Zamboni tournaments with the cleaning team.

Arm wrestling with patients.

And other things.

They made me happy. They made the people I worked with happy. They made my patients happy.

Like the man whose elbow flexors I had reconstructed, who then wrestled with that arm.

And I am pretty sure they made me better at what I do.

These episodes don’t take from my professionalism, my work ethic or how I treat patients. These little joys are not a break from the craft. They are part of the craft.

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We have built a professional culture where allowing yourself to be human and silly and fun at work is treated as a sign you are not serious. That you are not committed. That someone somewhere is outworking you because they are not smiling.

“If you have time to smile at work, you are not working hard enough. Somewhere out there is someone who is not smiling, who is working harder than you, and who is coming for your position.”

I read that recently. I found it unbelievably sad.

But here is what that image actually describes: a person working with a clenched fist and a frozen face, grinding through the day so they can be first. To me this is not ambition but a person engineering their own misery and calling it discipline.

Here is the counter-argument.

You can fake hours. You can fake urgency, and plenty of people do it well. You can fake being busy for an entire career.

You cannot fake being genuinely excited about your work.

It shows itself in what you notice, in the problems you choose or what you are still thinking about on the train home.

You can fake your enthusiasm and make it look like a performance. Whereas real enthusiasm forgets to perform, mainly because it is too busy being really interested.

Over ten years, the person who actually enjoys what they do, will outperform the person with the clenched fist. Every time. And they will still want to be there after all those years.

I have colleagues far up the ladder with nothing left to prove. They will still tell me about a recent tough case or reconstruction with something close to childish excitement. It is genuinely bringing them joy, and it is the most refreshing thing to listen to.

There is a corner of the internet that will tell you holding a regular job means you are an idiot. That you sold your soul.

Real freedom, the story goes, is only available to people selling courses and services from wherever they want, whenever they want. If you are employed, you are the one who didn’t get the memo yet.

It rests on two assumptions, both of which are wrong.

First, we are not all the same. Some people do their best work inside an institution, with a team, with resources they could never assemble alone. The solo path is not the apex of human potential. It is one shape of work, and it suits some people terribly.

Second, and more importantly, it assumes your job sucks.

It assumes employment is a sentence you are serving, not particular circumstances you deliberately chose.

If you choose the branch carefully, and you put in the years, and you get good enough that you genuinely can’t be ignored, you may well end up with work you actually like.

And if you still have hunger for more, the two are not mutually exclusive. Nothing stops you from holding the job and building the other thing alongside it. I have done both.

Depth creates freedom. Pick one trunk to grow before you branch.

Because mastery gives you the leverage to expand into leadership, writing, research, whatever else you are.

The people telling you to quit your job and go solo are not wrong about the possibility. They are wrong about it being the only one.

Grind culture and the gospel of the solopreneur look like they are separate, but they are not. Both are worshipping the conception that work is suffering. They just draw different conclusions. One argues for pushing through and stop complaining. The other one argues for escape and the pipedream of an effort-free alternative.

Neither acknowledges the option that work could be more than suffering but actually rewarding and fun. Both stories only focus on the wrong of it.

And we have become very good at describing what is wrong.

The workplace. The organisation. The health system. Everything upstream that shapes how a day goes.

Naming problems is part of my job. As department head I am supposed to identify these things and work every lever I have to move them. So of course I am part of this conversation.

But the discussion has skewed.

Problem-naming has become the whole conversation, and at some point it starts serving itself rather than the people.

Hearing patients laughing with their caregivers makes me genuinely happy when I look at my department. So are senior residents staying longer to teach juniors through surgical steps, not because they have to, but because they want to.

We have a language for burnout, for toxicity, for structural failure. We have almost no language for joy at work. For the team that made something impossible work because they actually like each other.

And when we never name the good, we start to believe it is not there.

I am not arguing we stop naming what is broken. We should.

I am arguing we also name what is working, what is joyful, what is keeping people at work.

Because if the only story we tell about work is what is wrong with it, we are not describing reality.

We are amputating it.

But teams that laugh together trust each other more. And trust is one of the highest-leverage currencies any institution can have.

In practical terms: faster decisions, fewer second-guesses, less wasted energy on politics, fewer sick days.

So joy is not soft. It is deeply efficient.

Employed work can be fun.

It is allowed to be fun.

And we should say so more often.

Joy is not a reward you collect once the work is done.

It actually is the thing.

When was the last time you allowed yourself to be genuinely silly at work?

To more from life,

Nicco

Sing along for fun at work

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That was my dad’s wisdom in a nutshell at my wedding. I can’t recall how many times I have come back to this nugget of gold. It encapsulates so many truths.

For one, the possibility: yes, you actually can have it all. And no, time and circumstances are only part of the equation.

Second, the condition: the inevitable gap between imagination and reality.

Third, the acceptance: accept the gap and you’ll be able to see what you actually received.

Similarly, but with a slightly different twist: if you love what you get, you always get what you love.

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As I have written before, I had set out to become head of department of a plastic surgery unit at a university hospital, to increase my zone of influence and better the health care system from within, for healers as well as patients. I mapped out a ten year plan with a start-with-the-end-in-mind backward planning process (C-tree). I checked all my boxes and achieved my goal after 9 years and 9 months.

Except it was a position in Denmark, a country I only knew from vacation and whose language I couldn’t speak.

Definitely different than I imagined. And in many ways, so much more. Everything from work-life balance, if you like that concept, to agency, to what daily life with a family actually looks like here.

More than a decade earlier I spent a lot of time working through my relationship issues in all of their flavours and colors. At one point I went through an exercise where I described my ideal partner: looks, traits, character. I got pretty detailed. I always imagined her to be from a different country, and that I wouldn’t marry.

I put in the work, made sure that I am less of the idiot I had been before. And suddenly I found myself asking a wonderful woman if she wants to marry me.

She also was from southern Germany, like me.

I’m not sure I like Mick Jagger’s popular “wisdom” that you can’t always get what you want. He left out the most important word: “right away.” Life didn’t subscribe to Amazon Prime, and delivery times are significantly longer. But it does deliver, if you accept the wait.

We overestimate what we can achieve within a year and completely underestimate what we can achieve in five. And we all have that time. We fear someone else is faster and further. Some are. But most people sprint, show momentum, and die off quickly, because their timeline was too short to hold focus.

Once we look at our whole life, the distortion gets even bigger. We have decades at hand. Enough to pursue multiple careers and develop mastery in multiple areas, if we feel drawn to that.

The Professional Amateur

I have become a professional amateur jazz saxophonist in my wedding band just by keeping playing for over 20 years.

The phrase sounds like a contradiction, but it’s not. “Amateur” comes from the Latin amare, to love. The amateur does the thing for the love of the thing. The professional does it for money, for obligation, for external validation, for any measurable result. A professional amateur brings professional discipline, practice, standards, consistency, to something done purely for love. That doesn’t make it a second-tier version of the real thing. It might actually be the best way to do anything.

Why? Because the amateur position has advantages the professional lacks. A professional saxophonist must play to survive: what the venue wants, what the market rewards. A professional amateur plays whatever the hell he wants. That freedom is not a consolation prize. It is the whole point.

Where is the difference to a hobby, then? Can “professional amateur” coexist with “second career”? If I go all-in on saxophone after my current career, do I stop being a professional amateur and become just a professional? Does crossing that line change the thing itself? My dad’s wisdom would say: yes, it changes, and yes, it’s still worth it. But I would have to accept it will look different than I imagined. A second career in music probably won’t look like the fantasy. It will look like work, because it will become work. But you would also get the perks of mastery.

We often look at ourselves one-dimensionally. As if proficiency and mastery only adhere to our professional work. We hold so many roles by definition, depending on our profession, lifestyle, family and social situation, our interests. Apply the long horizon to all of these and you begin to see that you are so much more than that one thing. That one profession, that one label you picked for introducing yourself to strangers.

The Valve System

Instead of looking at all areas of your life as competing for your time and attention at the same time, I see them as valves of different sizes that open and release at specified times. Everything that wants to get done needs a time and a place. As long as that is in place, you reduce the risk of too much pressure building up, or burning out.

Obviously, the valve size is not arbitrary. The thing you are currently pursuing to mastery, your current C-tree, has the biggest valve. Learning karate for the past six months has the smallest, as of now.

The question that should determine every adjustment: which of my identities is generating the most pressure right now, and is that pressure productive or destructive? Productive pressure is creative urgency, the thing that keeps you up because you’re excited. Destructive pressure keeps you up because you’re anxious. They are physiologically similar, but they feel different in the body. Learn to tell them apart, because productive pressure should get a wider valve, and destructive pressure usually needs something else entirely: a conversation, a boundary, a hard look at what you’re actually afraid of. Or at why you are attached to that identity in the first place.

The hardest part of the valve system is not logistics. It’s psychological. The reason we try to do everything at once is not poor planning.

It’s fear.

Fear that if you close the valve on something, it will die.

Fear that the window will close.

Fear that someone else is getting ahead while you wait.

The valve system only works if you genuinely trust that every identity will get its turn.

That you have enough time.

This is not a scheduling insight. It is an abundance insight. You have to believe there is enough life for all of it. Most people don’t, and that is where the shift happens.

We usually have quite a good idea of where pressure is building. What we lack is sitting down, listening to it, and adjusting our planning accordingly. I have weeks where hospital issues press so much that I have to rededicate spaces originally planned for something else. Other times I have creative spurts, in writing or in music, where I plan with my wife and family how we can best accommodate them. Sometimes that includes night or very early morning shifts that don’t feel like sacrifice, because of what the activity gives back.

But you learn to live with unfinished business.

What is the smallest viable valve? Not everyone can carve out a Monday morning. If you can’t, the question becomes: what is the minimum attention an identity needs to stay alive? A monthly afternoon. A quarterly weekend where you go deep on just that thing. The point is not the size of the slot. The point is that it exists, on the calendar, non-negotiable.

An identity with no valve is an identity you are slowly killing. And you will feel it as pressure, somewhere in your body, whether you name it or not.

What helps me tremendously is sitting down and writing out specifically what is pressing, what wants to get done, what feels too big. Break it into substeps and you begin to see where they might actually fit into your life.

You might also realize that the abstract idea you were idealizing is not what you still want, now that you look at the worldly details. Then go kill that identity. Let it go and make space for other things. I have a graveyard full of identities I outgrew.

We do not have to choose between our different identities. All we have to do is become clear about where we want to go with them, then allow them to develop over different timelines, and with outcomes different from our current expectations.

The Two Forces

My dad’s wisdom is about surrender: accept the gap between imagination and reality.

The valve system is about control: schedule the identities, manage the pressure, adjust the valves.

These two forces look like opposites. But the valve system is what makes surrender possible without resignation. You don’t surrender by giving up on things. You surrender by giving each thing its proper time and then releasing attachment to the outcome. You are not alternating between surrender and control. You are using the little control you have to create the conditions for meaningful surrender.

I lived this without naming it. My ten-year plan to become department chief was all control: backward planning, checkboxes, nine years and nine months of execution. And the outcome was surrender: Denmark, not the country I had in mind. The valve system is what let me hold both. I recently wrote about the same dynamic in The Micro Reset — surrendering to the surgery’s outcome inside an environment of total control.

Where to Start

When you feel pulled in twenty directions, pick the one identity that gives you the most energy right now, not the one that sounds most impressive. The one where you are most curious.

If you genuinely don’t know, walk yourself through this quick exercise: write down every version of yourself you’ve ever wanted to be, then circle the one you’d be most disappointed to never try. That’s your starting valve.

For me the breakthrough came when I gave myself a single, non-negotiable Monday morning slot dedicated to just one of those identities, the writer, for three months. Instead of that undefined ruminating urge to write with nowhere to go, I suddenly had a place and a time. I collect thoughts and ideas throughout the week, then sit down and use them, or not, on those mornings. It was never so much about the outcome. That part is nice, no question. It is the relief of finally being able to live out that part of me.

And whether this develops into a second career, who knows. My timeline is long enough.

To more in life

Nicco

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Sure, the neoadjuvant chemotherapy and radiation therapy the patient had received after a severe cancer diagnosis didn’t help with tissue viability. It felt like suturing butter. But that wasn’t the patient’s fault, and it was my problem to deal with.

And then I saw the face of my nurse and I remembered my personal micro-reset protocol that had helped me countless times before, developed in a situation just like this one.

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I put down the micro-instruments, detached from the microscope and closed my eyes. I took one really deep breath in through the nose, held it, and released through the mouth. Already there I could notice how tense I had inadvertently become, now that my muscles relaxed.

I then reminded myself that I had solved tricky cases before, and fully surrendered to the situation at hand. I literally stopped fighting it.

The next anastomosis was still sweat-inducing, I switched technique and it held. The flap came alive, we wrapped up, and it was fine.

Without that micro-reset, I might have continued to push through it the same unsuccessful way for another two hours.

That is not to say that I haven’t lost flaps in my career. Every surgeon has a graveyard, so to speak.

But here is what those years taught me: the fastest way to lose two hours in a high-stakes environment is to spend ten seconds not stopping.

Sounds backwards, but it’s not. You can see the ten seconds you lose. You cannot see the two hours you save. The mistake that didn’t happen, the conversation that didn’t escalate, the work that stayed clean instead of compounding an error because you kept gripping.

And there is a second reason: ten seconds of deliberate stillness, under pressure, feels exactly like the thing high performers have spent their careers avoiding.

Because most high performers are married to momentum.

Your pressure valve

But once things don’t go as planned, we tend to tense up and push through. And when that doesn’t yield success, we tense up even more and get stuck. This typically can’t be solved with more pressure. To the contrary, you need to find a way to release that pressure, so you can think clearly again.

Unfortunately, there has been a tradition in surgery of releasing pressure by taking it out on others. Screaming, yelling, bullying, kicking, throwing instruments, you name it.

And the same way we learn grieving from watching those around us, from the dramatic throwing yourself on the ground to the stone-faced silent intake, we learn to release pressure by watching those around us.

I believe that is something that has to be reflected upon consciously. You have to watch yourself and see whether the strategy you have adopted is a) serving yourself and b) not harming others.

This is where practices like yoga and breathwork come in handy. To be clear: what I’m describing here is not mindfulness. Mindfulness is the daily practice that makes these ten seconds available when you need them. The reset itself is something narrower, a mechanical intervention.

Of course you can decide that every time you feel the pressure rising inside of yourself, you go running or hit the gym. Which is great. Just not something you can do in an OR, or any other high-stakes environment, for that matter.

