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Is medicine a calling or just a job? Christie Mulholland thinks that question is the wrong one, and answering it keeps physicians stuck in burnout. Christie, a palliative care physician and certified physician development coach, returns to the show to introduce a four-quadrant matrix that maps how called you feel to medicine against how satisfied you actually are practicing it. This episode is based on her article “Moving beyond the false binary of medicine as a calling,” published on KevinMD. She walks through each quadrant (the calling, the craft, the wound, and the wall) and the specific coaching question that unlocks a next step for physicians living in each one. Christie also talks about how profit-driven systems benefit when “calling” stays the only acceptable answer, why work-life balance keeps getting squeezed out of clinical careers, and when a career pause becomes the move that smaller adjustments cannot replace. Listen for the question that names where you actually are.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Christie Mulholland, palliative care physician and physician development coach. Today’s KevinMD article is “Moving beyond a false binary of medicine as a calling.” Christie, welcome back to the show.

Christie Mulholland: Thanks for having me back, Kevin.

Kevin Pho: All right. Medicine traditionally has been called a calling, but that phrasing has come under greater scrutiny recently, right? So tell us what your article is about.

Christie Mulholland: Yeah, I think you and I both have been thinking a lot about this question, or debate rather, of whether medicine is a calling or just a job, or how people should think about it. And in fact, it was a question that you asked me in a prior conversation that got me thinking even more about this. What you had asked me was, if a doctor doesn’t feel like medicine is a calling, can they still be a good doctor? And my answer to you was, yes, of course they can. But I do think it’s important to have clarity and integrity about why you’re showing up to the job. And there might be things, like showing up for the job just for a paycheck, that would actually give you pause and make you want to reconsider the career.

So what I’ve been thinking more about is how to give doctors something more useful than just that question, because if you’re asking whether medicine is a calling or not, all you can really end up with is, maybe you can assign yourself to one camp or the other. But I wrote this article and created this tool that will talk about giving doctors something deeper and something more useful to reflect on: the reasons why they’re in medicine, how satisfied they feel with those reasons, and maybe some action they can take from whatever insight they develop.

Kevin Pho: So I think you’re right that this question is so much more than a yes or no answer. There are so many layers to it, and I think it deserves a system, it deserves language, so we can really articulate what we mean by that. So tell us more about what we were talking about.

Christie Mulholland: Yeah, so what we were talking about here is, I do think that, as the title of the article says, asking whether medicine is a calling or not presents a false binary. And false binaries already are problematic because they tend to exclude people from the conversation when people don’t really identify with one or the other side. So, like most things are when we examine them more closely, there’s actually a spectrum or a scale, right? How much of a calling does medicine feel like for me?

And so I thought about that first, and then what came to me was, there’s this other dimension. Do I want medicine to be a calling? Do I like practicing medicine? And how satisfied do I feel practicing medicine? So I thought it was really interesting to plot these two questions together and create a matrix that asks both of the questions and allows the user to put themselves on a scale. So I’m happy to talk about that more in depth. And I think listening to a podcast and trying to visualize something can be challenging, so I can describe what the matrix actually looks like.

Kevin Pho: How about, walk us through it. So I think that if a physician is questioning whether medicine is a calling or not, or whether medicine is right for them, just walk us through your system.

Christie Mulholland: Great. Absolutely. So there’s a matrix, or a grid, with two axes. On the vertical axis is the question, how satisfied am I with practicing medicine? And on the x axis is the question of how strongly do I feel called to medicine? How much does it feel like a vocation? And you can kind of think about that as like a Likert scale from one to 10, more strongly or less strongly on either question.

So you end up with four quadrants. On the upper right quadrant, this would be a doctor who both feels very strongly called to practice medicine and also has a high degree of satisfaction for medicine. And I gave this quadrant a name. The name for this one is the calling. I think this is where I start because it’s kind of the traditional thing that comes to mind for a lot of people when they think about what a doctor is. It’s somebody who shows up to work and time disappears. You’re rounding on your patients and you just feel lit up, and you think about your patients when you’re not with them. Maybe you even think you would do this for free if you weren’t being paid.

So that’s the calling, and in that quadrant I invite anyone using this tool to think about a coaching question. So the coaching question for the calling quadrant is, what does it take to sustain this? And am I satisfied with what this requires of me? Because I think even if you’re feeling very called and very satisfied, there’s still room to understand and have more insight about what does it take to stay where you are and stay happy.

