God, I hate the feeling of not being able to help a patient. Hate staring at a CT scan and knowing that there’s nothing left for the surgeon to do.

Hate it.

Because...It isn’t just disease those of us in healthcare fight against. It’s also the systemic barriers too, the insurance, the bureaucracy, the financial hardship—none of it within our power to fix, and yet we feel responsible for the outcomes.

This dread used to beat me down when I was a full-time surgeon, engulf me in a heavy blanket of powerlessness. My lone efforts were insufficient, my surgical expertise flaccid against the onslaught of forces that were completely out of my hands. 

There’s a name for that feeling.

For the last year, I’ve written weekly about the science of decision-making. We’ve unpacked cognitive biases—those shortcuts our brains take to save energy, even if they sometimes lead to worse choices—and explored Nobel Prize-winning decision science research. We’ve covered decision models, dissected the math behind choices, and discussed techniques to help us make more objective, rational decisions.

But. 

In all this intellectual exploration, there’s one fundamental element I’ve overlooked.

And it’s time I addressed it.

was a deeply mediocre grade-school student. Except in penmanship. I almost failed that. Drunk crickets trace neater paths through sand than I do with pen on paper.

Sister Viola P, of the Incarnate Word and Blessed Sacrament—a nun who believed in punishing grade-school evildoers by stuffing their butts in wastebaskets—sent my parents desperate entreaties to fix their son’s handwriting. 

Thankfully, cursive skill doesn’t play the role in my life they said it would.

To my parents and their friends, though, my penmanship was proof of one very important thing: their son was destined for medicine.

“No!” I’d respond. “I don’t want to be a doctor. I want to be a rock star!”

I became a doctor anyway.

What happens when your purpose is subjugated to your path?

On September 19th, the President of the United States signed an executive order, one that effectively guts the immigration of many high-skilled workers* into the US—including in healthcare.

According to the order, unless an employer is willing to foot an extra hundred grand, no one can come into the US to work in a “specialty occupation” —including healthcare.

For those of us in healthcare, this is going to hit. 

Hard. 

Your burnout’s about to get much worse. Are you prepared to weather this storm?

Since Charlie Kirk was killed by a 22-year-old kid in Utah on September 10, the internet has been at each other’s throats. “How could you speak ill of the dead” people have been speaking ill of “But have you heard the things he said?” people.

It’s been a mess.

It’s also been one of the clearest examples of confirmation bias I think I’ve ever seen

One day in the 1800s, a traveler found himself in Nobston, a town in Massachusetts. After a long day traveling, he’d settled into an inn where he planned to stay the night. 

Over dinner, he asked the innkeeper about the barren plot of land in the middle of town. It felt odd, he said, that such a piece of prime real estate could just sit there, fallow, with nothing growing on it.

“Oh, the Commons” the innkeeper said. “They weren’t always like that.”

The story he told explains why you’re burnt out…

I met Joel on a hospital ship a few years ago. That year, the Africa Mercy, as that ship is called, was docked off the coast of Cotonou, Benin. Joel had just arrived from the US—California, specifically—having flown some 36 hours to get there. It was a Sunday night, and he was making himself a sandwich.

I’ve been working on these hospital ships for nearly two decades now. They’re like a second home to me. 

To new volunteers like Joel, however, the Africa Mercy can be a labyrinthine, creaky place with walls imbued with the weird accumulated smells of five decades in operation, air conditioning that runs either too hot or too cold, and salads that taste oddly of chlorine.

“First time here?” I asked, pulling up a chair and setting my own plate of chlorinated vegetables down in front of me. 

“First and last,” he said. “Probably. Just found out I have colon cancer. It’s what made me finally decide it was time to do this, before it was too late.”

I think about Joel a lot. He never made an unreasonable choice.

And he never got to live the life he wanted…

At fifty years old, I walked into a tattoo parlor for the first time.

My artist, a woman half my age with intricate ink climbing both her arms, greeted me with a smile. I found her through Instagram, paid her deposit, and then waited nearly six months for the date of my actual appointment. She knew it was my first time.

The bunch of trainees practicing their fine lines on what looked like pork trotters, on the other hand. They didn’t. One of them—I kid you not—looked up from her work, caught my eye, and said, “First time?” 

She read my nervousness like tarot cards.

That’s because I’d been thinking about this tattoo for ten whole years.

3652 days of a debate with myself. That’s a lot of days. That’s a lot of indecision. And that’s because I’d been looking at the decision wrong.

You’re probably doing the same thing with your decisions, and it might be leading to permanent consequences…

Last week, a new client texted me at 2 AM from the hospital parking lot. She was halfway through her third overnight shift in a row. “You know what,” she wrote. “I’m done. That’s it. This is killing me. I’ve got to quit.”

And then, 10 seconds later: “But I can’t quit.”

Another 10 seconds: “But I need to quit.”

The thing about Sandy’s story (not her real name) is that her husband had seen her burnout coming a decade ago. He’d also seen it absolutely tank her during the height of the pandemic. 

He’d been nudging her toward a change for years. He’d even gone so far as to plot out three different exit strategies. 

She found a reason why each one of them would never work.

Was she just stubborn? Or was something else going on?

Read on…

Growing up, I had a stuffed animal that I loved. My mom tells me that the mother of one of my dad’s colleagues gifted him to me when I was still in utero. And he was never far from Baby Me.

I still have that stuffed animal.

Despite the fact that the rabbit is ugly, stained, and probably a health hazard, the thought of losing it feels like losing something of infinite value.

Irrational? Definitely. I’m a deeply sentimental person.

And also, it’s emblematic of something called the endowment effect — the cognitive bias where simply owning something makes it feel significantly more valuable.

