Advice physicians should follow. But don’t.

This is a truly wonderful piece from Emily Gibson, re-posted here with her permission from her beautiful blog, Barnstorming.  Enjoy!

octevening298As we drown in the overwhelm of modern day health care duties, most physicians I know, including myself, fail to follow their own advice. Far too many of us have become overly tired, irritable and resentful about our workload.  It is difficult to look forward to the dawn of the next work day.

Medical journals and blogs label this as “physician burnout” but the reality is very few of us are so fried we want to abandon practicing medicine. Instead, we are weary of being distracted by irrelevant busy work from what we spent long years training to do: helping people get well, stay well and be well, and when the time comes, die well.

Instead, we are busy documenting-documenting-documenting for the benefit of insurance companies and to satisfy state and federal government regulations. Very little of this has anything to do with the well-being of the patient and only serves to lengthen our work days — interminably.

Today I decided to take a rare mid-week day off at home to consider the advice we physicians all know but don’t always allow ourselves to follow:

Sleep. Plenty. Weekend and days-off naps are not only permitted but required. It’s one thing you can’t delegate someone else to do for you. It’s restorative, and it’s necessary.

Don’t skip meals because you are too busy to chew. Ever. Especially if there is family involved.

Drink water throughout the work day.

Go to the bathroom when it is time to go and not four or even eight hours later.

Nurture the people (and other breathing beings) who love and care for you because you will need them when things get rough.

Exercise whenever possible. Take the stairs. Park on the far side of the lot. Dance on the way to the next exam room.

Believe in something more infinite than you are as you are absolutely finite and need to remember your limits.

Weep if you need to, even in front of others. Holding it in hurts more.

Time off is sacred. When not on call, don’t take calls except from family and friends. No exceptions.

Learn how to say no gracefully and gratefully — try “not now but maybe sometime in the future and thanks for thinking of me.”

Celebrate being unscheduled and unplanned when not scheduled and planned.

Get away. Far away. Whenever possible. The backyard counts.

Connect regularly with people and activities that have absolutely nothing to do with medicine and health care.

Cherish co-workers, mentors, coaches and teachers that can help you grow and refine your profession and your person.

Start your work day on time. End your work day a little before you think you ought to.

Smile at people who are not expecting it, especially your co-workers. Smile at people who you don’t think warrant it. If you can’t get your lips to smile, smile with your eyes.

Take a day off from caring for others to care for yourself.  Even a hug from yourself counts as a hug.

Practice gratitude daily. Doctoring is the best work there is anywhere and be blessed by it even on the days you prefer to forget.

 

What Big Magic Can Teach Those Who Serve

“Do what you love to do, and do it with both seriousness and lightness.”*

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On the flight home yesterday I finished Big Magic: Creative Living Beyond Fear by Elizabeth Gilbert (She’s probably known to you for her NY Times Best Seller Eat, Pray, Love). For me, one of the overarching messages of her book was this – When you see what you do as your vocation (from Latin vocātiō, meaning “a call or summons”), and not just your job, it will transform how you view your work – a concept which I believe may be necessary (but not sufficient) to treat or prevent burnout.

As I read her thoughts on how to live a creative life, I realized that there were other ideas  that applied to physicians, physicians in training and others who serve:

 

Just show up. Every day.

“Most of my writing life consists of nothing more than unglamorous, disciplined labor. I sit at my desk and I work like a farmer, and that’s how it gets done. Most of it is not fairy dust in the least”

Learning and practicing medicine (or any other field) means showing up – really showing up – every day. Everyone in the first year of medical school learns that it is different than college. Cramming for exams is not only ineffective, it’s just wrong. You are no longer studying for a grade on a test…. it’s now about the patients you will take care of in the future. The same holds true during residency and when you begin your practice. It’s not just when you are a trainee.  Part of the “work” of medicine remains “unglamorous, disciplined labor”… keeping up with the literature, going to teaching conferences when you could be doing something else, finishing your hospital charts, being on call.

But the work of medicine is also about showing up every day in another sense, too – truly showing up for the people who rely on you – no matter what. That, too, can be “unglamorous, disciplined labor” when you are tired or stressed.

“Work with all your heart, because—I promise—if you show up for your work day after day after day after day, you just might get lucky enough some random morning to burst right into bloom.”

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They are your patients… from the first day of medical school until you retire.

Most of all, there is this truth: No matter how great your teachers may be, and no matter how esteemed your academy’s reputation, eventually you will have to do the work by yourself. Eventually, the teachers won’t be there anymore. The walls of the school will fall away, and you’ll be on your own. The hours that you will then put into practice, study, auditions, and creation will be entirely up to you. The sooner and more passionately you get married to this idea—that it is ultimately entirely up to you—the better off you’ll be.”