Moving to the upper left quadrant, this is somebody who feels very satisfied with medicine, but they don’t feel particularly like it’s a calling. It’s just one aspect of a full life that has other things that are exciting in life beyond just medicine. This might be somebody who feels they have great work-life balance. This quadrant I call the craft. Medicine is a craft, and it’s one part of a full life. So the coaching question for this quadrant is, what does a full life look like for me, and how does medicine fit into that?

Next I’ll move to the lower right quadrant. I call this quadrant the wound. I think this is particularly evocative for a lot of your listeners because I think there’s a lot of pain in this particular quadrant. But this is somebody who feels very, very called to practice medicine and to heal people, but they feel that the system is thwarting them from doing that. And the gap between the care they want to provide and they feel called to provide, and what the system actually allows, is very painful. So for somebody who might be living in this quadrant, the wound, the coaching question I offer is, what is one small act of agency that I can take today or tomorrow?

And then finally the last quadrant is the lower left quadrant. This is a doctor who doesn’t feel satisfied with practicing medicine and doesn’t feel called to practice medicine. They’re showing up, maybe it’s for a paycheck, but some days that paycheck doesn’t even feel like it’s enough. Perhaps it’s somebody who feels trapped, either by financial obligations, student loans, or even just not being able to imagine a different career is possible. So the coaching question in this quadrant, and I call it the wall. The wall is a physician who feels not particularly called and not particularly satisfied. And the coaching question I offer for someone living in the wall is, what is one step I could take to just get a little bit unstuck?

Kevin Pho: Super useful. I think everyone listening to this knows or has met physicians in each of those quadrants, right? So, for instance, when you describe the wound on the lower right quadrant, that sounds a lot like moral injury, right? The system thwarts them from pursuing their calling.

Christie Mulholland: Absolutely.

Kevin Pho: And then you have physicians in the upper left, right, the craft. And I think a lot of physicians kind of aspire almost to be there, right? Because medicine, like you said, it’s one part of their full life. So when reading your article, I think that the craft, like the upper left quadrant, traditionally has been seen as undervalued when it comes to what we think a good doctor should be. What do you think?

Christie Mulholland: I couldn’t agree more. And actually I opened the article by talking about someone named Julia. Julia is a resident doctor and I saw her on TikTok. And she is like the epitome of someone that I associate with the craft. And I will say that I don’t know Julia, and I don’t know how she conceptualizes this for herself, but Julia is a raver. She’s not just a resident doctor. She’s someone who goes out to a lot of dance parties, and there are videos on her TikTok of her doing après-ski, like dancing at a DJ party.

And it was the comments that pulled me in. And so many of these comments were like, “I wish my doctor was as cool as you,” or, “I want a doctor who has a life.” And so I do think that this quadrant, someone who’s a doctor and it’s really just one part of an otherwise full and happy life, I think this is very undervalued. And I think the system as it is currently set up doesn’t really make a lot of space for doctors like this to sustain that life.

Unfortunately, I have personally seen this in other doctors and lived it in myself, where I spent some time myself living in that quadrant of the craft, and over time it sort of got squeezed out of me as I got more into the career. So for myself, I was in a band during the end of med school, in the beginning of residency, and I loved medicine, but I equally loved this idea of myself being a rock star. But it was not always sustainable. I couldn’t always find a way to leave the hospital on time to go and play a gig.

Kevin Pho: Now obviously there are a lot of physicians still who see medicine as that binary choice, and they may not value those in that craft quadrant, right? So how do you push back against that? How do you push back against physicians, the system, and patients for that matter, who still view good doctors through that narrow lens?

Christie Mulholland: So I can’t change how people think about this, and I can’t change those doctors that don’t value other doctors not finding medicine to be a calling. That’s OK. What I would say in response to that is, there is room in medicine for all of us. And there are probably patients out there that do want that doctor who’s very self-sacrificing and traditional. And there are other patients, as we know from Julia’s TikTok comments, they want a doctor that has work-life balance. And there’s space in medicine for all of us.

So I can’t change the way people think about this. I do offer this tool, even to the skeptics. Take a look at it. Try asking yourself some of the questions. I actually created an interactive widget of this tool on my website, reclaimphysiciancoaching.com. Play with it and see what it evokes for you. You can take it or leave it.

Kevin Pho: How did you come up with this? What kind of research did you do to come up with this type of classification?

Christie Mulholland: I think that this type of classification really comes out of my experience being coached and in coaching, and going through my own psychoanalysis as well. And it’s really been the experience of what it feels like to have powerful questions asked of you. Those questions bring about more awareness of who you are, of how you’re living your life, and having that insight and awareness really breaks down the barriers to having a full career.

