Category Archives: Stress Reduction

Wellness for Emergency Room Residents

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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

How to Make Changes for Health

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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

Cardio Workouts That Aren’t Boring

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To maintain your fitness (and to be able to eat without gaining weight) it’s best to shoot for a minimum of 3-4 cardio workouts a week.  To be effective, the workouts should be 30 minutes or longer.  But – consistency is more important than intensity.  If all you have is 10 minutes, then do one of these 10 minute workouts or go for a fast 10 minute walk in the hospital.  If you can do three separate 10 minute workouts in a day, it is just as effective (at least for maintenance of fitness) as a 30 minute session.

Some people have incredible discipline about this (and the rest of us hate them.)  For mere mortals who basically have to really work at this, you have to have a different strategy….

The first thing you have to do is choose what kind of cardio you want to do.  The trick here is feeling like you are playing, not working.  Dancing counts… so does jumping rope. You have to look for fun ways to exercise

American College of Sports Medicine exercise guidelines for healthy adults

www.life123.com Examples of aerobic exercise

www.60in3.com cardio options

www.livestrong.com list of cardio exercises

For many people, music is the difference between feeling like you are playing during a workout vs. working.  Use music to create your own “Fartlek” workout.  Fartlek workouts are also called “speed play” – the idea is to incorporate random intervals of speed work into your workout so you don’t just plod along at the same rate.  One way to do this is to put your music on a random shuffle, or find a good (and free) music source that you can stream.  Change your speed and intensity based on the song, or part of the song you are listening to.  If the song is slow, decrease your speed (but increase the resistance if you are on a machine).  If the song is fast, move with it – increase your effort (e.g sprint if you are running) to keep in time with the music.

Have fun!  Go out and play!

Internet music sites:

  • http://www.pandora.com– internet radio that lets you design your own radio stations or choose from a large selection
  • http://www.folkalley.com– singer songwriters, irish music, bluegrass, etc
  • I’m sure there are a lot of other sites… if you have any that you use, comment below or email me.

Information on Fartlek workouts

Burnout and medical errors among American surgeons. Shanafelt et.al. Ann Surg. 2010 Jun;251(6):995-1000

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Ann Surg. 2010 Jun;251(6):995-1000.

Burnout and medical errors among American surgeons.

Shanafelt TD, Balch CM, Bechamps G, Russell T, Dyrbye L, Satele D, Collicott P, Novotny PJ, Sloan J, Freischlag J.

Department of Internal Medicine, Division of Hematology, Mayo Clinic, Rochester, MN 55905, USA. shanafelt.tait@mayo.edu

Abstract

OBJECTIVE: To evaluate the relationship between burnout and perceived major medical errors among American surgeons. BACKGROUND: Despite efforts to improve patient safety, medical errors by physicians remain a common cause of morbidity and mortality. METHODS: Members of the American College of Surgeons were sent an anonymous, cross-sectional survey in June 2008. The survey included self-assessment of major medical errors, a validated depression screening tool, and standardized assessments of burnout and quality of life (QOL). RESULTS: Of 7905 participating surgeons, 700 (8.9%) reported concern they had made a major medical error in the last 3 months. Over 70% of surgeons attributed the error to individual rather than system level factors. Reporting an error during the last 3 months had a large, statistically significant adverse relationship with mental QOL, all 3 domains of burnout (emotional exhaustion, depersonalization, and personal accomplishment) and symptoms of depression. Each one point increase in depersonalization (scale range, 0-33) was associated with an 11% increase in the likelihood of reporting an error while each one point increase in emotional exhaustion (scale range, 0-54) was associated with a 5% increase. Burnout and depression remained independent predictors of reporting a recent major medical error on multivariate analysis that controlled for other personal and professional factors. The frequency of overnight call, practice setting, method of compensation, and number of hours worked were not associated with errors on multivariate analysis. CONCLUSIONS: Major medical errors reported by surgeons are strongly related to a surgeon’s degree of burnout and their mental QOL. Studies are needed to determine how to reduce surgeon distress and how to support surgeons when medical errors occur.