Caring for others gives us joy but also gives us the responsibility to know the best thing to do for them. Whether you are a first year student, 3rd year resident or a PGY35 attending, we are all still learning. “Life long learning” is not just a phrase, it’s the reality of what we do.

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It’s called the practice of medicine for a reason.

“It’s a simple and generous rule of life that whatever you practice, you will improve at.”

Learn the art of deliberate practice early. Deliberate practice, to use a musical analogy I learned in Cal Newton’s fantastic book So Good They Can’t Ignore You: Why Skills Trump Passion in the Quest for Work You Love, doesn’t mean playing the piece from start to finish 20 times in an hour. It means spending 55 minutes on the small section that you struggle with, repeating it 100 times before you play the piece through once. It means instead of reading the comfortable material on the anatomy of the kidney, you deliberately tackle how the nephron works. It means that instead of doing the computer-simulated cholecystectomy 10 times you spend an hour tying intracorporeal knots in the trainer. Find the thing that is not easy and practice it over and over until it becomes easy.

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There is Peril in Perfectionism

“There are only so many hours in a day, after all. There are only so many days in a year, only so many years in a life. You do what you can do, as competently as possible within a reasonable time frame, and then you let it go.”

One of the greatest attributes of those who care for others is their devotion to the people they serve. But perfectionism, taken to its extreme, is dangerous. Extending your time to study for Step 1 beyond what is reasonable to try to get a higher score, revisiting decisions about patient care to the point of anxiety, worrying that your GPA has to be perfect are all counterproductive. The motivation to do well is like a cardiac sarcomere – a little worry will make you more effective, but stretched too far, there won’t be any output at all.

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Curiosity can overcome fear.

“No, when I refer to “creative living,” I am speaking more broadly. I’m talking about living a life that is driven more strongly by curiosity than by fear.”

It’s something most students don’t realize, but no matter how long you practice medicine, there are days when you are afraid. It takes courage to do what we do. Remember, being courageous is not an absence of fear, it’s being able to do what’s right despite the fear. I agree complete with Elizabeth Gilbert that curiosity helps. When you have something that doesn’t go the way you expect or frightens you, instead of beating yourself up (“I should have studied more”….”I could have made a different decision”…etc…etc) become curious. If you are thinking about a complication, commit to finding everything you can about the procedure and how to prevent complications. If you didn’t do as well on your test as you thought you should, look up different techniques to study, take notes, and remember information, and go back to make sure you really understood what was being tested.

Even more powerful than curiosity is gratitude. Fear and gratitude cannot exist at the same moment. Try it – the next time you are about to snap because your EMR freezes be grateful that you can see the computer, be grateful you have work, be grateful you have been trained to help other human beings …and see what happens.

“We must have the stubbornness to accept our gladness in the ruthless furnace of this world.”

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Your worth is not the same as your “success”.

“You can measure your worth by your dedication to your path, not by your successes or failures.”

Wow…. This one is so important.

It’s not what you make on Step 1. It’s not how many cases you do, how many patients you see or how much money you make. This concept is taught by every religion and philosopher I know – for a reason. Be devoted to doing the best you can and to forgiving yourself (and learning from it) when you fall short.

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One last thing….for medical students trying to choose a specialty – forget about finding your passion.

This is a little longer quote than the others, and mirrors a similar message in So Good They Can’t Ignore You: Why Skills Trump Passion in the Quest for Work You Love .

Find something, even a little tiny thing, that makes you curious (or fills you with wonder) and follow it. Dedicate yourself to following that curiosity and it will likely lead you to your career.

“May I also urge you to forget about passion? Perhaps you are surprised to hear this from me, but I am somewhat against passion. Or at least, I am against the preaching of passion. I don’t believe in telling people, “All you need to do is to follow your passion, and everything will be fine.” I think this can be an unhelpful and even cruel suggestion at times. First of all, it can be an unnecessary piece of advice, because if someone has a clear passion, odds are they’re already following it and they don’t need anyone to tell them to pursue it…..I believe that curiosity is the secret. Curiosity is the truth and the way of creative living. Curiosity is the alpha and the omega, the beginning and the end. Furthermore, curiosity is accessible to everyone…..In fact, curiosity only ever asks one simple question: “Is there anything you’re interested in?” Anything? Even a tiny bit? No matter how mundane or small?….But in that moment, if you can pause and identify even one tiny speck of interest in something, then curiosity will ask you to turn your head a quarter of an inch and look at the thing a wee bit closer. Do it. It’s a clue. It might seem like nothing, but it’s a clue. Follow that clue. Trust it. See where curiosity will lead you next. Then follow the next clue, and the next, and the next. Remember, it doesn’t have to be a voice in the desert; it’s just a harmless little scavenger hunt. Following that scavenger hunt of curiosity can lead you to amazing, unexpected places. It may even eventually lead you to your passion—albeit through a strange, untraceable passageway of back alleys, underground caves, and secret doors.