And a reason we stay stuck…

A friend of mine drank a gallon of milk, ate a live goldfish, got alcohol poisoning, and slept in a basement for a month, all to join a frat—where he then lived in literal squalor for the next academic year.

Nearly thirty years later, he still donates to their alumni fund.

In fact, there’s a weirdly inverse relationship between how much abuse he received at his frat and how loudly he defends the abuse. It was almost as if, the worse they treated him, the more loyal he became. 

Why? Read on, because it might just explain why we get stuck in toxic relationships, bad jobs, and expensive clubs..

You’re late to work. Again. 

As you sneak into the conference room, avoiding eye contact with your notoriously crotchety boss, your brain’s already machine-gunning a litany of perfectly reasonable explanations. 

Bad traffic. 

Your kid couldn’t find their science project. 

The coffee maker broke. 

You forgot your umbrella.

Thankfully, your boss never asks. He just glowers.

Right after you take your seat, your colleague also sneaks in. Your boss starts to look a little like a thwarted Yosemite Sam.

And you know what? He’s right to be angry. 

Sarah’s always late and this is just classic. She’s so irresponsible. She probably stayed up binge-watching Succession again. 

Welcome to the actor/observer bias, the reason you keep dating the same bad people and finding the same toxic jobs

In the produce section of a grocery store, a micro-drama unfolds between a couple. The two of them stand in front of a pile of tomatoes. She picks one up, inspecting its shine, its smoothness, its lack of flaws—and, having deemed it worthy, she places it in a clear plastic produce bag. 

While she searches for the next one, her deadpan partner grabs a tomato from the same produce bag and hands it to her. 

She evaluates his chosen tomato—ones she’s already selected. Her lips thin a little bit, and she rejects it. 

In the video’s 26 seconds, we’re witness to an intricate web of four different cognitive biases—four different patterns that distort our decisions….

There’s no quick fix for a hole it took years to dig

On a call with a client the other day, she dropped a line that I haven’t stopped thinking about.

She’s a physical therapist—I’ll call her Chrissy. She’s been in practice for 20 years. And she’s tired. Exhausted. 

She told me she wanted out, but also she had no idea what to do next. Did she want to stay in corporate PT? Start her own practice? Leave the bedside care?

I started describing how I work with clients to get them out of burnout. It takes eight weeks, I told her. In that time, we tackle some very big questions.

She took a deep breath.

“I was hoping there was just an antibiotic I could take for 10 days, and it would all get better.”

Noah Wyle never wanted to do another medical show.

The star of the ER, the show that launched the entire medical drama genre, refused to take a single medical role for fifteen years after the series ended in 2009. 

“I wouldn’t take a script if it was to play a doctor, even if it was a veterinarian,” he says. “The idea of putting a stethoscope around my neck just seemed like a really bad idea.”

And then Covid happened. To quote his 2025 interview with Variety:

As the world was just starting to retreat into lockdown in 2020, Wyle began getting DMs on Instagram from first responders overwhelmed by the first lethal waves of COVID-19. Some simply thanked Wyle for inspiring them to pursue a medical career with his performance on “ER.” But most of the messages were laced with an unmistakable desperation about the precarious state of the country’s health care workers — and how no one was telling their story.

“They were saying things like, ‘Carter, where are you?’” he says. “‘It’s really hard out here.’”

Wyle, meanwhile, was confronting his own pandemic-fed crisis…. “I just thought the world was coming apart. I didn’t know how to contribute anything of meaning or value anymore.”

And so The Pitt was born.

According to the National Center for Health Workforce Analysis, we’re recruiting new doctors just fine. The number of medical school entrants has increased nearly 6% since 2019:

By comparison, the US population has grown by only about 1.8% in that time. So, medical school recruitments are outstripping population growth.

And yet.

The US is projected to be short nearly 200,000 healthcare professionals in the next 10 years. That’s despite recruiting tons of new medical students.

What’s happening?

Well, imagine an old pipe. It’s faithfully carried water from a reservoir to your house for decades, making sure your sink works, your shower has enough pressure, your kids have water to drink, and your shower has the pressure it needs.

Over the decades, it’s started to show its wear… 

A year ago, a friend of mine took a senior leadership position at an NGO he’d admired for years. I’ve known Christiaan (not his real name) for at least a decade—he’s a soft-spoken, gentle, diplomatic Dutch guy. So, when I asked how it was going, I expected an equally diplomatic description of his new job in response. 

I got something altogether different instead. His answer was firm, immediate, and direct:

“Honestly, Mark, I love it. The best part is that my CEO sets the vision clearly, gives me everything I need, and then trusts me to get it done.”

Which got me thinking about the CEO we each have in our heads…Does that CEO trust us to “get it done”?

On the face of it, wellness programs sound awesome — resilience, well-being, work-life integration, and fostering growth of the person as a whole .

But wellness programs don’t work — at least, not in the way that increases actual physician wellness. 

What they do instead is keep physicians indentured to the system that burns them out in the first place. 

I sat at the airport café table, my flat white untouched, staring at my phone. I thumbed my passport absent-mindedly. The choices I'd made to get me to JFK that day felt heavy. What if I moved and hated it? Worse, what if I didn't move? What if I stayed put and resented never trying?

What was I supposed to do with all the potential regret? Could I really YOLO my way through life?

Can you?

Early in residency, doctors learn an important rule about working in a hospital: The longer you stay, the longer you stay.

In other words, the longer you stay at the hospital, the more work will be assigned to you, which, in turn, leads you to staying even longer. 

And that’s true in jobs, too.

But Job Lock doesn’t have to be permanent…