An old parable tells of a man who insists on using a leaky bucket to haul water. Each time he gets to his destination, the bucket is nearly empty. Finally, someone asks him why he won't take a few minutes to repair it. "I can't," the man snarls. "I'm too busy carrying the water."

Many physicians can relate to this tale. Instead of closing the office at 6, they overbook and leave at 8. Rather than let someone else see their inpatients, they make their own rounds. Instead of declining to sit on another HMO committee, they agree to chair it. Soon, they're overwrought, they snap at the office staff, work late each night, and neglect their loved ones. Frequently it takes a major event to get such doctors to slow their pace. It might be a heart attack, as in the case of the orthopedist whose story appears on page 134. For others, it's the breakup of a marriage or serious financial woes. On the other hand, some physicians never experience a cataclysmic event; they just abuse drugs, alcohol, or both.

This article isn't only for those doctors, but for those who fear joining them. If you're worried that you're losing your grip, life is passing you by too quickly, and burnout looms, read our tips for regaining control as medicine heads into what's likely to be another turbulent decade.

Create a healthy work environment. If one managed care plan in particular is causing you and your staff a disproportionate number of headaches, consider dropping it. Granted, deselecting yourself might not be feasible if the plan accounts for, say, 20 percent of your gross income, but it's an option for one that provides 5 percent or less.

"You're never going to eliminate all of the stresses that managed care creates, but you should try to minimize them whenever possible," says Edward E. Bartlett, a risk management consultant in Rockville, MD, who conducts stress management seminars for malpractice insurance carriers, medical societies, and other clients.

Karen Childress, a career and personal coach in Santa Barbara, CA, knows a couple of doctors who've opted out of managed care altogether and rely solely on fee-for-service patients. "Yes, their income has dropped somewhat," she says, "but it was more important for them to improve their lives before they hit the wall."

Few doctors, however, would be willing to make a change that drastic. For them, managed care is--and will remain--a fact of life. If you're having trouble dealing with this or other facets of your practice, it might help to have a practice management consultant examine your systems and find ways for you to work more efficiently. Don't know of a good consultant? Ask a colleague for a recommendation, or contact either the Medical Group Management Association (877-275-6462, www.mgma.com) or the National Association of Healthcare Consultants (800-313-6242, www.healthcon.org). Both groups can provide names of reputable advisers specializing in medical practices.

John and Judith Egerton, family practitioners in Friendswood, TX, recently finished paying for four college educations and completed several major changes to their practice that allowed them more free time. Then they bought a vacation home in the Texas hill country some 200 miles from their practice. Twice a month during the summer, instead of rushing back to see patients on Monday mornings, the Egertons relax on their large outdoor deck and enjoy sunshine and magnificent views while hummingbirds hover around a nearby feeder. "I used to feel like one of those hummingbirds," John says. "Flitting here and there, frantically trying to keep pace with my hectic office schedule. Now, Judith and I are able to take these minivacations and return to the office feeling refreshed."

Michael S. Smith, a Tucson neurologist, took longer than a few days to recharge his batteries. In 1992, he left his practice for six months to work as a volunteer for the US Forest Service. Soon afterward, he became medical director of Carondelet St. Mary's Hospital in Tucson. But after five-plus years in that position, he felt the urge for another change. "I got tired of people and institutions saying that they practiced quality medicine, without being able to define or measure it in any way," he says.

Smith enrolled in the statistics program at New Mexico State University, where he hopes to earn a master's degree this May. "I went through a lot of emotions when I decided to go back to school," he recalls. "Perhaps the toughest thing was going from being a 'somebody'--with my own secretary, as well as loads of responsibility and influence--to essentially being a nobody." Smith plans to use his degree to do exactly what most of his colleagues couldn't do acceptably: measure and improve quality. "I'm excited to get back into the fray," he says. "I never wanted to give up medicine entirely, and this is an area where I know I can make some strong contributions."

Don't ignore physical symptoms of stress. By age 45, William G. Porter, an internist from Charlotte, NC, was in desperate need of a career change. "I could tell what kind of day it was going to be by how early the pain between my shoulder blades began," he wrote in this magazine 10 years ago. "Even on the best days, it was there by midmorning, and I'd be taking a handful of aspirins between patients." Porter wound up teaching full time and taking frequent one-month vacations. "I spent most of that time happily relaxing on my front porch," he says.

Never ignore the signals that your body gives you, be they headaches that begin with the first patient of the morning or muscle pains that prevent you from getting a good night's sleep. Family practitioner Ahnna Lake, president of International Health Consulting in Stowe, VT, recalls a cardiology instructor who'd been experiencing chest pains. "His students told him to get himself checked out immediately," says Lake, a physician coach who assists doctors and other professionals in achieving career satisfaction. "He insisted he was fine, and to prove it he ordered them to run behind him up two flights of stairs. Only he dropped dead of a heart attack on the first landing."

Lessening the stress in your life--and, in turn, the physical manifestations of stress-- means coming to terms with what you can and can't control. "Physicians tend to think that they don't have much control over their practices," Karen Childress says. "But there's a whole range of things that they can control-- their finances, their health, their physical environment, how they manage their time, how their employees are trained.

"Identifying stressors won't necessarily make them easy to control; that requires a lot of work," Childress continues. "But, as I've seen with my clients, once doctors make one significant change, it gets easier for them to make more changes."

Perhaps the biggest adjustment you can make right now is learn to say No. "The physicians who say Yes to everything are the ones who get into the deepest rut the fastest," says Linda Kuhn, program manager for the Texas Medical Association's Committee on Physician Health and Rehabilitation.

Attend a stress management seminar.

