life Work

Deep Thoughts on the 20% & Margin in Medicine

September 21, 2021

I was going to run this morning but it is pouring.

Instead I will contemplate 2 things I have been thinking about, as inspired by Cal Newport.

I feel like my life is reasonably deep. Usually.

The First: This post, on the idea that “many knowledge workers end up toiling roughly 20% more than they have time to comfortably handle.”

I was somewhat struck by that for two reasons:

a) Personally, I do have the tendency to take on more than I can comfortably handle. I always have — even thinking back to my teens. I typically make things work, but I would not always call it “comfortable”. I’d love more margin, but not enough to actually . . . do fewer things.

b) Cal’s own endeavors seem far beyond what most people can comfortably handle, though perhaps there is something I am missing here. They are certainly well beyond what I could comfortably handle.

Not saying this to disparage; it’s just kind of funny to me because the idea of “less” and “margin” seems great in theory but is incredibly hard to put into practice when you have a number of things you want to do (as both Cal and I both seem to) and a limited time in which to do them (presumably). I know there is a recent time management book by Oliver Burkeman — Four Thousand Weeks — on this subject. I am definitely planning to read it!

The Second: In ep #131 of his podcast, a UK physician wrote in about having trouble getting much deep work done on her non-clinical days after working very long and focused hours on her non-clinical days. He pointed out that perhaps her body / mind telling her to rest on those non-clinical days is absolutely right, since she is already putting in ~30 hours of focused time.

He suggested that she make her other 2 days more relaxed, build in self-care rituals, start later, aim to do a few hours of quality work each day. I thought this was a great answer and absolutely felt seen by both Cal and the physician as sometimes I find that I just cannot sustain the same pace/level of concentration for hours in a row on non-clinical days.

But, I also thought about how not everyone has non-clinical days. Josh rarely gets a chance to have a slower paced day and is essentially entirely clinical. (I do think for him, his time in the OR is such a different kind of ‘work’ that it breaks up the types of demands a bit. But it’s still definitely not recovery time and would likely meet the criteria for Deep Work, as it takes concentration and a fresh-out-of-college grad could not be quickly trained to operate).

This past weekend, Josh and I were talking about wellness interventions that might actually work, and came up with the idea that perhaps every physician should have a 4 day work week. Doing this thought experiment, would it be likely to objectively improve wellness? As this intervention likely would cost $$$, would most physicians be willing to take a 20% pay cut to do it (assuming that clinical duties were truly reduced by 20% — which would be tough to do in reality, by the way)? I’m guessing “no”, but logically does that make sense when most doctors earn far above the ‘diminishing returns’ threshold for happiness? How about a mandatory “rest day” after a stretch of call? What if building in more rest and recovery actually made medicine safer/more efficient and didn’t actually cost money in the end? What if efficiency could be built into the system so that a provider could get help with things like charting and work fewer hours overall (ie, the way scribes assist some doctors in certain fields already)? All interesting questions to ponder.


  • Reply Amanda September 21, 2021 at 7:08 am

    So many good thoughts here. I definitely agree that I can’t sustain 9 hours on my non-clinical days. I actually only have 1.5 days of “Admin” per week but I don’t have any significant leadership roles in my group yet. But that much clinical time often leaves me worn out for those Admin blocks. I’ve sort of started accepting this and either go in later or leave early around 3-3:30 PM to get some errands or a workout done before my childcare is up for the day. I am not making as rapid progress on my work goals as I originally envisioned, but I am making progress and providing good care to my patients so I think that’s OK. I’m actually contemplating asking what a 0.9 FTE contract would look like next year after my contract is up to have a day off every other week. I’m fortunate that with my husbands salary we could definitely take a 10% pay cut, but skeptical about the workload actually being 10% less.

  • Reply gwinne September 21, 2021 at 7:47 am

    Really fascinating to contemplate. I’m reading Four Thousand Weeks this week and find it really inspiring.

    I don’t have a long comment in me but I think Cal would quibble with your use of “deep” here. You have an unquestionably full life, as does he, which I think is your point.