Why breath?

Breathing is the only one of your autonomic body functions under direct voluntary control, and it is directly wired into both your sympathetic fight-or-flight system and your parasympathetic rest-and-digest axis.

That means you can learn to influence and alter the state of your autonomic nervous system. Something professional athletes have known and used for a long time.

And the good thing is, it doesn’t take much. A few conscious, long, deep inhales and exhales go a long way. If you take one thing: make the exhale longer than the inhale. The exhale is when your parasympathetic system takes over.

Your mental interference

That is the physiological component. And then there is also the logic component.

Because the reason the tension and pressure build up in the first place is a Buddhist truth: your frustration stems from the difference between your expectation and reality.

The gap between how you want things to go and how they are actually going.

In my case it was the reality of the fragile tissue colliding with my wish that it would just behave as normal.

And the more we focus on what we want, on how it should be, the less perceptive we are to what is right in front of us.

Once we let that expectation go, through the micro-reset breathing for example, we are able to see reality as it is. And from there we can adjust our next move, which often then brings the result we had so desperately been focusing on before.

The hard part

Now all of this sounds fine. The challenge is not so much in the doing. The breathing and letting-go part is not particularly hard.

The challenge is remembering it when you actually need it. Because in the moment, stopping feels like the failure, and pushing through feels like the discipline. It’s the other way around.

What I tend to do when trying to learn or implement something new is set reminders through the day for exactly this.

Then run it when nothing is on the line. Do it twenty times in low-stakes moments. The twentieth rep is the one that shows up when everything is.

Also, when coming out of high-stakes situations where you haven’t done it, reflect on what happened and how it could have helped. A sort of personal debriefing moment.

And lastly, talk to people about it. I told my nurses, asking them to remind me when I get tense, or when they feel the situation is tense, to take a micro-break. Doesn’t mean they are always aware, but the more people are in the loop, the higher the chance of it actually happening.

Since we briefly touched on culture, there is another component to it. The notion that you might look weak and indecisive when pausing. In my experience, the opposite happens: the calmest person in the room, the one with poise, is the one everyone turns to.

The actual protocol

What I did at the microscope that day was the instinctive version. Over the years it has distilled into something you can actually install:

Seconds 0–2: Hands down.

Whatever you’re doing, stop doing it. The physical stop comes first.

Seconds 2–5: One long exhale.

Not an inhale first. A slow, deliberate exhale is the fastest available switch from sympathetic to parasympathetic tone. Do it longer than feels natural.

Seconds 5–8: Eyes wide, middle distance.

Stress narrows the visual field. Soften your focus, let the peripheral vision come back.

Seconds 8–10: One internal sentence.

Not a mantra. One sentence that names where you are: I am in this case, at this step, and the next move is X.

Ten seconds. Then you resume.

As always: take what you like, adapt it to your life, and hopefully create a way to navigate high-stakes, high-pressure situations better in the future.

To more from life

Nicco

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When I was in a ship museum recently with my kids, we came across a selection of really impressive ships in a bottle. We spent a long time discussing how to get a fully rigged ship, with so many intricate details and an obvious size mismatch, inside that bottle.

It had to go through that bottleneck. But how?

Turns out that these ship-in-a-bottle craftsmen design the ship’s body slightly smaller than the neck. The entire rigging including sails is fixed on mini-hinges so that they can be folded on top of the deck. After adding blue sand for the ocean you carefully ease the ship through the neck. Then you lift the rigging by pulling attached strings, and voilà: a full-fledged three-masted ship in a bottle. The magnifying effect of the rounded glass certainly enhances the impression.

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Nobody widens the neck.

That is the entire craft. You do not enlarge the opening to fit the ship. You reshape the ship to pass through the opening, and you restore it to full form on the other side. It is not that the bottleneck disappears, but that you change the ship going through. We often spend enormous energy trying to widen the opening. Sometimes the faster solution is to change what we are trying to pass through it. In other words: you don’t fight the constraints, you work with them.

That is also a fair description of what I do in an operating room. Much of reconstructive surgery is the work of moving through a small incision to rebuild something large underneath, which often feels like painting a room through the keyhole.

I recently joined a business retreat where we discussed bottlenecks. We spent a lot of time on how to identify, name, and tackle the most limiting one. I do think this is a valid approach in many circumstances. But I couldn’t help thinking about why bottles have necks in the first place. Without them, bottles would just be glass cans. We designed necks to control flow while pouring, a timeless mechanism to reduce speed and volume.

That means not every bottleneck is a flaw. Some constraints exist because they create order, precision, or quality. But as with many good things, overdone or context dependent, they can turn into obstacles.

So the real work is not removing every bottleneck. It is recognizing which one it is: the constraint that holds something together, or the one that has outlived its purpose. That judgment is hard enough with the bottlenecks you can see. It gets much harder when the bottleneck is not external but internal, because the ones pointing at yourself rarely look like constraints at all. They feel like facts about who you are.

The real bottleneck is often you

There are areas in our lives where an identified external bottleneck can be more or less easily fixed by changing workflows or hiring more personnel. That is the common way of looking at bottlenecks. But what about those circumstances where the bottleneck is you? You can’t always workflow yourself out of it, and if you try, you keep hitting the wall and asking yourself why.

As a department head, researcher, educator at two universities, writer, and family man, I’ve seen that in many cases I am the bottleneck. The superficial solution is to do less. While that may help in some areas, it’s not universal. The simple reason: we tend to see time as the main bottleneck factor, but it often isn’t. For me, the issue often isn’t time. It’s missing information, waiting for input, or lack of understanding. Those are external bottlenecks. Real, but usually visible.

But there are more subtle ones, rarely discussed: personality traits like avoidance. I realized things often stalled because I didn’t do what I promised. Superficially it seemed like a time-management issue. Looking deeper, I saw I hadn’t written to a particular person because I feared their reaction and avoided the conflict. These are the tasks that move from one day to the next, from one list to the other. Every time I opened my inbox I saw that draft sitting there. Every time I found a reason to postpone it.

These internal bottlenecks come in many shapes and forms. Decisions not taken, information withheld, topics not followed up on because of emotional roadblocks. Maybe for you it’s not avoidance. Maybe it’s fear of losing control, or people pleasing, or something else. Think of them as ships that were never folded properly for the passage.

It is here that I have learned to take my time, disassemble the whole thing, and put it back together in that wonderfully smart way, with rigging and sails and everything, so that it can unfold once we’re through the passage. Realizing my avoidance and reflecting on it helped me put these concerns directly into that unwritten mail, and the conversation turned out far less dramatic than the version I had rehearsed in my head. Before typing a single word, I had to sit with the discomfort and resist the urge to tiptoe away. The email is never the problem. The imagined future is.

Unsure whether the bottleneck is a trait or a system, external or internal? Ask: if a trusted peer took your role, would the constraint remain? If not, you’re likely the bottleneck. That is not necessarily bad news, because unlike market conditions, regulations, or other people, it is something you can actually work on, an area where you have full agency.

So, next time you face a bottleneck, ask: is this about flow, or am I shipwrecked? Use a magnifying glass and look beneath the surface of what you thought the problem was. Ask why it isn’t happening, and because of whom. The answer may be a broken system. But occasionally it is the version of yourself that still refuses to send the email. If it’s structural, fix it as best you can. But if it is you, and in my experience that is more common than we like to admit, then start there first.

To more in life,

Nicco

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Based on my fascination of well-known figures from the renaissance epoque - like DaVinci and Goethe - polymaths from a long-gone era, I set up to strive for a modern day renaissance life. Hence the name of the newsletter - The Renaissance Protocol.

Even though all of that made perfect sense to me, I learned over the last year through many interactions, feedback and conversations, that that name - The Renaissance Protocol - is more clunky and misleading than I was aware of.

And I realized, that if I need a whole paragraph or a 5 minute monologue to explain, what it is that I am writing about - then I might have a clunky name that buries the real point.

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You might have realized that I always end my essays with the salute to more in life. Which is the essence of what I am doing. Trying to get more from life - for my patients, for my family and not the least for myself.

That is why I am rebranding this newsletter to “More from Life - Essays on how to live a full human life where you can have it all”.

The content will stay the same but likely expand.

I will write on my interpretation of living a full human life.

As you might have noticed, I like visual images a lot, it helps me make sense of things if there is at all any.

I have chosen a tree as the image that represents that full human life best and symbolizes the aspects I find repeating in my writing and thinking.

These are - built around a single image: a tree. Its branches mirror the areas I keep returning to, the ones I’ll break down essay by essay,

• Love and relationship

• Family and society

• Work and success

• Health and Wellbeing

• Fun and Play

And Spirituality as the roots.

Going forward, each essay will nest under one of these branches.

This, because I am planning to include ALL topics that are relevant in my life. So you might see one essay on AI’s impact on my clinical work, then another on software development, then a note on meditation I actually used last Tuesday, and later, a raw piece on parenting. You get the point.

Against all better advice, I am not niching down but broadening up.

What I will ask you to do, is this: grab the branches that feed you. Ignore the rest. It might come back around later; it might not.

Root your tree deep enough that it can hold every fruit you’ll ever grow. That’s the full human life, yours to build, not mine to define.

To more in life,

Nicco

PS: I love to read your replies, and am always curious to hear your thoughts.

The “more from life” anthem

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One of the most remarkable traits of living organisms is the capacity for compensation. The ability to function despite partial failure.

I remember the first time this became obvious to me. I was rotating through liver surgery, treating patients with advanced tumors and late-stage disease.

In extreme cases we removed up to 70% of liver tissue, and the patient’s clinical function remained essentially intact. The remaining 30% ramps up production, increases its own mass, and compensates for the loss. The blood work looks almost normal, the patient feels almost nothing. To an untrained eye, there is no crisis.

But remove one percent more - past the critical threshold - and the system collapses. The liver fails.

Not gradually, suddenly.

I have thought about this principle ever since, because it is not only about the liver.

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The Invisible Phase

First, nothing happens for a long time. Then everything suddenly changes.

Anyone who has trained a skill knows this. The first months of learning an instrument, a language, a surgical technique: nothing works the way it should. You are practicing, you are showing up - and by all visible metrics, you are not improving.

Then something shifts. Something clicks, and what was impossible last week is available to you now. And once it is available, you cannot imagine not having it.

The shift feels sudden. It was not, it was just invisible.

What you experienced in those months was not stagnation. It was slow accumulation below the threshold of visibility. The liver was compensating. The liver was compensating. The liver was compensating.

And then it wasn’t.

This is also how many diseases progress. The change is so small, and your perception adjusts to each new normal, that it sometimes takes an extreme form before you realize how far you have drifted.

It Goes Both Ways

Here is the part most people miss.

The compensation principle works in both directions.

Toward growth: the plateau before the breakthrough. Nothing seems to change. The skill is not improvin, the project is not moving, the body looks the same in the mirror. And then it does - because you crossed a threshold that was invisible the entire time.

Toward failure: the hollowing out before the collapse. Burnout is not a sudden event. It is a slow depletion that the system compensates for, compensates for, compensates for - until it cannot anymore. The famous last drop. The one thing that tips you past the threshold you did not know you were approaching.

People do not burn out suddenly. They burn out gradually first, then suddenly.

I once ran a debriefing after we lost a patient. He had come to us with significant underlying cancer already weighing on his body. We operated to give him the best outcome possible at that stage. He was also a heavy smoker, which had compromised his local tissue and immune response. Plus he had a history of chronic sinus infections and came from a region where a specific antibiotic-resistant pathogen is endemic.

After the operation, he developed an airway infection. We could not wean him from the ventilator and he required a tracheotomy. Then, in combination, the cancer burden, the prior treatments, the compromised tissue, and the infection all collapsed together. The entire course of disease was slow, and then very sudden.

His family could not understand it. He had been managing, managing, managing - and then he was gone.

I explained it to them the same way I explained it to the team in the debriefing: the severity of a case is sometimes not visible, especially to an untrained eye. The body compensates for so much, for so long, that the threshold is invisible until the moment it is crossed. What looks like stability is often just compensation at its limit.

This is also true of careers. Of relationships. Of teams.

The compensation is real. The threshold is also real. And the challenge is that threshold often does not announce itself.

Why People Quit in the Invisible Phase

Early in my career I had a colleague who had been a former German champion in kayaking. I asked him how he got there.

He said: Honestly, I don’t know. There were so many people stronger than me, faster than me, smarter than me. But they all quit along the way. And at the end, there was no one left who was better.

The people who quit did not stop believing in the endpoint. Most of them still wanted it. They quit because the invisible phase gave them no visible evidence that anything was happening worth continuing.

This is the most expensive mistake you can make in any compounding domain.

The absence of visible progress is not evidence of no progress. In the things that matter most - skills, relationships, ideas, reputations - the accumulation happens precisely in the invisible phase. You have too fill the bucket up to the threshold before anything becomes visible.

Quitting in the gradual phase is pricey because it resets the counter. You do not get to keep the accumulation, you start from zero.

The tricky part is in differentiating it from the sunken cost fallacy where you keep throwing good money after bad one.

How to Survive the Invisible Phase

Most people assess their situation by measuring visible results. This is the wrong instrument.

There is a more useful one. Compare yourself to someone one or two years behind you on the same path. The gap between you and them - in knowledge, in judgment, in what you now take for granted - is exactly what you accumulated in the time it felt like nothing was happening. Teaching reveals this more clearly than anything else. You realize what you have learned precisely when you have to explain it to someone who hasn’t learned it yet.

You cannot compress the biology of adaptation, the accumulation of a skill, the building of trust. These have timescales that do not shorten. I have tried to shortcut them and found myself back on the same slow trajectory, having lost the time I spent trying to skip it.

What you can do is protect the invisible phase from yourself.

Name what you are building, not what you are producing. The commitment is to the practice, not the outcome.

I am building surgical precision. I am building a research portfolio. I am building a reader relationship. These do not have quarterly results. They have compound interest on a timeline you cannot see. That means I have to track the input, not the output - until I am past the threshold.

Before you abandon something that has not worked yet, do the inventory. How long have you been at this? What has accumulated? What would it mean for all of that to reset to zero? You may still decide to stop - some things genuinely have no path forward. But at least you will know whether you are quitting because the thing does not work, or because you ran out of patience five percent before the threshold.

The Threshold

We would like to know where the threshold is. We rarely do. That is not a problem to solve - it is a condition to accept. What it demands is vigilance. Awareness. Attention.

