Put Down the Knife: A neurosurgeon explains the importance of a work life balance




Stephen Batchelor, in his novel Buddhism Without Beliefs, observed that “death alone is certain and the time of death is uncertain.” This knowledge should guide us in one of our most important decisions: How should we spend our limited amount of time on earth?


Why do you work so hard?


There are many different reasons why people might work too hard. Often times they toil out of necessity. Some people work their fingers to the bone and still have bills that they can’t pay. Others work too hard for non-monetary rewards. As a neurosurgeon, I sometimes fall into the latter category. 

When I speak about lovely human anatomy (at least in public), I am often referring to the junction between the brainstem and spinal cord (craniocervical junction). The contrast between the beige, wrinkled cerebellar folia and the smooth, gleaming white floor of the fourth ventricle is breathtaking. Pulsations of clear, colorless CSF wash across the surface of the upper spinal cord like waves across the shore.  

The most common problem at the craniocervical junction that I surgically treat is called a Chiari malformation. This abnormality occurs when, for unknown reasons, a patient is born with a distortion of the skull, lower brain and upper spine. In the vast majority of cases, Chiari malformation is a mild anomaly and does not cause any symptoms. But sometimes the malformation is serious enough to cause severe symptoms and warrants surgery. Chiari malformation typically responds well to surgery and the patient’s neurological symptoms improve. 

It is hard to exaggerate the gratification I feel after successfully repairing a Chiari malformation. Surgery brings the concomitant adulation of the patient and her family and admiration of colleagues, staff and students. Mine is a noble profession and each successful surgery adds to the greater good of the community. Doing surgery is so rewarding that it is difficult to avoid falling prey to the temptation to add case after case, day after day, week after week, year after year.


Why is it bad to work so hard?


A wise colleague explained the danger of incessantly performing surgery.  “One missed dinner with the family turns into many. It is easy to convince myself that I have more important things to do than help the kids with their homework, but it is harder for them to be convinced. At the end of my career I would not remember whether I treated a hundred patients with Chiari or one hundred and fifty. But”, he said, “I will remember coaching my daughter’s third grade softball team. I will remember the look on her face after she cleanly fielded a grounder and threw the lead runner out at second. I won’t forget the dozens of times different girls from each team asked “are we winning coach?” after every out and between each inning”.


Can working too hard be bad for your brain?


King Solomon said, “Whoever quarries stones may be injured by them.” He observed that our occupations take a toll. Especially a job that requires us to trade our time and sweat for our daily bread. At some point those who ‘live to work’ will work themselves out of life. The admonition to a surgeon to ‘put down the knife’ can be generalized. Does your profession exact both physical and psychological costs? 




Neurobiological research has demonstrated the importance of a work life balance. Experiments have demonstrated that the failure to scale back on work carries high physiologic costs. Simply put, working too hard will damage your brain.

Researchers in Great Britain explored the effects of overwork on the brain. The government sponsored investigators, known as Whitehall II, published their work in 2009. The researchers administered a battery of cognitive tests to more than two thousand British civil servants to obtain a baseline level of performance and then repeated the tests five years later.  The tests evaluated verbal memory and skills, fluid intelligence (associated with short-term memory, abstract thinking, creativity, and problem solving), and crystallized intelligence (learning accumulated over the life span in education, work, and cultural experiences). Compared with those participants who worked no more than 40 hours per week, Britons working more than 55 hours per week had lower performance in all the cognitive realms tested. The negative association between long working hours and cognitive function were not altered by several potential confounding factors including age, sex, marital status, education, occupation, income, physical diseases, psychosocial factors, sleep disturbances, and health risk behaviors.

People who chronically overwork, especially those in high stress jobs, have a propensity to burnout. Burnout, first described in the 1970s, emerges when the demands of a job outstrip a person’s ability to cope with the stress.  At its worst, burnout manifests as an overwhelming sense of exhaustion, feelings of cynicism and detachment, and a sense of professional ineffectiveness and lack of accomplishment. Mounting neurobiological evidence shows that burnout takes a profound physical toll that extends beyond our professional lives, it extends to our brains.  

In 2014, scientists from the Karolinska Institute, Sweden, reported on the effects of burnout on the brain. They studied 40 subjects suffering from burnout symptoms attributed to chronic occupational stress and 70 volunteers who served as controls. They performed fMRIs on both groups to assess the brain circuitry. They discovered the functional connectivity between the amygdala (area of the brain involved in emotions and memories) and the front part of the cingulate cortex (an area involved with emotion, learning, and memory) was significantly weaker in the burnout group. The researchers also noted a deficiency of the connections between the amygdala and back and side parts of the prefrontal cortex (an area responsible for executive function) in the burnout group. On the other hand, the investigators reported that connectivity from the amygdala to the cerebellum (area that controls coordination) and the insular  cortex (a part of the brain active during psychological conflicts) were stronger in the burnout group than the controls.

In another study at the Karolinska Institute researchers recruited 40 control volunteers and compared them to 40 patients who suffered from burnout.  MRI studies of these patients determined that it was not only the circuitry that was affected by the burnout, but also the size of the brain structures.  Patients suffering from burnout showed volume loss in the prefrontal cortex when compared with the controls. Burnout patients appeared to also have shrinking in their dorsal striatum (caudate and putamen nuclei (areas that modify movement) and hippocampus (an area involved in emotion and memory),  but an increased volume of tissue in the amygdalae.  


Put Down the Knife


So, put down the knife. Keep a work life balance. Don’t burnout. Working too hard is bad for your brain.