    But “deep work” goes to a kind of practice (focused, sustained) rather than a quantity. You could have a part time schedule and still do deep work….and you could work an insane number of hours on “shallow” activities.

    I say this mostly as I’m also thinking about these kinds of questions, having too many “shallow” tasks that get in the way of “deep work” which is what I’m really paid to do…

  • Reply gwinne September 21, 2021 at 8:18 am

    Still thinking through this….

    Would it be possible to cut the number of clinical hours (i.e. the amount of time Josh spends in surgery) without taking a pay cut? Just wondering the extent to which that 20% margin translates across fields, as you suggest.

    Theoretically I could cut that 20% without sacrificing my major duties, changing my hours, or salary. On the flipside, there is no possibility of taking a .8FTE position. (I couldn’t cut a class, my research requirement, service obligations, etc.) But the random requests that come my way to do X, which is a ‘nonpromotable’ and uncompensated task? [i.e. reading manuscripts of students who are not in my classes?!] are largely accepted or not, by me as an individual without my immediate supervisor knowing about it. A way in which “knowledge work” can be distinct.

    Thanks for the thought experiment this morning!!

    • Reply CBS September 21, 2021 at 8:33 am

      Yes, I’m an academic and I went to 0.8FTE when I returned from mat leave, and honestly, I enjoyed that extra day with my kid, but it didn’t change my work requirements at all. I think you’d have to take a more significant hours cut to dodge that big class you hate teaching or an annoying admin role.

      I am starting a new job in a few weeks and am trying to think about how I structure my weeks. I’ll be on campus Monday, Tuesday, Wednesday, with teaching Monday/Tuesday and I know from past experience, I’ll struggle to write on teaching days. I can prep lectures, hold office hours, deal with admin tasks, maybe write an abstract or a blog but I need more focused time for anything substantive. I’ll be travelling to the job so trying to push emails and easy admin to the plane/bus time, since that’s “wasted” time. Packing good novels for the evening time so I’m not tempted to fill it with more admin or the scroll. When I’m home, I want to be able to write and spend time with my child and husband. We’ll see how it works in practice, but start as you mean to go on, I think.

  • Reply Gillian September 21, 2021 at 9:56 am

    I changed my schedule last year. I am 100 % clinical and see patients for about 10 hours a day 3 days per week. I then have two non-consecutive days for “admin” on those days I only work for about 4 hours from home while my kids are at school. I just did a week of time tracking and I am still working about 45 hours per week (I do some admin on 1-2 weeks nights and for a couple of hours on Sunday afternoon). 10 hours of seeing back-to-back patients is no joke, but I feel like when I am in that mode it is much more efficient to stay in that mode. On my admin days I exercise, cook, hang out with my kids and generally do life. One thing I want to try to implement is a block of time on Friday morning for more creative/speculative work (like Laura and Dorie Clark discussed on today’s BoBW). But overall the 3 long intense days and 2 more relaxed balanced days is working well for me.

    • Reply Elisabeth September 21, 2021 at 11:57 am

      This sounds like such a great system. Doing “life” during the week feels like a great way to trade-off from having 3 very intensive days. It would also make it feel more doable to fit in a few loose ends from work in fringe hours (evenings, weekends).
      One of my friends is a GP and she made the decision years ago to go down to a 4-day week (aside from call/hospital rotations). Friday is strictly an admin day. She goes to the office and completes charts, does some other work responsibilities but never sees patients. I know she still feels very stretched with a young family, but knowing she has a a more flexible day on Fridays – and that she has a place to push all the admin each week so it never accumulates too much – is a huge relief.

  • Reply Kathy September 21, 2021 at 10:18 am

    My father is a physician, and while I was growing up he regularly had four day work weeks. He’s a radiation oncologist, 50% of his patients are there for palliative care, and he wisely recognized that balance was key if he was going to stay in that profession long-term. Selfishly, it was wonderful to have him at home on that “off” day. Five years before he retired, his practice was bought out by a larger medical company, and not only did that day off disappear, but he had to bring his work laptop on vacation. It was striking to see him working on treatment plans at the airport between flights, when before “vacation” truly meant time off.