Awareness does not eliminate uncertainty. But it can help you notice the signals before the threshold becomes obvious.

In clinical medicine, we monitor for exactly this reason. Vital signs, lab values, imaging. We build proxies for the invisible. We measure what we can see in order to infer what we cannot.

You can do the same in the domains that matter to you.

For growth: pick one leading indicator for each thing you are compounding. Not the outcome but the input. Not “am I getting better?” but “am I doing the practice?” Not “is this working?” but “am I showing up?” The threshold exists somewhere ahead of you. The input practice is how you move toward it without needing to see it.

For deterioration: pick one early warning signal. What is the first thing that drops when you are being hollowed out? For some people it is sleep. For some it is humor. For some it is the ability to be fully present with the people they love. That signal is your threshold detector. The clinical marker that tells you compensation is reaching its limit before the system fails.

The Sudden Part

When the shift comes - in either direction - it does not announce itself. You do not feel it building. The kayakers who quit three months before the breakthrough felt nothing different in the weeks before they left. The people who burned out did not feel themselves crossing a line.

The only way to be present for the sudden is to stay conscious in the gradual.

First nothing changes. Then everything does.

Stay. And watch for signals.

To more in life,

Nicco

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I was early in my career, in New York visiting a friend on rotation at a law firm, and I had gone to Central Park mostly because I had read the installation was temporary and I didn’t want to miss it.

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Twenty-Six Years for Sixteen Days

Christo and Jeanne-Claude fought for twenty-six years to install The Gates. Seven thousand five hundred and three saffron panels on orange steel frames, lining twenty-three miles of pathway through Central Park. The installation stood for sixteen days, then it came down, the steel was recycled, and the park went back to being the park.

A few things fascinated me and made the installation feel so particular: the artists refused to drill into the ground. Not a single anchor. Not a single hole. Fifteen thousand steel base plates, each weighing between six hundred and eight hundred pounds, held the gates upright by weight alone.

The fabric hung from the crossbar at the top and was allowed to fall freely toward the ground. Wind moved through it. Weather moved through it. Millions of people moved through it.

Nothing fought the environment. Nothing tried to resist what was moving through it.

That was what I could not stop watching.

What Moves Through You

Years later, in a remote ashram in East Germany that I had hiked to while quietly afraid of surrendering to something cult-like, I remembered the gates while learning more about Buddhist teachings.

Listening to the phrase, “You are not your thoughts. You are not your emotions,” I couldn’t help wondering what it would feel like to become more like one of those gates. To provide a frame and an opening, but no resistance to whatever strange emotion, thought, or feeling decided to pass through.

Ever since, I’ve been trying to become a little more gate-like.

It has helped me tremendously, both personally and professionally.

I remember a case where I scrubbed into a repeatedly failing microsurgical anastomosis on previously radiated tissue.

The anastomosis had failed multiple times. It was the fourth attempt. Radiated tissue does not behave like healthy tissue. At times, it feels like suturing butter. I had been fighting the tissue with every trick in the book, as if technique could force biology.

What I noticed during the fourth attempt was that I had been gripping. Not the instruments. The outcome I had decided needed to happen.

That grip had been burning through everything: my read of the field, my feel for the tension, the quality of my judgment. It was more force and resistance against reality than anything else.

The image of the gates came back to me, and I loosened up. My grip on what I had decided must happen loosened as well.

Nothing changed, but I stopped fighting it.

And the anastomosis held.

High performers are told to control their inner state. Stay calm. Stay focused. Do not let your emotions affect the work.

As so often happens, it sounds reasonable. And nobody tells you how to actually do it.

Your surroundings do not change just because you decide they should. Emotions like fear arrive whether you invited them or not. Doubt arrives. Fatigue. Hunger. The flashback of something personal you thought you had parked at the door.

In short, the weather comes in regardless.

The question is never whether the weather arrives. The question is what you do when it does.

A rigid panel fights the wind. It splinters. It burns energy trying to hold. A saffron veil lets the wind pass through and remains standing.

The Buddhist formulation underneath this is simple: attachment is the root of suffering. Not the presence of difficult mental states, but the grip we take on them. The clutching. The resistance. The insistence that what is arriving should not be arriving.

That is where the splintering happens.

Not in the weather, but in the fight against it.

Christo and Jeanne-Claude probably did not set out to build a meditation tool. But I’m glad that by trying to make something beautiful that New York could walk through in winter, they did.

The Gate Principle

I started calling this The Gate Principle in my own work, because I needed a name for what I was trying to install in myself, and later to explain to others.

A gate only works because part of it refuses to move and part of it agrees to.

A frame that does not move. Your values, your clinical standards, your commitments, the decisions you made before the case started. These are fixed before the wind arrives. In the OR, this is the preoperative plan. In leadership, these are the decision rules you operate by. You do not negotiate with the frame during the storm. If it becomes negotiable during the storm, it was never truly the frame.

A veil that does move. Thoughts, emotions, sensations, intrusive self-talk, the entire internal weather system. These are attached only at the top, to the frame, and allowed to fall freely. The veil moves so the structure can remain intact.

A refusal to drill into the ground. We constantly try to anchor ourselves into permanence. We try to make the impermanent permanent. But no frame stays the same forever. You are free to change and update it whenever necessary or meaningful, according to what is important to you, not someone else. In that sense, the frame becomes self-anchored rather than ground-anchored, because it rests through its own weight.

The gate does not resist the wind.

The gate does not chase it either.

And letting the wind pass through is not softness. It is the only way to keep the structure intact.

The surgeons I trust most work this way. So do the leaders I learn from. The frame is non-negotiable: the standards, the preparation, the decision rules. What moves through them during the work, they let move through.

The Install

Name your frame first.

What are your three or four non-negotiables? The things that stand regardless of your internal weather? If you cannot name them, you do not have a frame. You have preference disguised as principle.

Write them down.

These are your steel.

Then notice where you are drilling into the ground. Where are you relying on external validation, fixation, or permanence? Each of those is an anchor you are trying to sink into concrete, and each one makes your framework dependent and ultimately inflexible.

Pull those anchors.

Then let the fabric hang and watch life move through it.

To more in life,
Nicco

PS: Forward this to someone in your life who has been trying to weld down their weather. And reply with one anchor you’re pulling this week.

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I nodded and held the open trash bag closer to her. “You haven’t touched this in over two years. We are not taking it with us.”

I had moved in with my future wife and we were preparing for our first move to a different city together. We went through the painful yet revealing exercise of taking each item in our shared household and deciding: keep, trash, or give away. Every single one.

It took long, it was hard, there were tears. Not because there was so much to sort through, but because every object required a small act of honesty. Do I actually use this? Will I actually wear this? Or am I keeping it because getting rid of it means admitting I was wrong to buy it in the first place?

Most of what we own exists in that gap between intention and action. We bought it for who we planned to become, not who we are.

I think about that move often. Not because of what we threw away, but because the same pattern shows up everywhere once you start looking for it.

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We hoard knowledge the same way we hoard kitchen gadgets.

The internet has turned all of us into gatherers. We save articles, bookmark tools, screenshot advice, subscribe to newsletters we never open. Not because we need the information now, but because we might need it someday. Because action requires energy, and saving something for later feels like progress without the cost of doing anything.

It is not progress. It is the illusion of preparation.

It allows you to feel engaged without ever being exposed to the risk of actually doing something.

The saved article sits in the same psychological drawer as the fondue set in the basement. Both represent a version of yourself that has not arrived yet and probably won’t, because the act of collecting has replaced the act of doing.

And the more sophisticated the material, the easier it becomes to justify not acting on it.

And if this were only a storage problem, it would be manageable. But accumulation without clearance has a cost that compounds.

I see this in the body every day. Your cells run a process called autophagy, a Greek word that literally means self-eating. It is the mechanism by which cells identify damaged proteins, broken organelles, and accumulated waste, and then break them down and recycle the parts. Yoshinori Ohsumi won the Nobel Prize in 2016 for mapping how it works.

When autophagy functions well, cells stay clean. When it fails, when damaged components accumulate faster than the system can clear them, the result is not a slow decline. It is disease - neurodegeneration, cancer, metabolic collapse. The body doesn’t gradually get worse. It tolerates the accumulation until it can’t, and then something breaks.

The apartment is the same. You tolerate the clutter until you move. The closet is the same. You tolerate the unworn clothes until you run out of hangers. Your digital life is the same. You tolerate the 47 open tabs until your laptop freezes.

And your mind works exactly like this too.

If you have ever journaled consistently over years, go back and read what you wrote three years ago. You will find the same unresolved questions, the same circling patterns, the same ideas you were “thinking about.” Not because you are stuck, but because thinking about something and acting on something activate completely different systems. Gathering more information about a problem you already understand is not research. It is avoidance with a library card.

Here is where the gathering instinct gets truly expensive. It doesn’t just waste storage space. It blinds you to what you already have.

When was the last time you took inventory?

Not of what you need. Not of what’s missing. Of what is already there.

Open your closet and actually look. You own clothes you forgot existed. Good ones. The ones you save for occasions that never come. There is a line I keep returning to, from a woman in her nineties asked what she would do differently. Her answer: wear that purple dress more often.

That is not nostalgia, it’s her regret of unlived but possible parts of life. She had the dress, she had the occasions. What she lacked was the habit of checking what she already owned before scanning for what she didn’t.

The same is true for knowledge, for skills, for experience. Most people I work with, the ones who feel behind, who feel like they need one more course, one more framework, one more certification before they can begin, are not suffering from a knowledge deficit. They are suffering from an inventory deficit. They have never sat down and catalogued what they already know, what they have already survived, what they have already built.

I call this The Inventory Principle: the practice of auditing what you already have before acquiring anything new. Not because acquisition is wrong, but because unaudited abundance is indistinguishable from scarcity.

When you don’t know what you own, everything feels like you are missing something. And that feeling is what keeps the cycle going.

One way to force an inventory is to externalize it. Take everything you know about a problem, write it down, map it out, or even dump it into a conversation and ask: based on what is already here, where do I actually lack information, and where do I lack action?

The distinction between those two is the most valuable thing you can clarify.

Most of the time, the answer is action. You already know enough. You knew enough six months ago. You have been gathering because gathering feels productive and doing feels risky.

Your cells already know how to solve this. Autophagy doesn’t gather new material. It clears what has accumulated, recycles the useful parts, and makes space for the cell to function. The process is not additive. It is subtractive.

And until that clearance happens, adding more only makes the system slower.

The most impactful thing you can do this week is not learn something new. It is look at what you already have and actually use it.

Open the closet. Wear the dress. Act on the thing you bookmarked nine months ago or delete it.

You don’t need more input.

You need clearance.

And until you know what you already have, everything new will feel necessary.

To more in life

Nicco

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Hold it in your mind for a second. The yellow skin, how it’s waxy and cold. You bring it to your mouth and bite.

Your salivary glands fired. I know they did, even though there is no lemon.

Now let’s unpack what just happened, because it matters more than it seems.

To produce that response, your brain had to form a visual representation of a lemon, cross-reference it with stored sensory memory, retrieve the knowledge that lemon tastes sour, calculate your body’s appropriate chemical counter-response, send a neural signal down the cranial nerves to your salivary glands, instruct the acinar cells to open their secretory pores, and release fluid into your oral cavity.

Every one of those steps happened in under a second.

One second or less, from image to reaction.

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We spend enormous energy talking about how difficult change is. How long it takes, how you need the right conditions, the right mindset, the right system before anything can move.

I used to believe that too.

Of course I also tried visualization the way it’s usually taught. Sit down, close your eyes, imagine success. See it clearly, feel it as if it has already happened.

So I did.

I vivdly imagined a side business taking off, passive income coming in. I could feel it.

And it felt good. And then nothing changed.

If anything, it made it worse. I had already “experienced” the reward, so the urgency and motivation to actually do the work dropped.

Looking back, I can trace more than ten failed attempts at building some version of a passive-income business back to exactly that pattern.

I was imagining outcomes. Not once did I sit down and think through what I would actually do the next day, or what would happen when things got difficult, or where I would get stuck. Or how that process should actually look like start to finish.

I was rehearsing the reward, not the work.

And the strange part is that I knew better.

In a completely different domain, I had already learned the opposite lesson.

In surgery, nothing is left to vague imagination. Before a complex case, I don’t picture a successful outcome and hope for the best. I go through the procedure step by step. The incision, the exposure, the critical structures, the points where things can go wrong, and what I will do if they do.

Not as a vague idea, but as a sequence. I actually built cards for that - SurgiCards, that I used for my training and offer my residents now as well.

Recently I even ran an online session on procedural goal setting, on the exact process I used to become head of department of a university department within 10 years, There I had an outcome AND a clear process plan.

The core idea is simple: if you can’t break something down into a sequence of concrete steps, you are not ready to execute it.

I just didn’t apply that to my own “side projects.”

And I missed that for years, despite using the same principle almost daily. But often we can’t transfer our own learnings from one area to another.

That is because the difference is often quite subtle.

Think about the lemon again.

You didn’t imagine yourself having successfully eaten a lemon at some point in the future. You imagined biting into it now. A specific action. We could have added specific substeps like picking the lemon up and raising the arm to your mouth.

That is why your body responded immediately.

Nothing moves because something sounds good. It moves when it’s clear what is next.

Most visualization fails because we focus on outcomes. A static image or short clip of you with the thing you want.

But the brain doesn’t act on pictures alone. It acts on associations, emotions and instructions. And vague outcomes don’t contain instructions.

Instead of imagining success, you imagine the next step.Instead of imagining the result, you imagine the process.Instead of imagining things going perfectly, you include where it gets difficult.

You run through the sequence.

Not to motivate yourself, but to remove some of the uncertainty about what comes next.

There’s a version of this in psychology as well. Alfred Adler called it “acting as if.” I always found that phrasing vague, but what he was pointing at is simple: once you act, the ambiguity disappears very quickly.

The system doesn’t change because you like what you see. It changes when the next move becomes obvious enough that it doesn’t require additional thinking to act.

That’s what you felt with the lemon. No debate, no hesitation. Just a direct line from image to action.

The mistake most people make is not that they don’t believe strongly enough. It’s that they are feeding the system the wrong kind of input.

A pleasant outcome is not enough. It’s too abstract, it doesn’t tell you what to do.

A concrete step does.

People like Michael Phelps with their 23 olympic gold medals have described this very process quite in detail. He imagined every single stroke and step of a race for hours right up to the ceremony.

The question is not whether you can change.

It is whether you can describe the next step clearly enough that you can’t not take it.

