This is a wonderful post from Lauren, who is married to a medical student.  Her very important advice applies to medical students, residents and practicing physicians.  If you want to read more of her writing, she blogs at  http://medicalwife.wordpress.com

While you’re busy becoming a doctor, don’t forget the person who is holding your hand.

I am not a doctor. I am not a medical student. I am not in any way a medical professional. But I have everything to do with the medical profession. I am the wife of a medical student.

My own “medical” career began in 2007 when my husband entered medical school. We dated long distance for two years, got married, and have spent the past year and half more or less living in the same city, same house, finishing out his medical school career. If you as a doctor in training could take any lesson from my experience it would be this: Don’t forget the person who is willing to go through all this with you- your wife, your husband, whatever. Don’t forget, or neglect, that person.

Being your spouse or significant other is hard. You work long hours, study all the hours you are at home, and often spend days and weeks away on rotations or on-call. Your career dictates where we live and when we get to have a family bigger than our dogs and us. Your job makes you tired and stressed out, all too often leaving us to clean up after you even though we too are tired and stressed out from working at our own job. We sometimes snap at you in frustration because we want our weariness and sacrifice to be acknowledged too. It’s not easy being married to you, a medical student.

I say this not to complain, but to remind you of the sacrifices made on your spouse’s (or significant other’s) part. We make these sacrifices willingly. We married you (hopefully) knowing what our life would be like for a long, long time while you learn and train and build a career. To be clear, this is NOT a complaint, only a gentle reminder.

Wellness doesn’t only refer to your physical and mental well-being, but to the state of your relationships as well.  The last thing a stressed out medical student or resident needs is a failing marriage or relationship. Take time to cultivate your marriage. Take time out of your busy life to enjoy your significant other, and appreciate them and their role in your career. This can be done in any number of ways, some more time consuming than others, some more costly than others, but all are ways in which you can help your spouse know that they are appreciated, cared for, and loved. Below is a list of ways my medical student husband has gone above and beyond to make sure I feel valued and our marriage is secure. As the wife of a medical student, I can assure you that these work.

-       Exercise together, if that’s your thing. My husband and I, when he’s not away on rotations, run/walk together with our dog on Saturday and Sunday mornings. He is far more capable than I (far, far more), but he takes the time to do my measly walk/run workout with me every weekend. When he IS away, he makes sure to ask how my workout went and chat with me about my most recent small achievement. He always reminds me that he’s proud of me.

-       Commit an act of service. Big or small. When my husband does the dishes. Or runs a load of laundry. Or vacuums (which I hate to do), I know he is doing his best to help out in spite of his busy work and study schedule. I see that he cares, even if it is just a chore or two, and I see that he doesn’t expect me to be his maid. It doesn’t take much to make your spouse feel their housework is noticed and appreciated, and one of the best ways to do that is by giving them a break from it.

-       Go on a date, even if it’s just for coffee. Yes. I know. Cliché, but so true. We like to go on dates on weeknights when he isn’t working. It breaks up the monotony of life and is a bright light in the middle of a long week.

-       Read together. Sometimes, when my husband has a ton of reading, he’ll suggest we lie in bed together and read. Me on my Kindle, him his latest textbook for a rotation. We play footsy and simply BE together in happy contemplative silence.

-       Make them a part of what you do. My husband shares what he’s learning with me. He has me ask him practice questions when studying for exams. By making me a part of what he does every day I never feel put off by it.

-       Surprise them! Flowers! A small present! A tasty treat! Any unexpected surprise is reaffirming and welcomed.

Most importantly, tell your spouse/significant other thank you. Tell them that you appreciate all the sacrifices they make to be with you while you go though this. Tell them you know it must be hard for them to get shafted out of time with you because you have to go to the hospital, again, but that you will make up for it soon (and follow through with that promise!).

Remember that (hopefully) your spouse/significant other makes this whole process a little bit easier by being the warm arms you come home to after a long night, by being your number one fan and constant encouragement, by allowing your career to come first sometimes. Remember the person holding your hand through all this, and take time to care for that relationship properly.