    The 20% is hard. In theory, I agree with Cal. In practice, the middle class is more precarious than it was forty years ago. I did more to get into a good college than my parents did, and my students today do more than I did. It’s one thing to cut back when you have security (tenure, an established track record at your job, making partner, etc), but cutting back early in your career could make it harder to gain that security. There is likely an added layer of this for people who are underrepresented in their fields. I’d love to see Cal grapple with this aspect of work.

    On Cal’s podcast, a caller asked about being exhausted the day after teaching. Cal’s answer centered on closing open loops. To my mind, he completely missed the performative aspect of teaching and the emotional energy required to engage students and manage a classroom. Is there a similar draw on emotional energy during clinic days that contributes to fatigue?

    • Reply Sarah Hart-Unger September 21, 2021 at 10:33 am

      There is a huge outlay of emotional outlay during clinic. And definitely a “performative” aspect as well, one that has to rapidly adjust to each audience.

    • Reply Elisabeth September 21, 2021 at 11:53 am

      I wonder (gender average, not stereotype as I love Sarah mentioning) if this emotional energy drain tends to impact women more directly. I would warrant a guess that is absolutely does.

      While my husband gets heavily invested in work challenges (business executive), he is able to detach himself emotionally from personnel issues, stressful negotiations, high-pressure meetings in a way I could never manage.

      I have gleaned some great fodder from Cal Newport’s work, but it always feels so heavily skewed toward men that I’m often yelling at the book/podcast/screen, sometimes literally. In discussing his own deep work he largely avoids avoiding talk about his incredibly supportive wife who, reading between the lines, does a tremendous amount of “shallow” work with family and home responsibilities so he can go deep. I also think that this emotional burden is going to disproportionately impact women who are already carrying more emotional responsibility at home and in relationships more generally? This is both a blessing and a curse; I think women’s emotional intelligence is a HUGE asset, but it can feel like a crushing liability if there isn’t enough white space cooked into the schedule to allow for recuperation…

      • Reply Seppie September 22, 2021 at 7:17 am

        I also get aggravated with Cal’s podcast on a pretty regular basis. He seems completely blind to the ways that gender influences experience and outcomes. One example is that he went through a phase of being like, huh, weird that no one has really talked or written about household management and the time that takes. I think that must be a result of having no female productivity authors on his radar. Though he professes to be an LV fan, and she def talks about time management of household labor! And he’s super dismissive any time someone asks what his wife’s days look like, or when she gets to do deep work.

        I also think that he just made up the 20% over number, and now is talking about it as if it’s fact. (Side note, I know that life is different for docs and lawyers than for many other professions, but I don’t think it would have crossed his mind that you would get rid of the extra 20% by going to .8 and taking a 20% pay cut. I think the idea is that you’re already working at 120% of capacity in 100% time, and that you will feel less stressed if you knock it down to 100.)

        I guess over all I just wish Cal had a little more curiosity and awareness outside of his own sphere. One more example – a listener asked a question about wanting to outsource pretty much all household tasks, but worrying about having relative strangers around all the time. Cal’s response was something like, hey, no big deal to have people on your property once a quarter to clean out the gutters. I don’t think it ever crossed his mind that the listener was thinking about cooking, laundry, etc.

        Anyway, I AM a fan of his books, but can only stand to listen to the podcasts sporadically.

  • Reply Irene September 21, 2021 at 12:16 pm

    So interested in everyone’s thoughts here. I can’t imagine how draining even one clinical day would be, maybe because I’m fairly introverted? I think people get drained by different things. When I am working on something with a difficult judgement call, that’s probably the hardest for me. I like to think I think hard about my work and it can be hard to know when I have done “enough”.

    One of the best things about working at home is the ability to take a real break when I’m burned out by focusing super hard. Like going for a walk for 15 minutes or so instead of scrolling on my phone which would for some reason be more acceptable than getting up and moving around in the office.

