Mid-Career Malaise

July 14, 2018

Written by Clay Smith

Acedia – spiritual or mental sloth; apathy

I recently read an article entitled The Mid-Career Demon (1).  Finding myself in mid-career, and with such a provocative title, my curiosity was piqued.  This family doctor found that his professional life had lost its sparkle and a “greyness” had fallen over him and his career.  Several of his long-time patients had recently died, and his own health was failing.  He and his work colleagues took a burnout inventory; surprisingly, his scores didn’t seem to indicate burnout.  Yet something was wrong.  He attributed it to acedia: “the desert experience for mind and soul, and it is known as the noonday demon because it vexes those who are in the mid-stages of life.”  This concept of acedia, the “mid-career demon,” intrigued me.  I felt this way too.

Living the Dream?

As I approached the start of my twentieth year at the same institution, with twenty years until retirement, I felt like I couldn’t see a light at the end of the tunnel.  For a few years, I had noticed a growing sense of despair.  I often felt intense sadness and dread while driving to work night shifts in the ED.  No one knew about this.  I would put on my “game face” once I got to ED and would throw myself into the work and, mercifully, get swept up in the busyness and bustle.  I couldn’t understand why I was so despondent.  Wasn’t I “living the dream?”  I’m still not sure I understand it fully, but I have been able to identify some of the potential contributors to my mid-career malaise.

Loss of Purpose – Prior to these feelings of despair, we had developed a successful website and podcast to summarize and present current medical literature called Keeping Up.  Eventually, the burden of content creation while working full time became overwhelming.  My partner in the venture needed to move on to other pursuits.  Ironically, I couldn’t keep up.  The project finally ended a dismal failure when our website was hacked and destroyed.  This produced a vacuum and loss of purpose in my professional life.

Schedule – Meanwhile, I became bewildered with the unpredictable nature of my schedule in the ED and decided to switch to doing night shifts.  This had the advantage of making my schedule predictable but the disadvantage of constant fatigue.  With relentless fatigue came a desire for a way out, for relief.  For me, there was no option to stop working or take a sabbatical.  With kids in college and children still at home, I simply had to keep going.  All I wanted to do was run away, stop the frenetic pace, and get off the roller coaster, but I couldn’t.  Looking for a way out, I began seriously planning to leave emergency medicine and start my own urgent care business.  The prospect of owning my own business was exciting; it was my ticket out of the grind of night shifts.  But the more I explored it, the more I realized it was not the right decision for me or my family.  I had invested months of time researching this opportunity and had gotten my hopes up that this would be the answer.  The unrealized hope made me feel worse –  more restless, more discontent.

Borrowing Trouble – At the same time, my wife and I were involved in estate and financial planning, with regular meetings to make sure our personal affairs were in order.  For me, this made retirement feel even further away.  With each difficult shift at work, I felt like I couldn’t keep going for another 20-25 years.  The estate planning had the unintended consequence of making me dread the future instead of feeling relieved to have our family affairs in order.

Relational Strain – To top it off, my children were growing up and leaving for college.  As we moved into an advisory-only role as parents, we had to learn how to navigate and cope with some of the life choices the kids were making.  As we made this difficult transition, our connection as a married couple began to fray.  We felt distant, defeated, sad, angry, discontent, and restless.  Something had to give.

Snake on a Pole

Things reached a low point one morning after a particularly hard night shift.  I went into my home office, which also served as my daytime sleep area, and couldn’t get the room dark enough to fall asleep.  I burst out of the room and complained to my wife that we needed room darkening blinds, as if somehow this sunny day was her fault.  It was a petty, full-throated pity party.  Obviously, she was taken aback, having never been opposed to installing room darkening blinds.  In my sleep-deprived, irrational state, this outburst revealed what was going on inside me: bitterness and complaining.  Ironically, the following Sunday the lesson was on the bronze serpent – a cautionary tale of venomous snakes unleashed to quell Israel’s complaining after the exodus and a bronze serpent lifted up on a pole to which those bitten could look and be healed.  It wasn’t my wife’s fault or my kids’ fault or my job’s fault.  A big part of the problem was that I had become a bitter person and a complainer, and it had poisoned my soul.

