When is a blanket wrapped around your shoulders at 4am more than just something to keep you warm? Everyone who has worked all night resuscitating patients in the ICU, operating on emergencies that can’t wait, or caring for patients on the ward has experienced the chill that accompanies the normal 3-6 am drop in body temperature.
When we wrap a blanket around our shoulders or reach for a fleece vest to keep warm, in a way it’s just that… something to keep us warm in response to a normal circadian rhythm. But I can’t help but wonder if it might help to look at these garments as more than just a source of warmth.
The word “mantel” is a wonderful, old-fashioned word. It’s defined as “a loose sleeveless garment worn over other clothes”. The blanket over your shoulders when you get cold in the middle of the night is a mantel, as is your (usually Patagonia) vest. Perhaps replacing white coats with these vests isn’t the loss of symbolism we thought – if we can see them as a modern day mantel.
A mantel is more than just a garment – it is also a symbol of authority and power. This religious text is the source of the idiom “taking up the mantel”, which means to carry on the teachings and the authority of those who have passed on their skills, values, and wisdom to us.
The next time you get cold when you are up all night and you zip up your vest or grab a blanket to put over your shoulders, pause for a minute to consider this: We live in a volatile time, where many forces seem to be dismantling systems to the detriment of patients and their healers… if we don’t protect our patients and our trainees, who will?
“The covenant we make is not simply about how we will do a job, it is also about who we will be when we don the mantel of “physician.” It prescribes our conduct, calibrates our moral compass, and entwines both with our identity.” Wendy Dean
I never use AI to write, but I did use it for the banner photo. I’ll always let you know when I do.
I read a fascinating study1 this morning (thank you to @docmom61.bsky.social for the link!) For those in medicine, you know why this paper on call schedules and sleep deprivation is important … because you’ve lived it.
This study prospectively compared two groups of residents working in pediatric ICUs who were assigned to two different call schedules. The cool science here is that they modeled different schedules to choose which one to test against “the way we’ve always done it”.
The first group (EDWR) was, in effect, the control group, since they were put into a traditional Extended Duration Work Roster (24-28 hrs of continuous call with up to 88 hours/wk of total call). The other group (RCWR) was assigned to a Rapidly Changing Work Roster with variable lengths of call designed to limit extended call hours . (“…scheduled continuous duty hours limited to 16 hours (RCR-16) consisting of a short day shift (7:00-15:00), a long day shift (7:00-22:00), and a long night shift (21:00-13:00).”)
The RCWR is not a schedule I’ve seen before, but it does make sense. More importantly, it’s based on mathematical models, not fingers on our hands or days in a week!* For anyone who has seen the unintended consequences (emotional as well as physical) of the isolating night float system, anything new to consider is a welcomed alternative.
Here are my takeaways…
Total amount of sleep in the week (regardless of the schedule) was associated with less impairment. Focusing on more sleep is always the right answer if you are a physician, physician-in-training, or other healer.
It was a little easier to get more sleep on the RCWR schedule. The big picture here is that we need to be able to think out of the box when it comes to call schedules. Just because it has “always been this way” doesn’t mean it’s the right thing to do.
There was a lot of variability (for many reasons, all discussed in the paper) This is hard science to do, but important.
*Lest we think we choose numbers in medicine scientifically… have you ever noticed that we usually prescribe antibiotics based on American football scores? (Think about it… just where did our standard 7, 10, 14, or 21 days come from?)
It has been said that the Inuit people have a hundred words for snow. When you live in a dangerous environment, it’s important to learn the variations of snow to survive. But, when you look into the origin of the “hundred words for snow”, it turns out it’s not exactly true – Inuits don’t have more words for snow than other languages…Their detailed understanding of snow is a lived, not spoken vocabulary.
The same is true for those who spend nights awake working in a hospital. We, too, have a lived vocabulary that includes hundreds of subtle variations of fatigue, even though we don’t have words to describe them. (The closest I’ve come to being able to describe this fatigue is in “sleep equivalents”, specific events or things that makes you feel like you have had more sleep than you actually did. For example, a shower after being up all night can give you the equivalent of anywhere from 20 to 60 minutes of sleep depending on how tired you are. Brushing your teeth after a hard night of call is usually 5-10 minute sleep equivalent. A good strong cup of coffee can be as much as 45 minutes of sleep equivalent – although it’s important to titrate it so you don’t end up with anxious jitters instead of just being awake.)
Knowing how to manage this level of fatigue it is part of medical training. (Don’t get me wrong… I’m not advocating that trainees must get tired on a regular basis to “learn how to manage it”) Learning to successfully manage the fatigue of long days and nights on call hinges on two things and both have to do with deliberate choices.
Learning not to trust your first instinct if you are sleep deprived is the first important lesson. Even if it’s a drug you know well, or the chest x-ray looks ok, stop and be deliberate. Consciously review the data, look at the options and, for really important decisions, ask someone to look at the situation with you.