I know I should study for the Absite this weekend, but I haven’t had a real day off in over a month”.

Here’s the scenario.  It’s Friday evening.  You’ll be back at work on Sunday.  You’re sleep deprived because you are a resident.   You haven’t spent any quality time with your significant other, friends or family because you haven’t had any real time off.  Next week has plenty of call and it would really help if you planned out good food for the week and cooked something.  And, by the way, you have the inservice exam coming up, so you really should study.

There is no one answer how to balance these things. Everyone will be a little different in what is most important to them, and different weeks will be different, too.  But, there are some basic concepts to think about that might help you plan how to spend your time off.

• Sleep is actually a high priority even though it feels like you are giving up social time.  Whether it’s visiting friends, studying or just goofing off, you won’t get the benefit of your time off if you are completely exhausted.  If you are sleep deprived, try going to sleep really early (8 or so) the night before your day off and see if it doesn’t make a big difference.

• Good food is important.  Be efficient, but be conscious about what and when you eat. Use a little of your down time to think about your week, plan what you are going to eat, and go shopping.  Find a good recipe for something easy to make and make a big batch for the week.  Or at least buy good quality frozen food that serves the same purpose.

• Get some exercise, but be realistic.  A serious workout can use up a big hunk of a day off.  For some, that’s great – the hours will be more than worth it.  For others, don’t beat yourself up.  It’s far better to figure out how to do 30 minutes 3 or 4 times a week than to be a “weekend warrior” for 4 hours on your day off.

• Don’t plan for huge blocks of study time on your day off.  You’ll wear out your neural pathways and you just won’t remember what you are trying to learn.  Like exercise, a little every day is much, much more effective than a big block on the weekend.  Plan now for the big test months from now… pace yourself!  (If you’ve just started studying for the Absite later this month – go for it.   But, as soon as the exam is over, map out a way to study for next year so you don’t do the same thing again.)

• Absolutely use a significant part of your day off to socialize with your family or friends.  It’s very isolating to live in the hospital and these hours are critically important.

• Once you think about what’s important to you, and make a decision about your day – enjoy it!  The worst way to spend a day off is to spend the time worrying that you should be doing something else.  There’s a reason that almost every religion in the world has the concept of “Sabbath” .  Human beings need real down time once a week to refuel.  It’s not “wasted” time, it’s essential time.

Last week I attended a wonderful lecture in Baylor’s Medicine and the Art of Compassion lecture series entitled  ”The Perils of Perfectionism”.  It was presented by Dr. Glen Gabbard, who is a psychiatrist and author with great expertise in physician wellness.   I can’t do justice to the entire lecture, but there were a few key points that I wanted to share:

Compulsion is one of our our greatest assets as physicians, but it can become one of our greatest liabilities.

One of the key personality traits that physicians need to have (and/or develop) is to be compulsive.  In fact, many of us choose medicine because it’s a good fit for our basically compulsive personalities.  Unfortunately, as Dr. Gabbard pointed out, unbridled compulsiveness can lead to “excessive devotion to work and productivity to the exclusion of leisure activities and friendships.”   How do you tell if a good thing (caring about patients, being compulsive) has become an unhealthy behavior?   Here’s some warning signs that he pointed out in his lecture:

• A reluctance to delegate tasks or work with others unless they submit to exactly the way you want it done
• Rigidity and stubborness
• Perfectionism that interferes with completion of the task (checking the reflexes 10 times on rounds instead of once or twice)
• Self-doubt
• Guilt
• An exaggerated sense of responsibility
• Failure to take vacation
• Cynicism
• Chronic fatigue
• Emotional outbursts
• Headaches
• Increased alcohol consumption
• Marital “deadness” or discord

It’s dangerous to look at the issue of physician stress with an “us-them” mentality

It’s easy to think that discussions of physician stress and impairment apply only to “other doctors” (or “other” medical students).  Unfortunately, the stress that comes with out of control perfectionism can lead to suffering for any physician.  In extreme cases, it can lead to physician impairment, destruction of relationships, burnout and physical illness.  As Dr. Gabbard pointed out in his lecture ”impairment is the endpoint on a continuum.”  Every physician, when exposed to the right combination of stressors, can become impaired.  The key is to realize that all physicians are susceptible, that it’s important to watch for warning signs, and that’s it’s even more important to seek help when its needed.