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*Italics are quotes from Big Magic: Creative Living Beyond Fear. Since I read this on my Kindle, I don’t have page numbers!

 

 

Yes, I’m a Surgeon and Yes, I teach Mindfulness

At the most recent ACS Clinical Congress, I was really struck by a presentation on mindfulness given by Sharmila Dissanaike and asked her if she would be willing to write about the topic for wellnessrounds.  To my delight she agreed!

 

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The recent #Ilooklikeasurgeon phenomenon reminded me that times do indeed change – albeit slowly. The peak of this phenomenon happened to coincide with my talk at the American College of Surgeons on “Mindfulness for Stress Reduction and Burnout Prevention”. If you had told me 10 years ago that I would one day deliver this brief lesson in stepping off the treadmill for a few moments, I would have said you were crazy. Surgery was only for the tough, and the tough don’t need breaks (or so we thought). As a woman surgeon, it was even more important to me that no chinks show in the armor, and being a trauma surgeon proved an easy way to solidify my “street cred” despite being a 5”2’ little brown woman with long hair.

So it has taken a while for me to feel confident enough to broach such a “soft” topic in a public surgical forum. Obviously age and (a little) wisdom has probably helped, but there is also a tangible change in the prevailing culture of surgery as exemplified by the #Ilooklikeasurgeon movement and other similar initiatives; where calling for help is no longer an (automatic) sign of weakness, and the surgical community has accepted that the good old days (or bad old days, depending on your perspective) are well and truly over. The next generation of surgeons is currently being greeted with much hand wringing and wailing and gnashing of teeth, for how could a group of kids raised in this limited workhour era possibly achieve the heights of excellence that the “old school” surgical residents achieved? Since the switch to 80-hour workweek happened exactly midway through my residency, I have the privilege of a foot in both worlds, and while I agree that our training paradigms do have to change, I am not yet ready to concede that the golden age of surgery is well and truly behind us. Partly, this is because of the audience that gathered for the session at ACS. What stunned me even more than the opportunity to speak on mindfulness was the full house that gathered for this session, and the enthusiasm and interest generated by a wonderful audience of men and women of all ages, and in nearly equal proportions – it embarrasses me to admit that I had expected to be speaking to a handful of younger female surgeons. Instead, I met the 65 year old broad-based general surgeon who came because he recently lost a younger orthopedic surgeon colleague to suicide – by stabbing himself through both femoral arteries, with surgical precision of course. I met several Governors of the College, who were in the classic “grey haired” demographic, and yet optimistic and enthusiastic about the future of surgery, and the improvements to be had by focusing more on our wellness – that “healing the healer” would have tangible results not just for our own wellbeing but also that of our families and our patients, and was thus an obligation, not an option. I met young surgeons a few years out of residency/fellowship who had already recognized the need for maintaining their own mental health in order to remain functional for as long as possible in order to maximize the productivity to be gained from their long training – working less was certainly not on their priority list. There was clear recognition of the systemic problems that drive a lot of surgeon frustration with ensuing burnout – bureaucracy, being treated as interchangeable expendable cogs in a machine, electronic medical records and endless paperwork topping the list – and yet there was also an acknowledgement that adjusting internal cognitive factors was at least as important for wellbeing as it was to try and change some of the external factors.

The methods I teach are focused on building resilience and capacity – characteristics that are both innate and learned, which can be developed and expanded through meditation and other techniques. One of my favorite analogies is that a spoon of salt in a cup of coffee renders it immediately unpalatable; the same spoon in a river or swimming pool would not be noticed. The spoon of salt represents the unavoidable daily irritants in our lives – the cases that run late, the scrub tech who doesn’t know what instruments you use, the colleague who lets you down in a key meeting. The cup of coffee of course is us – or at least, where most of us start. Instead of spending our lives either trying to avoid all these frustrations (which is futile) or becoming upset when they happen, mindfulness can increase our capacity to be with them fully, accept them for what they are and yet respond thoughtfully and effectively instead of blindly and automatically reacting with anger or frustration (which usually only causes us more trouble in the long run). Over time, we develop an increased capacity to handle irritation without it placing us in a perpetual bad mood, and increased resilience to bounce back from the inevitable traumas of life, both personal and professional.

