Every now and again, I am contacted by a physician (although professionals from other fields do this too) who is feeling a deep sense of urgency about revamping his or her job or life. He or she seems to be moved by a spirit of needing to "step up" to playing a much Bigger Game.

Instead of expressing mere job dissatisfaction, or a desire to earn a bit more money, these singular people feel an urgent need to have a much larger impact on their community or the world.

These are some of the words I detect in their conversations:

• Legacy
• Making a real difference
• Reaching many more people
• Creating a world-renowned program
• Helping whole communities
• Bringing meaningful improvements to impoverished countries 
  

In The Entrepreneurial MD's July newsletter article, I address what happens to us when we are inspired to play a Bigger Game. Human Development coach Rick Tamlyn, of The Bigger Game, has created a simple elegant model that I have elaborated on.

I hope that many of you are feeling these strong impulses -- our country and our world are sorely in need of a new Gandhi or a Mother Theresa or a Mandela or even a Dr. Paul Farmer of Partners in Health!

Is it YOUR turn to "step up to the plate"?

From time to time, I speak with physicians who are highly motivated to get into another business, but that is about as far as their enthusiasm takes the. They have the desire -- and can't muster up anything more. They are immobilized with indecision about what business to start. Several ideas have appeal until they are investigated further, and then suddenly they lose their lustre.

What is stopping them from taking the plunge? And what is to be done?

I suspect that any one or more of the following are flaring up:

1. Difficulty with tolerating the unknown: As physicians, we necessarily require a low tolerance for uncertainty. It is what urges us to relentlessly pursue the diagnosis until it is known. This attitude, however, costs us dearly when it comes to exploring options that affect our lives and livelihood.
   
2. Risk-aversion: Perhaps this originates in our choice of profession and the self-selection involved. Medicine is generally thought to be a "safe" career with a guarantee of employment.
   
3. Habitual thinking: We get lazy in our thinking - habits are easier to adhere to than to break.
   
4. Lack of confidence: It's hard to picture a physician truly lacking confidence as the demands of the career require a certain level of self-esteem. Instead, what I think what is at play here is a concern about not making the perfect decision. The one we know is absolutely right for us and guaranteed to produce a successful outcome.
   
5. Avoidance of taking responsibility: This is where we get to play the victim of our circumstances and sidestep the challenge of taking ownership of our lives and choices.
   
6. Confusion: A truism is that the confused mind always opts for "no". It's the safest way out of a mental challenge.
   
7. Expectations: This is on a par with habits. We get used to having our expectations met at a certain level -- financial, lifestyle, social, psychological -- and it is uncomfortable imagining living with anything different or less.

The unifying emotion in all seven circumstances seems to be fear!

Well then, how can one overcome fear, and create enough mental and spiritual space to foster the opposite - courage? 

In this article on positive psychology and courage from PsyBlog, "How to Build Courage Through Personality Traits and States of Mind", the author British blogger Jeremy Dean reviews a new model of courage and offers suggestions as to how to increase the positive factors that promote courage.

The factors from the blog post are (I encourage you to read the article for details as it is very helpful):

Courageous character traits

1. Openness to experience.

2. Conscientiousness.

3. Core self-evaluation

Courageous states of mind

1. Self-efficacy.

2. Means efficacy.

3. State hope.

4. Resilience.

Convictions and social forces

1. Inner convictions.

2. Social forces. 

My take on how to overcome the negative forces is to do what one client has opted for:

• work hard to set up a situation that allows time for reflection, thinking and for simply being.
• be willing not to know immediately
• trust that the subconscious and conscious minds are deeply engaged with the questions that matter
• find a "thought partner" who is equally comfortable sitting with the unknown and doesn't feel impelled to do the "doctor" thing and rush in and fix it
• become a doodler, journaller, list-maker, vision board creator. If you have to do something, let it be unstructured, random, irrational
• get physical - ride a horse, go for long walks, do yoga, jog, go kayaking

When you are feeling stuck, what works for you?

"No way - it's impossible!" I want to yell. After all, I was raised with the ethic that, in order to succeed, you have to keep the nose to the grindstone for hours a week.

But a brazen not-yet thirty-year old has written a book making the outrageous claim that you can succeed while working a handful of hours a week. A claim that, on closer inspection, proves me wrong.

Having seen the title The 4-Hour Workweek and author Tim Ferriss's name touted everywhere - popular publications, multiple blogs and podcast interviews - I  resisted getting caught up in what I suspected was a giant fantasy. No wonder it sat at #1 on the Wall Street Journal and New York Times non-fiction book lists - don't we all want to believe that?

I bowed to the pressure to read the book when clients began quoting sections to me. I finished my copy just a couple of days ago. And here I am, adding to the commentary!

The premise is somewhat brash - that you can go from corporate work junkie or entrepreneur slave to liberated life-loving income earner merely by taking advantage of a new mindset and 21st century technology.

The author is at times infuriatingly bombastic and "know-it-all" - no doubt to shake us out of our complacent victimhood - but I have to admit that he is the announcer of a secret that I, myself, am striving to uncover. How to accomplish more in less time, using Leverage.

What irks me most about the book is the term "New Rich" (no doubt a play on nouveau riche) that Ferriss uses to describe the statehood of having escaped work's drudgery. It sounds smug. Yet I have to be careful that this isn't just my envy speaking.

Terminology aside, the book is a paean to a carefully crafted lifestyle built upon the belief that "life doesn't have to be so damn hard". It is about self-reinvention and redefinition of reality. It thrusts at you the question: "How can you willfully extract more joy out of each and every day, instead of deferring it to some imagined future time, when your work is all done?"

Ferriss is generous in going beyond bragging about his own freedoms, and sharing the exact details of how to accomplish this for yourself.

