Flow and work

OHSU StudentSpeak is pleased to present this guest post from Gary Josephsen, M.D., an affiliate professor of emergency medicine, OHSU School of Medicine, and student preceptor.

The surprising way the concept of flow can turn our most challenging moments into our best moments

“How we spend our days is of course how we spend our lives.”
-Annie Dillard

The rules of medical education are: never stand when you can sit, never sit when you can lie down, and if you do lie down for a few minutes, never ever ask yourself if this will make you truly happy. Something like this probably happened to the British philosopher John Stuart Mill when he wrote, “Ask yourself whether you are happy, and you cease to be so.”

Mills, although brilliant, was not a particularly happy person, but don’t you deserve to be happy? Not just happy, but even ecstatic on a regular basis? Studies show that we are bad at predicting what will make ourselves happy. Many people overestimate how happy they will be after reaching major goals or even attaining financial success. You are, after all, investing a great deal of money in your education as a medical professional. Measures of happiness do increase with income, but only until it rises just above the poverty line. After that point, more income doesn’t translate into higher levels of happiness. Sure, money can’t buy happiness but should we get a little bump from the added security of solid finances, the privileges of travel, leisure, or even early retirement? When asked what they want to do in retirement, most answer either travel or drinks on a beach, but even then most fall short of “happily ever after.”

image001Why is happiness such a mirage in modern professional life? To answer this question, one might turn to Mihaly Csikszentmihalyi (pronounced just like is looks, |chek-sent’-me-high|), a psychologist most known for his study of happiness across cultures and circumstances. He describes our tendency toward affluent existential angst in his book, Flow: the psychology of optimal experience (Harper, 1990), a treatise on why we can’t “just be happy” and what to do about it:

“[In ancient China] there were few bathrooms in the palace of the Sun King, chairs were rare even in the richest medieval houses, and no Roman emperor could turn on a TV set when he was bored… regardless of all the stupendous scientific knowledge we can summon at will, people often end up feeling that their lives have been wasted, that instead of being filled with happiness their years were spent in anxiety and boredom.”

Csikszentmihalyi, whose concept of happiness is featured in his TED talk, has spent a career interviewing people to see if they are happy. In addition to the interview he gives research subjects beepers and then pages them randomly throughout their day. When paged they record what they are doing, how happy they are, and why. Beepers were given to students, factory workers, farmers, even shepherds, and, you guessed it: paging Dr. Happy… Dr. Happy please call extension 4580. The results were a surprise to everyone.

It turns out that the best moments of our lives are not the ones we would suspect. Travel, leisure, and beach cocktails are at best second-rate, even if they provide pleasant memories. Instead, what made subjects happiest were moments during demanding tasks with intense challenge. Csikszentmihalyi called this optimal experience or the flow state. Here is an excerpt from his TED talk about the best moments of our lives:

‘[E]cstasy’ in Greek meant simply to stand to the side of something. And [for me] it became essentially an analogy for a mental state where you feel that you are not doing your ordinary everyday routines… so many of [my subjects] described this as a spontaneous flow that I called this type of experience the ‘flow experience.’”

What Csikszentmihalyi discovered was that people were happiest when they were completely engaged in a challenging task, but not just any task. They had to be really good at what they were doing. This combination of high skill and high challenge focused the subjects’ minds. Csikszentmihalyi points out that even as humans we have a limited bandwidth for sensory data. Most people can’t listen to two people talking at the same time, it’s annoying. On the contrary, when we are highly skilled at a task that also challenges us, the sensation is euphoric rather than annoying.

The concept of flow [is] the state in which people are so involved in an activity that nothing else seems to matter; the experience itself is so enjoyable that people will do it even at great cost, for the sheer sake of doing it.”

This was how Csikszentmihalyi first discovered flow, but studying artists and composers who engaged in aesthetic activities that required them to make sacrifices. They were poorly paid and overworked but continued to suffer to produce their art and music. In their interviews, many said they did it because of the feeling of flow.

So what is flow? It’s a state of intense concentration on a task where subjects are so engaged they lose track of time. Many describe a feeling like they are standing outside of themselves, watching detached as they operate “in the zone.” Csikszentmihalyi often relies on examples rather than descriptions such as an Olympic skater who performs without conscious thought, operating automatically and merging with the music. It could also happen to a concert violinist performing onstage, or a big mountain skier cutting down a white Alaskan mountain face. The type of activity doesn’t matter, but it has to be hard and high-stakes. This is what extreme alpinist Marc Twight meant when he wrote, about complete absorption in extreme climbing: “it doesn’t have to be fun to be fun.”


Csikszentmihalyi divided experience into eight quadrants on a graph. To illustrate his point, take the case of tic tac toe. No one plays tic tac toe, but why? Quite simply, it’s too easy. There is no challenge so it falls in the lower left quadrant of the figure, labeled apathy. On the other hand, while no one plays tic tac toe, people love chess, which is both skill intensive and highly challenging. It pushes us straight up to the top right side of the figure, into the euphoric flow state. Knitting is found on the bottom right near the relaxation quadrant because it requires skill but low level of challenge, unless it’s a cutthroat knitting competition. To find the best moments where we enter the flow state we need to engage in challenging tasks where we have cultivated high levels of skill through practice and dedication. Csikszentmihalyi describes this here:

Contrary to what we usually believe, moments like these, the best moments in our lives, are not the passive, receptive, relaxing times—although such experiences can also be enjoyable, if we have worked hard to attain them. The best moments usually occur when a person’s body or mind is stretched to its limits in a voluntary effort to accomplish something difficult and worthwhile.”

What many people find is that the sage advice of finding happiness by following your passion is essentially looking for gold at the end of the rainbow. Happiness is fleeting as our passions and preferences change over the course of our lives, sometimes dramatically. But by cultivating skills and developing our abilities we make it easier to experience ecstasy in challenges at work and in our personal life.

If you are interested in something, you will focus on it, and if you focus attention on anything, it is likely that you will become interested in it. Many of the things we find interesting are not so by nature, but because we took the trouble of paying attention to them.”

What about optimal experience in medicine and surgery? Often during medical training, we find ourselves in the left upper quadrant labeled anxiety. This happens when we undertake important, challenging tasks before our skills are completely developed. When we take up a task with high levels of challenge and skill before those skills are ready it produces stress. Unfortunately, many people shy away from the stress which stunts their skill growth and they never get to enjoy the feeling of flow in their work. Instead they oscillate between worry and boredom. We have all felt this in our training. But pushing to cultivate your skills will make your most challenging days into your most rewarding ones. This is one of the many reasons that we are fortunate in medicine. We have everything we need to drink our fill of flow at work.

People like to ask if at the end of your life you would have rather spent more time at work. If we develop our skills and it’s a challenging day, then the answer is probably yes, or to please stop asking us stupid questions on our deathbed. Most of us work our whole lives with plans to travel and retire on the beach, but when we get to the end of the rainbow we lose interest in the pot of gold. Instead what we want is another challenge. The gold might be nice to pay off student loans, but it won’t make us happy in the long run. Remember, it doesn’t have to be fun to be fun, but it can’t be easy.

Dr. Josephsen is the author of The Bridge: Making a Difference on a Patient’s Worst Day, For the Physician Assistant and Emergency Nurse Practitioner seeking to Improve Patient Experience of Care, available on Amazon.

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2 responses to “Flow and work

  1. Wow! This post could not be filled with more profound thoughts. They are truly inspirational. Thanks for posting this.

    “The mind is everything. What you think, you become.”

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