PMID: 19934755 [PubMed – indexed for MEDLINE]

Elements of a Self-Care Protocol – from The Resilient Clinician by Robert J. Wicks

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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

How To Exercise Despite Your Busy Schedule

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“I used to run 6 miles a day but I haven’t done any exercise at all since I started my clinical rotations.”

The medical student who was talking to us on rounds today isn’t alone.  Exercising regularly during basic sciences isn’t that hard.  But it’s an entirely different issue when you start your rotations.  Figuring out how to exercise as a resident is even harder.

The first step is to realize why it’s important.

  • It’s the right thing to do.  Physicians do physical as well as intellectual work.  You are taking care of people’s families.  It doesn’t surprise you that policemen, firemen, astronauts and soldiers have physical fitness as a requirement.  It’s no different for us. .
  • You will have a life after training.  In your 20s and 30s, you may be able to get away with not being active, but those years of inactivity will be paid for later.
  • You will feel better physically.  You will have more energy.
  • You will feel better emotionally.  There is a direct effect of working out (stress reduction), but there is also the psychological benefit of taking care of yourself.

Once you recognize that regular exercise is important, you then have to realize that it’s not going to be easy.   There are two ways you can look at exercise in the context of a busy schedule.  First, think about it as activity, not “working out”.  Your goal is to be active, which you can approach by adding little bits of activity into your day:

  • Park your car in a distant lot, or at least at the back of the lot, to add walking.
  • If it’s safe, walk or ride your bike to work.
  • Take the stairs in the hospital (no matter how many flights!).
  • Buy a pedometer that counts steps and try to walk at least 10,000 steps per day.
  • Take a jump rope, stretching bands or dumbbells to keep in your locker or the break room to use when you have 10 minutes.
  • Do pushups and/or situps before you go to sleep or anytime you have a break in the call room.

Although increasing activity is essential to maintaining fitness, you really do need to have some “real” workouts in your week to build and maintain your overall fitness.  The goal for your week should be 3-4 sessions (at least 30 minutes long) of cardiovascular training, 2 sessions of weight training and stretching every day.

So, how do you actually fit this into the hectic schedule of clinical rotations or residency?

Step 1:  Make a list of things you like to do (not things you think you should do) in each of the three categories (cardio, strength training and flexibility).

Here’s an example for cardio workout:

Cardio – at home

  • Fast walk around the parking lot or neighborhood
  • Run (list different routes that work out to about 30 minutes to start with)
  • Jump rope in the driveway

Cardio – at gym

  • Treadmill
  • Elliptical trainer
  • Stationary bike
  • Racquetball
  • Basketball league on Tuesday nights
  • Monday – 5:30 am spinning class, 6:30 pm aerobics class
  • Tuesday – 5:30 am circuit weight class, 7 pm boxing aerobics
  • Thursday – 5:30 am aerobics class, 7pm spinning

Cardio – 10 minute workouts at work

  • Stairs
  • Fast “rounding” (do loops of the floors)
  • Jumping jacks
  • Up and down off a chair
  • Jump rope

Step Two:  Make a plan for every day of the week.

The real key to making this work is to plan ahead.  It’s just too hard, when you are leaving the hospital and every fiber in your being wants to go sit on a couch somewhere, to overcome that gravitational pull with the thought “but I should go to the gym”.  The only way you will be able to resist the gravitational pull of the couch is to have a plan.

Start by looking at your week and writing down what is likely to happen.  For instance, if you are on a q3 day call rotation it may look something like this

Schedule Comments
Sun Off
Mon On call
Tues Post call
Wed Out with friends after rounds
Thur On call
Fri Post call
Sat

Once you have the outline of the week, fill in the chart with the most reasonable option for exercise for the day… and then a back up plan in case the first option falls through.

