A little boy in the first grade goes to his mother and asks, "How come dad comes home, spends just a few minutes playing with me, has dinner with us, and then goes to his study to work the rest of the night on that briefcase of papers he always brings home? How come he doesn't spend more time with us?"

Mom gets down on one knee and gently says, "Your father is a busy eye surgeon. All day long he's helping lots of people see better. He has a lot of people counting on him. So many people, that even when he's finished his office work, he still has lots more left to do. That's why we only get to see him a short time each evening."

The little boy rolls this around in his head for a moment, applying what he knows of his innocent grammar school world, and with enthusiasm says, "Mom, I've got it! If dad's having such a hard time keeping up, why don't they just put him in the slow group!"

Unfortunately, very few ophthalmic surgeons voluntarily put themselves in the "slow group," even when burnout looms. More often, they work full tilt and a little harder each year, until they hit the wall. This wall can be a profound, disabling physical or emotional breakdown. But more commonly, it's simply a deceleration of the rate of practice growth, until a kind of equilibrium is reached, when the demands of patient care and the business' complexity are balanced by an individual's ability to keep pace.

In my consulting practice, as a business coach to some of the country's more ambitious surgeons, I look for early signs of burnout just like an athletic coach looks for early signs of physical injury. There's no point to increasing a surgeon's patient volumes or decreasing an athlete's marathon times if the result is an achiever who can no longer perform at all.

Like medieval siege warfare, your workload and stress can pin you down for years. If a surgeon's energy or attention to detail slackens even slightly more, the practice can actually spiral downward. I most often see this slow, grinding burnout in solo practices and in multi-doctor practices with just one owner, situations where all the responsibilities are on one person's shoulders.

Every surgeon has a different reaction to stress. Some of the country's highest-volume surgeons only get "crispy" at 300 or more major cases per month. At the other end of the scale, some anxiety-prone surgeons are like twitchy concert musicians, who can only go on stage if they are medicated for the stress induced by having to perform. Both reactions are obviously within the norm. Here are several ideas drawn from my travels around the country that may help to forestall or reverse burnout in your own setting:

1. Use diet and physical conditioning to offset mental and physical exhaustion.
Paradoxically, regular physical activity -- anything from long walks to formally supervised gym workouts -- can be both treatment and prophylaxis for burnout. That's perhaps why we see that some of the nation's busiest surgeons are extremely fit physically. It may help for you to enlist the help of a personal trainer or dietician to start a program, if you need an external source of discipline.
2. Increase delegation.
You don't personally have to do everything. Have your optometrist or senior tech take first call, with you available for standby. If you're in solo practice, take on a junior partner or recruit an administrator with enough sophistication to take the business worries off your plate.
3. Decrease your cost of living.
As the old saying goes, "When your outgo exceeds your income your upkeep becomes your downfall." Many surgeons slip unconsciously into a pattern of increasing the cost of their lifestyles just slightly faster than their hard work can keep up. The stress of excess debt and a spouse asking when the family's second home can be redecorated -- on top of an already stressful practice -- can put even the most burnout-resistant doctor over the top. If necessary, enlist your accountant or hire a financial planner to help you adopt a personal budget that's chronically 10% to 50% less than your net after-tax practice earnings.
4. Re-engineer or eliminate the unnecessary.
Not everything needs to be done. If you have a surgery center, and if you're burdened by residual hospital duties, draw back to courtesy status, if this is politically feasible. Are you writing letters when a quick call or an e-mail message will do?
Shift gears and communicate in the most streamlined way possible. If you dictate at the end of the day, shift to dictating in front of the patient at the end of the encounter. It really does take less time (because you're already oriented right then to the case), and it's working smarter because you save steps in discussing the treatment plan with the patient.
Learn to say "no" to responsibilities that don't make a proportional contribution to your business. You might continue an annual vision screening program in your community, but decline to speak once again during career day at the local high school. Any of the recent books on simplifying your life may help you commit to an under-committed lifestyle.
5. Establish boundaries
. Are you like the doctor I mentioned at the beginning of this story, with a satchel of paperwork to plow through each night? Consider setting boundaries. Even small steps, such as saying to yourself: "I never work Wednesday evenings, which are reserved for family night," can be remarkably liberating. Use your appointment calendar not only to be disciplined about when you're available to see patients, but also when you're not available at all.
6. Change the duration and periodicity of time off.
The typical eye surgeon takes about 4 weeks off a year. Half or more of this is commonly spent at national meetings. Granted, the meeting locations are often posh, but such meetings are hardly a break from the office.
Indeed, by the time you factor in the added stress of travel -- worries about leaving the office uncovered, the anxiety of hearing about how many laser-assisted in situ keratomileusis (LASIK) cases your old roommate Charlie is now doing -- you can end up returning home more stressed than you were when you left the office.
Examine yourself closely and adjust the frequency and duration of time off. For some of my clients, taking a long weekend twice a month is more rejuvenating than 2-week vacations, and can actually result in far less down time away from the practice.
At the very least, if you must combine vacations and continuing education, arrive a few days early to enjoy the meeting city with no responsibilities. Rather than trying to hit every meeting every year, rotate among the meetings and order audiotapes for any important sessions you simply can't miss.
7. Put yourself permanently in the slow group.
We can learn a lot from surgeons who, as they enter their 50s and 60s and become financially independent, start working a schedule that pleases them. Surprisingly, they rarely quit. Instead, they transition to 4-day weeks. They refer the toughest cases. They develop deeper relationships with a few pet patients and favorite staff members. If you're in your 30s or 40s, taking this approach early may grind the sharp edge off the least pleasant dimensions of your practice.

Be mindful that many of these steps I've recommended you take to reduce stress may have an almost inevitable adverse impact on your profitability. But this doesn't have to have a proportional impact on your take-home pay.

Indeed, the last thrashing efforts to get ahead can, in some settings, yield diminishing returns. An increasing number of my clients who were once striving to cross their finish line to economic freedom -- well before traditional retirement age --are now realizing there's nothing they like better than work.

After slowing down and eliminating the least pleasant aspects of their practices, they now happily work a little longer and end up with just as much financial security as they would have gained by trying to reach a premature finish line. As you may have experienced, a 5% decrease in your clinical or surgical schedule can have a 50% increase in your work life quality.

I'd like to end with a final thought, returning again to a child's perspective on life. If you're at or beyond the point of burnout, perhaps all you need to do is give yourself a "time out." You can't recapture the happiness you lost yesterday, but you can still experience tomorrow's happiness.