So why teach mindfulness to surgeons, when there are plenty of other things I could be doing that would probably be more directly beneficial to my career? Because I do believe that the biggest waste of potential is to take a motivated young person, put them through the grueling training to be a surgeon, set them out on a career that is of such benefit to society, and then allow them to flounder and become discouraged 5 – 10 years later, quickly discarding those hard-earned skills as they turn into full time administrators, wound care docs or some other alternate career path. Not that there isn’t value to these professions of course, and some people do realize at a late stage that they are better suited to another path – in which case all of these are excellent choices. But too often it is one bad outcome that leads to a malpractice suit, or some other event that proves just too difficult to handle, that completely derails an otherwise excellent surgeon and this lack of coping – the lack of capacity, and resilience – leads to a complete abandonment of what should be an intrinsically rewarding career.

If mindfulness, meditation and other strategies can help even one surgeon regain a wider perspective and avoid this outcome, then it will have been a worthwhile endeavor.

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Dr. Dissanaike is a general surgeon with primary focus in trauma, burns and critical care, and a Professor at the Texas Tech University Health Sciences Center in Lubbock, TX. She serves as Medical Director of the Level 1 Trauma Center and Co-Director of the regional Burn Center. She has an interest in ethics and humanism, and is on the ethics committees of both the American College of Surgeons (ACS) as well as the American Burn Association.

Celebrating Match Day!

Yesterday was Match Day.  At noon EST, just over 17,000 4th year medical students simultaneously found out where they will go for their residency training this July.

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Medical training is punctuated by ceremonies like convocation, the White Coat ceremony, the donor ceremony (to acknowledge the “silent professors” in anatomy) and graduation.  But of all the ceremonies, the one that is pure joy is Match Day.

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I truly believe that any physician disillusioned with their work, or even suffering from burnout should be “prescribed” attending a White Coat ceremony, donor ceremony and/or Match Day.  I’m serious!  These moments of ceremony allow us to remember the reasons we choose the profession of medicine and the joy of practice. If you are part of a medical school faculty, make a point to attend one or all of these ceremonies next year.  I promise, it won’t feel like an obligation, it will feel like a gift.  If you are not in a medical school, contact the Dean of Student Affairs at your alma mater or a school close to you – we’ll help make it happen.

During the five long days of waiting between Monday, when they find out that they matched and Friday, when they open the envelope to find out where they are actually going, many fourth year students often wish this process would be replaced with an email notification…. until they experience the celebration of Match Day…

 

Congratulations to all medical students graduating this year –  and to your families, friends, and professors!

 

Photos and video from Baylor College of Medicine

 

 

 

 

Compassion: Lessons from Roshi Joan Halifax

It’s not often that a talk completely changes the way I think about something.

I’ve been thinking and speaking about compassion fatigue for many years.  I recently had the privilege of hearing a wonderful talk by Roshi Joan Halifax. She made a strong and convincing case that “compassion fatigue” is a misnomer… and that we should think about this in a very different way.

We can never have too much compassion nor can true compassion result in fatigue.  

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Empathy and compassion are not the same thing.

Empathy is a necessary prerequisite for compassion, but compassion goes beyond empathy. Empathy is the ability to be with someone who is suffering, to be able to feel what they are feeling. Compassion, on the other hand, is being for someone who is suffering, being moved to act and find a way to relieve their suffering.

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Link to Roshi Joan Halifax TED talk “Compassion and the true meaning of empathy”

Self-regulation is the key to being able to remain compassionate and this skill can be taught.

We all respond to situations of suffering with “arousal”, a state that varies in intensity depending on the severity of the suffering, and our own memories and experiences.   How you respond to this state determines whether you can stay present, effective and compassionate.  Roshi Joan Halifax offered the mnemonic “GRACE” as a way to teach this skill to medical students, residents, physicians, nurses and other health care professionals.

G:  Gather your attention. Take three deep breaths.  Be present.

R: Recall your intention.  We choose careers in medicine to help heal the sick and to reduce suffering.  It’s not easy to remember this intention when we are overwhelmed.  But, in the moment we are faced with a human being who is suffering, we must let our own response (and the demands of the day) go and remember why we are here.

A:  Attend to yourself.  Being able to detect what is going on in your own body is the same “wiring” you use when you feel empathy.   After gathering your attention and recalling your intention, pay attention to what is going on in your body.  Watch your breath, feel where there is tension, pay attention to sensations.

C:  Consider what will really serve.  Moving from empathy to compassion is defined by considering the actions that will relieve suffering.  Really consider the person and the situation and decide what is most likely to improve the situation.

E:  Engage ethically.

