Things I Wish I’d Known From the Beginning: Preventing Back Pain and Injury

Posted on April 27, 2024 by marylbrandt

When it comes to protecting your lower back as a surgeon it’s all about multifidus.

So says Professor Takuya Shimizu, an orthopedic surgeon and professor of sports science at Chukyo University who I heard speak at the 124th meeting of the Japanese Surgery Society.

I never learned about multifidus in anatomy class, and if you are a physician, I suspect you didn’t either. According to Wikipedia, “The multifidus (multifidus spinae : pl.: multifidi) muscle consists of a number of fleshy and tendinous fasciculi, which fill up the groove on either side of the spinous processes of the vertebrae, from the sacrum to the axis.”

I hope the experts forgive my “translation” of their expertise, but here is what I wish someone had told me about protecting my back (and decreasing back pain).

Anatomy. In the first year of medical school we learn about the large muscles that flex and extend the lower back – rectus abdominis anteriorly and the erector spinae posteriorly. Deep to these muscles are the muscles that stabilize the segments of the lumbar spine, and multifidus, for surgeons, is probably the most important of these muscles.

This is the slide from Dr. Shimizu that explained this in a way I could really understand. The “global” muscle in his slide is the rectus abdominis which we contract when we lean forward to operate or examine patients. If you have weak segmental muscles (i.e. the multifidus), a disproportionate force will be transmitted to the weakest point in the spine. For most people, that’s L5-S1. If you work to strengthen the multifidus (“segmental strategy”) the force generated with flexion will be distributed along all the vertebrae – which helps prevent pain and injury.

How to strengthen the multifidus.

“Walk like a model”… which is a conscious, three step process as explained by Dr. Shimizu. The goal should be to do this as often as you think of it (on rounds perhaps?) … and hopefully for 10,000 steps a day! (any amount helps, though)

There are also specific exercises you can do to strengthen the multifidus. The classic core exercises known as “bird dog” and “superman” are among the most effective. (Dafkou, 2021). Others that help include side planks, quadruped leg lift, and one arm pushup on a counter or bench. There are many more, so if you want a complete list, just google “multifidus exercises”.

Another excellent option is Pilates, which has been shown to be effective in strengthening deep core muscles and reducing low back pain. (Eliks, 2019). Tai Chi, yoga and other similar practices are effective in strengthening core muscles as well.

This amazing art is from the team at Codex Anatomicus… make sure you check out their website!

p.s. If you are a physical therapist, sports medicine expert, or have other expertise in this area, please comment below to add your expertise!

p.p.s If your back really hurts, please go see a good physical therapist.

Things I Wish I’d Known From the Beginning: How to (really) keep a journal in medical school and residency

Posted on March 22, 2024 by marylbrandt

Most of us have the idea that keeping a journal involves a lot of time. For healers and healers in training that is one thing we don’t have… time. So here’s some realistic advice on how to approach journaling. Give it a try. I promise, it’s worth it.

Day One app on phone, Apple MacBook, and Apple Watches

How

Here’s how to start. Download Day One on your phone and computer. Read the (very short) instructions. This app allows you to use your phone (and/or computer) to write or dictate on the fly, as well as when you have more time. It also lets you easily include photos, links, and audio files. I’m sure there are other apps that do similar things but this is one I know is fantastic (BTW I don’t have any connection to this company).

If you are worried about security, you won’t be honest in your journal – which is important. Make sure that, like this app, whatever technology you use has the security of face recognition and passwords. That being said – even though it should (and will) be very secure, keep HIPAA in mind. No names, photos, or anything that might directly identify a patient!

Don’t worry about long entries. Use your journal as a “Captain’s log” – just a timestamp and a few words to jog your memory. Make an intentional effort to notice good things in addition to the things you struggle with.