You're not likely to change a lifetime of poor coping mechanisms in three hours, but a stress management seminar may well help you establish better habits. And your attendance could even earn you CME credit or a discount of up to 10 percent on your malpractice insurance premiums. Don't assume, however, that your state or local medical society will have a list of qualified counselors at the ready. Historically, medical societies have focused on support and programs for "impaired" physicians--those in the grip of depression or drug dependency--and have tended to let those who are merely stressed fend for themselves. But that pattern is beginning to change, albeit slowly, Kuhn says. "Organized medicine is definitely becoming more aware of the role mismanaged stress plays in causing burnout and impairment."

So where can you turn? In addition to Ed Bartlett, Karen Childress, and Ahnna Lake, many highly qualified individuals and firms help physicians balance their work and personal lives. For a list of contacts, see "Could a 'coach' get you motivated about medicine?" which appeared in our Jan. 10 issue. "Doctors are still very resistant to learning more about stress management, and that's unfortunate," says Ralph G. Bennett, a dermatologist in Hayward, CA, who has attended two of Bartlett's courses. "I've been able to make some extremely valuable changes in the way I work and in the way I think about myself."

In addition, on its Web site, the Texas Medical Association has plenty of valuable information on stress management. Go to www.texmed.org and click on CME. "The Texas Medical Association is the only medical society I know of that has developed an identifiable, proactive program for dealing with stress," says Bartlett.

Linda Kuhn appreciates the compliment. "We had always done a good job of addressing the end result of impairment, so it seemed logical to examine the problem of burnout at its source, to help prevent it," she says. Kuhn herself has been counseling stressed doctors for 17 years.

The TMA's Committee on Physician Health and Rehabilitation began offering a CME course on stress and burnout in 1995. The course is one of five offered to fulfill the Texas State Board of Medical Examiners' one-hour requirement of education in medical ethics or professional responsibility. Through September 1999, more than 1,200 doctors had attended the course statewide; 550 others had completed it via the Internet. "It quickly became one of the TMA's most frequently requested courses," says Kuhn.

Talk with a trained counselor. Unfortunately, many doctors feel that they'll be stigmatized if they take time away from patient care to seek ongoing help for their stress-related problems. "There's still a lot of that I-eat-stress-for-breakfast machismo out there, especially among surgeons," says Jeffrey J. Denning of Practice Performance Group in Long Beach, CA. Therefore, they're very slow to get counseling--if they seek it at all."

Denning has referred several clients to a local industrial psychologist, with good results. "In all cases, the doctors had problems that weren't directly practice-related but that affected their ability to see patients and run their businesses," Denning says. "They apparently weren't going to seek help on their own, but when we suggested they do so, a light went on. It was almost as if they needed someone's approval first."

Family practitioner Ahnna Lake has had similar experiences with doctors. "We're taught early on to keep our personal needs from intruding into our professional lives and to wear self-sacrifice as a badge of honor," she says. "In truth, though, our personal and professional lives are inseparable:"

Kay Gilley, CEO of Intentional Leadership Systems in Durham, NC, agrees. "Physicians are trained to push down the negative feelings, but at the same time they push away the love, joy, compassion, and enthusiasm," she says. "If you could take an ECG of physicians' souls, you'd see that most of them are flatlining emotionally. We try to get them to look at all of the things that are scary, painful, or angerprovoking, and get them to unload all of it."

A pediatrician who's in his mid-60s did the opposite of the Egertons: He sold his practice to his hospital, which hired him as an employee. Now, however, instead of working 60 hours a week, this doctor works 16, says Ed Bartlett. "He told me that even though he's a pediatrician, he has never had a close relationship with his own children. He should have made these changes years ago, but at least now he's been able to salvage the rest of his life."

Realize that you're not perfect. "We doctors must accept that we can never know everything and that our internal resources are limited," Lake says. "We can't deny our personal needs without paying a price. To be healthy, we have to reject the idea that we must be perfect."

Bartlett concurs, adding, "Many people who choose a career as demanding as medicine are by nature compulsive and perfectionistic. Their medical training feeds these tendencies. By the time they get into private practice, these personality traits are firmly in place." The notion that you can do it all often extends to family as well as to your practice, especially among female physicians, who often fall into the trap of thinking they can be Superdoc, Superwife, and Supermom. "The cold, hard reality," Bartlett says, "is that no one woman is capable of being perfect in all three of these areas. It's unrealistic."

If taken to the extreme, trying to "do it all" can cause serious injury--or even death, as we saw with the cardiology instructor. "One surgeon I met in Michigan told me that she began performing an operation while already in labor," Lake recalls. "By the time she finished the surgery, she was so far along, she had to be taken directly to the delivery room."

For dermatologist Ralph Bennett, being "perfect" means being able to spend enough time with each patient. Now, with his reimbursements dwindling, he has been forced to see more patients, reducing the time he visits with each. That's a frustration he continues to fight. "My new mantra is that I don't need to be perfect," he says. "These days, I have to constantly remind myself that 'almost perfect' is good enough."

Are you burning out-or just starting to smolder?

The following self-assessment can tell you how close you are to experiencing a level of stress that could be debilitating, either psychologically or physiologically. For each statement, respond "almost always" (4 points), "often" (3 points), "seldom" (2 points), or "almost never" (1 point). A score of 25 or more points is cause for concern.

* People expect too much from me.

* I'm under a lot of pressure.

* I feel overwhelmed.

* I don't have enough time to complete my work most effectively.

* I wish I had more support and assistance.

* I find myself becoming forgetful or indecisive.

* At the end of the day, I'm exhausted.

* I don't have enough time to do the things I really enjoy.

* I have trouble falling asleep because of everything that's on my mind.

From DA. Girdano, G.S. Everly Jr., and D.E. Dusek: Controlling Stress and Tension.