“Developing our capacity for compassion makes it possible for us to help others in a more skillful and effective way. And compassion helps us as well.”  Joan Halifax

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What happened to my workouts?

I’m just went through a particularly busy time and, once again, I didn’t find/make time for exercise.  I could give you the list of tasks, travel, call nights, etc that led to blowing off my workouts, but it wouldn’t be different from yours.

I know better.

If you haven’t seen it, this is a remarkably persuasive “lecture” (with very cool animation) on why we should make time to exercise.

 

Here’s what I’m going to do, based on previous experience and a lot of good advice from people who know more than I do:

1.  Put exercise on a calendar.

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Schedule exercise as an appointment – every day.  I personally think call days and post-call days should be exempt (if you are up most of the night).  Sleep trumps exercise if you are really sleep deprived.  It’s understandable there will be a day, maybe even two, when something comes up that you can’t control …and you miss your workout.  But the end result of having a plan for everyday is that you’ll work out 4-5 days a week (instead of 0-2)

2.    Put your shoes on.

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For most of us, it’s not doing the exercise that’s so hard, it’s getting started.  I think the “10 minute rule” is key.  Put your shoes on and start your workout no matter how bad you feel or how much you don’t want to do it.  If, after 10 minutes, you still feel that way – stop.

3.    Just do it.

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Self explanatory.  Sometimes you just have to make up your mind that the benefits outweigh your desire to sit on the couch.   If you don’t like to work out – talk yourself into it.

4.    Keep track

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Watching yourself improve is a great incentive to keep going.  Set up goals for slow and steady improvement and then log what happens.  We’re all good at science – think about approaching this as one big “experiment”.  When things don’t work out the way you expect, log it.  Buy a notebook or find an app you like.  Use your log to figure out what works and what doesn’t.

I’m in.  For the next month I’m going to set and meet a goal for 150 minutes/ week of real exercise.  Join me?

Yellow Hospital Socks: Gold Humanism Essary Award Winner

The following is the 2012 First Prize winning essay in the Arnold P. Gold Foundation Annual Essay Contest, written by Carmelle Tsai, a Baylor College of Medicine student.  It’s my pleasure to share it with you – and congratulations to Carmelle!

 

There is nothing normal about being a physician, or training to become one.

On the second day of medical school, I cut open a dead man’s body. Soon thereafter, I found myself in the lab many times over, pulling various body parts out of drawers and staring at them for hours. Alone. Sometimes until midnight.

I have stood in a trauma operating room, wearing a gown splattered with a dying person’s blood. I have seen, heard, and smelled things I never thought could come from the human body. I have stuck tubes and needles into other people’s flesh. I have put a gloved finger into someone else’s rectum more times than I care to count.

It’s just. Not. Normal.

It’s horrendous, grotesque—plain weird, some of the stuff we do. But it’s all in the noble name of medicine, of saving lives, of healing. I know that. We all know that. We even think it sounds heroic. So to soften the somewhat uncouthly nature of what we do, we give procedures benign names and talk about them gently, as if doing so could somehow preserve the dignity of the human beings involved. We kindly write on the chart “Below the Knee Amputation,” and we gently explain that we will be doing a “simple procedure” to remove your cyst.

And yet once in a while, I just want to scream: “It’s NOT OKAY! It’s NOT NORMAL! There is NOTHING NORMAL about using SAWING OFF a poor old woman’s leg!!!” It’s like something inside of me cries out just for us to call it what it is, and to quit tiptoeing around, pretending that what we do is dignified.

Before I entered medicine, I always knew I wanted to heal my patients compassionately by listening, holding their hands, and being present with them. But what I did not understand was how I would learn to steward medicine by healing patients and myself through some less-than-likely moments.

I was wheeling Mrs. N into the operating room. She was a sweet, middle-aged woman with a husband and three kids. The anesthesiology team and I worked together to be compassionate and kind as we prepped her for surgery.

Though things were chaotic the moment we burst into the OR and were greeted by a barrage of shiny machines and people, we all set swiftly into motion. As we did, we paid attention to Mrs. N’s comfort as best we could. My resident smiled as he told her about his own kids. The nurses thoughtfully brought her a pillow. I held her hand as the arterial line was being placed.

“Y’all are so sweet,” she said with a tinge of Southern drawl.

I smiled at her through my surgical mask as I gave her oxygen. Soon, Mrs. N was asleep. As the resident began to place her central line, I walked around the monitors, tucked in her blanket, and adjusted the sock on her left foot that had gotten twisted around in the pre-surgery shuffle.

As I gave her foot a reassuring pat, I caught myself thinking, “What? You’re ridiculous, Carmelle. She’s asleep. She can’t tell that it’s cold and she’s not awake to be annoyed that her sock is on funny.” For a moment I felt foolish. I mean, really?

