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Designing one’s life in medicine
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  1. Lynae Conyers1,
  2. Scott Wright2
  1. 1 General Internal Medicine Fellow, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
  2. 2 Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
  1. Correspondence to Dr Lynae Conyers, Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA; lconyer3{at}jhmi.edu

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Introduction

Design thinking is both a mindset and a practice; it is a method for problem solving that uses specific approaches, including empathy and prototyping, to discover creative solutions via an iterative, human-centred process. These methods were originally applied to the designing of goods and services, and it has been lauded for inspiring creativity that emerges from a genuine understanding of the needs of the end user. Design thinking is now taught in many fields, including business, information technology, engineering and education, to name a few.

As detailed in the book Designing Your Life, authors Burnett and Evans have adapted the design thinking framework and applied it to an area they term ‘life design’.1 In the book, they describe design thinking principles that ultimately translate into an approach for crafting a well-designed life through the application of specific regular practices that may facilitate flourishing through proactive living. In explaining the rationale, they elucidate benefits of this approach well beyond having confidence related to where one is heading and expound on the perils of failing to thoughtfully chart a course forward. The authors began by teaching life design courses to undergraduate students at Stanford who fretted about their futures and how to build on their early successes. In their teachings and book, they define a well-designed life as ‘one in which who you are, what you believe, and what you do all line up together’.1 From preliminary studies, data suggest that students participating in life design were both better equipped to envisage their desired career and felt emboldened for the actual pursuit.1

While the potential utility of these life design tools and lessons for a pluripotent 20-year-old college student is easily imagined, what might be their practicality or benefit for those who are further differentiated? Burnett and Evans assert that these principles can be learnt and applied at any point in one’s life. For example, in the field of medicine, the decision to become a doctor is only the tip of the iceberg, and the paths that lead from there are numerous and diverse. One career-related decision quickly begets others. Of particular interest to medical educators and mentors in medicine is how these concepts might be applied to designing a professional life in medicine.

Missed opportunity

There is considerable and compelling evidence that many in medicine are unhappy. Physician burnout dominates our current professional discourse, understandably so given a prevalence of around 50%.2 While burnout is not unique to medicine, trainees and early-career physicians are disproportionately affected by burnout compared with age-matched college graduates in other fields.3 Similarly, depression is high among resident physicians with a summary estimate of 28.8% in a recent meta-analysis.4 Among all physicians, death by suicide is higher than in the general population.5 While the reasons for these sobering statistics are certainly multifactorial and complex, might part of the equation be a mismatch between values or expectations and the lived experience in the profession? If so, could some of it be mitigated by exposure during training to a life design process that encourages regular self-exploration and reflection about enhancing the congruence between one’s view of life and work?

Trainee attrition may also offer insight into a need for life design in medicine. According to the Association of American Medical Colleges (AAMC), among American medical students not obtaining dual degrees, approximately 3.5% do not graduate within 8 years, which is used as a proxy for never completing training.6 At the graduate medical education (GME) level, approximately 1100 trainees fail to complete their training each year in the USA.7 While the absolute numbers are not high, preventing loss of trainees during medical school and residency is a desirable goal, given the global concerns about a looming shortage of healthcare professionals. In the case of residency training, individual programmes become pointedly stressed to balance coverage within their hospital with the loss of even one person. Losing a resident during training creates a ripple effect, placing much burden on the system and remaining residents to cover shifts, often at the expense of elective time and even vacation. Might this be indicative of a missed opportunity for improved career guidance earlier on in the training process? One could take a similar view of the common practice of medical students applying to and ranking multiple specialties during the residency application process. Dual applying, or ranking more than two types of training programmes, may reflect systemic constraints; this may be expected to occur when applicants apply to programmes for which there are a limited number of spots for training, making the match highly competitive. In such instances, however, trainees are truly not designing their lives but are instead leaving their futures, and the decision about how they will spend their professional working lives, up to someone else.

Medical training is a long and seemingly linear process; 4 years each of college and medical school, followed by residency training, perhaps fellowships, and then the eventual ultimate job. Along this journey at every stage, once one career decision has been made, several more quickly follow. Myriad factors are known to influence career decisions in medicine, including role models, mentoring relationships, financial considerations and work–life balance.8 Current strategies employed to assist medical trainees with career decisions vary across undergraduate and GME. For medical students, clinical rotations serve as an essential part of experiential learning of the practice of medicine and also afford learners the opportunity to have a front-row seat for observing what life is like in a given specialty. However, students must be thoughtfully observant to truly take in this information, and many are overly concerned with soaking up knowledge or impressing supervisors to appreciate the details of their teachers’ lives. Further, the time dedicated to clinical rotations is limited, making it impossible to show learners many of the adjacent possibilities. This is why career exploration is increasingly being incorporated into the formal curriculum in several ways, such as longitudinal courses dedicated to career and specialty exploration. Pairing medical students with faculty advisors, either one-on-one or in groups through ‘learning communities’ or ‘advisory colleges’, is being tailored for career decision support and mentoring by many institutions. Extracurricular programming, such as specialty interest groups and shadowing experiences, is also being used to create more opportunities for career discovery.

