baseline level of competence; you’ve grabbed those peaks and tugged them upwards above the rolling hills of averageness. Usually, these are areas of interest, and you’ve chosen to explore them further because they tickle you. Or perhaps they aren’t intrinsically interesting, but they’re the sort of things where increased training can expand your scope of practice into areas you do find interesting; for instance, you want to practice flight medicine, so you learn about scene safety, patient packaging, and altitudinal effects on gas physiology.

These areas of competence and specialization mix and intermingle, supporting and impacting one another. But perhaps it’s not obvious why both are important.

Why maintain broad competence? Because you don’t get to choose your patients. The best you can do is work in a specialized ICU, but you still need competence from wall to wall within that realm. We take care of sick people, full stop; we don’t get to tell people to consult the rod ophthalmologist because we only handle cones. It’s all our problem.

So then why specialize? Because bare competence will let you do the job adequately, but not do it with virtuosity or panache. To your team, your ICU, your department, the field of critical care as a whole, you may not be a burden, but you will not contribute anything either, at least beyond your pulse and presence. Nobody will ever ask for your opinion or help. You’ll never assume care of a patient and have a new idea. You won’t ever start a project, design a study, write a paper, or give a talk. You’ll just be wallpaper. Good enough to draw a paycheck, perhaps, but nothing more. If you want a job like this, it can be yours, but it seems to me the foundation for a bleak, boring career.

(Years ago I was part of the CrossFit community, an exercise program based around broad competence, with the goal of becoming an athlete who was “good at everything” and has no major weaknesses. While this approach has its uses, at one point a professional football player pointed out its downside: for some people, particularly those without the gifts to excel at everything, their specialized skill is their whole ticket into the big leagues. Without it, they’re nobody; if they boosted all their weaknesses by 20%, but sacrificed a mere 10% from their core skill, they would no longer have a job.)

Although some level of broad competence is needed, that’s a minimum expectation, the entrance fee you need to pay to play. Beyond that, people care about the areas where you’re exceptional, not average. Odds are, you do too.

Be good at something. It makes life interesting.


So, perhaps you’re an APP approaching the end of your training, or you’re a fellow soon to become an attending, or whatever. Soon you’ll have the basic skills to practice critical care medicine. Beyond that, the world’s your oyster.

Pick a few specialties, and set out to pull up their peaks. Make that corner of medicine your own, your wheelhouse, the niche where you know more than most people. In exchange, other areas can receive less of your attention, but ensure they still remain above the watershed of competence; truly pathological weaknesses aren’t acceptable no matter what else you might be good at, and in the fast-moving world of medicine, maintaining competence requires some grudging attention to even to the least appealing domains.

If you can achieve that balance, you’ll have an interesting career, provide mostly good and occasionally brilliant care, and create opportunities for yourself in non-clinical areas such as research, administration, and education. And that’s a nice work-work balance to have.