What is the thing you keep telling yourself requires more time, more preparation, more readiness before you can begin?

Don’t imagine the end result.

Imagine the first move. Then the second, then the moment where it gets uncomfortable and you would usually stop.

If you want to level up, think it backwards. Which step is right before the desired outcome. And which one before, and so on and so forth.

Walk through it.

At that point, time is usually not the problem anymore.

The lemon is just the simplest proof of that.

To more in life

Nicco

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To be fair, they were nice and trying. But the only thing remotely vegetarian was a “soup” - and how wrong can you go with a soup. It came after an eternity, rolled in on a tray with silver domes that were lifted for us movie-like.

We got served a grey, murky soup that consisted of flour and sandy beans. After two spoons it was clear that I couldn’t eat it. But we carried on, said how happy we were. We felt bad while we ate it, we felt bad after we ate, also because we ate it.

About a year later I found myself in a French movie that was badly translated to German, the kind where the mismatch between voice and lip-sync is already irritating. The plot and acting were bad too. And although both my wife and I didn’t enjoy it one bit, we talked ourselves into seeing it through.

In both cases, nothing external forced my decision.

What decided was simply what ranked higher in that moment.

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Upon reflecting on these episodes I realized that I was lacking a clear internal hierarchy of what is important to me and what is not.

And since that hierarchy wasn’t explicit, something else took over decisions.

Like classical sunk cost fallacy, normal people pleasing, and the quiet discomfort of breaking a situation once you are already in it.

Over the years it became more and more apparent to me how helpful it is to have a clear internal hierarchy. You can call these values or core beliefs, although it is not exactly the same.

What matters more is this: whether you have defined the hierarchy actively - or whether it is defining you.

This hierarchy helps you not only in decision making but especially in prioritizing. And this - along with the ability to focus - is one of the most underrated skills I know.

Everybody agrees that in order to produce or create something meaningful you have to focus. But that is only the second step. If you are not clear what to focus on, that focus goes to waste.

You don’t act on what matters most, you act on what you ranked highest.

And that is why people can be completely sincere about what matters to them - and still behave in ways that completely contradict it.

Priority by definition means that there is only **one thing** that is most important. It doesn’t allow for equal parallels. And that automatically creates a hierarchy of priorities.

Especially when building and living a multifaceted renaissance life it becomes crucial to be able to prioritize constantly to accommodate for the never changing, limited resources of time and attention.

Not because you lack options - but because you have too many.

Luckily not everything can be done everywhere at equal quality. I obviously can’t operate in a conference room. Or give keynote lectures in the OR—although that could work.

But thanks to the ever-connected, hyper-digital world we live in, many things can be done in many places under many circumstances.

This means if you know the order of what is important to you, you can adjust on the spot based on your current situation.

Obviously technical setup and preparation are paramount here.

For example, I always keep a current draft of a grant proposal, research paper or newsletter piece open in my cross-device-synced writing tool. Which means if I have an opening, I can hop in there and continue where I left off.

Most systems don’t fail because they are bad, they fail because they are built on the wrong hierarchies.

The system shouldn’t decide for you what you do, it only enables what is already ranked high enough to be picked.

Now this is by no means a manifesto for “multitasking” or frequent context switching. Multitasking per definition is not possible, because you can focus only on one thing at a time. Perceived multitasking is just rapid context switching, like a flickering light—and it drives you equally nuts.

The science is pretty solid showing that frequent context switching is inefficient and ineffective. So I am definitely advocating for deep work sessions and longer periods of uninterrupted time slots to create work that has quality and depth. It is the same in the OR. I do best when I am doing one surgery at a time, not when I am jumping between theaters.

That being said - not all work is heart surgery or Pulitzer-worthy literature.

For everything else, internal hierarchy and a reliable system that supports your prioritized areas are a godsend.

They don’t make decisions for you, they remove the need to renegotiate them every time.

They reduce the mental load of having to think through on the spot what to do, how to react, what to prioritize - so you can use your mental bandwidth to actually do things.

I regularly review that internal hierarchy of priorities. I draw it, map it, adjust it, delete it, scrap it, remix and rebuild it.

Because if you don’t define your hierarchy deliberately, it will default to something else - comfort, politeness, inertia - and quietly run your life for you.

So the question is not what matters to you.

It is what is currently winning - and whether you actually chose that.

To more in life

Nicco

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I was a bit puzzled because I thought I was well aware of these facts. What I realized during the following conversation was though, that I seemingly was suffering from a delusional time perception I haven’t been fully aware of. Because apparently, all the other things I am doing or planning or about to be doing - and was telling her about - seemed to demonstrate that I had either forgotten about these facts or a serious issue with time perception.

Jobs had his reality distortion field. Musk has his. I am not them, and I don’t intend to be. But their results fascinated me enough to ask: what would it look like to build that mechanism for myself?

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But I often get asked about how I am able to do all of the things I do - running a surgical department, in-depth academic work, teaching, hosting a podcast, building a speaking career, making music and being a passionate father and husband in a family of five. I have started writing this newsletter to identify the answers to this question.

And after that conversation with my wife, it became clear to me that one of these traits that help me with everything I do, is this:

I am delusional.

Not so much in the clinical sense, but close enough to be useful.

Psychiatry has a precise definition for delusion.

ICD-10 code F22 describes delusional disorder as a fixed belief system maintained with full conviction despite contradictory evidence, while the individual’s general cognitive function remains intact.

That last clause is the interesting one.

The person reasons logically, plans effectively and acts in the world without impairment.

Except for one thing: they live in a reality others cannot see.

The clinical definition describes a disorder. What I am about to propose is the deliberate practice of the same mechanism, pointed at your own potential instead of away from reality.

I call this Deliberate Delusion - a self-constructed belief about what is normal for you, maintained despite evidence to the contrary, while your reasoning and execution remain intact.

The belief is not there to describe reality accurately. It is there to help you decide direction and optionality. Reality still corrects the path.

What is normal?

We think normal is what everybody else thinks normal is. Everybody is eyeing the others to find out what is acceptable and adjusting to stay part of the group.

These definitions are fluid and differ widely — historically, culturally as well as geographically.

But they are all regressions to the mean.

Normal is not reality. It is the average of other people’s limits.

Deep inside we know that “normal” doesn’t really exist as it is a social construct, and thus it doesn’t serve our very personal needs. But as long as we don’t challenge our need for belonging, it will influence our every decision and action.

Everything you can see around you right now, the device in your hands, the chair you sit on, came to life through someone’s thought. It didn’t exist before. Someone was delusional enough to imagine it and persistent enough to make it real.

This is nothing new. Every religion, every nation, every currency is a shared delusion that enough people decided to treat as real. Every company is this. The difference is that you don’t need to warp anyone else’s reality. You only need to do it for an audience of one - yourself.

I have developed a delusional view about what I consider normal for myself. In that view I consider myself as much a single person as I see myself as a family father. I can hold opposing perceptions simultaneously - a form of compartmentalisation that lets me treat each identity as fully real, even when they contradict each other in terms of time, energy and attention. I consider my day job that objectively takes 8–9 hours each day as only filling about 20% of my time.

It is a perceptual mechanism I have built - partly deliberately, partly not - that makes the impossible feel normal. I am still fully present while I do what I do and when I am where I am.

I just don’t see why it would prevent me from doing everything else as well.

If I were to draw an “objective” outside view of a standard day time allocation, it would look like this:

If I were to draw my internal perceived daily time allocation, it would look like this:

Which brings us back to reality distortion fields, because this is what it is. A distortion of reality.

We all distort reality. The question is not whether, but how deliberate that distortion is. And it touches something deeper: what your definition of normality - and thus reality - actually is.

Human history is filled with people who held delusional beliefs for decades and turned them into reality. It is also filled with billions of delusional ideas that failed. Survivorship bias is real and this is not a framework for predicting success.

It is a framework for expanding what you consider possible for yourself.

But Deliberate Delusion has an Achille’s heel , and it is worth being honest about.

I recently watched a portrait of Joe Alexander. He desperately wanted to become a professional NBA basketball player. Coming out of high school, he wasn’t on anyone’s radar.

What followed was by his own account a state of Deliberate Delusion. He decided to hold two very firm beliefs.

#1 If he outworked every other player on earth, he could reach the NBA.

There was absolutely no evidence for this. The belief was, by any reasonable standard, delusional.

#2 The only thing that matters in life is basketball.

That if he failed, his life would be miserable. It was a deliberate axiom, where he decided to stay away from anybody who believed otherwise. He explained, that you cannot spend time with people who question your belief. You cannot even think it once. Because the moment you do, the belief loses its strength, and without it, you cannot produce the work that closes the gap.

Through that fixed conviction and relentless work, he transformed himself and was drafted 8th overall in the 2008 NBA Draft.

And then? His NBA career lasted roughly two seasons. He went on to play professionally overseas for over a decade, in Russia, Israel, Italy, Turkey and France. A real career, but not the one the delusion promised.

The delusion got him in the door, which alone was extraordinary. But the isolation it required, the refusal to let anyone question the belief, also made him lonely. When reality pushed back, there was no community around him to absorb the shock.

This is the difference between what I call lonely delusion and Deliberate Delusion.

Lonely delusion demands that you cut off anyone who doesn’t share your belief. It produces intense short-term output at the cost of sustainability, relationships and the ability to adapt when the world doesn’t match your delusion.

Deliberate Delusion, as I practice it, works differently. You hold the fixed belief about what is normal for you. But you don’t isolate. You communicate it, you let it pull others in, and you stay embedded in the life you are building across all its dimensions.

You can also make an argument for a delusional belief you first buy into yourself, but then communicate it so strongly that others can’t help but follow along and help you build towards that goal together.

It comes down to aligning your inner and outer communication.

What to do with this?

You have been rational and realistic your whole life - you know how that feels.

How about trying to be delusional for a while and see how that feels.

Here is what I want you to do:

Create a current realistic time allocation bar.

And then create one where you allocation more time to the areas you want to have more of in your life - despite “better knowledge”. For a week pretend that that is how your time is allocated and see what happens.

My wife asked me if I knew I was a father of three working full-time as a professor and department head. I do. I just refuse to let that define the boundary of what is normal for me.

To more in life,

Nicco

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This wasn’t a testament to love’s triumph. It was a quiet indictment of what happens when someone mistakes avoidance for transcendence. He had not risen above anything. He had simply sealed a living part of himself in the basement of his psyche, and there it waited — patient, undigested, unresolved — until the door cracked open.

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I relate to him more than I’d like to admit. I can explain Kriya mechanics, I’ve sat hundreds of hours in Vipassana silence, I’ve taught meditation to rooms full of people. And yet I still experience anger, pettiness, resentment. There are domains of my life that have genuinely loosened their grip on me — alcohol, nightlife, certain forms of validation — and there are other domains, like wealth, where I can feel the old contraction still alive and active.

Not because I’m failing at spiritual practice.
Because I haven’t resolved that pattern yet — not through repression, not through indulgence, but through genuine, embodied understanding.

This distinction is the heart of what I’m exploring here.

Suppression is a Disguised Form of Attachment

Suppressed desire does not disappear. It simply relocates. It moves from conscious awareness into a part of the nervous system that doesn’t use language, and from there it shapes behavior, emotion, and fantasy. It becomes a background vibration influencing everything — the tone of a conversation, the way you interpret a message, the decisions you make without quite knowing why.

Buddhist phenomenology, modern psychology, and Jungian shadow work all circle around this same observation: whatever you refuse to face directly ends up steering you indirectly.

We see the consequences everywhere.
In religious scandals.
In spiritual communities where people claim purity while their unresolved urges leak out in twisted forms.
In “ascetic” people whose entire identity depends on convincing themselves — and the world — that they are above desire.

These are not failures of morality.
They are failures of contact with reality.

And after teaching, practicing, and observing for long enough, I’ve come to recognize three broad ways people respond when a domain of life pulls on them: money, sex, status, pleasure, power, comfort, ambition, beauty — whatever their particular magnet happens to be.

The Three Modes of Relating to Desire

There are many sub-variations, but the essential structure is surprisingly simple:

1. Supression

You declare yourself “beyond” something, not because you’ve resolved it, but because you don’t want to feel its pull. You cut yourself off prematurely. You climb the metaphorical mountain. You pretend the longing isn’t there, even though your body knows better.

2. Unconscious Indulgence

You give in to the desire without paying attention. You repeat the cycle automatically, learning nothing. You wake up years later in the same place, slightly more tired, slightly more bruised, still confused about why the satisfaction doesn’t hold.

3. Lives Resolution

You turn toward the desire rather than away from it.
You observe it without collapsing into it.
You allow the full arc to reveal itself: the anticipation, the high, the crash, the subtle aftertaste that remains once the thrill evaporates.

And eventually — not through rejection but through understanding — the charge weakens. The grip loosens. The desire flattens into something uninteresting, not forbidden.

This third mode is messy. It doesn’t offer the aesthetic appeal of renunciation or the dopamine of indulgence. But it is the only approach that reliably dissolves the underlying attachment.

Ancient Initiations and the Modern Equivalent

Ancient cultures understood this challenge long before we had psychological language for it.
Some confronted fear and craving through controlled ordeals:

• Egyptian initiates spent days in darkness, sealed inside a sarcophagus.

• Tibetan practitioners practiced solitary retreat in caves, exposed to the raw material of their own minds.

• Native American rites involved fasting, isolation, and vision quests.

• Tantric traditions used carefully structured encounters with pleasure and discomfort.

The purpose was not punishment.
It was contact with what the individual avoided, compressed into an accelerated environment.

Did every ritual work? Probably not. Many were simply attempts at forced transcendence — suppression dressed up as spirituality. But the underlying principle is worth keeping: human beings require direct experience to understand themselves. Not theory. Not moral framing. Not spiritual performance.

Today we don’t get a cave or a ritual burial.
We get inboxes, bank statements, relationship tensions, aging bodies, career disappointments, unexpected losses, subtle humiliations, fragile egos, persistent cravings, and the uncomfortable reminders of our own limits.

These are the initiations now.
Not elevated or symbolic — painfully ordinary.
But no less transformative if approached with the same seriousness.

The Seven Ordinary Initiations

Over the next letters, I will explore seven domains that consistently shape the inner architecture of a person’s life. These are not arbitrary. They are the terrains where human attachment tends to root itself most deeply:

1. Family

The earliest blueprint — the emotional loyalties, unmet expectations, patterns of guilt and belonging that shape us long before we choose anything consciously.