“The desire to excel must be differentiated from the desire to be perfect.”

I thought this was a wonderful rule for physicians to remember.  We all want to do our best, and we all want our patients to do well.  We want to excel, but we can’t ever be perfect.  Physicians don’t have control over many outcomes – some patients will develop complications or die despite our best efforts.  And… we are human.  Mistakes will be made.  The goal is to minimize them, learn from them, and forgive yourself.

“A physician that treats himself has a fool for a patient” (William Osler)

Every physician should have a personal physician.  As much as possible, the relationship should be as ”normal” as possible i.e. even though you are a doctor, you should be treated just like any other patient.  That’s not as easy as it sounds, but it’s the right approach for both you (as a patient) and the physician treating you.   Why go to the trouble of finding a personal physician?  If you become ill, it’s nice to have an established relationship with the person who will be treating you.  It’s also nice to have someone you can talk to if you are feeling burnt out.  Depression, stress, and impairment can all be treated.  It’s really no different than going to the orthopedic surgeon if you break your arm.  If you need help, talk to your primary care physician or a mental health expert.

Some of our greatest lessons come from dying patients.

Anyone who has had the blessing of caring for a dying patient has learned from them that there are only two important things in life: to live wisely and to love well.  Our family and our friends are our greatest treasures.   Learn to spend time taking care of yourself  and nurturing these important relationships.  It’s easy to fall into the trap of putting off this important work… but don’t.    “The fool with all his other thoughts has this also:  he is always getting ready to live.”  (Epicurus)

I came across this lecture by Lily C. Conrad, MD PhD FACEP on Wellness for Emergency Room Residents and thought I’d share it.  It’s a good review and makes some interesting points.  She raises issues applicable to all residents as well as more specific issues for residents in Emergency Medicine.

The concept of renewal is critical:

• A single-minded devotion to career is impoverishing
• By neglecting restorative activities physicians tend to lose their emotional resilience
• We need to establish time for rest, revitalization, exploration and emotional and well as intellectual growth

Link to the lecture – Wellness for Emergency Room Residents

We all know the basics about how to be healthier and how much that can influence our risk of cardiovascular (and other) disease in the future.  Knowing is easy.  Changing is hard.

There is no doctor who wants to be fat, smoke, or eat poorly.  If you smoke, don’t exercise, eat poorly or are significantly overweight you already know

a) you have a higher risk of premature death and, worse, disablility

b) you’ll have decreased energy and generally feel worse than people who are fit

c) it’s going to be a lot harder to counsel patients about what to do for their health

It would be fantastic if we were all issued a magic wand as part of our medical supplies.  It would be so much easier to make changes in our lives and our patients lives by a wave of a magic wand.  There is no magic wand, but we (and our patients) can make changes using what is known about behaviors and changing behaviors.

The American Heart Association has recently published a review of the literature and recommendations on how to sustain changes that improve health.  I’ve put the link below to the entire article but here’s my summary (and slight translation) of what they found worked to change behaviors:

1. Set goals
2. Use a system to monitor the change
3. Create or discover a support system you can use on a frequent and regular basis
4. Establish a way to get regular feedback on your progress
5. Believe you can do it (and work on strengthening this belief)
6. Reward yourself when goals are achieved
7. Find role models for your new behavior and spend time with them (or what they have written)
8. Brainstorm to use your innate ability to problem solve.  Don’t accept “I can’t”
   or “never” in your vocabulary of change – find creative ways to move past these obstacles.
9. Learn from the times you fail (which is normal). ‘Try again. Fail again. Fail better.’  Samuel Beckett