    I think the hardest thing about being a working parent is the lack of recharge time. If I am not working I’m parenting which is wonderful but hard in a different way especially if I’m worried about one or both kids. So it’s hard to recharge when work is a lot emotionally. I also feel like the pandemic just added and added stress onto an already heavy emotional load for so many families and it’s hard to figure out how to recover when it seems unending.

    I guess stay at home parents probably have a similar problem, unless they have child care to let them recover. I don’t know, I’m feeling sad my oldest is getting out of “little kid” territory but right now also just feels like so much.

    • Reply Michelle September 21, 2021 at 5:49 pm

      I work purely clinically (as an Optometrist) and am very much an introvert. I only had the option for 5 days a week because I needed the healthcare for our family. It was incredibly draining and I don’t know how I did it so long. I was seeing more and more patients since the pandemic began and even had my lunch taken away from me.

      So.. I finally found a position where I can work 4 days a week (32hrs) and still have healthcare. It is a dream!! I highly recommend the 4 day schedule to everyone. However, if I could somehow find some non-clinical position, that would be the real dream!

  • Reply Christina September 21, 2021 at 12:44 pm

    Ah, yes, Cal Newport and deep work. I am a fan of his and I listen to the show but I often have difficulty implementing his strategies on a consistent basis.

    I think his advice is very good for people who have largely self-directed, output based jobs, where the main thing that matters is having excellent work published.

    As a lawyer, yes the quality of your work matters, but to your firm’s bottom line, it is the number of hours billed that is key. There is no benefit to getting a 6 hour job done in 4 hours. You will still need to find and do an additional 2 hours of billable work somewhere. In other words, there are no “economies” by doing deep work really– any time saved is put right toward some other work. And I am also tired by doing mentally taxing work such that filling all moments of my life with meaning is just exhausting.

    I also hear him sometimes have almost like a caveat on his podcast about deep work as a parent of younger children or babies. He recognizes that not a lot can get done on any sort of level, much less a deep level, when there are kids around that need tending. I agree, but as I have 2 kids (one of whom is a toddler!), that recognition doesn’t really help me all that much.

  • Reply Chelsea September 21, 2021 at 12:58 pm

    I think I remember Cal saying that he also felt like he was doing too much but – like most of us – there wasn’t really anything he was willing to give up. I’d have to guess that part of what makes his schedule work-able is that he really doesn’t teach very much in his “real job”. I feel like I remember him saying he only teaches one class a semester or even just once a year (which would be totally normal R1 with a big research emphasis). So he actually does have a lot of normal, 8-5 time to do all of his side projects.

    +1 to being in awe of people who are able to sustain that “on” focus you have to have as a physician, surgeon, teacher, SAHP, etc. My friend’s husband is a tugboat captain on the Mississippi River and he has – hands down – the most grueling schedule I’ve ever heard. He works 6 hours on, 6 hours off for a month straight, every other month He lives on the boat the entire time and has to squeeze in eating, sleep and any personal communication during a 6-hour off block. She said when he gets home, he’s absolutely wrecked.

  • Reply gwinne September 21, 2021 at 1:18 pm

    I’m interested in all the related questions this thread has opened up, including numbers of hours worked, the type of work, the significance of the work, the location of work, and the approach to the work, among them…

    In my own case (university professor in humanities field), I find teaching *exhausting* (because all the social interaction as introvert) and *meaningful* but teaching days are not my “deep work” days. I imagine medicine would be similar? I’m really not sure how much Cal’s “deep work” translates beyond what he terms “knowledge work”?

    To the childcare question…..I could work 40 hours doing shallow work or 40 hours doing deep work and I’d require the same amount of childcare. (I’ve heard Cal make this point)

    • Reply Abby October 7, 2021 at 11:46 pm

      It doesn’t seem that he does extend it much beyond knowledge work. I just listened to Podcast #123. The first point he made is that most us are making “deep work” too esoteric; he defined it operational as focusing on a single knowledge task, without distractions like email, until you reach the next stopping point. It doesn’t have to be particularly long or produce a magnum opis to be deep. Then he answered a homeschool mom of twelve was asking how deep work applied to her. He expressed his admiration and The impression I got is that he never meant his concept of deep work to be applied outside a corporate, knowledge work job.