2. Wealth

Money functions as a mirror, reflecting whatever meaning we project onto it. Safety, freedom, worth, revenge, recognition — rarely the number itself.

3. Social Status

Recognition feels like nourishment until you realize it binds you to external evaluation in ways that quietly suffocate inner autonomy.

4. Health, Sickness, and Death

Aging is an unsparing teacher. The body becomes the curriculum nobody can skip.

5. Romantic Relationships and Sex

Most longing in this domain is projection; we chase aspects of ourselves we haven’t met, packaged in the form of another person.

6. Spiritual Life

Meditation, when misused, becomes escapism wearing sacred clothing. Avoidance disguised as depth.

7. Indulgence: Food, Pleasure, Stimulation

These behaviors reveal patterns of emotional regulation. When observed without numbing or shame, they burn themselves out through simple clarity.

My Own Case Study: What Has Resolved, What Hasn’t

Some domains have truly completed their arc for me.

I no longer drink — not because alcohol became morally unappealing, but because I finally saw the entire cycle so clearly that the appeal evaporated. The anticipation, the short-lived lift, the flattening afterward, the way it pulled me away from myself. I repeated this pattern enough times with awareness that the desire simply thinned out.

It was the same with nightlife, with casual sex, with status games inside academia. Observing the mechanisms long enough stripped them of their glamour. They lost their spell.

But wealth is different.
It still activates something.
I still project meaning onto it — security, potential, maybe even proof. I still feel a subtle charge when I look at numbers. That charge is evidence that I am not done here. The pattern is not complete.

This is why I can write about this honestly: I am not reporting from a perfected state. I am writing as someone in the thick of his own curriculum.

What Resolution Actually Involves

Resolving a desire — allowing it to lose its charge through lived understanding — is not a neat process. It is not indulgence, not abstinence, not rationalization, not moral superiority.

It looks more like this:

• You allow yourself to feel the pull without acting blindly.

• You notice the full arc of the experience rather than the peak.

• You stay present for the aftermath rather than distracting yourself from it.

• You stop narrating the experience with morality — neither elevating nor condemning it.

• You let the pattern reveal itself in its entirety.

Over time, the intensity lessens.
Not because you fought it, but because you understood it from the inside.
Understanding removes the mystery, and without mystery, the compulsion fades.

When a desire truly loses its power, it doesn’t become forbidden — it becomes boring. Not intellectually boring. Somatically boring.
The nervous system stops responding because it finally knows the outcome.

That is the real resolution.

Conclusion: Ordinary Life as the Real Initiation

We don’t need caves, or rituals, or extreme deprivation.
We need a willingness to stay in contact with life as it is, especially in the domains that still catch us off guard. The uncertainty — “has this dissolved or am I lying to myself?” — is not a flaw. It is a safeguard against delusion.

In surgery, every practitioner knows the feeling of the patient they hesitate to confront — the case that seems more complex, more delicate, more demanding. But avoidance has never closed a wound. Resolution comes from engagement, not distance.

The same principle applies internally.

So the real question becomes:
Which domain is yours?
Which “patient” is waiting for you to stop avoiding?

To more from life,
Nicco

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They quit because the shoes are in the wrong cabinet.

Top shelf. Behind the winter boots. You have to move two items, something will fall, and by the time your brain has simulated this obstacle course, it has already whispered: not today.

We usually blame discipline. But is it really discipline? The culprit is embarrassingly small: a missing charger, a dead laptop, shoes in the attic. One irritating step, and that energy-hoarding beast in your skull calls it a day.

This is the physics of friction applied to human behavior. Once you see it, you can’t unsee it.

And once you can’t unsee it, quitting the wrong battles becomes much easier.

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Your Brain Is a Cheapskate (And That’s Not a Bug)

Like every living system, we are wired for one thing: conserve energy.

Every decision costs cognitive resources. Every initiation moment — every “startup” — feels expensive. Anything requiring “extra” activation gets flagged as unnecessary expenditure.

We all know the theory: healthy habits promise compounding returns — longer life, more muscle, smaller belly, fewer surgeries, less pain. You’d think that alone would motivate change.

But your brain doesn’t calculate in decades.
It calculates in seconds.

And right now, that cabinet friction with your running shoes feels like a threat to the system.

This isn’t weakness. It’s rational energy economics operating on incomplete information.

Every doctor has a truckload of stories where patients choose short-term comfort over long-term consequences. Instant gratification often wins, not because of ignorance, but because of friction stacked at every behavioral step.

It’s why a patient with a lifestyle-induced lower-leg amputation might be smoking outside the hospital entrance the next day. Incomprehensible — until you look at the layers of friction in their life that make their choices feel rational, without actually being rational.

Physics has known this forever: static friction is highest at the start. Once something moves, momentum is cheap. Your body mirrors it — initiating muscle activation costs more effort, maintaining it costs far less. Even your neural circuits follow the same pattern. The first sentence you write? Maximum cognitive load. The tenth? Flow state.

This is why “just do two minutes” works when it works. You’ve paid the activation toll. Quitting now costs more energy than continuing.

But productivity gurus still praise willpower as fuel.

Willpower is wet matches in a storm.
It sparks, then dies.

Architecture is what holds.

Why Surgeons Thrive on Low Friction

In the operating room, nothing is left to chance.

Instrument setup, team positioning, lighting, temperature — everything set up to minimize friction. No “where’s the clamp?” mid-incision.

I don’t want to decide where the scalpel is. Ideally, it finds my hand because the environment was designed for that outcome.

We eliminate microdecisions because in surgery, as in every other field, decision fatigue has a cost.

Contrast that with daily life:

High-friction writing:
Laptop in another room, password expired, forty tabs open, notifications bombarding your senses.

Low-friction writing:
A dedicated device, pre-loaded doc, single purpose, specific chair. Nothing else is possible.

One demands intense amounts of willpower every time.
The other requires one structural decision upfront.

Identifying these friction points — or bottlenecks — is central to leadership in any field.

The art isn’t fixing every bottleneck.
It’s fixing the ones that actually constrain flow. The ones with a clear return on effort. If fixing the friction costs more than the friction itself — don’t fix it.

Some friction doesn’t matter if the workflow doesn’t matter.

Recently, we noticed insufficient quality in our electronic health-record coding. A friction analysis revealed a maze of buttons and forms that required a precise order. The solution was a semi-automated click-guided questionnaire that moved the doctor through the process without friction — and now coding in that area is nearly flawless.

The Part Where You’re the Problem

Here’s the uncomfortable truth: sometimes the friction is real, but the reason it’s there is buried deeper. Because often, we built it ourselves.

If you say you want to write but never charge your laptop, that’s not an accident.
If you “plan to run” but your shoes keep migrating to the attic, that’s not inconsistency.

It’s avoidance dressed as nuisance.

We construct elaborate obstacle courses around things we don’t truly want. Call it self-sabotage, call it subconscious protection — the result is the same.

You’re not doing what you said you’d do. Not because you can’t, but because you secretly don’t want to.

I’ve done this. I have a trove of buried startups, abandoned languages, countless projects rotting in digital graveyards. Each one teaching the same lesson:

When I truly want something, I remove friction. When I don’t, I build excuses and call them obstacles.

I’ve learned that this is okay — as long as I admit it to myself. That I don’t want it anymore. That I said yes because I didn’t have the guts or experience to say no.

The hardest move in personal growth is also the most liberating:

Honesty with yourself.

Don’t want it? Stop saying you do. Kill the guilt, let it die.
Do want it? Stop expecting future-you to be a hero. Remove every barrier you can.

Both demand truth.
Only one demands courage.

The Three-Audit Protocol

Think of yourself as the CEO of your own life. Not in the hustle sense — in the self-mercy sense. Helping future-you spend energy where it actually matters.

Run your frictions through these filters:

1. The Relevance Audit

Is this workflow even important?
Some bottlenecks don’t deserve your energy. Fix only the constraints that shape your life.

2. The Honesty Audit

If friction keeps recurring, ask: Do I truly want this?
If no, drop it. This single move frees more capacity than any productivity system.

3. The Design Audit

If you do want it, map the real chain from intention to action.

Not “go to gym.”
The actual path:

Find clothes → check if clean → locate water bottle → find keys → drive → park → change

Count every bail-point.
Then eliminate the first three:

Lay out clothes.
Pre-pack the bag.
Put the keys on top.
Stack your phone on the keys.

You haven’t increased discipline.
You’ve decreased activation energy.

One Example From the Mess

I wanted to draw more again after an on-and-off relationship with it. Over almost ten years — zero drawings.

The friction diagnosis was simple: it was a solo project competing with family time.

The solution was just as simple: my son loves drawing too. So we started a joint online class. We put it on the family calendar. Shared accountability, shared joy, and suddenly I had drawing time and time with my kid.

One structural decision.
Problem solved.

This is core to how I manage my different renaissance identities — surgeon, researcher, father, musician, writer, artist. I’m constantly hunting friction thieves.

Your Move

Pick one area this week. Work. Health. Parenting. Creativity.

Where’s the quiet friction stealing disproportionate energy?

Maybe it’s your running shoes in your cabinet, maybe it’s something bigger.

Remove one obstacle today and watch the stream flow again.

If you’re willing to share:
What’s the friction point you’re eliminating next?

Hit reply or post it below.
Your insight might unlock mine or someone else’s.

To more in life,
Nicco

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In oncology, I’ve learned something far more uncomfortable:

The old “normal” is gone — and trying to restore it, is what causes the real suffering.

The Body You Remember, The Life You Lost and the One You Have to Build

Every week in my clinical practice I see the same pattern: patients who have survived cancer, completed treatment, undergone reconstruction — and are still devastated with the result.

Not because the surgery failed.

Not because the outcome is poor.

But because they are grieving a version of themselves that no longer exists.

For years I assumed this was a communication problem. Then an expectation management problem.

Now I see it as identity grief.

And it shows up far beyond medicine — in burnout, divorce, career collapse, aging, and every major rupture that separates the self we remember from the self we own now.

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The Case That Made the Pattern Impossible to Ignore

Recently a patient came to me after years of reconstructive procedures: failed implants, expansions, complex reconstruction, multiple revisions.

From a technical point of view, the final result was good.

But she was devastated.

Not only because of the complications.

But because the reconstructed breast did not match the internal breast memory she had carried — a sensory imprint of a body of a time before her illness.

She asked me:

“What can you do to give me my breast back?”

“Will I ever be like before?”

“When will I feel normal again?”

These are not surgical questions.

They are grief questions.

What she truly meant was:

“Who am I now, that the old version of me is gone?”

No operation — no matter how skillful — can answer that. No operation can solve that.

A Lesson From Early in My Career

As a junior doctor on a burn ward, I witnessed a moment I didn’t understand at the time.

A young woman survived a severe car fire and lost one leg below her knee. When she woke up, she was terrified and disoriented. She demanded to see a senior attending.

He was a former navy officer. Direct, uncompromising. A die-hard christian.

He walked in and said:

“You have lost the idol that was your body.

The body you remember is gone.

Your life is not over — but that version of you is.”

She screamed. She broke. Everyone in the room thought he had gone too far. I thought to myself “You can’t say something like that at this moment.” Apparently you can.

Months later she thanked him.

Because he named the truth she was coming to fight long before she could face it.

He ended the bargaining — the mental loop where the mind tries to reverse time instead of moving forward.

I have never forgotten that moment.

And I see the same mechanism in breast reconstruction, in high performers after burnout, in founders after collapse, in anyone whose old identity is no longer accessible.

The Expert Wisdom Triad

There’s an old surgical triad:

The good surgeon knows how to operate.

The better surgeon knows when to operate.

The wise surgeon knows when not to operate.

I used to think this was about anatomy and risk.

Now I understand it’s also about identity.

Operating on someone who is still psychologically anchored to their pre-cancer self — still worshipping the idol of their former body — is not surgery.

It is enabling a fantasy that the past can be restored.

And that guarantees dissatisfaction, revision spirals, repeated disappointment, sometimes even conflict.

This is because the psychological contract is impossible.

Now most patients after cancer adapt quickly. But not all do, and identifying these, is important. For them, as much as for ourselves.

The same applies outside medicine:

• Trying to “save” a relationship that has already ended

• Forcing a return to a pace of life that burned you out

• Attempting to reclaim youth instead of aging into a new identity

Sometimes the wisest intervention is naming what is already gone. And then re-construct from there.

The Restoration Fallacy

After any major rupture — cancer, trauma, burnout, divorce, status loss — the mind gravitates to the same trap:

The belief that the old self can be restored.

That you just need the right intervention, the right recovery protocol, the right timeline — and you’ll be “back.”

But the old baseline is gone.

This is the Restoration Fallacy — the mistaken belief that wholeness comes from reclaiming what was lost.

It doesn’t.

It never has.

The Reconstruction Path

There is only one path that leads to real stability:

Building the next self — not resurrecting the old one.

Forward, not backward.

New, not restored.

This is the line I use with patients and anyone facing irreversible change:

“You cannot rebuild the old self. You can only build the next self.”

Instead of resignation it is more an alignment with reality and the foundation of actual healing.

Why High Performers Struggle Most

There are many groups other than cancer patients that are especially vulnerable to the Restoration Fallacy.

High achievers are especially vulnerable to the Restoration Fallacy.

A burned-out executive tries to return to their old pace.

An athlete tries to reclaim their old body.

A founder tries to recreate the confidence they had before collapse.

They’re not rebuilding, they are trying time-traveling.

Burnout, illness, loss, aging — these things don’t just change your performance abilities - they actually change your identity.

And identity cannot be restored.

The Tool We’re Building

In my department, we are beginning piloting a brief clinic-based screener to detect when a patient is still anchored to their pre-cancer body identity — still trapped in the Restoration Fallacy.

Because no amount of surgical excellence can help someone who is fighting the wrong battle.

Reconstruction only works when someone is ready to build forward, not reach backward.

And I suspect this applies far beyond oncology — to any domain where a former self has been lost.

The Real Work

You cannot return to the version of yourself that existed before a major rupture.

But you can build forward from there.

In surgery we do not reconstruct the past.

We assess what remains, accept what is missing, and build from there.

Identity works the same way.

Wholeness is not the restoration of the old self, it is probably more the construction of the next self, a new self where you can feel whole again.

The moment you stop bargaining with the old story, you can finally begin writing the new one.

In surgery as in other areas in life, the work is not really figuring out how to get back. But to decide what kind of future you can build from where you are at this moment.

To more from Life

Nicco

The Renaissance Protocol reflects on identity, performance, and building a life that integrates across domains.

