Taking the Reading Cure for Physician Resiliency

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Illustration by Jim M’Guinness

The Pharos/Spring 2020 11
Taking the reading cure
for physician resiliency
Abraham M. Nussbaum, MD, MTS
Dr. Nussbaum is the Chief Education Officer at Denver
Health and Hospital Authority, Denver, CO. He is Associate
Professor of Psychiatry, and Assistant Dean of Graduate
Medical Education at the University of Colorado School of
Medicine, Aurora, Colorado.
When you are a psychiatrist, people avoid you
until the end of the party. They joke about how
you are analyzing them, or throw their hands
over their heads to prevent you from reading their thoughts.
Most partygoers avoid “shrinks” until the lights are low-
ered. Then they gravitate over to tell irrational thoughts
and dark desires. Addiction, depression, suicide is the kind
of cocktail talk happening at physician parties these days
where the theme is often burnout. At these parties, there
is a chance for the shrink to tell his/her own burnout story.
Since I am a shrink, I usually start with my mother.
She read her way from a violent childhood to a liberal arts
school. When she became a mother, she read stacks of books
to her children. One year, we checked out so many books
from our local public library that they created a plaque de-
claring us the “Library Family of the Year.” I read constantly.
My mother prescribed Jane Austen novels, but toler-
ated Marvel comic books, before anyone imagined they
would dominate multiplexes, and Rolling Stone magazine,
back when rock music ruled the airwaves. I fell into their
pages, reading issues over and over again until I had saved
enough to purchase more issues from the used bookstore.
I developed favorites—Jim Starlin’s comics, Greil Marcus’s
criticism. My reading habit changed me.
Reading increased my attention span. I pursued longer,
more complicated narratives. I burrowed backwards from
Marvel Comics to Greek myths, whose characters they
pirated. I traveled forward from Rolling Stone to DeLillo
and Faulkner, whose styles they aped. I traveled time and
space in my mind. The journeys complicated my thinking.
Instead of heroes and villains, good and bad records, I
began to understand how the same person can be hero
or villain, and how a bad record is sometimes the one to
which you want to dance. Reading built up my interior life.
Increasing connectivity
Neuroscientists know that on the days you read a novel
you increase the connectivity between the left angular
supramarginal gyri and the right posterior temporal gyri,
portions of the brain associated with story comprehen-
sion and perspective taking.1 When you read a novel with
which you are emotionally engaged, you exhibit more
empathy.2 Reading prolongs your life, slows memory loss,
improves mental flexibility, deepens self-reflection, and
reduces stress more effectively than a coffee break. When
you read fiction on Monday, neuroscientists can identify
increased connections in your left temporal cortex and
central sulcus on Thursday.3

Taking the reading cure
12 The Pharos/Spring 2020
Reading connected me to places I had only imagined,
taking me from a public high school in Colorado to a pri-
vate college in Pennsylvania, from working for homeless
people in Chicago to working with a North Carolina bio-
ethicist whose office was in a literal ivory tower.
Then I read my way into medical school, where
rote memorization and rapid
regurgitation replaced Russian
fiction. I was quickly habituated
to constant work without deep
reading. I read as what Nicholas
Carr calls a power scanner, skim-
ming multiple texts at the same
time for their content without ever
falling into a text. I read in the
shallow end.5
There were moments in the
deep end. The medical humanities
faculty assigned readings that re-
minded me why I endured medical
school.6 I met a classmate who also
loved books. I fell in love with her,
and in the words Brontë wrote for
Jane Eyre, “Reader, I married [her].”
Clinical work was a series of
alarms and alerts, call nights and clinical crises, which
required immediate responses formed from instinctual
behaviors at the base of my brain.
6
By the time I reached
residency, the work left me in the shallows. I read ab-
stracts instead of journal articles, pull quotes instead
of essays.
Books became decorative accents instead of
interlocutors.
While the work exhausted me, it also formed me into
a physician who could efficiently diagnose and treat a
patient. With clinical skills, I was employable. I inter-
viewed for jobs across the country, but came home to live
near—but not too near—my mother. I took a job at Denver
Health, an academic safety-net system affiliated with the
University of Colorado, attending on an inpatient psy-
chiatric unit with indigent patients experiencing mental
health crises.