My resident looked at me and raised an eyebrow. I shrugged.

In a few moments, a surgeon would be cracking open Mrs. N’s chest. Then we would put her heart on bypass. Then her entire aortic valve would be replaced. A turned-around sock hardly seemed like a big deal. Plus, the groggy and awful dry-heaving that would precede her extubation, and the pain from having her insides all cut, moved around, and put back together would surely distract her from the ugly yellow hospital socks. And I was right. Later when I saw Mrs. N post-op, I wasn’t even sure if she was wearing socks.

I pondered about Mrs. N and her socks on the way home that day. It reminded me of my first day of anatomy. Before we were about to unzip the bag and remove our cadaver, I made all my teammates stop and just breathe for a moment. I wasn’t really sure why—again, what does it matter, right? The man was already dead and his body had been in formaldehyde for months.

But I realized it did matter. I understand now that my humanity is why I do these things. It is not for the dead man, for Mrs. N, or for anyone else. It is for me. And because it matters to me, in some roundabout way, it matters to Mrs. N, and to all my patients. Because in medicine I am meant not only to heal, but to be healed.

And that, I have found, is what it truly means be a steward. It is to invest in my patients by being humbled enough to recognize that they offer me something too. As much as medicine gives physical healing, and the holding of hands and compassionate silence give emotional healing, it is part of my own healing to maintain that same humanity in the moments that patients neither see nor experience.

I am not any less broken just because I know more about the human body. Just because my normal involves everything that most people think is crazy or disgusting does not mean that I am any different. I also don’t like being cold. I don’t like wearing my socks backwards. I am scared of foreign situations. I am in need of healing.

And so if reminding myself that what seems cruel and abnormal is still compassionate means that I will kindly refer to sawing someone’s leg off as a “below the knee amputation” or tuck in the blankets on a sleeping patient, damn right I’m going to do it. There is no way we can steward medicine if we cannot allow ourselves to be healed, too. Yellow hospital socks and all.

Time off, Days off, and Vacations

As my vacation is winding down I’m struck again by how restorative time away from work can be, and how much we all need these breaks.

The word vacation has the same roots as vacate (from Latin vacātiō – freedom, from vacāre – to be empty).  Vacations – whether daily, weekly or annual are effective only if you really walk away from work.    It’s particularly hard to disconnect from email, the internet and texting … but “needing” to stay connected electronically may keep you from connecting with your surroundings and your loved ones. If the idea of emails piling up adds to your stress, compromise by scanning, deleting (and not answering) your emails when you are on vacation.

There’s a tendency to think that vacations have to be a planned trip away for at least a week… but here’s another perspective from WebMD.com:  “While it is ideal to have a full week or two off from work, it may not always be feasible, and there’s still the rest of the year to deal with. Weekend getaways are also good for rejuvenation. So is an hour to yourself during lunchtime or a few hours on weeknights.”

Some ideas….

Plan a half-hour or hour (on days you can) to disconnect and “vacate” from your work in whatever way makes you happy.

Try to really have a full day off every week (call schedule permitting). There’s a reason most religions in the world build in a day away from work – it’s part of the rhythm of rest we need as human beings.

Plan a long weekend away (or even a day) by yourself or with loved ones every couple of months.  Make it time free of electronics – go hiking, sit on a beach, stay at a great bed and breakfast, eat great food.

If you have vacation days you are storing up – start using them!  And, when you take those days off work, don’t use them to “catch up” on chores or other tasks…take the time you need to recharge your batteries.

Why we need vacations from treecitytimes.com

The Science Behind Vacations: Why we Need a Break from lbtimes.com

Why Summer Vacations (and goofing around on the Internet) Make You More Productive from TheAtlantic.com

Starting Clinical Rotations: Practical Advice

Don’t sit in the back of the plane.

The basic sciences are important to learn the vocabulary and grammar of medicine.  Clinical rotations are different – it’s where you actually learn to be a physician.   If you use the analogy of learning to fly, in basic sciences you are studying the book on how to fly the plane.  In your clinical rotations you are in the plane, watching and learning from the pilot.  Which means you have to be in the cockpit.  You cannot learn to fly a plane by sitting in the back.

In every situation you encounter in the hospital, imagine that you are “flying the plane.”  When the resident starts to write the admission orders say “Do you mind if I write them and you show me how?”  On your surgery rotation, be in the holding area early and ask the anesthesia resident if he/she will explain how to intubate, show you how to intubate, or even let you try.  When you are writing an admission H&P on a baby in the ER, imagine you are the only doctor who will be seeing that patient.  Let the adrenaline of that thought guide you to the computer to look up more about the condition, how to treat it and what you would do if you were the only person making the decisions.