Interventions to Promote Physical Activity and Dietary Lifestyle Changes for Cardiovascular Risk Factor Reduction in Adults. A Scientific Statement From the American Heart Association Artinian et al, Circulation. 2010;122:406-441

Do’s and Don’ts of Goal Setting from www.sparkpeople.com

Elements of Change from zenhabits.net

The following is taken from The Resilient Clinician by Robert J. Wicks.  Dr. Wicks writes primarily for psychiatrists and other mental health workers, but his advice is applicable to anyone who works with patients.

There are basic elements of a self-care protocol that most everyone needs to renew themselves on an ongoing basis. It really doesn’t  require too much to take a step back from our work routine to  become refreshed and regain perspective. Some of the basic elements  might include:

• Quiet walks by yourself

• Time and space for meditation

• Spiritual and recreational reading-including the diaries  and biographies of others whom you admire

• Some light exercise

• Opportunities to laugh offered by movies, cheerful  friends, etc.

• A hobby such as gardening

• Phone calls to family and friends who inspire and tease you

• Involvement in projects that renew

• Listening to music you enjoy (Wicks, 2003, p. 50)

Other simple steps at self-care and renewal might be:

• Visiting a park or hiking

• Having family or friends over for dinner or evening coffee

• Going to the library or a mega-bookstore to have coffee,  a scone, and to peruse the magazines

• Shopping for little things that would be fun to have but  not cost a lot

• Taking a bath rather than a quick shower

• Daydreaming

• Forming a “dining club” in which you go out once  a month for lunch with a friend or sibling

• E-mailing friends

• Listening to a mystery book on tape

• Reading poetry out loud

• Staying in bed later than usual on a day off

• Having a leisurely discussion with your spouse over  morning coffee in bed

• Watching an old movie

• Making love with your spouse

• Buying and reading a magazine you have never read before

• Fixing a small garden with bright, cheery flowers

• Telephoning someone you haven’t spoken to in ages

• Buying and playing a new CD by a singer or musician  you love

• Taking a short walk (without listening to music) before  and after work and/or during lunchtime

• Going to a diner and having a cup of tea and a piece  of pie

• Going on a weekend retreat at a local spirituality center or  a hotel on large grounds so you can take out time to walk,  reflect, eat when you want, read as long as you’d like, or  just renew yourself

• Arranging to spend a couple of days by yourself in your  own home without family or friends present just to  lounge around and be alone without a schedule  or the needs or agendas of others

• Getting a cheap copybook and journaling each day as  a way of unwinding

I became aware of this book last week through one of the anesthesia residents at work (whose chairman made this book required reading for all residents in his department).  Dr. Gautam is a psychiatrist who has specialized in caring for physicians and is an expert in physician wellness.  She uses training for an Ironman triathalon as an analogy.  Physicians have to “train” for different roles (personal and professional) if we want to prevent burnout.  She proposes a training program that helps keep balance in the complicated life of a doctor. The book primarily addresses physicians already in practice, but the information is very applicable to trainees, as well.

Here’s her website if you are interested:  http://www.drgautam.com/gautam/books.htm

Most medical students and residents eat poorly.  It’s not really a surprise – the days are packed with work from sun-up to sun-down.  There are no planned meals because there can’t be.  Food is a quick bite when it is available.  It’s feast or famine.  On the far end of the scale, the stereotypical diet of a resident is no breakfast (but usually coffee), a doughnut and coffee grabbed on the run once you get to work, some mid-day meal of fast food, and pizza on call.  Food, particularly fast food, becomes solace.  In the stressful world of residency, this kind of “comfort food” becomes a “reward” for the hard work and tribulations. It’s not rocket science.  This kind of diet doesn’t give you the energy you need to function at your peak.  It is also a diet that is very likely to lead to weight gain.  In your 20s, your body can cope with this suboptimal fuel, but it’s not ideal.  However, what “works” in your 20s won’t work as you get older and could even be responsible for a heart attack, diabetes, or other medical problems in your 40s and 50s.  On a more philosophical level, you would never advise this kind of diet to one of your patients.  None of us want to be hypocrites.