The book is laid out following Ferriss's DEAL reinvention process, which involves:

Definition: The work here involves questioning all your assumptions about your notions of job, life, vacation, wealth, and stress.

Elimination: In this section, you are given ideas and tools to get increasingly "unplugged" - from email, Blackberrys, laptops and phones, amongst others. The reward - more time.

Automation: Now you get to the real personal challenge - how to use outsourcing, technology and your own mindset to create more income.

Liberation: This final "how-to" section is focused on our new definitions of free time, lifestyle and regained control, and the yield here is more mobility.

Each chapter is accompanied by Questions (How has being "realistic" and "responsible" kept you from the life you want?) and Actions (Define your nightmare, the absolute worst that could happen, if you did what you are considering doing?). Periodically, Ferriss issues a Comfort Challenge - pretty whacky stuff like Eye Gazing and Getting Phone Numbers of at least two unknown attractive members of the opposite sex. All designed to get you used to being stretched way past your comfort zone.

My enthusiasm for the book stems from my own belief that we are in a very privileged time. Whereas 30 years ago it was difficult to imagine succeeding in an entrepreneurial business built around a lifestyle, and still find both meaning and purpose greater than the Self, I personally have experienced that it is possible. With my Virtual Assistant on the East coast, my software coder in India, and the assortment of software applications that lurk inside my computer and on the Web, I'm half way there!

Technology, globalization, and dramatic lowering of business operating costs have been largely responsible.

"But I'm a physician running a practice/working as a hospital executive/working for a corporation. I can't fall for this pie-in-the sky stuff!" I  hear you protesting. That's true, and it is likely that many of Ferriss's recipes will not work for you. There is, however, a fundamental premise that's worth examining. You are less trapped than you think!

You, too, can take advantage of many of the tools and resources that the book promotes. I didn't appreciate quite how far I've gone in my journey to liberation, using automation, outsourcing and discipline. And several of my physician clients are starting to apply similar ideas in order to restructure how they work in both their clinical practices and their businesses.

It all starts with an audacious, obnoxious, rules-busting attitude like Tim Ferriss's!

It is a rare entrepreneurial physician, or any wannabe entrepreneur, who does not encounter a period of feeling completely bogged down. Stuck in the morass of doubt, lack of knowledge, or overwhelm.

For someone who is accustomed to feeling confident and knowledgeable about his or her work activities, this can be a scary experience. And the discomfort can be enough to halt the aspiring entrepreneur's efforts and send him or her scuttling right back to a satin-lined coffin job.

A recent book, Getting Unstuck: How Dead Ends Become New Paths, by business and career psychologist Timothy Butler of Harvard Business School and CareerLeader, offers insights to walk you gently out of the sticky mud and onto a new path.

In the interest of full disclosure, I have not yet read the book - I have it on order. Instead, I offer you an excellent article and review called Feeling Stuck? Getting Past Impasse from Harvard Business School Working Knowledge.

The key take-home points of the article are:

• The experience of being stuck is a combination of feelings and thoughts that tend to appear gradually, rather than arriving overnight
• When we are stuck, our somewhat static version of reality is no longer working for us. Reality in fact is dynamic and changeable. And we have gotten left behind. So continuing with our usual approaches to problem-solving will not help us break through.
• Being at an impasse suggests we need to change our whole approach to and even understanding of, the problem. We need a fresh perspective.
• The 6 phases of being stuck are:

1. The arrival of a crisis
2. The deepening of the crisis
3. We finally realize that our old model isn't working
4. We begin to listen better and to be open to a new type of information
5. We experience deepening of insight into the patterns of the self
6. We take action

• Without the experience of being stuck in one place, ....."we cannot grow, change, and—eventually—live more fully in a larger world". It is our ability to work through our "stuckness" and to learn the lessons this challenge offers that encourage us to move on to new adventures and avenues of self-discovery.
• What awaits us beyond the impasse is the unknown -- "how our life is going to open up next. It's pretty scary and also pretty exciting".

Ivo Drury's insightful blog post about physician identity reminded me of a conversation I had earlier this week on the same topic with a physician coaching client.

She is an established physician entrepreneur with a growing business, who still practices clinical medicine part-time as a hospitalist and internist. In order for her business to move to the next level, she is being forced to consider leaving practice altogether to devote time to business expansion.

This loss of her physician identity feels both disconcerting and irreversible, and is creating stress.

It feels appropriate to share my experience of this dilemma here.

I recall my thoughts at the time of leaving clinical medicine to go full-time as a hospital administrator. My move out of practice was precipitated by realizing I'd been kidding myself in the belief that I could successfully divide my time between my hospital Medical Director role and my busy family practice patient load.

After much soul-searching, I concluded that what lit up my day was NOT placing a stethoscope on someone's chest, doing a Pap smear or writing a prescription. Instead, my joy came from talking to patients, somehow making a difference in their lives, and using my brain to "detect and solve".

I wasn't as attached to "being a doctor" as I imagined. My real attachments were to being an "interactor" and "problem solver". And at my core, I was still ME.

I was delighted to discover that what fulfilled me was translatable to other environments. And that wherever I went, there I was!

As a hospital administrator, the job I assigned myself was to talk to the doctors and hospital employees, detect and solve problems, and make a difference to their days.

As a physician business and leadership coach, I do much the same - I live and breathe our conversations, explorations and discoveries.

If you are struggling with a shift in identity, here are some questions to ponder:

• What do you love most about being a doctor?
  
• Which of these joys are portable or translatable to other careers or environments?
  
• If you are no longer a practicing physician, who are you?
  
• Who were you before you became a physician?
  
• What do you want your grandchildren, or a future generation, to say about you at your funeral?

And if you have any good suggestions to help other physicians who are engaged in this struggle, please share them here!