0845 OR crew dancing to YMCA before the patient arrived

1015 Boring rounds, but team is cool. Really bad dad joke from Joe.

Similar to a “captain’s log”, your journal can also be a way to make “field notes” – as though you are an anthropologist studying yourself – it’s a remarkable way to sort out what is working for you and what needs to change.

p.s. Save your journal as a password protected PDF on your computer and resave it frequently. #BackupsAreCritical

Why

Getting past deficit framing. Human beings “deficit frame” by default. Stated another way – we are programmed at a very primitive level to look for anything that might hurt us. As a result, we tend to remember bad things more than good things. Journaling helps keep the balance, and reminds us that we have the power to override our primitive responses to look for mystery, joy, and laughter in our days. It is also therapeutic – Journals let us look for patterns in things that distress us and give us the ability to “talk” these issues out.

A diary for important events. As healers we learn constantly. There will only be one time something is a “first”…the first patient you examine as a medical student, the first murmur you hear, the first chest tube you put in. Write down what happened and how excited you were! Keeping a log/journal like this is also a wonderful way to realize how much progress you make as you advance in your training/practice.

Venting. As human beings, we need a (safe) place to vent. A password protected journal is perfect. Try freewriting – just let it rip without any editing or thought. Even better – vent on a separate piece of paper that you rip to shreds and throw away when you are done… then turn to your journal to describe what you said and did.

Some other thoughts

Gratitude. At the end of every day (or at 2am if you are awake on call), force yourself to write down three things from the day that gave you a sense of gratitude. There are good studies that show this is a powerful tool to ward off burnout and decrease depression and anxiety. It’s also a wonderful way to keep deficit framing at bay and remember why we do what we do.

Mindfulness. This kind of journaling is also a great way to practice mindfulness. In addition to your “captain’s log”, look for moments where you are “between” things, and use these moments as a mindfulness tool. Just stop, take a couple of deep breaths and notice what’s around you.

1620 In the airport, sitting in a food court.. There are a few families, a table with what I assume are work colleagues, an older gentleman with his hamburger (dinner?) who is taking a break from work. I wonder why someone his age is working? There must be a story. There are smiles everywhere. A TV behind me is discussing sports – specifically field kicks in football (which seems a little strange in basketball season?).

Prompts. If you find yourself stuck, try using these questions. Consider writing them down in the morning and then set an intention to answer them at the end of the day. They will float in your subconscious during the day, leading you to look for stories, delight, surprises, and things that need healing.

What story from the day warrants telling?
What delighted me today?
What surprised me today?
What needs healing today?

The world is bursting with wonder, and yet it’s the rare productivity guru who seems to have considered the possibility that the ultimate point of all our frenetic doing might be to experience more of that wonder.

Allison Fallon, The Power of Writing it Down: A Simple Habit to Unlock Your Brain and Reimagine Your Life

I’m cross-posting on Substack if you prefer to read this content there!

Things I Wish I’d Known From the Beginning: How to Hack Eating Well

Posted on February 27, 2024 by marylbrandt

It is hard to eat well when you are a med student, resident or busy doc (also true for busy people not in medicine!). The key to eating well if you are busy is to have a strategy. You/ve developed strategies for studying to get where you are… so you have this skill set already! (Trust me, if you can learn how to take out a gallbladder or diagnose a complicated infection, you can learn to do this, too.)

As I’ve written before, here are the basic steps that you need to follow to eat well if you are “too busy to cook”:

Find recipes that sound good (but take less than 30 minutes to prepare)
Fill in a calendar with the plan for your meals (at work, on call, at home)
Make a shopping list
Shop once, then (mostly) follow your plan

For the last 6 years, I have used an app that make this process incredibly easy. Paprika is not free, but it’s money well spent. I recommend downloading both the phone app (which right now is $4.99) and the app for your computer ($24.99). Try the phone app first if you aren’t sure, but I think you’ll find the laptop version is more than worth the money.

The reason I think this app is perfect for healers, healers in training, and anyone who is super busy is because it takes the four steps listed above and puts them all into one place. It not only makes it easy to choose recipes, plan your week and shop, it almost makes it fun. Here’s how:

Find recipes that sound good (but take less than 30 minutes to prepare)

Click on the browser tab to find new recipes and download the ones that work for you. As you save recipes in the app, it becomes your own personal “cookbook” which is searchable by category, name, or ingredients.

Fill in a calendar with the plan for your meals (at work, on call, at home)

This was the first moment I knew this was a great app. All you do is drag and drop the recipes you want into the appropriate day. Wow.

