I was in Italy grabbing a ride to my hotel from the Florence train station. While waiting in line I noticed a slightly older taxi driver standing by his cab in the middle of the taxi stand while three or four drivers took off ahead of him. He seemed slightly disoriented. Sure enough he was our driver. Florence is an insane place to drive with people and motorcycles darting in front of your car every few seconds. It is part of the experience. From the moment we left the station he began to curse at everyone in his way. “They should be using the tunnel under the street. Get out of my way. Don’t you know cars to have use the road?” He did not stop his tirade until we reached our piazza. He clearly was more than burned out and had no interest in any conversation. The stress in his car was palpable. I do not know him or anything about his life. What I do know is that being chronically angry may be the strongest factor for creating burnout and depression. How could it not? Physician Burnout The burnout rate in every state survey shows that 50 – 55% of physicians are burned out. My spine fellow recently put an article on my desk showing that 65% if neurosurgeons are burned out. It is both disturbing and predictable. There is a tremendous amount of stress in medicine and we are not trained how to process it. Additionally the medical culture engages in behavior similar to the cab driver in that we frequently become upset about things that we have no control over. Dr. Fred Luskin, in his book, Forgive for Good, describes this phenomenon as the “unenforceable rules.” When you are frustrated about any situation or relationship that you have no control over you are wasting your time and destroying your quality of life. An example would be that you wish your spouse would watch less TV or treat you better. It is fine to wish it but when that wish becomes a demand in your mind it has now become an unenforceable rule. When you begin to write down a list of things that are upsetting you will find that it is pretty long and most of them are not solvable – at least by you. The Emergency Room One classic medical example is the emergency room. I worked in the ER throughout my residency when I had a few gaps in my schedule. The vast majority of ER visits are not emergencies. Examples include sore throats, back pain, neck pain, a low-grade fever, stomachache, etc. All of which could wait to the next day to be seen in a doctor’s office. Many of these patients show up around two to three o’clock in the morning. It is about time when the physician is trying to grab some sleep. Many will begin to complain about the patient showing up with a minor problem at that hour. It is understandable and frustrating. However he or she will also tee off on the patient letting them know that they should not be coming to the ER with a non-emergent situation. First of all the physician is expected to work a full shift and be available the whole time. Second, is educating that one patient going to stop the other thousands of those who will be following? Why spend one second being upset about a runny nose at two o’ clock in the morning? Why not just take care of it and move on? Talk about an unenforceable rule. It is fine to wish that patients were more aware of what constituted an emergency but when you become upset that all of them don’t then you have turned this wish into a demand. Indeed the burnout rate in ER physicians is as high as any part of the medical profession. What are your unenforceable rules? What are some of your unenforceable rules? “My claims examiner is not responding to my needs. I wish my spouse would lose some weight. I hate bicyclists in my way to work. My boss is not that nice to me. I want to be free of pain now. I just want m life back.” Take a few minutes to write them down. It will be long list in that there are many things wrong with this world and life is imperfect for everyone. Just with age and repetition many of these legitimate wishes will turn into demands. Unfortunately becoming upset about them not only drains you but worsens the problem. For example people suffering from chronic pain commonly become socially isolated. One factor is that anger is not attractive, which pushes others away. One wish, of course, is to have more friends and become frustrated when they don’t seem to want to spend as much time with you. There is also a tendency to complain others about your pain and situation, which becomes old quickly. Staying upset about situations you have no control over will drive you into the ground and bury you. The first step is to become aware of your own unenforceable rules and how they play out in your life. Develop your own tools to process these “wishes” and truly move on.