Seven solutions
Symptoms of Maslachian burnout were absent. I
experi-
enced personal accomplishment and professional efficacy,
but never emotional exhaustion, depersonalization, or cyn-
icism.
8
During training, I had been overworked to the point
of dissociation, fatigued to the point of narcolepsy, and
overwhelmed to the point of breaking a pager by throwing
it across a call room. But as I began life as an attending, I
was armed with solutions to prevent burnout.
The first solution was a paycheck. After years of living
with a single car and moonlighting every golden week-
end to pay for childcare, we ascended into the magical
zone where money buys happiness.9 We
bought an additional car—which did not
leak motor oil—and paid for childcare—
which was not sketchy—out of our reg-
ular salaries.
The second solution was a place.
Physicians can find employment across
the country. I returned to Colorado for
the climate, the climbs, and the cous-
ins among whom we could raise our
children.
The third solution was sleep. I knew
the health benefits of regular sleep and
took a job with a large call pool and
a dedicated psychiatric emergency
service so my sleep would be consol-
idated for the first time in a decade.
The fourth solution was mission.
Eighty percent of my patients were
uninsured. All were profoundly ill. Denver Health’s re-
sources were limited, but its care was not, and it inspired
me to join a mission-driven organization.
The fifth solution was teaching. Teaching medical stu-
dents and residents made me a better physician.
The sixth solution was improvement. The hospital
adopted Toyota Lean strategies decades ago, embedding
process improvement into the institution’s egalitarian and
collegial culture.
The seventh solution was exercise. The hospital had a lit-
tle gym, so I started using its elliptical machines three days a
week in an eff
ort to regain the fitness lost during residency.
But some stresses cannot be sweated out and some
problems overcome all your solutions. I achieved full
discouragement after a few years. A physician left our
practice. The hospital kept his position open for 
months, doubling my caseload and halving my attention
to each patient and student. When a patient had a bad
outcome, it triggered an investigation. I was perversely
relieved, believing the investigation would induce real
reforms. Instead, the investigation increased documen-
tation burdens, which meant less time with trainees
and patients. While multitasking patient care, medical
education, and childcare, I was skimming and scanning
in the shallows.
1. Paycheck
2. Place
3. Sleep
4. Mission
5. Teaching
6. Improvement
7. Exercise

The Pharos/Spring 2020 13
effect change while teaching me why my seven solutions
had faltered.
Valuing the seven solutions
The paycheck taught me to value labor with pay. When
you value money, you think about how much you have. It
is never enough, so you think about how much you don’t
have. When you value labor with time, you think about
how and with whom to spend your time. We redoubled
efforts to live below our means, reprioritized our student
loans (they expire in ), and declined remunerative but
distracting opportunities.
The place became harder to appreciate as commutes
grew longer and our children’s school suffered under poor
leadership. We thought about leaving, but the reading cure
taught me to engage the place differently. I started bike
commuting and volunteered as our son’s middle-school
basketball coach. We lit our corner instead of fleeing it.
My sleep fragmented and shortened as I accepted more
responsibilities. The reading cure taught me to wake early
and begin the day with deep work, to (almost) never chart
or answer emails at night, and to keep one weekend day
as a Sabbath.
Our mission became obscured by relentlessly pursuing
deliverables. As new administrators asked only about
relative value units (RVUs) and return on investments,
the mission of attending to the indigent eroded. Morale
sank. Good physicians and nurses fled. The reading cure
reminded me why we built public hospitals in the first
place. Refocused on the mission, many good practitioners
stayed to outlast the administration.
My teaching thinned as I gave the same chalk talks
weekly. To broaden my skills, I enrolled in a course for phy-
sician-educators and learned to lead educational programs.
Our improvement efforts led to metric-chasing. The
metrics that the Centers for Medicare and Medicaid
Services uses to measure work as an inpatient psychiatrist
are items for smoking cessation, alcohol use, and antipsy-
chotic polypharmacy. Each are necessary, but insufficient.
The existential questions asked by my patients—how can
I survive my despair, and how can I forestall psychosis?—
are not assessed. While facing their questions, pursuing
metrics about discharge medications and immunization
rates seemed beside the point, so I rechanneled improve-
ment activities into real betterment.