Make a shopping list and go shopping.

This is when I was completely sold. When you pull up the recipes you’ve chosen, there is a little “hat” icon at the top:

When you click this icon EVERYTHING IN THE RECIPE appears in a shopping list. Click what you need and repeat for the week’s recipes and voilà – your shopping list.

Because this app is on your computer and your phone, just take your phone with you to the grocery store. As you pick up each item, click the box next to it to take it off the list. If you are sharing the app with your significant other or roommates, anyone can add to the grocery list or unclick things they have bought.

Try using this strategy (instead of eating the bagels, pizza, peanut butter and other “free” foods in the hospital) for a few weeks. I promise you’ll feel better, learn better, and have more energy to take good care of your patients.

(BTW – I have no ties whatsoever with the makers of this app!)

LIKE THIS:

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How to Ace Your Clinical Rotations

Posted on January 9, 2024 by marylbrandt

I don’t know many other professions that organize their teaching the way we do in medicine. In medical school, we start off with 18-24 months in a classroom and then send our students out on “rotations”, a month or so at a time in different medical specialties. The number of months (and years) is different, but the concept is the same for all professional medical training. In some ways it’s an old-fashioned apprenticeship – with all the good and bad parts that come with that kind of learning.

No matter how easy or hard your rotations might be, here are four important strategies to help you learn more and enjoy the process while you do it:

Photo credit

1. Be mindful, deliberate and excited about learning.

This is probably the most important piece of advice I can give. Clinical rotations are often a whirlwind of work and you can be swept away without realizing it. Residents can ignore you, people can be cranky, patients can be difficult… and in the midst of all this, you are expected to learn to be a doctor. You have to stay in charge of that mission, no matter what is happening around you.

Take a little time to reflect on why you are doing this and what kind of person/doctor you want to become. When times get tough (and they will) hold on to it. If it helps you, come up with a slogan to repeat. If needed, write it on a piece of paper to keep in your wallet or on your wrist.

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Learn to practice mindfulness. Mindfulness will keep you grounded and decrease your (normal) anxiety. Mindfulness is not hard to learn, but it’s hard to master … which is the point of a “practice”. (e.g. the practice of medicine)

Learn to keep “beginner’s mind” (and write about it). The very first time you walk into an operating room it will seem like (almost) magic. It’s astounding, right? We have drugs to induce a painfree unconscious state… there are instruments that can delicately dissect out a nerve… I could go on, but you get the picture. When it’s new, it’s astounding. That sense of discovery can be nurtured even for things that have become more routine. This is a practice (yes, you have to practice this, too!) which will add joy to your learning… which, by the way, means you’ll learn more!

Get an app like Day One, a highly rated app for journaling. Use it for a brief notes to record “firsts” (first drainage of an abscess, first time you see a rare anomaly, etc). Take photos (HIPAA compliant!) to remember the places and events of your day. List at least one thing a day that delights you. (Trust me on this one… it helps!)

2. Understand what you are going to learn (the big picture)

On every rotation, you will be given a list of learning objectives. By all means, study the things listed and make sure you know them (they will be on the test). BUT… please realize that diseases don’t stay conveniently siloed in a single specialty so this is not learning “surgery”, it’s learning about how surgeons approach a specific disease you will see elsewhere, too. You also need to know that what is listed as learning objectives today may well be obsolete tomorrow (if they aren’t already).

You have chosen a career that ethically demands life-long learning. That means that one of the most important skills to learn is how to develop a system of learning that you can use in medical school, residency and later in practice.

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3. Develop a system for lifelong learning now

Learning is iterative. You will learn broad concepts on each rotation along with a “fly over” of the entire terrain of the specialty You will need the information you learn on your surgery rotation on your medicine rotation when you are consulted on a patient with an ischemic leg who needs surgical treatment, or on your pediatrics rotation when your patient with a pneumonia develops an empyema. If you choose surgery at your career, you will read and learn the same topics throughout your residency (and after) but with increasing depth.