Schedule 1st choice Back up Comments
Sun 24 hours off! Racquet ball with friend then weights at the gym Long bike ride with friend then weights at home
Mon On call 5:30 am spinning class or run before work Do stairs at work for total of 30 minutes
Tues Post call 8:30 aerobics class at the gym Swim at the YMCA
Wed Work at 6am Run before work Out with friends after rounds
Thur On call Take stretch bands and do weight work out on call. Do stairs at work for total of 30 minutes
Fri Post call Run before going home Gym before going home for 30 minutes on elliptical trainer
Sat Rounds 6-9 Gym for weights30 minutes on bike at gym Gym for weights after roundsRun in the evening

Step 3:  Cut yourself some slack (i.e. be flexible)

This is an ambitious schedule and there is no way it’s going to happen.  But – if you plan for 7 days, you’ll probably do at least 3 or 4.  If you plan for 3, you are likely to do just 1.   It’s also important to remember this isn’t another task on the scut list.  Above all, going to work out should feel like time to play and decompress … not another “task”.   If there’s a day you leave work to go to spinning class.. but realize you really want to be outside, go play in the park!

Step 4:  Keep a gym bag in your car

Load up a bag with anything you might need to work out – for any contingency.  Get a big bag so you can have your gear for swimming, spin class, running… whatever you like to do.  Even though it’s rare, there will be some days that you get out earlier than planned .. or the call schedule is messed up and you really aren’t on call.  Every once in a while you get a totally quiet day (yes, they are rare, but they do happen) and you can “run an errand” with the permission of your chief resident.   Take advantage of those days to take care of yourself by going to work out.

Attitude, Composure, and Peak Performance

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Anger is the only emotion you can’t show if you are a professional.  You can be angry, you just can’t show it.  Last week I lost my temper at work.  It’s rare for me to lose my temper, but when it happens it’s a good time for reflection on what happened.

Tennis is unique as a sport for a lot of reasons.  It’s an individual sport (which immediately puts it in a different class than team sports).  It’s also not a race, so that makes it different from cycling, running, swimming,etc.  It requires a lot of strength and cardiovascular fitness, like gymastics, and a lot of strategy, like golf… but it’s different than those two sports as well.  To be a successful tennis player you have to be fit, strong and smart.  But like other athletes, these are necessary but not sufficient – there is still one more critical skill that has to be mastered – the ability to control your emotions.

Athletes at their peak have mastered the sport, but they also have learned how to manage adremalin and control emotions. “Peak performance” is a term usually applied to athletes, but the concept applies to physicans as well.  How do we “train” to be able to work at our “peak”?  As someone who teaches surgeons, it’s one of the biggest challenges I face.  We can teach young surgeons how to operate, we can teach them when to operate… but we can’t convince them that they can do it on their own.  The ability to stand with confidence at the baseline in the French Open or at the OR table to start a big case has to come from within and is the result of practicing the task and managing the stress.

Sam Stosur is one of my current favorite tennis pros to watch.  Her game is magnificent but its how she has struggled with and learned to manage the stress of competition that I really find fascinating.  During a recent match she had two words written on her wristband – “Attitude” and “Composure”.  It served as a reminder to her to take a deep breath and focus on the task at hand.  Physicians are no different – we need to find ways to remind us to adjust our attitude and maintain our composure.

Next time I’m tempted to get upset at work, I think I’ll remember Sam Stosur’s wristband…

Photo credit

 

Starting Medical School – What To Do This Summer

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I’ve had several new college graduates ask me what they should do this summer to prepare for medical school.    It’s easy – don’t worry about it!  There is no studying or preparation that will improve how you do.  Seriously, you’ve been accepted and you will do fine.  I know you are anxious, but I can absolutely guarantee you don’t need to study anything to get ready!  That being said, I do have some advice about what to do this summer:

Take a vacation (or two or three…).