      Also, if you are wondering more about his own child care, work-home balance, he goes through it in detail. I liked that he talked about his template for the day, rather than a “typical day.” Honestly, he seems to do a pretty good bit of both home and work tasks but in his mind, these are separate spheres of life. I think we all need to respect the exhausting, fast paced work of parenting better, in which the little short interactions/tasks (making dinner, maintaining the house, teach manners, correcting poor behavior, reading, playing, etc.) are in fact the deep work.

  • Reply Kri September 21, 2021 at 1:26 pm

    I’m a primary care physician and the default in my group is 0.8 FTE, which we all currently divvy up as a 4 day work week. I honestly can’t imagine sustaining 5+ in the longer term!

    • Reply KV September 21, 2021 at 11:03 pm

      THIS. Am also in primary care. Have only ever worked 4 days per week (anywhere from 0.7 to 0.9FTE), and I can’t imagine myself ever working a 5 day week if I was 100% clinical. Maaaaybe a lot of admin or teaching would change my opinion on that, but I doubt it. My weekday “off” is both my recharge day and my “get everything else done day” (dentist, bills, any appointment that’s kid-related, my therapist appointment etc).

      As far as pay, my family is fortunate that my non-physician spouse earns a similar salary to mine. I’ve never felt it necessary to earn more money. Most of my primary care friends/colleagues also happily work 4 days. So there is definitely a segment of the physician population that would like to sacrifice some income to get their time back.

      • Reply JCL September 22, 2021 at 4:27 pm

        Ditto – 4 day/week urologist in private practice. 100% clinical. 3.5 year old twins. Chronic health condition. Many hobbies. Between life maintenance (haircuts, car appts, bimonthly therapy appt, workout classes, meeting with our accountant, vet trips for my pets, my own doctors appts, ad nauseum), those days off fill up VERY QUICKLY. Huge life-saver to have somewhere to put those appointments rather than trying to start clinic/OR late or leave early.

  • Reply Erika September 21, 2021 at 1:38 pm

    This is fascinating. And for me this is a great reminder that some of the balance I had when I worked from home for 15 months has just completely disappeared. I’m largely in my office now and any real breaks have disappeared. I used to go prep dinner for 10min, pick the kids up at the bus (20min roundtrip), walk to the post office, etc. Now I sit at my desk and scroll the internet when I need a mental break from focused work. I’m less active and definitely less happy, but often forget that I had that 15mo holiday from this feeling. Maybe being intentional about working 20% less would help! I’ll be curious to hear how others not in medicine would think about implementing this away from the 1 day off a week approach (not in the cards for me).

  • Reply coco September 21, 2021 at 5:56 pm

    this is something I realized early this year. I should not fill my plate 100% or even 120% which is what I used to do for the main reason that if I do that, I won’t have time to think strategically and forward looking as I was trying to just deliver what is promised. So I had a chat with my manager and asked for 20% of freedom. It has been game changing… as it really allowed me to have space to grow and think bigger pictures and brought much more value to my work because of that. Obviously this cannot happen for everyone nor every manager will allow that, but giving good reason and quick results made a difference.

    my current default is to schedule 4 days week unless something comes up on Friday, which happen more often than not, but mentally it’s liberating to know that I have one day off to do work or self care, which all contributes to better wellbeing which makes me more productive the next week.

  • Reply Emily September 21, 2021 at 6:44 pm

    Hi Sarah,
    I recently discovered you and your podcasts and I am so glad I did! I am a psychiatrist and a soon-to-be fellowship PD so I relate to your work situation. Also married to another doc. Regarding wellness, I am not convinced that working less is a magic bullet for physician wellness. I would rather work 60 hours a week in a state of flow and doing meaningful work than spend 40 or 30 hours a week feeling ineffective. I would argue that some of our clinical work is deep, but there is nothing deep about dealing with EMR issues, tracking down records, fighting fax machines or insurance companies etc. I appreciate that some practice settings are better about these issues than others though. Does your husband more easily find flow in the OR? I almost never feel like I am in a state of flow on my clinical days, unfortunately.

