One of the screensaver images on the computers at my hospital has a famous quote from Winston Churchill, “Never, never, never, never quit.” These words are meant to inspire us in the face of adversity. History abounds with tales of valiant men and women overcoming failure, and it is a common theme in countless movies, plays, and novels. But is encouraging someone to never, never, never, never quit really the right advice?
Every year residents meet with me to declare their future plans. A resident may come into my office and say, “I want to do a toxicology fellowship after residency.”
“Why?” I ask.
“Because I like toxicology!”
“Then read a textbook. But you have to tell me why you are going to extend your training during the prime of your income-earning years. Why are you going to give up hundreds of thousands of dollars in total pay over two years and work for a fellow's salary? How does this help you achieve success in your life? How will you leverage this additional education to make you a happier and more fulfilled person in the future? Figure this out, and come back to me with a better plan.”
I do not say this because I think fellowship training is a bad idea. On the contrary, I heartily support developing diversity in professional skills. But it is also imperative for residents to know how to make the best use of their limited time and energy as opposed to beginning an activity when the chances for success are unlikely. This becomes even more difficult if time, money, and effort have already been invested in the endeavor. These sunk costs coax many of us never to quit, even though quitting might be the best thing to do.
The podcast “Freakanomics” looked at this issue in its Sept 30, 2011, episode, The Upside of Quitting. (http://bit.ly/2D6KhrF.) The hosts analyzed the benefits of quitting in economic terms, and provided anecdotes to substantiate their position. One involved a man in his early 30s pursuing a career in professional baseball. Interviews with him and his wife detailed a man consumed with making it to the major leagues, only to fall short on multiple occasions.
He was unwilling to quit in spite of the economic and emotional effects his ambition had on his family as he scratched out a meager living as a minor league baseball player. His wife confided that the time had come for him to give up his dream and get on with life before he loses any chance of excelling in a different career. Still, the man had invested so many years into playing major league baseball that he couldn't bring himself to quit.
The folly of this human reaction is an economic and a psychological phenomenon called loss aversion. We have trouble quitting when we really should. It affects not only individuals but also companies and even nations.
The United States' involvement in the Vietnam War is a classic example of loss aversion. Despite overwhelming evidence in the 1960s that total victory for the United States was not possible, the administration of President Lyndon B. Johnson could not accept defeat because of the blood and gold that had already been invested. The idea that Americans had died in vain created intense public and political conflict, and President Johnson eventually doubled down by sending in more young, drafted men until half a million soldiers inhabited the tiny, Southeast Asian country.
It was not until 1974 that the war ended with the iconic photos of Americans evacuating in the face of a North Vietnamese offensive, and the total victory we desired went to our adversaries. The inability to quit a decade earlier led to a greater sacrifice in the end.
The business of emergency medicine has similar situations with dramatic, life-threatening implications. Countless times we are cast into the uncomfortable role of extending a life at an extraordinary cost in suffering and money due to a family's or patient's desire to fight to the end. Our collective experience tells us the sacrifice will outweigh the benefits, but we try to accommodate our patients' wishes.
How does a resident avoid loss aversion? They need to find mentors, ask questions, and listen. It is easy to get lost in trying to do too much with the incredible number of opportunities that intelligent young adults with high compensation have in our country. In the old days when I was training, the specialty was too young for many attendings to have enough experience to advise their residents on practical matters.
I found myself in numerous situations over the first 15 years of my career where my eyes were bigger than my stomach, and I struggled to extricate myself from many lost causes because of my apprehension at forfeiting my sunk costs. EM residents now have an incredible number of resources that provide amazing detail on everything from real estate to investing to various EM business models. More importantly, they have wise elders in their program who will help them pick the right options and advise them to quit the ones that will inevitably not work out.