  • Visit family and friends – take a road trip and connect with people you haven’t seen in a while
  • Hang out on a beach, go for some great hikes, read some great novels
  • Sleep late, eat well, and just rest

Develop (or strengthen) an exercise habit.

  • Use this summer to develop  a daily exercise routine that you can take into your busy medical school life.  Overall, your goal for the summer should be to develop a balanced exercise program (cardio, strength training and flexibility).  If you’ve never done any strength training, hire a trainer and learn about it.  Your goal during medical school should be at least 30 minutes of cardio 4-5 times/week, 2-3 strength training sessions (that cover all the major muscle groups) and stretching everyday.  If you develop a balanced exercise routine this summer, it will be much, much easier to continue this once you start medical school.
  • Commit to doing at least 30 minutes of exercise a day this summer.    Running is by far the best cardio exercise for medical students.  Use this summer to become a runner.   http://wellnessrounds.org/why-you-should-run-and-how-to-get-started/

If you don’t know how to cook, learn.

Starting Medical School: Rules of the Road

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If you are reading this because you are preparing to start medical school – welcome!  You are now part of one of the most noble professions in the world.  You are no longer just a student, you are part of a profession… as of now.

Medical school is a wonderful, but at times difficult experience.  As you start this fantastic journey, there are a few “rules” I think might help:

1. You can drink from a fire hydrant, but you’ll need to learn how.

The amount of information you are going to be exposed to in medical school is logarithmically more than you had to learn in college.  It really is like being asked to drink from a fire hydrant.   You are going to have to study more, study better and actually use the time in class to learn.  (more posts to follow with concrete tips on how to do this.)  But – here’s the good news.  You’ll be able to do it.   Everyone who has gone through this has thought at various times that a) everyone here is smarter than I am, b) the admissions committee must have made a mistake and I’m not really supposed to be here and c)  there is absolutely no way to read all of this material.  And… we all discover that a) we are just as smart as everyone else (sometimes in different ways, but all effective) b) nobody made a mistake – we really are supposed to be here and c) you have to change the way you study, but you really can learn this much material.

2. Make your bed.

You wanted to become a doctor for a myriad of reasons, but one of them was surely because service to others is important for you.   Therefore, you are already primed to sacrifice a lot of your needs for other people.  Sacrifice is part of the culture of medicine.  But, it’s like a Starling curve… a little sacrifice makes you better, but too much makes you ineffective.  Doctors are notorious for this; we forget that if we don’t take care of ourselves, we really can’t take care of others.   “Make your bed” is a simple rule (and action) which helps you remember that you need to take care of your environment, your fitness, your nutrition and your spiritual wellbeing as you are learning how to become a physician.

3. Act like a doctor.

We (all practicing physicians) see you as a doctor already.  I know this is a really hard concept for first year medical students, but it’s absolutely true.  You have started your apprenticeship and, unless you are one of the very, very few who change their mind, you will have an MD after your name in 4 years.  With all of the joys and privileges that come with this role, there are a few responsibilities to start thinking about as well.  Start thinking about your decisions, words and actions in this context.  You’ll learn a lot of specific details about professional behavior as your apprenticeship goes on, like protecting patient confidentiality, peer review, etc.,  but the core values of professionalism start when you enter the profession, which is now.

4. Kindness matters.

It is remarkable how our paths in medicine cross over and over again.  The person sitting next to you on the first day of medical school may be someone who will be an intern with you in 4 years or who will refer you patients 10 years from now.  You and your classmates will be going through classes together (like you did in college), but this is different.  You are starting your professional life together as well.  The camaraderie that results is a gift and is also very important personally and professionally.  Don’t blow off the class events.  Don’t stay home to study instead of going to class.  Go out of your way to meet everyone in your class and really get to know them.  Cultivate and nurture these important friendships.

