New Year Resolutions

The “clean slate” of a new year almost always leads us to think of resolutions … things we could change to make our lives better.  This is a great time for reflection to realize what you have accomplished, where you’d like to be in a year, and what changes you need to arrive at that goal.  I just finished reading Making Habits, Breaking Habits: Why We Do Things, Why We Don’t, and How to Make Any Change Stick by Jeremy Dean which provided some useful ideas about making resolutions.

Photo credit

Know why you want to make the change

“There has to be an ultimate goal that is really worth achieving or the habit will be almost impossible to ingrain.”  Jeremy Dean

Let’s take one example – losing weight.  It’s fine to say you want to lose weight… but why?  Wanting to fit into your clothes is not a trivial reason, but will it really motivate you when it gets tough as much as these?

  • Being able to “walk the walk” when you talk to patients about losing weight
  • Reduction in your risk for diabetes, heart disease, cancer and a variety of other health problems
  • More energy, better mood, less pain…

What’s important is that you find reasons that resonate for you.  Do a little research and write down why you want to make the change.  Plan to review this, and revise it when needed, on a regular basis.

 

Make the resolution then make a plan.

Photo credit

To continue the losing weight example, what are the specific new habits you want to develop?  Are they “SMART” changes?   (Specific, Measurable, Attainable, Realistic and Time-Based).  For example…

  • I will eat 8 servings of fruits and vegetables every day.
  • I will set the alarm clock 15 minutes early to do push-ups, crunches and squats before I go to the hospital.
  • I will plan my meals and shop once a week so I can take healthy food with me to work.
  • I will schedule my workouts every weekend so I can attend at least two spin classes a week.
  • I will cook one healthy dish on the weekend that I can eat for at least 4 meals during the week

 

Develop the “what if” plan.

 Photo credit

The next step is to imagine all the things that might derail you and write down a specific plan for each of them.  This will be an ongoing process… as you come up with new excuses to not follow through with your new habit, add it to the list.

Back to the example of losing weight….

  • If I forget to bring fruit/veggies with me to work, I will go to the cafeteria or lounge to get at least 2 servings to eat at work.
  • If I walk by MacDonald’s and feel drawn in by the smell of the fries, I will remember that I’m trying to set a good example for my patients
  • If I hit snooze on my alarm clock, I will move it across the room.
  • If I think I’m too tired to go shopping for the week, I will remember that this is the key to having healthy food at work.

“Making healthy habits should be a voyage of discovery.” Jeremy Dean

 

Keep track.

Photo credit

Self-monitoring is critically important to maintaining a new habit.   It doesn’t matter if you use an app like My Fitness Pal, a calendar, a spreadsheet or a system like the Bullet Journal… stay accountable by keeping track.

 

As the habit becomes engrained, change it a little to keep it interesting.

Photo credit

Working out with exactly the same routine quickly becomes boring. It’s one of the reasons people love group classes like spin classes  – the instructors are always changing the routine.  Be mindful and creative… but stay out of ruts!

“Making or breaking a habit is really just the start. To develop a truly fulfilling and satisfying happy habit, it’s about more than just repetition and maintenance; it’s about finding ways to continually adjust and tweak habits to keep them new; to avoid mind wandering and the less pleasurable emotional states that accompany it. There is great enjoyment to be had in these small changes to routines. When life is the same every day, it gets boring.”  Jeremy Deans

 

Photo credit

Looking for inspiration?  Here’s a list of New Year’s Resolutions for medical students, residents and busy docs.  Pick 1 or 2 and start working on your plan, your what-ifs and how you will monitor them!

