Last One, Fast One: The Mantra I Carried Into Medicine

Last one, fast one.

Coach’s voice echoed across the pool. I watched the pace clock tick the seconds away, took a deep breath, submerged, and pushed off the wall.

That was the mantra before the last interval of a set. A challenge to give it everything. Keep tearing the body down so the resilience builds it back up.

I bought in every time. It worked, I like a challenge, and I am a rule follower. I was wired for a mantra like that. I suspect other people in the pool were too, which is probably why he said it.

There was also a small part of me that believed something else. If I loafed on the last one, if I did not give it my all, I might miss my shot. Don’t get me wrong. I was a good swimmer. I swam in college. I was not Olympic caliber, not even close. But there was a little voice in my head that said, what if? What if this is the one that makes the difference, the one that takes you to the next level? I did not want my own effort to be the limiter. I cannot control my genetics. I can control what I give.

That mantra bled over into my life. Or perhaps it worked on me because my life already mirrored the principle. If you are a physician reading this, I suspect you carried something like it too. You do not get through medical training without a similar mindset.

In the pool, the set ended

Here is the thing it took me a long time to see. Last one, fast one worked in the pool because the set ends.

Coach said that was the last one, and it was the last one. You touch the wall. You cool down, climb out, grab something to eat, and come back tomorrow. There was a limit. Someone else was drawing the boundary around the effort, and the boundary was the protection.

Medicine does not have a wall. Nobody else is drawing the boundary, and when a boundary does exist, there is frequently someone working to break it down. There is always another chart. Another in-basket message. Another committee you should “volunteer” for. Every ask is one more thing, and the one more thing is never the last thing.

So the mantra kept its shape. The mindset stayed. The container was gone.

Training rewards this, which is part of why it is so hard to see. The resident who stays late to finish notes, even close to violating work hours, gets called reliable and hardworking. The one who picks up an extra admission near cap is a team player. The person who went home on time with the work done was sometimes called efficient, though more often people wondered quietly whether they were missing details.

The mindset seeps in. It starts driving the work. And then you are twenty years in, still treating every patient and every chart as the last one, still moving as fast as you can, only to find another one waiting.

Effort tells you how hard. It does not tell you where.

Intensity became the goal. Intensity is not a goal, and it is certainly not a direction.

The research points the same way. When Shanafelt and colleagues surveyed 465 internal medicine faculty at an academic medical center, the largest predictor of burnout in their model was not workload. It was how much effort went toward the one activity each physician found most meaningful. Faculty spending under 20% of their time there burned out at a rate of 53.8%, against 29.9% for everyone above that line. One department, one institution, published in 2009. Read the number as a direction rather than a dose.

A physician who works harder in the wrong direction still lands somewhere they did not choose. They get there sooner, with less left over. That is what it looks like from the inside when, about ten years into a career, something starts to feel off.

Effort is an engine. It is not a steering wheel. Something has to sit above it and point it.

The mindset stayed. The container was gone.

What an intention statement is

An intention statement is three or four written sentences. I think of it as something close to a five-year plan. It rests on your past experiences, what you learned from them, and how you plan to use that going forward.

It is not a resolution. A resolution names a behavior and expires around the third week of January.

Goals are a different animal. Goals are specific, measured, and time-bound, and they are what drive you toward your intention. I walked through that sequence a few years back in three steps to planning a medical career: long-term legacy, medium-term intentions, short-term SMART goals.

Most physicians I know have the goals covered. Board recertification. A promotion packet. A target FTE. If someone asked what those goals serve, could you answer in one sentence?

That gap is where career drift starts, and it is quiet enough that you can live inside it for a decade.

The three parts

1. The past, or the thing that formed you

Think about your own experience. Not the version on your CV.

It is the night shift when you were alone and had to make the call yourself. It is how you felt walking in the door and catching your child’s first step.

Two sentences. Do not interpret them yet.

2. What that experience taught you

Some of this will surprise you, and the surprises are usually the useful part.

It might sound like this: I am quiet and fairly introverted, and I was surprised to find I am good at explaining complicated things in a way people understand. Or: I do not love small groups, but I enjoy lecturing.

Write it plainly. If the sentence flatters you the whole way through, sit with it longer.

3. How you intend to use it

Not a promise. Not a target. A direction you can hold yourself against on an ordinary Tuesday.

The test is whether the sentence survives a meeting. Someone asks you to take on one more thing. Hold that ask up against what you wrote, and you have your answer.

What changes once you have an intention statement

You will not work less. That is not the promise, and anyone selling you that is selling something.

What changes is that your effort becomes answerable to something. The committee invitation gets measured against a sentence you wrote. So does the FTE conversation, the moonlighting offer, and the fellowship you keep almost applying for.

Plenty of those still get a yes. The difference is that the yes is a conscious choice.

None of this is a one-time exercise, which is the argument underneath the idea that physician development never finishes. Intention comes early in that work, because everything downstream depends on knowing where you are pointed.

The mantra was never the problem. It got me through a lot. It only needed the thing the pool handed me for free: a wall, and someone to say when the set was over. An intention statement is how I write that part myself now.

Questions physicians ask about intention statements

How is an intention statement different from a personal mission statement?

A mission statement describes who you are. An intention statement describes what you plan to do with what formed you. The second is easier to write and easier to use, because it names a direction instead of an identity.

How long should an intention statement be?

Three or four sentences. Longer than that and you are writing an essay. Short enough to fit on a coffee mug and you have written a slogan.

What if the experience that formed me is one I would rather not repeat?

Those often make the strongest statements. The point is not to celebrate the experience. It is to name what the experience taught you, then decide on purpose what you carry forward.

How often should I rewrite it?

Once a year is plenty. Attach it to something already on your calendar. Contract renewal season works, and so does the week your annual review lands.