After trying to make the right choice for residency training, the choosing and life planning is far from over, even if the student was lucky enough to match in their preferred GME programme. Prior work among internal medicine residents discovered that career plans change during residency for nearly two-thirds of trainees, often late into residency training.9 Best practices for helping residents to plan their careers and lives in medicine are not known. A primary strategy has been a focus on mentoring relationships. Residents also use elective time to explore potential desired specialties. Qualitative studies have described residents’ career planning needs during training; it is suggested that residency experiences and exposures alone are inadequate for the structured career exploration that is needed and desired.10 These authors also learnt that residents specifically want to be able to discover more about career opportunities and to access enhanced guidance and mentorship in this area during residency training.10

Life design in medicine

Life design principles can be helpful for all in the formative years of career development, and they should be effectively used to assist medical trainees to map out their careers. Select practices from the book may be especially relevant to career decisions in medicine.

Pursuing meaningful work

Building a compass is one of the first exercises introduced in the book Designing Your Life.1 The process begins with the writing of two brief essays, one detailing one’s ‘lifeview’ and the other one’s ‘workview’; questions around the purpose and meaning of life and work are explored in these pieces. Next, one is encouraged to reflect on how these views are complementary versus conflicting or incompatible. The ultimate goal of this task was to seek congruence between ‘who you are’, ‘what you believe’ and ‘what you do’. Experts on burnout in medicine contend that engaging in meaningful work may be the quintessential antidote to allay, or even prevent, burnout among healthcare professionals. Faculty retention within academic medicine is bolstered by facilitating engagement in meaningful work, particularly that which falls at the intersection of the individual’s values, passions and strengths. This guided introspection is constructive because it thwarts the devastating pitfall of ‘living someone else’s life’, such as allowing external expectations (eg, family) to guide pursuit of a particular specialty or medicine in general for that matter.

Achieving awareness through reflection

Another concept emphasised repeatedly in the book that is relevant to planning a life in medicine is wayfinding. This is defined as learning to navigate when the end point or destination is not clear.1 Practically, the authors encourage taking stock of one’s regular activities, noting where one feels most engaged and then using this information as a guide for future endeavours. The value of reflection in professional growth in medicine is well established. The reality is that, with long duty hours and seemingly endless material to master, residents are often in ‘survival mode’ moving from rotation to rotation, thereby making it difficult for true reflection on the future beyond one’s next day off. In this context, structured or guided reflection such as that described in the book could be extremely useful for trainees as they navigate career exploration and decisions. While the final destination for careers in medicine may be several steps beyond where residents reside, reflecting on what the career is expected to be like at multiple points in the future for those in that field (both the ‘work’ and the ‘life’) is necessary.

Considering provisional selves

A fundamental way to gain useful insight on any plan in design thinking is prototyping. In design, it involves creating a preliminary, scaled-down version of the product to bring the ideas to life, to test the practicality and to get feedback. An equivalent in life design involves trying out different options or genuinely imagining provisional selves. This can happen across preordained curricular elements during medical training, such as rotating through the core clerkships as a medical student, or via subspecialty services or electives during residency training. However, a notable limitation for trainees using clinical rotations for true prototyping is competing priorities. Their focus is understandably on getting a top grade or securing a needed letter of recommendation, and they may be too busy or distracted to reflect on whether they can truly see themselves thriving in a particular area of medicine or role. If life design is to take hold in medical training, it may require the creation of opportunities for trainees to explore possible future selves in low-pressure, low-stakes situations. A closely related practice outlined in the book is the ‘life design interview’, where individuals are encouraged to conduct an in-depth interview with those who are living a life they may want to emulate.1

Conclusions

Undeniably, designing a professional life in medicine is not a simple task. Looking admirably at the careers of successful role models and mentors in medicine can often give the false impression that the path is linear and that the destination was clear from the beginning. Many medical trainees and physicians may not be devoting adequate attention to life design in medicine. Those of us who have the honour and responsibility of working with medical trainees may need to more proactively assist them with the often daunting, soul-searching task of career exploration and planning. Some of the tools described in Designing Your Life, if not the book itself, might be incorporated into the medical education curriculum.

Acknowledgments

Dr Wright is the Anne Gaines and G Thomas Miller Professor of Medicine and is supported through the Johns Hopkins Center for Innovative Medicine.

References

Footnotes

  • Twitter @GIMMedEdDoc

  • Contributors LC and SW developed the presented idea. LC wrote the manuscript. SW provided critical feedback and revision of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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