Yes, you need to be pushy and, yes, sometimes it will backfire.  Be reasonable, but stay engaged. If it’s not an appropriate time to be assertive, stay in the game mentally by asking yourself what they will do next, what you would do if you were making the decisions, or what complication might occur from the decisions being made.  Write down questions you will ask after the smoke clears if it’s not appropriate to ask during a stressful situation.

Know what you are expected to learn before you start.

I am not a fan of “learning objectives”.  If they are done well, they are very helpful, but most people don’t take the time to do them well (or don’t know how to do them).  For the rest of your professional life, you are going to have to define your own learning objectives.  So, in a way, learning how to do it early – during your core rotations – is also part of the skill set you need to know.  (Word of advice, though – even if they are very poorly written, you need to read any objectives you are given and make sure you accomplish them.)

Start with a basic textbook.  You will NOT be responsible for learning all the details in the textbook!  Textbooks are written for residents and practicing physicians.  But – a good textbook will give you an overview of the topics.

The strategy:

1.     Make a list of the topics covered in a general textbook.  There are usually 2-3 good textbooks for every specialty.  Ask other students or residents which one(s) they recommend.  You will probably rotate on sub-specialty services during your core rotation, but don’t get bogged down in looking in sub-specialty textbooks.  Stay with the general textbook.

2.     Plan to skim and make notes on every major topic.  These should be “big picture” notes, not every detail.  If there are 60 chapters in the book and your rotation is 2 months long, you should be shooting for one chapter a day.  Keep track and make sure you get them all covered during the rotation (not after).  When you are done with the rotation, these notes should be all you will need to review for the shelf exam.

3.     Don’t read the chapters in order – read them as you see patients (see below). But, make sure that all the chapters are covered since it’s unlikely you will see patients with every disease in the book.

Practice being professional.

It’s really important to be professional and to be seen as professional in all your interactions.  First of all, it’s the right thing to do.  Secondly, a bad interaction with a nurse on the floor can lead to a poor evaluation by your attending.  Make learning how to behave as a professional one of your learning objectives.  Learn from those around you.  Which residents and attendings are the most professional?  Why?  When you see bad behavior (and you will), think about it – what would you have done differently?

Learn from every single patient you see.

Use every patient to learn about their specific disease.  Even if it’s the 30th patient with appendicitis you’ve seen you’ll still learn something new.  (or use it to learn about their hypertension instead)

The strategy:

1.     Keep a notebook with an entry for every patient you see.  You can use 3×5 cards or an electronic equivlaent, if you prefer.  In fact, many hospitals have 3×5 cards with the patient info available in the patient’s chart for docs to take. (Remember HIPAA – it is better to do this without any protected information!)

2.     Make yourself read something about every patient you see.  If you haven’t read the textbook chapter on the subject, that’s where you start.  If you have read the textbook, review your notes and read something new (UpToDate or PubMed for example)

3.     Make yourself write down a minimum of 3 things you learned from the patient in your notebook (or on your 3×5 card).

Be the doctor for patients that are assigned to you.

You will be assigned patients to follow during your rotations.  When this happens, make up your mind that you are going to “wear the white coat”.   What if you were the only doctor taking care of Mr. Smith after his surgery?  In addition to reading (see above), ask the residents to help you write all the orders.  Write a daily note and make sure your notes are at the level of the residents (ask them to review and critique your notes).  When a drug is prescribed, know the dose you are giving, the effects of the drug and the potential side effects.  When a x-ray is ordered, be the first person to actually see the image and know the result (and make sure you call the resident as soon as you do!).  Don’t get any information second hand – make sure you see the results and the images yourself.  At any point in time, if the attending asks, you should be able to present your patient as though you are his/her only doctor, which means how they presented, their past history, social issues, test results, procedures performed and how they are doing now.

Prepare for conferences.

Every service has at least one or two weekly teaching conferences.  In most cases, the topic (or cases) are known before the conference.  Ask your residents or attendings the day before the conference for the topics and/or cases that are going to be discussed.  Use the strategy outlined above to prepare e.g. consider these “vicarious” patients and learn from them as if they were a patient assigned to you.

Come early, stay late and keep moving.