I needed help.  The symbol of a snake on a pole as a healing icon was first seen in ancient Israel but continued in Greek mythology as the Rod of Asclepius, a contemporary symbol of many medical organizations, including the American Medical Association.  Just like the ancient Israelites, I needed to look up, outside myself, to be healed.  My internal desire to stop complaining and cultivate gratefulness was only part of my path out of the darkness.  External factors were also key.

Around that time, my cousin asked if I would lead a medical trip to Haiti.  I was very skeptical but began extensive discussions with other clinicians who had knowledge of Haiti, and we formed a plan.  It was a great trip, and I have had the chance to continue the work to improve the health of the rural villages we serve in a sustained, holistic way over the past several years.  This helped restore a sense of purpose to medicine for me.  Another part of my journey was the reality of pressing needs.  In retrospect, being forced to get up, go to work, and put into practice what I was learning was essential for me.  To not complain and feel grateful on sabbatical would have seemed false.  But to do better in the midst of ongoing stress felt genuine.  In addition, my wife and I got professional counseling for our marriage.  I had resisted this for years, thinking I should be smart enough to solve marriage problems myself.  I was wrong.  There were knots I simply couldn’t untie.  In a few sessions, our counselor had taken us far beyond where we could have gone alone.  Another aspect was friendship.  We had friends who loved and accepted us in spite of our problems.  They took us to dinner, to concerts, and had us over to talk, cry, pray, laugh, or just to make cookies.

Where Am I Now?

It would be unrealistic to say that all the issues have been resolved as I enter the latter half of my career.  Who doesn’t battle sporadic sadness, disillusionment, or feelings of discontentment with work?  The difference is that my outlook has changed.  As our children grow older, their problems become more complex.  Gone are the days when we can settle a simple dispute over who gets to play with a toy.  Now there are marriages, engagements, failures, heart-wrenching life decisions, and more.  Grief and mourning as a parent are just a text message away. 
But incredible, soul-lifting excitement and joy are also that close.  As our family grows, with the addition of daughters and sons-in-law, our joys grow as well.  My wife and I still periodically meet with our marriage counselor, and I am no longer under any delusion that I can solve such complex problems myself.  Some recent changes in my roles at work have also been refreshing.  I started this website, JournalFeed, which is simpler (and hopefully more secure) than Keeping Up, and I was given the opportunity to help direct a new venture involving local retail clinics.  JournalFeed has been a creative outlet, and the retail clinic venture has opened up new facets of learning about leadership, education, administration, finance, innovation, and the joys of university politics.  I still work more than half my time in the emergency department but have stopped doing night shifts, given the new administrative responsibilities.  My wife says it has made a big difference in my personality, that some of the spark is back, which I didn’t realize had gone.

Don’t Accede to Acedia

Mid-career malaise is nothing new.  Faculty from my own institution wrote about this 16 years ago (2).  But the phenomenon of physician burnout is occurring with increasing frequency, with up to 50% of physicians in training or in practice currently experiencing it (3).  A recent systematic review found that institutional-level interventions helped with physician burnout, such as shortened attending rotation length, modifications to clinical work processes, shortened resident shifts, duty hour requirements, and practice delivery changes.  Also, efforts at an individual level improved burnout, such as facilitated small group curricula, stress management, self-care training, communication skills training, and mindfulness-based approaches (3).

The causes of burnout are complex, multifaceted, and highly personal.  The turning point for each person will be different.  Burnout isn’t a battle we fight once and permanently overcome; challenges will continue as we progress in our careers.  For me, ongoing healing comes through the combined impact of gratefulness versus complaining, service to others, skillful counseling, close relationships, and the freshness of new roles and new challenges.  Armed with these, I can face acedia, the so-called mid-career demon, and keep moving forward and finding joy during this season of my professional life.

References

1. Daaleman T. The Mid-Career Demon. Ann Fam Med. 2018;16(3):264-266. doi:10.1370/afm.2232.
2. Spickard, Jr A, Gabbe S, Christensen J. Mid-Career Burnout in Generalist and Specialist Physicians. JAMA. 2002;288(12):1447. doi:10.1001/jama.288.12.1447.
3. West C, Dyrbye L, Erwin P, Shanafelt T. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet. 2016;388(10057):2272-2281. doi:10.1016/s0140-6736(16)31279-x