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!

 

 

Gratitude, Thanksgiving and Being On Call

Thanksgiving week is here. Our families will gather together to eat our traditional meal, swap stories, argue about whether cornbread or white bread dressing is better and nap on the couch while watching football. I’m in charge of the corn bread (my great grandmother’s recipe) and the corn bread dressing (my grandmother’s recipe).  It’s a great time to recharge and to be thankful for family, food on our table, and the many gifts in our lives.

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I’m not on call this Thanksgiving, but I have been in the past.  I have a fond memory of Thanksgiving when I was the Chief Resident in our county hospital Emergency Room.  I bought the traditional dinner, including a large turkey, for my team… and then realized we didn’t have enough microwaves to heat it up properly.  I won’t go into the details of how we handled the problem…. but it turned out that the rarely used autoclave in the ER was big enough for a turkey.  We were grateful for ingenuity and a hot dinner!

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I will be thinking of the physicians, in practice and in training, who will sacrifice time with their families this year to take care of others.  To the physicians, nurses, hospital staff, police officers, fire fighters, soldiers, clerks and anyone else who spend this holiday helping others – thank you.  We are grateful.

 

“Gratitude can transform common days into thanksgivings, turn routine jobs into joy, and change ordinary opportunities into blessings.”  William Arthur Ward

Thanksgiving Gratitude

Gratitude is not only the greatest of the virtues but the parent of all others.”  Cicero

Gratitude is a powerful tool.  There is good evidence that being grateful leads to a greater sense of well-being and less stress.   Practicing gratitude on a regular basis can be as simple as “counting your blessings” every morning, or listing things you are grateful for on your scut list, in a journal, using an on line journal or on your smart phone.  Another useful practice is to write letters (to send or not) to your parents, teachers, friends or mentors to thank them.  If you aren’t convinced that practicing gratitude can have a profound effect on your well-being,  take the “2 minute challenge”.  Get a piece of paper and for two minutes write down everything thing you are grateful for.  Don’t lift the pen off the paper and keep writing (non-stop) for the entire two minutes.

Today, as I am spending time with family and friends, making our Thanksgiving feast and counting our blessings, I am reminded that all over the United States, there are physicians, residents, nurses, therapists, and support personnel who are spending this holiday taking care of patients.  Along with the patients and families in their care, I am thankful for their sacrifice and their compassion.  It is a blessing to have the skills and the heart to care for others, and we are grateful for that privilege .

“If the only prayer you say in your whole life is “thank you,” that would suffice.  Meister Eckhart

 

Thanks Doc Cookie Bouquet

 

Why You Should Run and How to Get Started

I hate running.  Whew.. that’s out of the way.  BUT – I have been a runner in the past, I live with a runner, and it’s absolutely clear to me that running is the ideal cardio exercise for medical students and residents.  So, I’m going to try to convince you that you should incorporate running – even in a very small amount – into your daily routine .

Why Running is Perfect for Medical Students and Residents

  • It’s cheap.  Other than an good pair of running shoes (and don’t buy less than good ones), there is no expense.
  • It’s portable.  A bag with your shoes, shirt and shorts can stay in the trunk of your car.
  • It’s social.  Once you identify a friend or two who agree it’s a good idea to run, you can do it together.
  • It’s efficient.  Short runs are still a great workout.  Unlike other workouts which require planning, travel and time to complete, you can walk out the front door and run.
  • It’s empowering.  You can set goals and easily accomplish them.  There are a lot of times during your training that you will feel things are out of your control. Setting a goal (I’m going to run a mile) and then doing it (Yeah!) is empowering.
  • It does more than just get you fit.  There are good data that show that exercise in general (and running in particular) decreases stress, improves depression, helps sleep, etc. etc.

How to get started

This month’s Runner’s World (May 2010) is a guide for beginners.  I really recommend you pick it up.  (I’ll list a few websites below, too)  Here are the key concepts on how to get started running:

  1. Don’t do too much to start with.  Start with walking and add in small amounts of running.  “Every able-bodied person can be a runner,” says Gordon Bakoulis, a running coach based in New York City, :Just start slowly and build up gradually.” (Runner’s World May 2010, p 68)
  2. Be consistent.  Your goal is to exercise every day. Cardio is an important part of your exercise, but not all of it.  You can run every day, but you’ll have to find  time to do resistance and flexibility training as well.  Alternatively, you can view resistance days as “recovery” from running i.e. alternate the days. Commit to some kind of exercise everyday.  Plan your week to make sure you get at least 3-4 cardio sessions/week – and then cut yourself some slack if something happens that pushes you off track.  It’s human nature – if you say you are going to run every day, you’ll probably run 4 or 5 times.  But, if you say you’ll run 3 times a week, it will probably end up being only once.  (For more information see the entry from April 3, 2010 – “Exercise for Medical Students and Residents”)
  3. Read, ask questions, learn about this skill.  Every city has a “runner’s store” (which is different from a store than sells running shoes).  Ask the runner’s in your class where they go to buy their shoes.  The store will have shoes, but it will also have very knowledgeable people who will be delighted to help you learn about running.

http://www.coolrunning.com/engine/2/2_3/181.shtml

http://www.active.com/running/Articles/10_Steps_to_Start_Running.html

http://www.runnersworld.com/article/0,7120,s6-238-261–9397-0,00.html#

http://completerunning.com/archives/2006/09/12/100-beginner-running-tips/

How to fit it in and how to stay motivated

  • I know you don’t want to hear this, but early morning is the best time to run.  It’s an energizing way to start the day, you “get it out of the way”, and you don’t have to fight the siren song of the couch at the end of a long day.  If you do choose to run at the end of the day, change into your clothes before you leave school or the hospital and run before you get home.  If you have willpower of iron you might be able to lace up the shoes and run before you go to sleep … if it works for you, great!  (but it won’t for most people) .
  • Think about signing up for a fund raising group.  Running for kids with cancer makes you feel pretty silly about whining….
  • Register for a 5K race – having a goal to finish  (and getting your first time) will be motivating
  • “Gratitude is contagious.”  Kristen Armstrong, in this month’s Runner’s World,   suggests that instead of feeling like you “have” to run that you think about what a gift it is that you “get” to run.  “If you view your run as an opportunity, your attitude will get an adjustment”.

http://www.runnergirl.com/motivation.shtml

http://www.tips4running.com/Motivation.html