Subscribe here or at therenaissanceprotocol.com

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So there we were, crammed into the ICU kitchen — me and 15 surgery residents and consultants — trying to have a “crucial conversation” about the state of the union and training fairness. The kind of meeting that in any functional institution would happen in a conference room with a whiteboard and decent lighting.

Instead: fluorescent overhead buzzing, the smell of reheated hospital food, a microwave beeping every 90 seconds.

Dr. S started it: “Why does Dr. X get three flap cases this month when I only got one?”

Then Dr. M: “The schedule isn’t balanced. You promised equal rotation.”

Then Dr. K: “This whole system is unfair.”

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I tried to explain. That the goal was to provide equal distribution. But that the schedule depends on a million little things — which patients come through the door, who calls in sick, which skill levels are available. In a system under strain, distribution becomes a secondary matter to ensuring patient safety and keeping the boat afloat.

Not merit. Not fairness. Not divine justice.

And then I said it: “Life isn’t fair.”

The room went cold.

A nurse walked in to warm up a patient’s dinner. Microwave beep. She squeezed past us, clearly annoyed we were taking up her workspace.

I kept talking: “The sooner you accept that life isn’t fair, the sooner you can focus on—”

The head nurse — the one who’d been tolerating our presence — finally had enough:

“Gentlemen, we need the kitchen. Patients need dinner. You’ll have to continue this elsewhere.”

Three residents stood up, walked out mid-sentence, mumbling: “Yeah, yeah. Life is not fair.”

We filed out. Everyone angry. Me questioning whether I’d just made everything worse. Nobody got what they came for.

The Suffering of Non-Acceptance

Looking back, I realized that I had that same sense of entitlement when I was younger. It was actually one of the reasons why I opted against an academic surgical career right after med school — because I was sure the system was flawed and unfair.

I also overestimated my skills and ignored the fact that surgery — by definition a craft — requires a step-by-step apprenticeship that compounds over time and experience, and can only partially be sped up.

The underlying problem though was something else.

It was the fight against reality itself.

Expecting the world to operate according to a principle — fairness — that simply doesn’t govern how things run. And fairness by itself is highly subjective — fair is where I feel treated fairly.

So when reality refuses to comply with expectations, we have three options:

Option A: Keep fighting. Keep scorekeeping. Stay angry that the universe isn’t delivering what you’re “owed.” Option B: Accept reality as it actually is, then figure out how to act on it. Option C: Quit.

Most of us are stuck in Option A without realizing it’s a choice.

And boy, is Option A exhausting.

The Buddha’s equation for suffering:

Obviously, we’re not the first to figure out that there’s a problem. The Buddha already described this brilliantly in this little formula:

Reality - Expectation = Suffering

The bigger the gap between how you think things should be and how they actually are, the more you suffer.

You end up expending enormous energy trying to change something that isn’t changeable — how things already are at any given moment. And things like the fundamental randomness of how life distributes opportunities.

Often we focus on how things were and are — tracking who got which cases, calculating “fairness” metrics, building resentment toward colleagues who “got lucky,” or waiting for someone to fix the system.

None of this made us better surgeons. All of it made us miserable.

So while we’re litigating fairness, we’re missing the things — or cases for that matter — we actually did and do get.

When we’re so focused on what we weren’t getting, we can’t extract maximum value from what we have.

That’s what fighting reality actually does:

It doesn’t change reality — it just blinds you to the opportunities within it.

What I Was Trying (Badly) to Say

I wasn’t trying to tell my residents to give up and resign.

I wasn’t telling them to accept exploitation or stop advocating for better training.

I was trying to free them from an unwinnable mental battle that was paralyzing their growth.

What I should have said: “Accept reality as it is, not as you want it to be. THEN you can change your position within it.”

But I didn’t use those words then.

I was standing there as senior consultant, no longer subjected to the randomness they were experiencing, telling them to accept being subjected to randomness.

Of course they walked out.

They thought I was saying: “Life is unfair, so stop complaining.” What I meant was: “Life is unfair, AND you can still win — but only after you stop fighting the unfairness itself.”

That distinction matters.

My buddhistic meditation retreats helped me a lot with that. And life wasn’t stingy with opportunities to put my learnings into practice. I learned that lesson a lot through constraint.

I learned it, for example, from being parked — twice. And when I learned it, I was the one being parked, not the one doing the parking.

Right before certification, staff shortages meant I spent six months in outpatient clinic instead of the OR.

Wound checks. Suture removals. Minor procedures. Post-ops. Pre-ops.

Not exactly the complex reconstructions I’d trained for, not the microsurgery I wanted.

I could have spent those months resentful — counting the cases I was “owed,” calculating how far behind this set me.

Instead, I decided to act as if I were already independent.

Not a frustrated resident serving time, but a consultant running that part of the department. That single mental shift changed everything. I began managing patients like I was the attending — documenting, communicating, and triaging with full ownership.

Additionally, I used every gap to write or analyze data for my research papers and academic career. I found myself sitting at the top of the staircase for lack of rooms before my clinic started, generating boxplots.

Those minutes added up. On the longer timeline, all of this gave me leverage. I wasn’t behind — I was ahead. My gift was hidden inside the constraint.

But I only found it after I stopped waiting for someone to rescue me from it.

Different year, similar frustration: I found myself parked in burn surgery.

Burn debridement after burn debridement. Skin graft after skin graft. Repetitive. Monotonous. Not exactly intellectually thrilling.

I found myself complaining to one of my mentor attendings. What he said stuck with me ever since:

“Look for opportunity in every little case. There’s gold to find everywhere for your surgical skill. Any necrosectomy can be turned into an exercise to identify and preserve perforators.”

He was essentially teaching me to accept the case I had, not to mourn the case I craved.

So I began treating every (burn) case with strategy: primary plan, backup plan, danger zones, anatomical structures to preserve.

I even built custom “surgicards” — case-prep index cards assessing these items — that served me and others I shared them with very well.

This pushed me extremely forward, not because the cases changed, but because I did. Those burn months taught me more about tissue handling and three-dimensional thinking — and system thinking in surgery — than any “exciting” microsurgery rotation.

These parkings were valuable not because they were secretly great opportunities disguised as setbacks, but because accepting them as reality forced me to create my own opportunities within the constraints.

That’s what I was trying to tell my residents in the kitchen.

Not to “accept unfairness and give up,” but to “accept unfairness and find the gold inside the constraint.”

It’s something like an acceptance paradox: accepting unfairness gives you more power, not less. It feels like resignation — but it’s actually the starting point for change to come.

But there’s actually more going on. If you thought ‘life isn’t fair’ was hard to hear, this one cuts even deeper:

Nobody Owes You Anything

Nobody is obligated to make life fair FOR you.

Not your partner. Not your mentor. Not your department. Not the universe.

For unknown reasons, we think we’re entitled to things. Just because we are. Or we did certain things.

“I did my time, I deserve the good cases.” “I sacrificed my life, the system owes me.”

That thinking destroys you. It will make you resentful.

And you can wait forever for fairness.

Once you start accepting that nobody owes you anything, you become appreciative of the things you do get.

Now, I’m not saying that you should accept systemic injustice.

Fight for better work-hour regulations, demand safer conditions, advocate for structural reforms.

But do it from a place of accepting the current reality, not denying it.

Acceptance isn’t resignation. It’s the prerequisite for effective action.

Landing

I still don’t know if my residents took with them what I had intended. When I left, they gifted me a book with the title Life isn’t fair — so I guess something stuck.

But I can’t teach acceptance anyway.

Only life can. And boy, isn’t it a great teacher. You get lesson after lesson delivered straight to your door.

And a hospital is essentially a high-speed pressure chamber that beats that lesson into your bones until fairness stops making sense as a framework.

There is often not much to do about the circumstances at any given moment. But there is often much to do about how you decide to deal with them.

I can stop reinforcing the illusion that fighting reality is productive.

Accept reality as it is. Not as you wish it were. Not as it “should” be. Not as it would be if things were fair.

As it is.

Only then do you stop suffering and can start moving.

My kitchen meeting was a disaster — but maybe that was the point.

Maybe you can’t teach acceptance in comfort.

Maybe it only lands when the nurses kick you out, the microwave keeps beeping, and reality refuses to cooperate.

Maybe that’s when you finally stop arguing — and start living.

To more from life,

Nicco

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I didn’t grasp how much this would limit me. Three decades later, I’m still paying interest on that shortcut.

Charlie Parker said, “Master your instrument. Master the music. And then forget all that bullshit and just play.” Somehow I went from A to C while skipping B entirely.

My play-by-ear ability carried me through 25 years in a wedding and party band—enough to have fun, enough to get paid. But that deep understanding? Still missing. Still nagging.

For years I tried composing, both conventionally and with computers. Always hit the same wall—the music inside me couldn’t get out because I’d skipped the foundations.

AI eventually gave me a workaround, let me develop different skills to become the composing artist I’d wanted to be.

But there’s a pattern here I’ve watched play out in my own life and in countless others I’ve met: that urge to cut corners. Skip the hard part, jump to the fun part.

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The Plateau Trap

We all know how learning works. Early progress is intoxicating. Visible gains, rapid improvement, constant dopamine hits.

Then you hit a plateau where progress stalls and the fun evaporates.

That’s when three options appear:

a) Quit and start something new.

b) Develop grit and push through.

c) Try to jump over the plateau.

I kept choosing c). Every time I tried to skip it, I paid for it later.

Medical school: I decided—based on probability and time efficiency—to skip hand anatomy details. Too complex, statistically unlikely I’d need it.

A decade later I was working in hand surgery, painfully grinding through anatomic textbooks every morning and evening for months to make up for that “strategic” decision of my younger self.

The pattern holds across domains: skip the boring fundamentals, pay compound interest later.

The Truth About Talent

I used to wonder if talent was real. Watching my kids grow up, I see what psychology and neuroscience describe: innate inclination meeting environment.

Talent brings you curiosity for something - sometimes physical dexterity - and enough energy and motivation to stick through that first plateau. The new height brings the next boost of motivation for the next plateau. Success breeds success. And it’s compounding.

Talent often happens when your environment fosters curiosity early and helps you through that first plateau at a young age. The grandfather playing chess with you. The mother taking you to dance classes. The family that lets the three-year-old play with instruments freely.

These are pedagogues meant in its original sense—someone who guides a child.

Then it becomes a game of compounding effort. It’s hard to catch up with someone who has ten years of deliberate practice from childhood. We dismiss it as “just gifted.” But it’s not magic - it’s a head start, and you’re fighting uphill carrying basics they automated years ago.

Still possible, though.

What This Means for You

First: get honest about your innate inclinations. We all have them—maybe just not in the areas we think we should.

Second: develop grit. It’s the decisive differentiator. And it’s a muscle you can train.

In most conversations, especially with personnel I try to find out: “What are you unexpectedly good at outside work?”

I don’t like that classical “what are your strengths” too much. I want the thing they do for fun that they’re oddly skilled at.

The product manager who DJs weddings and intuitively reads crowd energy. The engineer who restores vintage motorcycles and has mechanical empathy most designers lack. The nurse that’s sailing and accustomed to quickly changing (weather) environments.

These aren’t soft skills—they’re transferable pattern recognition capabilities sitting dormant because we thought they didn’t belong at work.

I’ve held parts of myself back for years because I thought they wouldn’t be beneficial—or worse, wouldn’t be allowed in my environment, in my position. I’m gradually learning to integrate my own goofy extracurricular skills into my work.

And learning from my own blocks I can now try to ask “what boring fundamentals are you trying to skip?”

Including myself. Especially myself.

I spent years trying to compose without theory, lead with insufficient information, diagnose without mastering anatomy. The pattern still holds: you can’t shortcut mastery.

But you can build systems where admitting “I skipped the basics” isn’t career suicide—it’s the first step to getting unstuck.

Where we help each other develop that necessary grit.

Where we hold each other accountable not through pressure but through genuine support.

Master the fundamentals. Then forget them and play.

By the way, I’m still learning scales. Thirty years later, some lessons finally land.

To more from life,

Nicco

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It has done so — uninterrupted — for more than 500 years. Without electronics. No fancy software or smart algorithm. Just pure craftsmanship built on first principles — deep knowledge about mechanics, precision and physics.

On the way home I thought about my ten-year-old espresso machine that still pulls perfect shots, and my Italian boots I’ve worn almost every day for a decade. All of them still work — not because I care for them obsessively, but because they were built to last. They were built with me the customer in mind, not the company building it.

It made me reflect: How much of what we build today — in medicine, in business, in life — is designed to last? Maybe even outlast us. How much is built to keep working when we’re no longer there to fix it?

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The Leadership Parallel

We talk a lot about innovation, rarely about sustainability. Yet leadership, when looked from this perspective is the art of building clocks, not alarms. The craft of building sytems that keep ticking because they’re built on principles, not personalities.

The best teams don’t need constant supervision.The best departments don’t collapse when a leader is away. The best organizations don’t rely on adrenaline and pressure to function.

In healthcare especially, we’ve built too many alarms — urgent, reactive, human-dependent. And that has it’s place in high-stakes acute situations. But even there medicine works better, when it has been built like a clock: reliable, self-calibrating, graceful under pressure.

Constraints Are the Compass

Every system has at least one bottleneck. As do our own lives.

Professionally, mine currently is clear: too few consultants to meet surgical demand. But that’s only the superficial bottleneck, there is a tighter one hidden underneath — it’s in the system itself.

In Denmark, referrals and patient flow are centrally governed and this defines how cases loop between providers, how inefficiencies compound. Parts of these constraints have to be solved with policymakers.

So I’ve been working at the political level to change what’s possible. But that takes time. Meanwhile, we need all hands on deck in the OR, in the clinic.

Which means, that I can’t delegate parts of my workload. And suddenly I have become the bottleneck.

The question isn’t how to remove all constraints. It’s which one to optimize for right now.

Identifying where the bottleneck actually is, and what to do about it - that is already half the equation.

But here’s what I learned the hard way: If you want things to work like a clock, you have to built them without yourself as the coo-coo jumping out of your little black forest hut every other minute.

I inherited a microsurgical unit built around deep specialization — one surgeon, one approach, one way of knowing. It worked brilliantly while that structure held. But the moment it changed, the system faltered.

So from day one, I started re-building like a clock — teaching, assisting, rotating with my colleagues, creating as much redundancy as possible. Not because the old way was wrong, but because I wanted to build a clock that ticks whether I’m in the room or not — a system that survives transitions.