For more details on how to set up your system, check out How to Ace the NBME Shelf Exams, In-Training Exams and Your Boards. Here’s a summary of the key points:

Remember it’s school.
Make a list of all the topics in the textbook.
Breathe deeply. You are not going to read every page in the textbook in addition to your assigned reading.
Create a schedule to SKIM every chapter
TAKE NOTES. All the time.
Figure out how to store your notes so you can find them in the future
Go through your daily notes in the evening and then store them in your system
Review, review, review

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4. Take care of yourself.

Pay attention to ergonomics, diet, exercise and sleep. Most importantly, take care of yourself emotionally and spiritually. You can’t learn or serve others if your tank is empty. Be intentional with this, too. If it helps, make a list every day of things you’ll plan to do, things that help you thrive. Review it before you go to bed. Celebrate the things you did and don’t be hard on yourself for the ones you didn’t get to.

Don’t forget to take a “Sabbath” every week. True time off is critical for recovery from this stressful work.

If it gets too hard, seek help. It’s a sign of strength, not weakness, and most (if not all) of your fellow students, residents, and attendings have been there.

Being someone who goes to work every day to learn how to heal other people is one of the most amazing jobs on earth. When the administrative issues or political conflicts get to you (and they will), just remember – you are learning to take care of another human life with the goal of relieving their suffering. What could be more important than that?

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“Let us never stop speaking the obvious…”

Posted on January 5, 2024 by marylbrandt

For those who try to heal the scourge of gun violence…

L’Anima Semplicetta

Dear Mr. St. John: Thank you

for thinking of me. I am fine,

though I have no words

to say how it is here. You ask

what you should do. Set down

your poem about the man who’s blinded

by the smoke, while climbing up

the Mount of Purgatory and about

the “simple soul.” Take back

the bullet from my brain.

Pick up my school-books and my hat

from the pavement. Follow

the stray shot back. When you get

to Marshall, take the gun from his hand.

And re-collect the smoke. Tell him

I’ll come sometime, to loose

the knot of anger from his neck. But you

must keep on walking, to my school. Climb up

its seven stone steps. And on the fourth step, sit

and weigh the flattened bullet in your hand.

It is such a light, slight thing;

and it is not. It is all the weight

of our whole world. It is what

we make. Now do something that will not

make sense: touch it to your lips —

this cold, dark coal — then set it just

beneath your tongue. Of course

it leaves a bitter taste. Let i

dissolve. Let it become your bones.

Let it cloud your brain. Let it impair

your speech. And let your tongue,

at all the worst of times, suddenly

speak the obvious. Let it never

stop speaking the obvious. Yours, Ebony.

Richard St. John

from The Pure Inconstancy of Grace

(Truman State University Press, 2005)

Why I’m Thankful for #ThisIsOurLane

@ThisIsOurLane

Gun Violence Archive

Delight!!!

Posted on January 4, 2024 by marylbrandt

For the last several days I’ve been using the practice described by Catherine Price in this New York Times article (and I’ve ordered The Book of Delights by Ross Gay, too!)

“The basic premise of a delight practice (which I learned about in the essay collection “The Book of Delights” by Ross Gay) is simple: You make a point to notice things in your everyday life that delight you. This could be anything — a pretty flower, a smile you share with a stranger, the sight of a person playing a trumpet while riding a unicycle down a major Philadelphia thoroughfare (true story). Nothing is too small or absurd. Then whenever you notice something that delights you, you lift your arm, raise your index finger in the air and say, out loud and with enthusiasm, “Delight!” (Yes, even if you’re alone.) Ideally, you share your delights with another person.”

This is an embodied practice (because of the the motion of pointing up) and a practice that creates a “delight radar” as we begin to look for moments of delight during the day. Not surprisingly, as you notice more moments of delight, you feel grateful… and as your gratitude increases your life becomes lighter, happier, and more meaningful.

“This year, like all of them, will be filled with conflict and tragedy. But it will also be filled with delights. Resolve to notice them.”

p.s. I do limit myself to pointing up and just thinking “Delight!!!” if I’m in the middle of the grocery store 🙂

Set New Year Destinations (instead of resolutions)

Posted on January 1, 2024 by marylbrandt

Ryder Carroll suggests that goals should be lighthouses, not rules. Instead of the usual New Year’s resolutions, this year set your goals as destinations… as “lighthouses” in the distance. Write them down and revisit them often (every journey needs a map).