The answer is to cook for yourself.  Not everyone likes to cook, and not every one knows how.   I’m going to make a case that you should learn.  Trust me – if you can learn to take out an appendix, or diagnose a pneumonia, you can learn to cook.   I’m going to assume that you are single for the sake of this description.  But, if you have a significant other, it’s even more important to cook at home.  He or she can participate in helping with the meal preparation, and, by doing this together and for each other, there is added benefit for your relationship.  Having dinner at home with a significant other will become an “anchor” to your day that will become very important to you.  As hard as it is to work around a busy schedule, if you can eat together, and have a real conversation, you will both benefit greatly.

Cooking is a wonderful therapy for the stress of medical school and residency.  If you’ve never learned how to cook, this is a hard time to learn complicated techniques, but it’s not hard to learn simple techniques.  There are several advantages of cooking for yourself that outweigh (on most days) the hassle of spending the time.  The act of cooking for yourself can be a time of “decompressing” from work.  Arranging vegetables, cutting them, smelling the odor of the food appeals to all your senses and is a moment in the day that you can intentionally slow down.  It’s very important that the recipes you choose are simple and quickly prepared.  No one wants to come home to a 2 hour task in the kitchen after a hard day.  Cooking for yourself has other benefits as well.  First, it is tangible evidence that you are taking care of yourself.  This is not a trivial point.  There are days during your training when it seems no one is taking care of you.  Having concrete evidence that you are caring for yourself is an antidote to that feeling.  Secondly, you will eat better.  By cooking from fresh ingredients, you will decrease the amount of pre-packaged and fast food.  Even without medical school, you know that this will result in better nutrition.  Thirdly, you will eat cheaper.  Other than the “free” pizza (ethically debatable, but financially clear), processed food is usually more expensive.  And lastly, you can share.  It isn’t any more work to make 4 or 6 portions of a dish than it is to make 2, and it usually isn’t that much more expensive, either.  If you can convince one of your colleagues that this is a good idea, you can cook for each other on alternate days.   Likewise, you can cook larger amounts and, using freezer ready containers, freeze portions for yourself for the future.  Doesn’t homemade pasta with a side of fresh vegetables really sound better than the greasy middle of the night food that is available in most hospitals?   It’s true that you can’t cook just anything with the kind of schedule you will have in medical school and your residency.  But, there are few key rules that will make it possible for you to do this, enjoy it, and eat well.

Rule 1:  Don’t cook anything that takes more than 30 minutes to prepare.

Let’s be realistic – you are not going to walk into your home at 8 o’clock at night, hungry, and spend an hour preparing something.  But – there are very nutritious dinners that take less than 10 minutes, so getting home late is no excuse.

Rule 2:  Plan ahead.

The first step in preparing dinner for most busy people is to open the refrigerator door and ask “What can I eat tonight?:  If you are anything like I was in residency, the refrigerator had some cheese, some vegetables (often way past their prime), and maybe some leftovers.  Not very appetizing.  There is an easy way to prevent this from happening.  On whatever day you have off and have time to shop, spend 30 minutes making a menu.  Start by making a table for the week with what is happening.

	Breakfast	Lunch	Snack	Dinner	Comments
Sun
Mon					On call – take Tues meals, too
Tues
Wed				Out	Out with friends after rounds
Thur
Fri					On call
Sat

Once you have an outline of your week, fill in the blanks with the meals.  Now, most of us can handle “hamburgers” or “Raisin Bran” as a menu item… but it’s more fun, and healthier to branch out a bit.  So, if you are not used to looking for new things to cook, how do you find recipes?  Cookbooks can be fun, particularly if you are looking for a particular ethnic food or a style (e.g. low-fat) of cooking.  If you like cookbooks, and bookstores, find the used book store nearest you and go to town!  There are also web sites for recipes.  Many of them also have “cooking lessons” on line.  Most cooking shows have a web based recipe site as well.   So, say you start by searching the web and find this recipe. (for this particular recipe, I’m assuming you have no concerns about calories)  It looks easy, and like it would taste good.   So you print it out.