My exercise stagnated as I went nowhere on that
elliptical machine. I read that resiliency was improved
by challenging activities, so I joined a CrossFit gym and
learned to move in a manner I never imagined. I met
I fantasized about quitting.
Then the only other remaining doctor on our service
suggested I apply for a moonshot grant which offered
to pay half of my salary for two years to study alien-
ation among physicians. I read the application materials,
PubMed-stalked the primary investigators, and prepared
an application proposing an online survey of alienated
physicians. I showed the application to my wife who asked,
“Is a survey really what you want to do? That is a wild
grant. You should give them a wild idea.”
I scrapped my application and wrote a fantasy proposal
to critically read physician memoirs to understand medi-
cine’s current crisis.
The reading cure
When I received the grant, fantasy became reality, and I
began the reading cure. Every other month, I was relieved
from clinical duties to read deeply. After dropping off our
children at school, I would lay on the couch, reading for
hours. I found it hard to concentrate. Wasn’t there a page
to return, a patient to see, a student to supervise, an e-mail
to respond to? Eventually, my thinking would slow and I
could read: a British mathematician on the limits of quality
improvement, a Dutch feminist philosopher on the logic of
care, a fourth-century Greek theologian on the injustice of
medicine. I read Nigerian folklorists, Austrian social crit-
ics, Canadian historians, and American physician memoirs
by the dozen.
I began with the first real contemporary physi-
cian-memoirist, Sir William Osler. Osler formalized the
teaching service and medical rounds which defined my
training. It was only after my training ended that I had suf-
ficient time to read his works. In Osler’s writings, I found
orienting exhortations like the chapter “Books and Men”
in Aequanimitas, where he wrote, “Books have been my
delight these thirty years, and from them I have received
incalculable benefits. To study the phenomena of disease
without books is to sail an uncharted sea, while to study
books without patients is not to go to sea at all.”
10
To sail a charted sea, I read.
While reading, I found a cure for full discouragement.
The reading cure was neither flashy nor disruptive, but
incremental and accretive. Reading in the deep end re-
newed my ability to carefully attend to texts, ideas, stories,
and, ultimately, the people in my life. Back in the deep end,
I could see myself, family, colleagues, trainees, patients,
and even, hospital administrators, as people to appreciate.
The reading cure was no restful vacation. It was, like
all good therapy, a remoralization renewing my ability to

Taking the reading cure
14 The Pharos/Spring 2020
people different from me, but similar enough to wake up at
 a.m. and pay an over-muscled -year-old to yell at them.
Masochists always find their sadist.
The best training was reading itself. The reading cure
settled and soothed me, like a mindfulness practice, but
also induced critical and creative work that renewed my
medical practice. A reader, like a good physician, has to
listen to the book, gathering data and building an alliance,
before responding.
Reading widened the gap between an event and my
response, a gap which had been closed by our electronic
health record and my smartphone. With a book, I was
left guessing at what would happen next, what the author
meant, and why characters made their decisions. Deep-
end thoughts.
When I had shallow thinking, the bottom was closer.
A small storm—a rejected paper, a late admission, a traf-
fic jam—precipitated a destructive wave. Those kinds of
storms occur every day. The reading cure allowed me to
see beyond daily storms. I began to understand why events
occurred, how to resolve them, and, at least on occasion,
to anticipate storms. When you are in the deep, the bot-
tom is harder to find, and a small storm generates waves
upon which you can travel.
The philosopher Kieran Setiya observed that at mid-
life you look back at your travels, surveying the paths
you took, the paths you did not take, and the paths you
ruined. This can be distressing, as you realize that fewer
choices are available to you at midlife; some options have
permanently expired and there is no objective way to tell
if you traveled the best path. At midlife Setiya advises dis-
tinguishing between telic value (the value you receive from
advancing toward a goal or accomplishment) and atelic
value (the value you receive from being immersed in an
activity). At midlife, Setiya advises that if you are bored by
past accomplishments but unable
to set out toward radically
new ones, you should seek
atelic value.11
Medical training is
telic—complete a course,
pass a test, earn a de-
gree, match in
a residency, secure a fellowship—but medical practice is
atelic—you seek value from being immersed in the care of the
people you meet as patients.