“When goals are lighthouses, success is defined by simply showing up, by daily progress no matter how big or small…” Ryder Carroll

At least once a day think about how to move in the direction of your goal(s). If you veer off course, that’s part of the journey…. look up, find your lighthouse, and correct your course.

Potential New Year “Lighthouse” goals

Learn more about compassion and practice it
Be a better friend
Write genuine thank you notes to people who have helped you
Become stronger, faster, more fit
Eat real food for as many meals a week as possible
Find out more about who you are through meditation
Keep a “stop doing” list
Be better at your work through deliberate practice (practicing and learning the things you don’t like and aren’t good at)
Read things that bring you joy
Keep a journal, even if it’s just 3 things you are grateful for every day
Learn the names of as many people at work as you can
Take the stairs as often as you can
Make your living spaces enjoyable spaces
Get good sleep as often as possible
Learn Spanish (or any new language)
Be on time
Remember people’s birthdays and send a card
Start the day with intention

This revised post was originally published here

Stumbling Into Grace

Posted on December 30, 2023 by marylbrandt

Most surgeons perform around 500 operations a year for the 30 to 40 years they are in practice. If you add the procedures we do during training, surgeons walk into an operating room with the intention to heal ~15,000-20,000 times during their professional lives. In addition, for every patient a surgeon treats with surgery, there are at least 10 to 20 they will have seen who don’t require surgery but do require care. So the lives impacted during a typical surgical career number well over 100,000 and, when you include their families and friends, probably approaches half a million people.

Nadia Bolz-Weber is a theologian and writer who shares her journey and her remarkable teaching in “The Corners” on Substack

Photo credit – and link to “The Corners”

In her post The Sacred Act of Having No Idea What We Are Doing: On Complimenting Strangers and Sharing our Chicken Dinners, she shared this story…

She shakes my hand and says, “we’ve met – but I do not expect you to remember. I’ve waited 7 years to be able to tell you this: You shared your chicken with me that night and you have no idea what it meant.”

Not what I was expecting her to say.

She went on to tell me how that night, she was at a real low point in the middle of a very painful divorce. We were in the green room and she was supposed to introduce me and she was exhausted and hadn’t eaten all day. Apparently I looked up from my huge chicken dinner and was like, “I’m never gonna eat all of this, please help me out here” and it nearly made her cry.

I have literally no memory of this, but even if I did, I could never have known what it meant to her.

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We’ve all had a moment when someone, often a stranger, arrives at a moment of need to share their chicken dinner… or say just the words that heal something we may or may not have known was broken. Whether or not we recognize it, these moments create a subtle but profound shift in the way we view the world and ourselves. And, unbeknownst to us, we deliver the same moments of healing and grace to others. These moments can be deliberate, but more often they are not… and are as simple as picking up a small child covered in bandages to give them a hug, complimenting a stranger’s smile, or bringing a cup of coffee to an exhausted colleague and asking them – really asking them – how they are.

I can’t do it as well as Nadia Bolz-Weber, but here’s my blessing for you….

May you find yourself stumbling into sacred moments (even though you don’t know what you are doing, and probably don’t recognize them). And may you be open enough to recognize, accept, and celebrate the grace of chicken dinners, smiles, and cups of coffee that heal your soul.

Creating a community by talking in a sane and cheerful way to the world…

Posted on December 28, 2023 by marylbrandt

When I first started this blog, I really wanted to title it “Everything I wish someone had taught me about learning and practicing medicine when I was in training (and beyond)” … but that was a little wordy for the name of a website… hence “Wellness Rounds”.

Ten years is a long time for a blog. Teaching and thinking about how we live and move in the world (particularly as healers) is still a passion for me, but I have new tools and more time now that I have retired from the physical work of surgery (one never really stops being a surgeon, though… more on that later). I found myself agreeing with Neil Gaiman, as quoted recently on Cal Newport’s website – “I love blogging. I blog less now in the era of microblogging… I miss the days of just sort of feeling like you could create a community by talking in a sane and cheerful way to the world.”