The second lesson in managing fatigue is maybe even more important. The bone deep fatigue of medical training is not solely the result of sleep deprivation. When you stay up all night you also lose the liminal spaces of waking and falling asleep, the threshold between night and day. In scientific terms, this means there is a major disruption of your circadian rhythms. But it’s more than just physiology. The drowsy moments between sleep and being awake take place in the liminal spaces of dawn and dusk. We lose more than orientation to daylight when we lose this liminal space. The Irish poet and priest John O’Donoghue, teaches that liminal spaces are moments and places where the spiritual touches the finite. By losing the profoundly important rhythm of rest – including these liminal spaces – we end up physiologically, psychologically, and spiritually unmoored.
You have to be deliberate here, too. By trial-and-error work to find the things that ground you, the things that help you recover in a deeper way than just catching up on the sleep. Make lists of anything and everything that helps you recover from call for the times you are too tired to remember or choose. Look at those lists before you leave for your call day and choose something to do for yourself when you leave the hospital the next day. It might be going to the gym for a light workout, having a great cup of coffee in a cafe, a slow, grateful walk outside, playing with a pet, a hug from a loved one…or finding a way to “play” outside.
May the sacrifice of time and sleep you make for others come back to you as joy … and may you find deep rest in knowing you make a difference in so many lives.
Working as a surgeon for as long as I have, trust me, I have learned the agony and ecstasy of foot care. After a long case or after 24 hours on my feet it’s the agony. But I’ve learned how to make my feet happy… and I’ve learned that it’s not that hard.
The ideal hospital shoe has a wide toe box, is flat, laced (I’ll get to clogs in a minute), lightweight, slip-resistant, fluid resistant, and can be thrown into the washing machine. You can expect to spend around $100 for these shoes. Don’t get cheap shoes – spend the money!
Although many running shoes meet these criteria, my current favorite shoe is from Merrell, which has been a go to company for me for years. The other major contender right now for favorite hospital shoe among medical students and residents is All-Birds.
Even though I wear lace up Merrells most days at work, I love clogs when I operate. They let me back my feet out of them and lower my heels to stretch my calves. I can kick them off and stand barefoot for a while if I need to change the pressure points on my feet. I had Dansko clogs for years, which are almost a tradition for surgeons, and then changed to Merrell clogs (which are pictured above) Although they are great for standing, the problem with clogs is that your toes have to grip the shoe when you walk (or run to a code), which means they aren’t the best shoes for the rest of your day.
Here are some other options beside running shoes, Merrells, and All-Birds to consider. If you have tried these or have other shoes I should add to the list, please let me know!
Atoms – Great reviews and an amazing story about the owner of the company
Bala Shoes – designed by nurses with consideration for structural differences in women’s feet
There is practically nothing worse for your feet than wearing high heels. (Sorry if you love them). If you wear them, please wear them only for special occasions and keep the heels as low as you can. If you are wearing heels in the hospital because it hurts to not wear heels, that’s a huge red flag and you need to really work on it.
Compression socks have the potential to change your life. Ok, maybe that’s an exaggeration, but this is one thing I wish I had started earlier in my career. It’s not clear that they do anything to prevent the occupational hazard of varicose veins, but boy do they make your legs feel better at the end of a long day.
Make sure you throw an extra pair of socks in your call bag. There is nothing that feels better than taking your shoes and socks off after 10-12 hours, massaging and stretching your feet (if you have time) and putting on new socks before the second half of a 24 hour call. BTW, the same is true for shoes. Swapping out shoes (if you have two good pairs) is also really nice for your feet during a 24-hour call.
A friend recently lent me this book which is written by Katy Bowman, with the help of 4 “goldeners” (all older than 70) about what they wish they’d known about caring for their physical wellbeing. Feet are literally the foundation of our musculoskeletal “chain” and unhealthy feet not only hurt, they can affect the function of your kness, hips, and back. Here is the routine recommended in the book to care for your feet. It only takes about 10 minutes and is something you will look forward to doing at the end of the day since it feels so good.
Dorsal foot stretch. Put the top of your foot on the floor and stretch your toes and ankle. Hold it at least 30 seconds and repeat it at least three times. If you get bad cramps (which is normal if it’s tight) it just means you need to keep doing it. Let the cramp subside and start again.
Sole of the foot stretch. Buy this foot massager (or one like it) right now! Stand on it to to stretch and massage every single square centimeter of the sole of your foot. You’re welcome.
Toe circles. Grab each toe separately, pull on it a little and then move it in a circle (both ways) for several rotations.
Toe stretches. Pull each toe away from each other (medial to lateral) then put your fingers between the toes and leave them there to continue the stretch
Toe lifts. Lift your big toe first and work your way up to lifting the other toes as individually and as high as they let you.
As an alternative, if you want a guided yoga practice for your feet, check out this video from the amazing Adrienne Mishler.
Every time you take a shower, look at your feet with intention. If you have calluses use a pumice stone to take off the layers of dead skin. Don’t let your toenails get out past the end of your toes and never cut them in a curve like you do your fingernails. If you start to get an ingrown toenail, soak your feet twice a day, dry them well, and then wiggle dental floss under the corners of the nail. Leave the dental floss in place until the next time you soak and then put another piece under the corner of the nail. Continue doing this until the nail grows out enough to be cut straight across. Since toenails grow about one millimeter a month, plan on it taking at least a month.
By the way, if you’ve never had a professional pedicure, ask around to find a good place and try it. It’s not just for women, so if you are a man who has never tried this, step out of your comfort zone (no pun intended) and try it at least once!