In pursuit of the atelic life
In pursuit of the atelic life, I redesigned my clinical ser-
vice. Before my season of reading, physicians averaged a
tenure of eight months before we burned them out. When
the moonshot grant expired, I asked permission to imple-
ment the reading cure for our faculty. After doing so, our
quality metrics improved, our RVUs increased, and our
physicians stayed on service for years.
My fellow physicians ask me often how I have stayed. I
tell them that after the grant ended, I continued a version
of the reading cure. I regularly, and simultaneously, read
a portion of three books—one that delights with its lan-
guage, one that builds my clinical knowledge, and one that
challenges my thinking.
I am even, finally, fulfilling my mother’s wishes and
reading Jane Austen.
When I ask other physicians what they are reading, they
often reply they are too busy to read. I sometimes share a
Michiko Kakutani profile of a retiring leader from The New
York Times. Kakutani wrote that the leader he interviewed
said that books “…gave him a renewed appreciation for the
complexities and ambiguities of the human condition.”
12
The leader also said, “At a time when events move so
quickly and so much information is transmitted, the ability
to slow down and get perspective, along with the ability to
get in somebody else’s shoes—those two things have been
invaluable to me. Whether they’ve made me...better…I
can’t say. But what I can say is that they have allowed me
to sort of maintain my balance…this is a place that comes
at you hard and fast and doesn’t let up.”
12
Weathering the storm
When you are balanced, you have the resilience to with-
stand a storm.
The retiring leader to whom Kakutani referred was
no physician, it was President Barack Obama who told
Kakutani that he survived the most demanding job of his
life by reading an hour each day.
Physicians and other health professionals labor in
places that come at them hard and fast
and don’t let up. To maintain balance,
physicians need a way to ward off
burnout, to endure with the sick,
and with themselves. Physicians
need to read widely and deeply,

The Pharos/Spring 2020 15
trying out lives they will never live, and understanding the
lives they are living.
Reading, physicians will find that Hippocrates already
knew that a physician’s life was challenging. He wrote, “For
the medical man sees terrible sights, touches unpleasant
things, and the misfortunes of others bring a harvest of
sorrows that are peculiarly his; but the sick by means of the
art rid themselves of the worst of evils, disease, suffering,
pain and death.”
13 From others’ misfortunes, physicians
have long harvested sorrows of our own.
Reading physicians will find Walker Percy’s The
Moviegoer of interest. Percy was a physician. He was also
the survivor of a long line of suicides. His grandfather,
father, and mother all committed suicide. Percy lived
under the specter of self-negation. To ward off suicide,
he enrolled in medical school. While in training, he made
extra money by performing autopsies. From a cadaver, he
developed tuberculosis. In an era before disease-alter-
ing treatment, driving a different epidemic, he took the
reading cure. Convalescing, he read widely and deeply.
He wrote a novel, but never published it. He wrote a
second novel, published it, and received the National
Book Award.
In Percy’s novel, the protagonist is a young man named
Binx Bolling, who is trying to determine what to do and
whom to become. Near the end of the book, Binx decides
to become a physician. He explains, “There is only one
thing I can do: listen to people, see how they stick them-
selves into the world, hand them along a ways in their dark
journey and be handed along, and for good and selfish rea-
sons.” 14 As Binx observed, being a physician is a particular
orientation in the world. It can be dangerous: physicians
harvest sorrows from other’s misfortune. It can also be re-
markable: physicians bear witness to others’ dark journeys.
Reading is the way to endure on dark journeys.
My mother read herself out of poverty. She read me
into medicine. Now I am a parent myself. Last year, our
middle child read Charlotte’s Web at school. Her teacher
asked each student to create a web of their own. In the
middle of their web, each child was instructed to write the
word which best describes them. Our daughter cut white
string into her approximation of a web, glued them onto
black construction paper, and shaped them to declare that
she was, above all, a reader. When she brought it home, I
knew that she would have a habit which sustained her on
her own dark journeys.
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The author’s address is:
Office of Education
Denver Health and Hospital Authority
601 Broadway, MC 0278
Denver, CO 80203
Phone: 303-602-6920
E-mail: abraham.nussbaum@dhha.org.