He goes on to point out what all of us are experiencing – that more and more of us are leaving the world of microblogging on social media (Twitter, Bluesky, Facebook, etc) but feel a loss for the ways we have been connected by these platforms.

He then predicts the start of a new era of finding community online: “But it’s interesting because people are leaving (social media). You know, Twitter is over, yeah Twitter is done, Twitter’s… you stick a fork in, it’s definitely overdone. The new Twitters, like Threads and Blue sky… nothing is going to do what that thing once did. Facebook works but it doesn’t really work. So I think probably the era of blogging may return and maybe people will come and find you and find me again.”

Enter the idea of a commonplace book, POSSE, and reinventing how I communicate with my readers…

What is a commonplace book?

Wikipedia describes a commonplace book as “a way to compile knowledge, usually by writing information into books.” In physical form, it’s a notebook you use to write down quotes, ideas, often organized into subjects (which is what makes it different from a journal). It can also be a collection of index cards or other notes. One of the best examples of a modern approach to a commonplace book is the Bullet Journal (which is a simple approach to organizing information and tasks that so many people find helpful)

I knew in general about commonplace books, but hadn’t really thought about a website as an online commonplace book, until I read this post from Chris Aldrich: “Hello! I’m Chris. I use this website as my primary hub for online identity and communication. It’s also my online commonplace book.”

What is POSSE?

As described by Chris Aldrich, POSSE is one of the concepts put forth by the IndieWeb movement, a new philosophy of online publishing that decentralizes the big platforms like Twitter, Instagram, etc by Publishing (on you) Own Site, and Syndicating Elsewhere (i.e. POSSE).

In other words, post on your own website and then send it forth.

I’m sold on the idea of the IndieWeb and love the idea of a digital commonplace book as a creative way to care and share.

p.s. I’m going to simultaneously post on Substack, if that’s easier for you to access.

Do What’s Right

Posted on December 8, 2023 by marylbrandt

I have the extraordinary of gift of sitting with my father, Floyd Brandt, in hospice this week. His (beautiful) heart is failing, but his mind is still sharp, and his spirit is completely at peace. The following is his last lecture as a professor (to his graduate seminar in Business Ethics)

It gives me great joy to share it with you.

Retiring is a little like having your first child. There is nothing particularly unique about the exercise except it is a first time experience that requires no specific skills or expertise and arrives with an unknown outcome .

The initial inclination while preparing comments for a last class is to draw from all the literature and all of one’s experiences to craft some statement filled with lasting words capable of shaping the hearts and minds of students for their remaining years.

Shortly after entertaining such a prospect, it became immediately apparent that teaching has taught me that that while the words may be forthcoming, the impact is not likely to be so resounding. Given that reality, the best course of action is to make a few short comments and say good-bye.

The closing line from Stephen Sondheim’s song “Send in the Clowns” came to mind. “Isn’t it rich, isn’t it queer, losing my timing so late in my career.”

In these last few minutes of the last organized university class that I will teach, I would like to suggest to each of you:

Define what is important to you. Attempt to determine what you are worshiping, because without that understanding, you are adrift and likely to be pushed ever-which-way.

Come to terms with the finite and the infinite dimensions of your being. Until you come to terms with the end of your existence, you will find living in the present to be difficult.

Cultivate the disciplines necessary to contend with the vagaries of the world around you. Perhaps the most important are the disciplines of the mind and of the spirit. The first step is often that of finding a quiet place to meditate and contemplate.

Learn the significance of uncertainty, choosing, and evaluating and then celebrate them. The definition of who you are is largely a product of the questions you ask and the choices you make. It is difficult to learn that the choices made today are the offspring of choices made yesterday.

Experience the joy of thanksgiving. Recognize that joy and hope are rooted in faith in the belief that what you have and what you are is a gift. As much as possible expunge the demons of comparison and competition and accept that sweeping out the harpies circling round the “enthroned self” never ends.

But then how does one end a last class in ethics except to recall that ethics is obedience to the unenforceable; a product of what you ask of yourself and not what others ask of you.

And finally, do whatever is right.