NEW ORLEANS PASTA

ESSENCE OF EMERIL (FOODTV)   SHOW #EE123 – http://www.recipesource.com/main-dishes/pasta/11/rec1100.html

1 tablespoon olive oil

16 ounces chicken breast half, cut into strips (about 1/2 cup)

1/4 cup chopped chorizo sausage

2 tablespoons chopped green onions, plus extra for garnish

1/2 tablespoon chopped garlic

Tabasco and Worcestershire sauce

3/4 cup heavy cream

1/4 cup grated Parmesan cheese

1/4 pound shrimp, peeled and deveined

1/2 pound penne pasta, cooked al dente and tossed in oil to coat

Creole spice, salt and pepper

In a large saute pan heat oil, add chicken and sausage and cook 5 minutes, stirring often. Add green onions, garlic, 2 dashes each Tabasco and Worcestershire sauce or to taste, and cook for 1 minute. Add cream, cheese, shrimp and pasta. Cook, tossing, to heat through. Adjust seasoning to taste with Creole spice, salt and pepper. Serve garnished with green onions.

Yield: 2 servings

Now what?  First, cut and paste the ingredient list to a shopping list.  If you are compulsive, you can organize it into meat, dairy, produce, etc (it makes shopping easier, but it’s not essential).  You’ll need to add a vegetable or salad to balance this out nutritionally. (I picked broccoli as an example) If you can afford the calories, add a desert. (Ice cream in this case)  Then decide what night in your schedule this will work best.  This recipe will take about 12 minutes total so it would be great for a night you are getting home late.  You can either share the other portion with your significant other or you can take it with you the next day as lunch.  You can double the recipe and have it more than one night.   For example:

	Breakfast	Lunch	Snack	Dinner	Comments
Sun
Mon					On call – take Tues meals, too
Tues
Wed				Out	Out with friends after roundsThaw shrimp for tomorrow
Thur				NEW ORLEANS PASTA (CHICKEN, CHORIZO)Steamed broccoliIce Cream	Freeze one portion for later
Fri				NEW ORLEANS PASTA (CHICKEN, CHORIZO)Steamed broccoli	On call
Sat		NEW NEW ORLEANS PASTA (CHICKEN, CHORIZO)Steamed broccoli

Shopping list:

2 lbs chicken breast (16 oz x 2)

1/2 cup chopped chorizo sausage

1/2 pound shrimp, peeled and deveined

heavy cream   (need 1 1/5  cup)

Parmesan cheese  (need 1/2 cup grated)

Olive oil

Creole spice

green onions

garlic

broccoli (4 portions to steam)

One pound penne pasta

Ice cream

Rule 3:  Cook (or prep) today today to eat tomorrow

As soon as you get home from the grocery store:

• Freeze any meat that is for later in the week (and make a note to yourself to put in into the refrigerator to thaw a day or two before you are going to use it.)
• Wash the vegetables, dry them and put them away
• Wash lettuce for salads and dry completely (a spin dryer is the best).  Store in a zip lock plastic bag with a paper towel in the bag (which absorbs any residual water).  Make sure you squeeze out all the air you can before closing the bag.

Take advantage of days off to cook things that may take a little more time or effort.  While  you are watch the football game on Sunday, you can cook chili in a crock pot for Wednesday.  If you know that your vegetable stir fry on Tuesday is going to be after a long day, go ahead and chop all the vegetables and meat a day or two before when you have the time and have them stored in the refrigerator.   When Tuesday rolls around (and you are exhausted from work), you’ll have all the ingredients chopped and ready to throw in the pan.