    • Reply Kari (Misspelled my own name as kri above!) September 22, 2021 at 1:12 am

      I gotta say – having done both, I think the 4 day work week is just objectively better. I’m 2 years out of residency, which I found very fulfilling and I think fitting of your description: 60 hours of hard, fulfilling, deep work. I was also a chief resident and had some extra duties in my 3rd year relating to that. It was truly all very meaningful work, and I do not at all miss the volume of it. I now work 0.8 FTE – 4 x 9-10 hour days – and I can’t say I would trade a thing. They’re both hard, but 3 days off of clinical duties per week (and on as a parent/household member/human – and of course with some periodic charting) are what make this career sustainable for me.

      My husband doesn’t bring in a paycheck – he’s home full time with our kids – and finances are a non-issue. We did the same in residency with a much smaller paycheck.

      Just my 2 cents!

  • Reply Sara B. September 21, 2021 at 9:34 pm

    Newport’s podcast has had me thinking about the 20% over capacity theory and how it relates to medicine, too. I work in a setting where we can be quite self-directed about our hours in a physician-led democratic group (EM) – at this point (11.5 years out of training), I can work as little as I want (as long as those hours are fairly distributed across our 24/7 schedule). I’m also immersed in a culture of “work as much as you can”, “quadruple threat”, with other physicians who are very motivated by earning more money and seemingly not much else. We have a few late-career docs with large administrative roles who work far fewer clinical hours, but most of us (including me) hold multiple roles that are each nearly half-time or more. This is not the kind of culture where people would take a 20% pay cut for a significant improvement in quality of life. Its actually otherwise a great group of people and a great place to work, except for this. I think many of our younger docs might prefer a more relaxed way of being, but it is easy to get sucked in. Me too. I’ve just taken on a HUGE leadership position that is the antithesis of the lifestyle-centric career planning Newport talks about. Why? Because its hard to be where I am and not want to be in a leadership role and to do more; because if I don’t step up, the job will go to another hard-charging sole breadwinner alpha male who will perpetuate this culture and I am crazy enough to think that if I stay in this game then I can help change it for others.) I’ve cut back my clinical hours (quietly) to help compensate, and I feel like I have to be careful to be seen as always on while slowly putting up boundaries to craft a more reasonable lifestyle.
    And I laughed out loud at “I’d love more margin, but not enough to actually . . . do fewer things” because you could have been talking about me.

    • Reply Sarah Hart-Unger September 22, 2021 at 5:27 am

      FULLY GET THIS PART: ” Because its hard to be where I am and not want to be in a leadership role and to do more; because if I don’t step up, the job will go to another hard-charging sole breadwinner alpha male who will perpetuate this culture and I am crazy enough to think that if I stay in this game then I can help change it for others.”

    • Reply JCL September 22, 2021 at 4:37 pm

      #1. Kudos on the quiet clinical cutback. Classic Laura Vanderkam 🙂
      #2. Is there a chance that the “hard-charging, sole breadwinner alpha male” is actually the one getting the raw deal? Or, at least, an equally mediocre deal? Like, if he works all time to great accolades and financial success, but has no hobbies, poor health, and hollow relationships, he hasn’t “won”. Not to say that all of these guys fit that mold, but I ran into plenty in my Urology training who did.

      My co-residents and I often played a game called, “whose life would I want,” and it was usually those quiet mid-performers…

      • Reply Haley September 23, 2021 at 12:11 am

        I really like your idea about who “wins”. I’m a psychologist, I work about .6 FTE, and often feel like I have to defend my decision to not add more to my professional plate. When you have the ability to accomplish more and a history of achievement it is baffling to some people that you might not always be striving, they may view you as complacent. But I also have two kids, a husband, hobbies, and want to enjoy my life. Winning looks different for everyone.

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