5. Enjoy the journey

The first year or two of medical school may, at times, seem like an obstacle course you have to “get through” to get to the “real stuff”.  The basic science curriculum is not a rite of passage!   It turns out that even the “trivia” (or at least that’s what it will seem like) is important.  You are learning a new vocabulary… a new language.  If you don’t learn the breadth and depth of this new language, when it comes time to apply it to patient care you won’t be “fluent”.

You are about to embark on a life changing (and fulfilling) journey.  This journey is a privilege and it is very, very special.  Take a few minutes everyday to write down the events of the day.  The first time you hear a murmur in a heart will be just that – the first time.  Take a minute to record what that was like.  You are going to have a lot to process as you start studying anatomy – more than just the names of the structure.  “Talking” about it in a journal is a great way to make the transition we all make in the anatomy lab.   There are also going to be some hilarious stories and events that you’ll forget if you don’t write them down.  When you look at them later, you’ll be glad you recorded them.  Recording these moments doesn’t have to be by writing.  If you are an artist, you may want to use drawings.  Photos of your classmates (and some of those humorous moments) will become a treasure in the future as well.  (but remember the professionalism rule!)

How to Eat Well On Call

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It’s Saturday and I’m on call – and it’s going to be a busy day!  We have about 75 patients on the service, we already have 4 cases done and another 4 posted, and it’s still early (~4pm)   I have a fantastic resident with me today.  We just were chatting about what we are going to do for meals today.  He didn’t have breakfast and has only had a Coke and a “borrowed” bowel of Kix cereal from the recovery room so far.  I had whole wheat toast with some goat cheese before I left my house this morning, and I here’s what I have to eat today:

  • Strawberries
  • A handful of frozen cooked shrimp with cocktail sauce (they’ll thaw by the time I want to eat them)
  • Frozen peas (I put them in the microwave for a minute but, like the shrimp, frozen would be fine because they’ll thaw) + goat cheese, olive oil, vinegar, salt and pepper
  • Leftover whole wheat orzo, artichoke hearts, tuna and lemon pasta from last night
  • An apple
  • Lemon wedges for water

My resident’s Coke is probably more than I used to have as an intern… which is STUPID.   Eating well is important to feel well, perform well and do the right thing for your patients. There is one word that explains the difference between my resident (and what I used to do) and what I do now… planning.   “I’ll just get something from the restaurant across the street later…”, “There will probably be food leftover from the GI conference…” .. “I can always eat a bagel from the lounge..” … NOT.   When you finally have a minute to grab something to eat, you won’t usually have time to go look for the food.  It’s a lot easier if its’ there and ready to eat.

Here’s how to do this right:

1. Buy a good “lunch box” .

I like the hard plastic ones that fit in an outside, insulated carrying case.  It’s a lot easier to clean up if something spills than the usual “lunch box”.

You can use plastic (disposable) containers to carry your meals with you.  I’ve switched to glass containers because some of the data about heating the plastic containers in the microwave started sounding convincing.  It does mean you have to keep track of them and bring them home, but I suspect in the long run (if I don’t lose them) it will be cheaper than the plastic containers.   I particularly like the ones I bought because the seal is so tight that they don’t ever leak  (even for things like soup).

2. PLAN.

The night before call, figure out what you are going to take. Make it good stuff, too!  Call nights are not the “what I know I should eat” nights.  You need to have real food (i.e. not processed) but don’t skimp.  When you get to the “I really deserve those french fries” time of your call (which we all do) you will have really delicious and balanced food  in the refrigerator.

3. Pack your meals for the next day the night before (no matter how late it is or how tired you are).

It’s the only way you’ll actually do this.   None of us when we work this hard have the energy to put together meals for the day at 5am.  This takes a little effort but the payoff is real.  You will absolutely eat better, have more energy, maintain your weight and do a better job.  Don’t forget to throw some fruit in – and to make sure it’s washed so you can just pull it out of the refrigerator for a snack.