There is a Japanese concept called “ikigai,” which provides a useful heuristic for spending your time. It is the intersection of what you love to do, what you are good at doing, what the world needs, and what you can be paid for. Its appeal is immediate. After all, it is a perfect use of our lives: find something that merges our unique skills and desires with what benefits society and what society values. Bliss!
I think ikigai is important for our lives and jobs in medicine. In a prior column, I talked about the importance of directing skepticism to the domains that cost more, have more serious harms, are invasive, where reason can persuade, etc. I made this argument to persuade the younger generation to shift their energies because I believe more net benefit to society would result from this shift. Here I wish to focus on those of us who spend time with patient care or traditional scientific research. How can we make better use of our time within our fields?
Be hard on yourself
A colleague of mine examines his CV every 5 years and color codes all his projects. Was this high impact (green) — something that would change how I practice or make a difference in the lives of others? Modest impact (yellow) — something that helps others, but bolsters or supports other ideas and not drives change by itself? Or low impact (red) — the work was sound, but unlikely to have any real effect? Then, going forward, he makes it a point to say no to yellow and red projects, so he has time to say yes to green ones.
For years, I have done something similar. I divide my work into thematic areas and ask for each group: are we changing the field or at least changing minds? A year ago, I decided that on the topic of physicians’ financial conflicts of interest, we had reached stalemate and were unlikely to change anyone’s mind. All of the work we had done, which I thought was clever and persuasive, was most likely merely preaching to the choir. I discussed with my research team, and a few colleagues, they agreed: we could publish another 20 papers but would not swing more votes. We gave up that line of research.
This is also a reason why I enjoy working on topical issues. When an issue is new, is fresh, there are lots of swing votes. If you persuade people of sound principles of evidence-based medicine in these moments, eventually they apply those to situations where ideas are more ossified. Picking on a longstanding practice is challenging.
My point is that life is short, and one cannot bang on about something if one feels that further work in this direction is unlikely to improve outcomes for people, change minds, or impact others. The world doesn’t need preaching to the choir. Now before you find something I wrote or do that you think violates my rule — remember, this is all in your own estimation! For better or worse, I still believe in causes on which I write.
Make your own decisions
We all outsource some decisions. Recently, I bought a particular brand of TV based on the recommendation of a trusted friend. The truth is, I didn’t care enough to do the research myself, and assumed he did. We cannot do the same thing in our practice and research.
We all learn in medical training to trust but verify. For instance, if someone tells you about a past echo or CT scan for a patient, you should trust them, but later it doesn’t hurt to read the report yourself. How often have we found a critical detail was neglected? The same applies to your beliefs on complex issues and topics. Verify what you are told.
And yet we live in a moment, where it is increasingly easy to not do this, to trust someone else’s interpretation of the data. The problem is they too may be relying on someone else, and so on and so on. When beliefs are not independently arrived at, tribes form, and hostility, and you become a little less you, and more the product of other’s wishes and desires. Society does not benefit from these coalitions — in fact, they tear us apart. If you wish to pursue ikigai, you have to reach conclusions yourself.
Who pays, and for what?
The last part of the equation I wish to push on is payment. Medicine, like all professions, is to some degree influenced by money. In our lives, we all must consider it. It affects the choice and prestige of the specialties. It affects the specific activities we take part in at our work. A few extra weeks of service may sound onerous, but less so if it compensates well.
One of the four ikigai principles is to do what pays. But in medicine, we have some control over this. Our field decides how procedures and cognitive work are reimbursed. We have some say over what pays well versus poorly. We desperately need for reform. The specialties that draw the top step 1 scoring students have few spots. Meanwhile, primary care could use a boost. Hours of follow-up are essentially uncompensated. These imbalances must be fixed.
In order to serve society, and ourselves, we must reimagine how medicine should pay. So many of the challenges we face could be solved by reimagining what we need more of, and what we can do with less, and paying accordingly.
No matter where you are in your career, you have to think more about finding your purpose. That comes when you are good at what you do, and take pleasure in it, while providing a benefit to society, which values your work. This process needs continual reassessment. Entire chunks of your workweek or large projects may no longer have impact or ability to persuade. If this happens, you should abandon those efforts, at least until you have a better approach or new idea. Finally, when what society needs and what society pays for are misaligned, we have problems — this is true in the pharmaceutical industry and the way we pay doctors. Correcting them could give us all more purpose. In the meantime, we have to find it on our own.
Vinay Prasad, MD, MPH, is a hematologist-oncologist and associate professor of medicine at the University of California San Francisco, and author of Malignant: How Bad Policy and Bad Evidence Harm People With Cancer.