And there is so much evidence that coaching and being asked powerful questions like these, the coaching enhances career satisfaction, it reduces burnout. And I really believe that this is the power of coaching, is asking the right questions and the powerful questions that help you to understand yourself more deeply. And that understanding allows you to take action more aligned with your values.

Kevin Pho: So if a physician is in those lower two categories, right, the wall or the wound, obviously we as fellow physicians want them out of those categories, right, in order for them to continue practicing medicine and lead a full life. I know the coaching questions you ask are a great first step. What are other incremental things that they could do to potentially get them to leave those two quadrants?

Christie Mulholland: Yeah, so the coaching questions are really just meant to open a door. They’re not a prescription, and they’re not going to change your situation. The questions are an invitation to consider coaching. So coaching is one powerful tool, and incrementally over time, working with a coach to help you develop these insights and take little actions little by little each week or each month. So that’s one thing.

And then I do think that the other potentially bigger step that somebody might consider taking, if they’re in the wall or they’re in the wound, is taking a pause. I call this a pause point. This is the point where you are looking at this matrix, you’re really not happy with the situation that you have, you find yourself not feeling satisfied in medicine for one reason or another. It can be very difficult to make a big adjustment that is needed while you’re still kind of living inside of that grind.

So sometimes I do think that stepping back from medicine, taking a career pause or a sabbatical, is needed. Sometimes it’s not enough to just make small, incremental adjustments to your life. Sometimes you find that you’re actually living the wound or you’re living the wall, and it’s very painful and you feel stuck. You can’t necessarily get unstuck without making a more drastic change. And I offer normalizing taking a career break as an answer for those people.

Kevin Pho: I definitely appreciate the nuance that you’re introducing to this construct. A calling is definitely not a yes or no answer. But let me ask a blunt question. Do you feel that systems are co-opting that word, calling? They would rather keep it a binary, and perhaps use it as an opportunity to take advantage of those physicians, say in the upper right quadrant.

Christie Mulholland: So I think this is the one side of the debate, right? We’ve got the older doctors perhaps, and the system is on the one side saying that medicine is supposed to be a calling and everybody needs to be called, and that’s just the way it is. And then I do think that younger generations take it, it really is, it’s what you said, it’s that corporatized medicine is exploitative and it’s exploiting people’s altruism.

So yes, I absolutely do think that, to the extent that the system is designed to just extract profit out of patients and health care workers, yes, I do think that system benefits from people defining medicine only as a calling. But I also think that systems are not people, right? So systems don’t, it’s not that the people in charge are exploiting the altruism of doctors, it’s really just that if you design a system where profit is at the center, that’s going to be a natural byproduct. That system exploitation.

Kevin Pho: So what are some small ways we can advance your construct and present a more nuanced view, and perhaps better value those physicians in the upper left, those who consider medicine more as a craft, other than having more physicians define themselves that way? What are other small things that we can do?

Christie Mulholland: So I’ll give an example of a small thing that we could do, and then maybe I’ll give an example of a bigger thing that we could do. A small thing is that we can role model having work-life balance, and especially if you are in any kind of leadership position, or you’re in a position where younger doctors are looking to you for guidance, use all your PTO. Let’s start there. Take some time off. Talk in a work meeting about the vacation you took and something that you enjoyed outside of medicine. That’s a very small thing that I think we’re not doing enough of in medicine, is bringing in more of our humanity.

And then I think a bigger change that we could make as a profession would be to normalize taking longer breaks from medicine, letting people work part-time, allowing for that in this system where it’s not just this standard full-time, 100 percent effort that everybody has to do. You’re in or you’re out. But we could make space for people that do want to design their lives and their careers in a way that’s just a bit more balanced.

Kevin Pho: We’re talking to Christie Mulholland, palliative care physician and physician development coach. Today’s KevinMD article is “Moving beyond a false binary of medicine as a calling.” Christie, as always, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Christie Mulholland: So my take-home message is that, as I said before, medicine is not just a calling, or it’s not just a job. This is multidimensional and it’s nuanced. And I offer my matrix as a tool for you to explore more deeply your feelings about how called you feel to practice medicine and how satisfied you are practicing medicine. And with that exploration, I offer you some coaching questions to explore and develop more insight, so that you might have a better idea of what a next step could be for your career. And if you’re interested in exploring this even more deeply, consider working with a coach, because these powerful questions are exactly why coaching can enhance career satisfaction.

Kevin Pho: Christie, again, thank you so much for sharing your perspective and insight. Thanks again for coming back on the show.

Christie Mulholland: Thank you so much for having me back.