The Penstock Paradox

I've been catching up on Lisa Rosenbaum's Not Otherwise Specified podcast series on primary care. https://not-otherwise-specified-podcast.nejm.org/e/when-no-ones-watching/

The final episode is titled When No One's Watching.

Near the end, Jonathan Han, a family physician and residency director, talks about the kinds of things that rarely are captured by metrics: the relationship-building, the moments of connection, the acts of stewardship, the things we do because they matter.

They don't generate RVUs and won’t be highlighted on a business annual review.

Yet they may be among the most impactful things we do.

Rosenbaum draws a parallel to Olympic figure skater Alysa Liu, who stepped away from competition and returned on her own terms. Her music. Her choice of coaches. Her focus on artistry over medals.

What followed was some of her best skating.

The thread connecting them is that when we over-index on external measures, we risk crowding out the very things that make excellence sustainable.

It would be easy to assume that if you put more time and effort into meaningful activities, the automatic outcome is burnout.

But I've seen it work differently.

Think of a hydroelectric dam.

The reservoir represents your reserves, the energy you bring to the work. Water flowing in represents the things that restore you. Water flowing out represents the demands that drain you. (Thanks to Dr. Kemia Sarraff for this part of the metaphor)

The penstock spillway, though, is the really interesting part.

Water flows through it too, but it isn't simply draining away. The movement converts potential energy into usable power to fuel the dam itself.

Meaningful work can function the same way.

It looks like outflow. It takes time, attention, and effort you don't always feel you have. But something about the nature of it converts the effort rather than simply consuming it. The calibration isn't always obvious. But it starts with knowing what your penstock is.

Years ago, I worked with a chief resident who was remarkably gifted and loved art.

As most lead residents know, the role comes with more than enough work already. Long hours, constant interruptions, and near endless competing priorities.

Yet whenever a resident, faculty member, or staff member caught her attention for some reason, she would often create a handmade card with a personal note of encouragement.

She did it simply because creating and encouraging others brought her joy.

The cards would appear one person at a time, without fanfare. Yet they made a lasting impression on nearly everyone who received one. They certainly did on me.

Not too long ago, a friend and mentor reached out at a particularly perfect time. When I told her it was exactly what I needed to hear in that moment, she replied that someone once told her:

"Prompts to encourage, when obeyed, have the power to change the world."

She added:

"I've always tried to listen to those prompts and, today, your name was whispered in my head. Never fails."

I think the chief resident was doing the same thing.

Responding to the nudge that someone or something mattered. Acting on it despite fatigue.

And by doing so, she connected to something deeper than the demands of residency. The cards weren't merely another task consuming her reserves. They appeared to be one of the things helping replenish them.

That’s what I call the Penstock Paradox.

We can be exhausted and rejuvenated at the same time.

The things that sustain us and the things that matter most to others are often the same things that will never appear on a performance review.

Reflection

What is your handmade card?

How do you want to measure how well you did at the end of the day, week, month, or even year?

I'd love to hear.