Taking care of patients in the hospital is a team sport.  The best medical students become part of the team early and are appreciated and – therefore – taught more.  It’s just human nature and it’s just the way it works.  Don’t brown nose, don’t show off…. just show up.   If there are labs to look up before morning rounds, be there 10 minutes early and look them up for the residents. If you don’t know the answer to a question the best response is “I don’t know, but I’ll find out!” If there is scut work to be done that you can help with, volunteer to help before you go home. Anytime you can, make the residents look good. It’s particularly important not to try to one-up the residents.  You will have more time to read than the residents, so you may actually know more than they do about a specific topic.  But, if the attending asks a question and the resident gets it wrong, don’t correct them in front of the attending.  (Unless it’s a critical issue and you think the patient might suffer in which case you have to speak up!)  Whenever you can, set up the resident to succeed.  “A rising tide floats all boats” – if you help them look good, you will look good and the team will look good. Don’t ever sit in the lounge waiting for someone to come tell you what to do.  There are patients to see, conferences to attend, rounds to do, labs to look up… the hospital never sleeps!

Practice having a balanced life.

Compassion fatigue is a constant threat to practicing physicians.  Taking care of yourself, staying connected to family, friends and the outside work are all critical components of preventing compassion fatigue.  This, too, is a skill you need to learn during your rotations so you can carry it with you into your residency and your practice.

Enjoy!  You are finally a “real” doctor!’’

Your experiences on your clinical rotations will be among the most special of your life. Buy a new journal and take time to jot down the funny and not-so funny occurrences of daily life in the hospital.  You will see some extraordinarily beautiful moments of human life.. and some horrendous examples of what people can do to other people. We all learn to deal with these extremes by telling stories. Write down these stories when you can.  It’s also special to record your “firsts”… the first time you set a fracture or hear a murmur of aortic stenosis will be the only “first time” you have.  It’s a special world you are entering.   You’ll want to remember it by taking notes, recording stories and with pictures of your team and unique sights around the hospital. (No patients, though – remember HIPPA!)

Congratulations! You are well on your way to the privilege and joy of practicing medicine.

“Failure”

Dear Dr. Brandt,

I enjoy your blog very much. As a second year medical student, I know that my peers and I all struggle with what we view as ‘failure’ at some point or another. I imagine this problem doesn’t stop (…ever), especially since medicine seems to attract people who hold themselves to extremely high, if not impossible, standards. If you’re looking for topics, I wonder if you might have some insight to offer on how to deal with the downfalls along the way.

Dear colleague,

It is part of our profession that we will never stop trying to be perfect and – just as true – that we will always fall short. As a student, it tends to be about the tests you are taking and the feeling that you will never study enough.  As a resident, it’s the feeling that you don’t know enough to make the decisions you are being asked to make. As a practicing physician, you will at times stay awake at night worrying about your decisions, even when you know you did the best you could.  All of this sounds like a huge downside to the profession we’ve chosen, but it’s actually a blessing.  One of the core personality traits of physicians is that they care.  In a way, all of the stress about not doing well enough happens only because you have empathy and compassion for your patients.

Although it’s hard to believe at the beginning, with time you will realize that the feeling of having “failed” is actually a gift.  You’ll discover that “mistakes” and, more importantly, “near misses” become your most valuable teachers.  What’s important is that you grasp the opportunity to learn from falling short, rather than beating yourself up.  “Failing” at a task (or test) is different than being a “failure.”  When you have moments you feel you could have done better, use it as motivation to study a little more, go back to the textbook, look up one more article, or review all the facts again.   William Osler, in his famous book to medical students (Osler’s Aequanimitas) talked about keeping a journal of mistakes:   “Begin early to make a threefold category – clear cases, doubtful cases, mistakes.  And learn to play the game fair, no self-deception, no shrinking from the truth… It is only by getting your cases grouped in this way that you can make any real progress in your post-collegiate education; only in this way can you gain wisdom with experience. “

So, to answer your question about how to deal with the downfalls along the way –  Start by revisiting your motivation. Remember why you started down this path in the first place.  If you are trying your best to do the right thing, and are humble about the fact that you are human (and will therefore fall short) you can end every day with satisfaction and a sense of accomplishment. That being said, make sure that you work with focus – that when you study or work it is with dedication to the patients and families who are trusting you with some of the most precious decisions of their life.  When you fall short, use it as motivation to learn.  But, in this process, make sure you are taking care of yourself by taking time for good nutrition, exercise, social interactions and spiritual growth.   The worst thing you can do when you feel inadequate is to just work more and more.  This leads inevitably to compassion fatigue, which makes you less effective (and will make you suffer).   Compassion fatigue is a common diagnosis for care-givers; it happens to every medical student, resident or physician at some point in time.  Just like any other diagnosis, the next step is treatment.  In a nutshell, the treatment is self-care.   Here are few sites that can help you with tips to prevent and treat compassion fatigue:

Top 12 Self-Care tips

Preventing Compassion Fatigue