One Must Imagine Sisyphus Happy

In his book The Happiness Advantage, author Shawn Achor describes the traditional formula for achieving happiness: If you work hard, you will be successful, and then you will be happy. It’s the mission statement of every medical student. It’s the secret formula drilled into each of us from childhood—through grade school, college, medical school, and residency. It endures as the operating system upon which many of us run our practices.

However, Achor says this formula is all wrong. Hard work may bring success, but not always. Fate is fickle, and hard work is no guarantee of success. As the Preacher said, the race is not always to the swift, or success to the wise, learned, or skilled, “but time and chance happeneth to them all.” Even when hard work does yield success, there is no guarantee it will bring happiness. More often than not, each victory pushes the goalpost farther away, sending us back into a vicious circle of more hard work and more striving for success. It’s an endless and absurd cycle.

This description of the endless cycle of work, success, and delayed happiness reminds me of the myth of Sisyphus. Sisyphus, the King of Ephyra, was a clever guy whose ingenuity displeased Zeus one too many times (this is how most of these stories begin). As Sisyphus neared the end of his life, he continued to try and squeeze out more days among the living. Each time the gods tried to send him to the Underworld, he would come up with a clever way to cheat death. Finally, the gods had had enough and devised what they imagined to be a fitting eternal punishment:
The gods had condemned Sisyphus to ceaselessly rolling a rock to the top of a mountain, whence the stone would fall back of its own weight. They had thought with some reason that there is no more dreadful punishment than futile and hopeless labor. (Camus, The Myth of Sisyphus)
Sometimes it feels as if we physicians have been condemned to a fate worthy of Sisyphus. But instead of having the infernal stone roll back down each day, we reach the top of the mountain only to find an even higher peak we must ascend. We clear the task list in our EHR only to find dozens more have arrived overnight. We work to improve our quality metrics, only to see the targets move farther out of reach the next year. It’s an endless and absurd cycle.

Forward, we must roll the rock. Despite our achievements, there is no resting on our laurels. There is no permanence to our accomplishments. Consider board certification—it is fitting that the seal of the American Board of Family Medicine incorporates a phoenix, the mythical bird that is consumed in its own fire and must regenerate from its ashes. It’s an appropriate metaphor, but they could have easily substituted a sketch of Sisyphus pushing his rock.

No wonder so many physicians feel burned out. The AMA defines burnout as “a long‑term stress reaction characterized by depersonalization, including cynical or negative attitudes toward patients, emotional exhaustion, a feeling of decreased personal achievement and a lack of empathy for patients.” It’s a real problem, and it’s pervasive and growing. A study published in 2015 found that 54% of physicians reported at least one symptom of burnout. Burnout is also a likely factor in the 300 to 400 physician suicides each year. The toll of burnout is devastating to physicians and to our patients and profession. Burnout threatens patient safety, tarnishes the patient’s perception of care, and crushes the passion and purpose that drives quality care.

There are multiple factors causing the epidemic of burnout, but the consistent theme is the radical transformation of medical practice over the past 40 years. The changes in the practice of medicine have been both dramatic and disruptive, driven by an aging population, the growth of consumerism, and a payment system that expects both high quality and cost control. These expectations have driven more and more physicians into employment relationships with subsequent loss of control over their workflow, schedules, and staffing. Combine this with the revolutionary changes wrought by the introduction of electronic health records, and you have a perfect storm of dysfunction— the breeding ground for burnout.

The radical transformation of medicine over the past 4 decades has taken a toll on the men and women who work on the frontlines of our profession. However, many of these changes were necessary—and dare I say—beneficial. Medical care is much more effective and safe than it was a generation ago. We may bemoan the demands of consumerism, but patients deserve high-value quality care, and it is only proper that we be good stewards of their healthcare spending. Electronic health records have been disruptive, but who among us would return to paper charts and forfeit the benefits of population health management that can be accomplished only by using a modern information system. Medical care is much better because of these changes. There will be no returning to halcyon days of pen and paper, and un-accountable care.

Fortunately, there are hints that the tide is turning in the battle to address physician burnout. There is wider recognition of the serious nature of burnout and greater acceptance that burnout is a systemic problem and not a matter of personal weakness or poor work ethic. Our professional organizations, including the AAFP, are making burnout a focus of their attention. The AMA Steps Forward program has an excellent module on preventing physician burnout, and the AAFP recently introduced Physician Health First, a web-based resource on physician well-being.

There are many resources available for addressing burnout, but the first step is to change our personal formula for achieving happiness in our professional lives. We can’t afford to wait for success to achieve happiness. We must learn to use happiness as a tool for achieving success. Many of the recommendations for preventing burnout are common sense. Some are as simple as practicing what we preach to our patients. These include sharing our concerns with trusted colleagues, treating our staff the way we would want to be treated, and thinking of our patients as partners instead of customers. We need to take vacations (36% of burned-out physicians take less than 2 weeks off per year, and 5% take none), exercise regularly, and cultivate outside interests and hobbies. And we need to work with our partners and employers to ease administrative burdens, develop a team-based approach to EHR documentation, and work collaboratively with hospitals and administrators on achieving quality goals.

We also need to do a better job connecting with each other, and that starts with being a member of this Academy. I urge you to ask your colleagues to join the SCAFP and attend our annual assemblies. Get involved. Volunteer for a commission or committee. This Academy is the best way to support each other as we work to promote the interests of our patients and profession. Please continue to support the SCAFP and the AAFP with your dues, and help us expand our membership so we can continue the fight for meaningful quality standards and relief from unnecessary administrative burdens.

In his essay, The Myth of Sisyphus, which addresses the issues of suicide and dealing with the absurdities of life, Albert Camus retells the story from another angle. In Camus’ version, Sisyphus comes to accept his burden and finds meaning in ascending the mountain each day. He puts his whole being into the task and finds respite in the purposeful walk back down the mountain each day. For Sisyphus, the “rock is his thing,” and he recognizes that “the struggle itself toward the heights is enough to fill a man’s heart.” Rather than the perfect punishment, the gods had provided Sisyphus with the perfect reward: A life of duty, purpose, and reflection. As Camus concludes: “One must imagine Sisyphus happy.”

As physicians, we should also find happiness in tackling our daily tasks. Unlike Sisyphus, we have the advantage of providing a service that is valued and respected. As we lean into our “rock” each day, reflect that our work is improving the lives of others and that alone should fill our hearts with joy.

This article was published in South Carolina Family Physician.