I see that as the biggest test of my leadership: not having the answer, but having the patience to build a system that can find it.

And there’s more to that: building a system that doesn’t depend on you or any particular person means building one that doesn’t isolate either. Often when we build pinnacles we remove these people from the “herd”. Yet we are all social beings and despite differences in personality can neither we nor the group thrive in isolation.

I’ve been thinking about the etymological difference between loneliness and being all-one - alone. One isolates, the other integrates.

The same is true for systems. A healthy department, like a healthy human, needs solitude and connection —focus and exchange.

And to foster that we need to create joint routines, create places for communication and sharing. In ultra-optimized healthcare and remote work, this becomes both more important and harder.

One of the few fix points we cling to almost religiously is our joint morning routine. The team gathers for handover from night shift, we look at the day ahead, the next day. We discuss cases, rotate through educational pieces and mini journal clubs.

It’s persistent in its rough structure — the ritual itself is sacred —but we’re constantly evolving and adapting within it.

That’s the clock: reliable rhythm with built-in flexibility to adjust for timezones.

Another lesson I learned while improving systems: Start with gratitude and appreciation. Every system has been set in place originally because it helped a problem at that point in time. Usually not everything is bad. It means appreciating what currently works while improving what can be improved.

It helps to accept the status quo as is and take everyone with you on the journey of change.

Kindness and Clarity

And doing so with kindness is key. The people and mentors who have impressed me most were the kind ones. The ones that have reached the top but stayed humble. That talked to the housekeeping personell the same way they talked to administration. I recently watched Alex Hormozi - successful entrepreneuer - diagnose a failing business in an hour with ruthless precision, but absolute kindness.

That combination stayed with me. This is what we need, not only with our patients - diagnosing and treating with ruthless precision and absolute kindness. It is the same for leadership and change management.

We serve nobody when sugarcoating essential flaws. And we serve everyone when pointing it out with loving kindness. And the go do something about it.

Like a clock, marking every hour ruthlessly, but with a sort of loving kindness.

That’s what I want to build — in my department, in my work, in my life.

Not alarms that scream for attention every hour, but clocks — quiet, elegant, enduring clocks — that keep time long after I’m gone.

What in your world still runs beautifully — simply because it was built right? And what would change if you led today with a craftsman’s patience instead of a sprinter’s urgency? Where are you currently the bottleneck, and what one constraint, if addressed, would let your team move without you?

to more from life

Nicco

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I was actually trying to shove in the second fork of a limp salad from the cafeteria while standing. “Surgeons don’t need to eat!” I was waiting for a hint of a smile, a smirk, anything indicating that he was joking. But nothing, just cold grey eyes. The second time I was “caught” was in a different hospital, exiting the elevator heading for lunch when I was tapped on my shoulder and stopped by my chief attending: “If you have time to eat we obviously have too much staff in our department,” she said.

For years I was peeking nervously over my shoulder when having lunch, if I dared to have it at all.

Back then I was a fifth-year surgery resident, a father, and a grown man. And I was afraid to have lunch. Clearly there is something wrong.

This absurd reality reflects a deeper problem in our profession - a fundamental misunderstanding of what it means to be a physician. The solution lies in distinguishing between two fundamentally different approaches: the Old School physician mindset that glorifies suffering, and what I call the New School physician mindset that prioritizes our wellbeing as the foundation for excellent patient care.

To the basics: ASICS - anima sana in corpore sano - a healthy soul in a healthy body - this is an eternal truth that we preach our own patients day in day out. But we are not able to apply it to our own lives. On the contrary.

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Becoming and being a doctor is no walk in the park. Everyone knows that, and I knew that, and after all, it was my free choice. The long hours, the responsibility, the administrative and legal burdens, the at times abominable working conditions and environments have been pointed out time and again. The stress can be enormous.

The statistics tell a sobering story. Burnout among physicians remains high worldwide. A comprehensive COVID-era meta-analysis found an overall prevalence of ≈55%, with significantly higher odds among frontline clinicians and regional variation (Macaron M.M. et al., Frontiers in Psychiatry, 2023; https://doi.org/10.3389/fpsyt.2022.1071397).

The statistics tell a sobering story. Burnout among physicians remains high worldwide. A comprehensive COVID-era meta-analysis found an overall prevalence of ≈55%, with significantly higher odds among frontline clinicians and regional variation (https://doi.org/10.3389/fpsyt.2022.1071397).

In emergency medicine, pooled international prevalence reached ≈43% (95% CI 32–54%), underscoring that high stress is a global, not regional, phenomenon (https://doi.org/10.3390/healthcare11152220).

In the United States, the most recent Mayo Clinic Proceedings data show physician burnout falling from 62.8% in 2021 to 45.2% in 2023, returning to pre-pandemic levels yet remaining alarmingly high (https://doi.org/10.1016/j.mayocp.2024.11.031).

We are one of the professional groups with the highest rates of illicit substance and drug abuse, suicide rates and premature deaths. And this is no longer only affecting physicians themselves - physician burnout directly correlates with increased patient safety incidents, decreased professionalism, reduced patient satisfaction, and higher turnover intentions, as demonstrated in comprehensive BMJ meta-analyses (https://doi.org/10.1136/bmj-2022-070442).

A particularly insidious contributor to modern physician burnout is electronic health record (EHR) fatigue. We spend more time documenting care than providing it - studies show physicians spend 2 hours on EHR tasks for every hour of patient contact. This administrative burden represents a form of moral injury, forcing us to prioritize documentation over healing. The ICD-11 now formally recognizes burnout as an occupational phenomenon resulting from chronic workplace stress, acknowledging that systemic factors like EHR burden require organizational-level solutions alongside individual interventions (https://doi.org/10.2147/JHL.S389245).

But one of the root problems lies somewhere else. It is a force that at times opposes change for good from within.

It is our common mindset. The mindset that defines how we think we as physicians have to act and interact within this system.

This is what I call the Old School physician mindset.

The practice of medicine is often associated with that of a selfless practice. A term that has been badly misunderstood. Selfless in the sense of no ego, no personal agenda driving the practice, yes. But it never was intended to deprive us from our natural physical, emotional, spiritual and social needs, that we - human beings after all - have, too.

I oppose the implicit and explicit suggestion of physician martyrdom as the only way of practicing medicine.

Neither the Hippocratic oath, nor Lasagna’s modern interpretation of it or Inman’s “First do no harm” indicate at any point that our profession should go at the expense of our own wellbeing.

Yet the Old School mindset has often created a toxic culture where suffering becomes a badge of honor. As a collective, we take some sort of sick pride in suffering, comparing who works and harms himself more. It leads to a twisted form of false, perceived heroism, where a delusional mind fights its very own body.

I lost one great grandfather physician to morphine and one grandfather physician to myocardial infarction. I have seen colleagues smashing trash cans, kicking holes in walls when the pressure got too high and their underdeveloped coping strategies failed. I saw them literally smoke themselves to death, or get admitted to their own ICU in a diabetic coma.

I have seen way too many near accidents such as wrong surgery site markings, faulty prescriptions and other concentration deficit derived mix-ups. And I have seen a patient die because of a catastrophic cascade of decisions made by physicians trapped in ego-ridden decision making. This should not be.

The prospect of working the rest of my life in such self-wrecking conditions made me quit medicine for good twice.

Only one mentor’s reminder to “focus on changing what is within your reach. Change from within” kept me coming back.

This mentor’s wisdom points toward a different path - one that acknowledges the reality of systemic problems while empowering us to take control of what we can change. The problem is not that these things happen, but that we shrug them off as something inevitable, as the status quo. This is what I call the old school physician’s mindset which puts a skewed idol image of our profession first.

In contrast, a New School Physician mindset puts ourselves as doctors first.

Not the profession. Not the patient, but ourselves.

Safety first. We know that from first aid guidelines and airplanes - make sure you don’t endanger yourself, it helps no one.

We can’t give if we have nothing to give, if we get consumed in the process.

We must stop postponing it to some indistinct point in the hazy future.

To be clear, this is not about creating a medical la-la land for physicians. And it is definitely not about jeopardizing patient care because of petty personal issues.

The New School approach is actually about becoming better physicians through conscious self-care. It is about acknowledging one’s personal needs. It is about building up the strength and courage to express those needs, even against implicit or explicit threats from our peers or more importantly against imagined threats of our minds.

It is about taking responsibility for your own life. It is about actively deciding how to spend our time; how to do what we do. It is about making conscious choices for ourselves.

The moment we become true and honest about ourselves to ourselves, we become better doctors as well.

So what does this look like in practice? How would this look like? Take one step back and take a bird’s-eye view on your current life.

And then examine your life’s situation as you would with your own patients.

What are the most pressing issues?

What would you recommend to a patient under those kinds of circumstances?

I believe there are many things we can do in the realm of mindset, organization, lifestyle and communication to help us feel better again.

And most likely, every single one of us already knows exactly what that would be in our case.

When we embrace this New School approach, the benefits extend far beyond our personal wellbeing. If we know our truth and can stand up for it, we become independent from other people’s conflicts of interest. We then can start treating our patients to our best knowledge.

And we can be truthful and honest with our patients as well, without having to be afraid to disappoint them or make them feel bad.

And most importantly without risking harming them by harming ourselves.

This would also reduce pressure and stress, and foster wellbeing far more significantly than any external health reform ever could.

It doesn’t and shouldn’t take away the responsibility to improve structural and institutional conditions - but it is an important pillar to tackle this multifaceted challenge.

This is the future of medicine I envision - one where healthy physicians provide the best possible care because they’ve learned to care for themselves first. This is what a New School Physician would look like.

The choice is ours. We can continue perpetuating a culture that glorifies suffering and ultimately harms both physicians and patients, or we can choose to become New School Physicians - one conscious decision at a time. The transformation of medicine begins with transforming ourselves.

I wrote this piece in 2016. Back then I was too afraid to publish it.

I have slightly adjusted the text and updated some references - which haven’t fundamentally changed, what is telling in itself.

Since then I have moved through the ranks to be now in a position where I see this problem perpetuating itself also on the administrative side. And realizing that I have become part of the problem myself - and to a certain extent - hopefully part of more structural solutions as well.

The challenge requires both individual and systemic approaches. While evidence shows that interventions targeting medical residents yield only modest benefits when implemented in isolation, combined approaches show greater promise (https://doi.org/10.1186/s12909-024-06195-3). This reinforces the need for what I call the CARE framework - a practical approach for New School Physicians:

The CARE Principles

Consciousness: Developing awareness of your own needs, limits, and warning signs. This means regularly checking in with yourself: Am I hungry? Tired? Overwhelmed? Start with simple daily check-ins.

Advocacy: Building the courage to express your needs and set boundaries. This includes saying no to excessive overtime, requesting adequate break times, and speaking up about unsafe working conditions. Practice starts with small assertions.

Responsibility: Taking ownership of your wellbeing through concrete actions - overhauling diet, exercise and sleeping habits one at a time, getting up earlier to experience the feeling of “having time” again, and seeking professional help when needed.

Expression: Opening up about your challenges to colleagues and superiors, and fostering honest collegial check-ins. Taking microbreaks in the OR and using scrubbing-in times for genuine connection. Creating psychological safety in our teams.

While I don’t think that magic AI tools will make all our problems - or jobs for that matter - suddenly disappear, I see the potential to ease some of our burdens.

A lot of creative thinking, openness and persistence is required to move the needle on many other areas.

Let’s reflect and create change in the way we interact with ourselves, our colleagues as well as our system - one day at a time.

To more in life,

Nicco

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“Dude, you have to try this. Really, she’s the best, I swear.”

Forty‑eight hours later, I was on a mat, eyes watering—part pain, part relief. What blindsided me were the unexpected challenges: relentless pressure wringing my muscles like a sponge, sharp jolts up my spine with each strike, and the sheer will it took to stay still while my body screamed for mercy.

Had I known, I might have hesitated.

Six brutal double‑fist hits on my back. “Finiiiished,” she whispered. And with that, my first‑ever no‑oil martial arts-like thai-bodywork session on my skinny doctor’s frame was over. I felt great—painful but great. I had to wince a little again once I paid, but I figured the short‑ and mid‑term effects were worth that pain, too.

I felt like a pirate with a wooden leg walking home, and my whole physique felt kind of off the next couple of days. It took me a while to realize, that this was actually how aligned and normal should feel. Two days later I felt awesome.

The athlete’s unfair advantage

Watching the Olympics or the FIFA World Cup, it’s obvious: high‑performing artists—masters of their field—are surrounded by professional supporters who keep their bodies, minds, and spirits at their best so they can give their best. Massage therapists, nutrition pros, stress managers, dieticians, prescribed rest plans—you name it.

But look at two top‑performing areas where this logic often breaks down: healthcare professionals and C‑suite executives.

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For some reason, we accept that people who run around a field for 90 minutes chasing a ball need full‑stack support. Yet the people who run multi‑billion‑dollar companies—and people who literally have your health in their hands—are somehow expected to figure out elite performance solo, maybe with the occasional foot massage from a spouse.

We can complain about salaries and systems, but that won’t move us forward. What we can do is steal the gladiator mindset: a fierce, proactive approach to self‑preservation, where you treat your body and mind like the ultimate arena weapon and invest in them relentlessly to outlast and outperform.

We can acknowledge the investment, build our own support group, and share the nuggets of gold with each other. Looking back, consciously and subconsciously, that’s exactly what I did.

How I built my support team

Over the years, partly by design and partly by necessity, I assembled exactly the kind of high-level support network that elite athletes take for granted:

Structural care

A physiotherapist who regularly cracked my motion apparatus—spine and all—back into place after 6–8‑hour surgeries and long stretches in unnatural positions.

Recovery and bodywork

- A highly skilled Kalari Ayurvedic therapist for 72‑hour rejuvenation system reboots: herbal‑infused oil massages, sweat boxes, sinus clearance, and sense‑grounding food and environment.

- Massage therapists in every city I moved to. I spent a fortune on all of them—and I’m 100% sure I’m above where I’d be without them.

Nutrition and planning

Regular assessments of my diet and practical ideas to meal prep, including for crazy clinic days.

Mobility and mindset

Hundreds of hours in yoga classes and meditation retreats. Another fortune spent—and I’m 100% sure these are major reasons why I’m in better physical shape at 42 than at 22.

I don’t need epigenetic testing to see how much better off I am than many of my same‑aged colleagues. I quit smoking and drinking decades ago. I spend a large part of my salary on taking care of myself. I can complain that it had to be me who paid for it. At the end of the day, it’s me who has to live in this body. While it would be nice if someone else paid, I’m happy to do it myself.

