The Treadmill and The Inbox

I am writing this on a treadmill. Not because I want to be. I'm doing it because four days into a long-awaited break, my limbic brain has exactly one plan: lie on the couch, binge television, and play Oregon Trail on the Nintendo Switch until everybody in the wagon party dies of dysentery. Admittedly, I’ve acted according to my limbic system for the first three days of the break. And have a solidly passing record of getting my wagon trains to Oregon City. 

My prefrontal cortex, that killjoy, has a different plan. My prefrontal cortex has noticed that I have not set foot in a gym in months, that my energy is in the basement, and that these two facts are almost certainly related. Over the last couple of years, I’ve had a goal of not dying old and debilitated. That goal hasn’t changed, but it has been quietly moved to the back burner while I was maximally clinically busy and approaching burnout, which, if you have been reading along, you know has been the theme of my last several months.

So: on a treadmill. I do not enjoy it. But my rational self knows that I will feel better after moving my body. I also know that "feeling like it" and "benefitting from it" are usually at two opposite ends of the spectrum. (And you’re not a failure if the same thing happens to you; we’re evolved this way. Click here for a primer on the motivational triad.)

The other thing on today's list of Things I Do Not Want To Do is my work inbox. Not working the inbox, to be clear. Just reading it. Specifically, reading all the educational content I have been ignoring for a month: the professional organization emails, the journal alerts, the thing from the thing about the thing. (I just read the PROPOSITIS Trial, and noted, but I’ll still be proning every single baby with bronchiolitis that I feel needs it, thank you very much.) Pure input, no output. Learning is effortful in exactly the way the treadmill is effortful, and it pays out in the same way: later, not in the moment, and quietly.

Which is how I ended up reading, on a treadmill, during my vacation, about how my colleagues are leaving the profession nowadays.

The new AMA national survey in The Permanente Journal examined physicians who have already exited clinical practice (not those who are just thinking about it). The mean age at departure was 48.1 years, nine years younger than the comparable cohort in 2008. I’m 46, so that number came as a shock. Eleven percent of them completed residency and never practiced. The top reasons they gave were "hassle factor" (44.7%) and "too stressful" (44.5%). And then, the number that made me actually step on the stationary sides of the treadmill to make sure I was reading it correctly: women physicians left at a median of nine years in practice. (Men, twelve.)  

Nine years. That is barely long enough to become the person you spent a decade training to be.

Meanwhile, the AMA's 2025 Organizational Biopsy reports burnout at 41.9%, down from 43.2% the year before and 48.2% before that. Which is good news, and I want to hold both of these things at once without letting either one comfort me into complacency. Burnout is trending down. And the women are still walking out three years earlier than the men, disproportionately citing stress, health concerns, and the care of children and parents. Two-thirds of the departed cohort were women. The trendline is improving for a workforce that is simultaneously bleeding out the very people it is increasingly composed of.

Here is what I keep turning over. The survey calls the reason "hassle factor." That is a remarkably polite term for the thing I wrote about last week: the accumulated friction of a thousand small indignities that never rise to the level of a crisis and therefore never get addressed. Nobody leaves medicine because of one peer-to-peer. They leave because the peer-to-peers, the parking garage, the inbox, the invisible labor, and the fact that you are the one the school calls when your child has a fever, all quietly add up to a life that costs more than it returns. And then somebody writes it down in a survey as "hassle factor," and it goes into a bar chart, and the bar is 44.7% tall.

The answer is not to white-knuckle your way to year twelve so you can match the men. (Besides, did any of us go into this thinking we’d only be doing it 12 years?) That’s not the point.  The point is that leaving medicine is not a failure of grit. None of us would be in the position of contemplating leaving medicine if we didn’t have grit, because we never would’ve gotten to practice medicine in the first place. It is a rational response to an equation that stopped working. And the equation stopped working for reasons that mostly aren't yours.

But the equation has two sides. One side is the institution, and that side moves at the speed of institutions, which is to say glacially, and mostly not because of anything you do. The other side is what you actually have some purchase on: the friction you can remove, the baseline you can hold, the thing you don't want to do that you know will make the next six months more survivable than the last six.

So I am on the treadmill. I am reading the inbox. I’m practicing self-compassion when I feel the itch to answer emails that seem acute. I put my “must do” and “nice to do” tasks into Claude and asked it to craft a break for me that would let me make progress on what’s fallen behind while leaving ample time for rest and reflection. Not because it's fun. Because the alternative is finishing my break and still having nothing left, and I would very much like to still be here at year twenty, doing this on purpose.

What's the thing you don't want to do that you know would help your relationship with being a physician? Not the big one. The small, boring, prefrontal-cortex one. Email and tell me. I'm on a treadmill, and I have time.