And I’ve also seen the cost of not investing.

Stress‑induced psychosis that leaves a colleague found completely incapacitated, with their car inexplicably discovered burned out kilometers away—and neither they nor anyone else can remember what happened. Being admitted to your own ICU because of ignored diabetes. The extreme emotional and monetary costs of a failed marriage when you’ve prioritized everything except the relationship that matters most.

These aren’t abstract warnings. These are people I know. These are versions of myself I narrowly avoided becoming.

Where leaders fall behind

We normalize 14‑hour days, ignore ergonomics, and skip planned recovery. We treat ourselves like amateurs and then expect elite output.

You can’t perform like an elite athlete if you treat yourself like someone who just started.

So take an honest inventory:

Strip down and face the mirror. Look at your physique. Not with judgment—with curiosity. What does this body tell you about how you’ve been living?

Sit down, close your eyes, and scan inward. Feel where your body is tight or in pain. Notice what you’ve been ignoring.

Open your fridge and see what’s actually in there. Not the aspirational meal prep from three weeks ago—what you actually ate this week.

Ask yourself: Is this what you’d recommend to top performers if they asked for your professional advice?

If yes, congratulate yourself. You’re in the top 1%.

If not, don’t be hard on yourself. Nobody taught us this. We weren’t taught it in medical school, business school, or at any step in our careers. We have to learn it and take care of it ourselves.

The good news: it can be done. It’s not impossible. And while not everyone has equal resources, most of us have more capacity than we’re currently using.

Good / Better / Best: make it accessible

Not every season permits the “best” stack, and not everyone starts from the same place. The goal is progress, not perfection. Small, consistent upgrades compound dramatically over time.

Good (low cost, low time commitment)

- 10 minutes of daily mobility work—even just a simple down-dog or a basic stretching routine

- Evening screens‑off wind‑down starting 30–60 minutes before bed

- Sunday meal prep for 2–3 weeknights so you’re not choosing between skipping meals and drive-through at 9 PM

Better (moderate investment)

- Monthly bodywork session—massage, chiropractic, or whatever modality works for your body

- Dietitian consultation once per quarter to reality-check your nutrition against your actual schedule

- Basic sleep protocol: caffeine cutoff by 2 PM, light management - dimming lights after sunset, blackout curtains - consistent bedtime within a 30-minute window

Best (full stack)

- Integrated care plan with 2–3 key providers who communicate and adjust based on your specific demands

- Quarterly assessments and metrics—sleep quality, HRV, regular relevant lab work based on your health picture

- One to two immersive recovery retreats per year—whether that’s a meditation retreat, an ayurvedic panchakarma, a structured wellness program, or simply a week with zero connectivity and plenty of movement

A note on access: Not everyone can afford everything, and financial or time constraints are real. Start where you are. A free YouTube mobility routine done consistently will outperform an expensive program you never use. The key is to stop treating professional support as indulgent and start treating it as essential infrastructure.

ROI you can feel

Pick your measures, but the trend lines matter more than any single data point:

Physiological:

- Better sleep efficiency and steadier mood

- Lower resting heart rate and higher HRV

- Fewer overuse injuries and fewer sick days

Performance:

- More surgical stamina and clarity in hour six of a complex case

- Clearer decision‑making under pressure

- Consistent energy through afternoon meetings instead of the 3 PM crash

Relational:

- Actually present when you’re with your family, not just physically there while mentally reviewing the day

- Patience with your team when things go sideways

- Capacity to mentor junior colleagues instead of just surviving your own workload

Creative:

- Mental bandwidth at 8 PM to actually work on that project - that thing - instead of scrolling

- Saturday mornings where you wake up with energy to create, not just recover

- The cognitive space to think about your art, not just your to-do list

You probably didn’t sign up for The Renaissance Protocol just to optimize your quarterly reviews. You’re here because there’s a creative part of you that’s been on hold—maybe for years—and you want it back.

But here’s what nobody tells you: you can’t reclaim that dormant passion by just “making time for it.” That’s a very important first step. But your photography hobby doesn’t just need more calendar slots. It also needs you to not be physically depleted when those slots arrive.

Renaissance living isn’t about cramming creativity into an already maxed-out system. It’s about building the infrastructure that makes the full life—the one with both performance AND passion—actually sustainable.

The support team isn’t optional. It’s the foundation.

Start now

Pick one area where professional help could elevate you to an elite support level. Not three. Not “I’ll think about it.” One.

Research it this week. Find a provider, read reviews, ask colleagues who seem to have their act together.

Make an appointment now. Put it in your calendar before you close this email.

Protect one hour a week. Treat it like a board meeting or a surgical case—non-negotiable unless there’s a genuine emergency.

Iterate. After 4–6 weeks, assess what’s working and adjust. Add a second support pillar when the first becomes routine.

You didn’t hesitate to invest years and six figures into your professional training. Your body and mind are the platform that training runs on.

Thank me later.

Your support team isn’t just about performing better at work. It’s about having enough left over for the parts of life that make you feel alive. That’s what Renaissance living actually means.

To most from life

Nicco

-----

What’s one area where you need better support? Hit reply and let me know—I read every response, and I’m always collecting recommendations to share with the community.

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“What are you doing there?” Utter disbelief rang in the voice of my attending, as if I were spraying communist slogans on his house.

I was actually trying to shove in the second fork of a limp salad from the cafeteria while standing. “Surgeons don’t need to eat!” I was waiting for a hint of a smile, a smirk, anything indicating that he was joking. But nothing, just cold grey eyes. The second time I was “caught” was in a different hospital, exiting the elevator heading for lunch when I was tapped on my shoulder and stopped by my chief attending: “If you have time to eat we obviously have too much staff in our department,” she said.

For years I was peeking nervously over my shoulder when having lunch, if I dared to have it at all.

Back then I was a fifth-year surgery resident, a father, and a grown man. And I was afraid to have lunch. Clearly there is something wrong.

This absurd reality reflects a deeper problem in our profession - a fundamental misunderstanding of what it means to be a physician. The solution lies in distinguishing between two fundamentally different approaches: the Old School physician mindset that glorifies suffering, and what I call the New School physician mindset that prioritizes our wellbeing as the foundation for excellent patient care.

To the basics: ASICS - anima sana in corpore sano - a healthy soul in a healthy body - this is an eternal truth that we preach our own patients day in day out. But we are not able to apply it to our own lives. On the contrary.

Subscribe now

Becoming and being a doctor is no walk in the park. Everyone knows that, and I knew that, and after all, it was my free choice. The long hours, the responsibility, the administrative and legal burdens, the at times abominable working conditions and environments have been pointed out time and again. The stress can be enormous.

The statistics tell a sobering story. Burnout among physicians remains high worldwide. A comprehensive COVID-era meta-analysis found an overall prevalence of ≈55%, with significantly higher odds among frontline clinicians and regional variation (Macaron M.M. et al., Frontiers in Psychiatry, 2023; https://doi.org/10.3389/fpsyt.2022.1071397).

The statistics tell a sobering story. Burnout among physicians remains high worldwide. A comprehensive COVID-era meta-analysis found an overall prevalence of ≈55%, with significantly higher odds among frontline clinicians and regional variation (https://doi.org/10.3389/fpsyt.2022.1071397).

In emergency medicine, pooled international prevalence reached ≈43% (95% CI 32–54%), underscoring that high stress is a global, not regional, phenomenon (https://doi.org/10.3390/healthcare11152220).

In the United States, the most recent Mayo Clinic Proceedings data show physician burnout falling from 62.8% in 2021 to 45.2% in 2023, returning to pre-pandemic levels yet remaining alarmingly high (https://doi.org/10.1016/j.mayocp.2024.11.031).

We are one of the professional groups with the highest rates of illicit substance and drug abuse, suicide rates and premature deaths. And this is no longer only affecting physicians themselves - physician burnout directly correlates with increased patient safety incidents, decreased professionalism, reduced patient satisfaction, and higher turnover intentions, as demonstrated in comprehensive BMJ meta-analyses (https://doi.org/10.1136/bmj-2022-070442).

A particularly insidious contributor to modern physician burnout is electronic health record (EHR) fatigue. We spend more time documenting care than providing it - studies show physicians spend 2 hours on EHR tasks for every hour of patient contact. This administrative burden represents a form of moral injury, forcing us to prioritize documentation over healing. The ICD-11 now formally recognizes burnout as an occupational phenomenon resulting from chronic workplace stress, acknowledging that systemic factors like EHR burden require organizational-level solutions alongside individual interventions (https://doi.org/10.2147/JHL.S389245).

But one of the root problems lies somewhere else. It is a force that at times opposes change for good from within.

It is our common mindset. The mindset that defines how we think we as physicians have to act and interact within this system.

This is what I call the Old School physician mindset.

The practice of medicine is often associated with that of a selfless practice. A term that has been badly misunderstood. Selfless in the sense of no ego, no personal agenda driving the practice, yes. But it never was intended to deprive us from our natural physical, emotional, spiritual and social needs, that we - human beings after all - have, too.

I oppose the implicit and explicit suggestion of physician martyrdom as the only way of practicing medicine.

Neither the Hippocratic oath, nor Lasagna’s modern interpretation of it or Inman’s “First do no harm” indicate at any point that our profession should go at the expense of our own wellbeing.

Yet the Old School mindset has often created a toxic culture where suffering becomes a badge of honor. As a collective, we take some sort of sick pride in suffering, comparing who works and harms himself more. It leads to a twisted form of false, perceived heroism, where a delusional mind fights its very own body.

I lost one great grandfather physician to morphine and one grandfather physician to myocardial infarction. I have seen colleagues smashing trash cans, kicking holes in walls when the pressure got too high and their underdeveloped coping strategies failed. I saw them literally smoke themselves to death, or get admitted to their own ICU in a diabetic coma.

I have seen way too many near accidents such as wrong surgery site markings, faulty prescriptions and other concentration deficit derived mix-ups. And I have seen a patient die because of a catastrophic cascade of decisions made by physicians trapped in ego-ridden decision making. This should not be.

The prospect of working the rest of my life in such self-wrecking conditions made me quit medicine for good twice.

Only one mentor’s reminder to “focus on changing what is within your reach. Change from within” kept me coming back.

This mentor’s wisdom points toward a different path - one that acknowledges the reality of systemic problems while empowering us to take control of what we can change. The problem is not that these things happen, but that we shrug them off as something inevitable, as the status quo. This is what I call the old school physician’s mindset which puts a skewed idol image of our profession first.

In contrast, a New School Physician mindset puts ourselves as doctors first.

Not the profession. Not the patient, but ourselves.

Safety first. We know that from first aid guidelines and airplanes - make sure you don’t endanger yourself, it helps no one.

We can’t give if we have nothing to give, if we get consumed in the process.

We must stop postponing it to some indistinct point in the hazy future.

To be clear, this is not about creating a medical la-la land for physicians. And it is definitely not about jeopardizing patient care because of petty personal issues.

The New School approach is actually about becoming better physicians through conscious self-care. It is about acknowledging one’s personal needs. It is about building up the strength and courage to express those needs, even against implicit or explicit threats from our peers or more importantly against imagined threats of our minds.

It is about taking responsibility for your own life. It is about actively deciding how to spend our time; how to do what we do. It is about making conscious choices for ourselves.

The moment we become true and honest about ourselves to ourselves, we become better doctors as well.

So what does this look like in practice? How would this look like? Take one step back and take a bird’s-eye view on your current life.

And then examine your life’s situation as you would with your own patients.

What are the most pressing issues?

What would you recommend to a patient under those kinds of circumstances?

I believe there are many things we can do in the realm of mindset, organization, lifestyle and communication to help us feel better again.

And most likely, every single one of us already knows exactly what that would be in our case.

When we embrace this New School approach, the benefits extend far beyond our personal wellbeing. If we know our truth and can stand up for it, we become independent from other people’s conflicts of interest. We then can start treating our patients to our best knowledge.

And we can be truthful and honest with our patients as well, without having to be afraid to disappoint them or make them feel bad.

And most importantly without risking harming them by harming ourselves.

This would also reduce pressure and stress, and foster wellbeing far more significantly than any external health reform ever could.

It doesn’t and shouldn’t take away the responsibility to improve structural and institutional conditions - but it is an important pillar to tackle this multifaceted challenge.

This is the future of medicine I envision - one where healthy physicians provide the best possible care because they’ve learned to care for themselves first. This is what a New School Physician would look like.

The choice is ours. We can continue perpetuating a culture that glorifies suffering and ultimately harms both physicians and patients, or we can choose to become New School Physicians - one conscious decision at a time. The transformation of medicine begins with transforming ourselves.

I wrote this piece in 2016. Back then I was too afraid to publish it.

I have slightly adjusted the text and updated some references - which haven’t fundamentally changed, what is telling in itself.

Since then I have moved through the ranks to be now in a position where I see this problem perpetuating itself also on the administrative side. And realizing that I have become part of the problem myself - and to a certain extent - hopefully part of more structural solutions as well.

The challenge requires both individual and systemic approaches. While evidence shows that interventions targeting medical residents yield only modest benefits when implemented in isolation, combined approaches show greater promise (https://doi.org/10.1186/s12909-024-06195-3). This reinforces the need for what I call the CARE framework - a practical approach for New School Physicians:

The CARE Principles

Consciousness: Developing awareness of your own needs, limits, and warning signs. This means regularly checking in with yourself: Am I hungry? Tired? Overwhelmed? Start with simple daily check-ins.

Advocacy: Building the courage to express your needs and set boundaries. This includes saying no to excessive overtime, requesting adequate break times, and speaking up about unsafe working conditions. Practice starts with small assertions.

Responsibility: Taking ownership of your wellbeing through concrete actions - overhauling diet, exercise and sleeping habits one at a time, getting up earlier to experience the feeling of “having time” again, and seeking professional help when needed.

Expression: Opening up about your challenges to colleagues and superiors, and fostering honest collegial check-ins. Taking microbreaks in the OR and using scrubbing-in times for genuine connection. Creating psychological safety in our teams.

While I don’t think that magic AI tools will make all our problems - or jobs for that matter - suddenly disappear, I see the potential to ease some of our burdens.

A lot of creative thinking, openness and persistence is required to move the needle on many other areas.

Let’s reflect and create change in the way we interact with ourselves, our colleagues as well as our system - one day at a time.

To more in life,

Nicco

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