  1. Learn to meditate and spend at least 10 minutes every day meditating with HeadSpace. (Here’s the TED talk that introduced me to this great app.)
  2. Eat fruits and veggies with every meal.
  3. Walk 10,000 steps per day.
  4. Take the stairs instead of the elevators.
  5. Learn the names of all the people you work with… the guy who mops the floor, the clerk at the desk, the person who works in the blood bank.
  6. Write down three things you are grateful for every night before you go to bed.
  7. Log all cases (if this applies to you) the same day and finish medical records within 24 hours.
  8. Use a system like the Bullet Journal or Remember The Milk to become more organized and never miss a deadline (including the birthdays of your family and friends)
  9. Cook your own meals at home (take a class if you need to).
  10. Be on time to conferences, rounding, meetings, classes, etc.
  11. Spend at least half a day a week “unplugged” and use it to play.
  12. Keep a journal to remember the important events of the day, vent about things that upset you, and make plans for the future.
  13. Read something that is not medical every day.
  14. Stop eating fast food.
  15. Drink less alcohol or stop all together.
  16. Get at least 7 hours of sleep any night you are not on call. (and have a plan post call to sleep more)
  17. Cut out all added sugar.
  18. Drink more water.
  19. Keep your house neater… or at least a part of your house!
  20. Stop texting while driving.
  21. Learn about motivational interviewing to help your patients.
  22. Read a major textbook in your field in one year.
  23. Learn something new from every patient you see
  24. Try a new way to exercise every month
  25. Set your intention for the day every morning.
  26. Eat breakfast every morning.
  27. Set limits on checking email, Facebook, Twitter, Instagram and other social media sites.
  28. Practice mindfulness.
  29. Plan your meals for the week on the weekend to make sure you have great food on call and at work.
  30. If you have to sit a lot at work, come up with a plan to not be so sedentary.

 

Photo credit

 

 

 

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.

 

The Secret to Medical School is Practice

The first official event for new students at Baylor College of Medicine is Convocation.  One of the highlights of the ceremony is when a rising fourth year medical student is named as the DeBakey Scholar. The DeBakey Scholar Award was conceived by the Baylor College of Medicine faculty in 1973, as a tribute to Dr. Michael E. DeBakey, one of the founders of the Texas Medical Center and a medical icon, who was revered throughout the world as the most famous surgeon of the 20th century.  It is awarded by a select committee of faculty at the college’s Convocation Ceremony to a currently enrolled medical student, who has completed all but their last year of medical education. The recipient is considered to be “living model of excellence” in residence for the incoming freshman class and the other underclass students and is chosen because of demonstrated excellence in scholarship, integrity, academic leadership and service.

award%20885[1]

This year’s award winner, Nader Zamani, delivered an inspiring talk to the entering class which he called “ The Secret to Medical School is Practice”. I asked his permission to share the text of his speech with you here.

 

I’ve been asked to speak with you briefly this morning to tell you what I wish I had been told during my own orientation. Though I am hardly in a position to impart any advice, I can definitely tell you about my experiences over the last 3 years and what has been beneficial for me. And let me be among the first to acknowledge that the emotions of excitement, anxiety, intimidation, and even fear that you may be experiencing right now are normal.

They are normal because you know that medical school will not be easy. Yes, you will be pushed. You will experience physical and emotional challenges. And at times, your patience, and even your compassion may be tested.

However, through it all, you will thrive. And when you succeed, not only will you appreciate the journey that much more, but you will also realize how much you have accomplished.

Given the challenges of medical school, you are here because you deserve this opportunity. Though I completely understand that this in itself may be intimidating to know that you are now among a class of incredibly bright and driven students, this is actually one of the best parts of medical school. And to help calm some of your anxiety, please recognize that doing your best does not mean that you have to be the best in any one subject. Doing your best is simply an obligation to yourself to set realistic goals, to ignore the external concept of ranking, and to realize that it is acceptable to say “I don’t know.” In fact, this is only in this way that you will continue to learn and to adapt to the challenges that you may encounter.

Over the next few weeks, you will receive great advice from upperclassman and our wonderful faculty about how to do well. And over the next few months, you will develop study habits that allow you to digest and process the material that you are being taught. You’ll learn how to seek out opportunities that supplement your interests, and to collaborate with faculty mentors to develop a balance in your lives that not only fulfills the demanding aspects of medical school, but also caters to your own health. As I quickly realized, taking care of yourself is one of the most important aspects of medical school, and as you will see, we are lucky to be in an environment that not only realizes that, but makes it a priority.

I have heard many times throughout the course of medical school that to be successful as an academic physician, one needs to devote 1/3 of their day to reading, 1/3 to writing, and 1/3 to thinking. And most recently at the Department of Surgery’s Inaugural Research Day, Dr. Malcolm Brock of Johns Hopkins University told us that it is the thinking part of this formula that ultimately results in the quality research and discovery that has the potential to impact our practice of medicine. 

The formula for medical school, however, has to be a little bit different. From my experiences, the 3 factors that would have to be in the formula are:

1) Studying – which includes actively keeping up with the material, asking questions, reviewing, really thinking about what you are learning, and trying to apply these concepts to a clinical setting.

2) Taking care of yourself – which includes eating well, exercising, trying to get enough sleep, and maintaining your social support systems.                                       

3) And one of the most important factors — Service. 

Similar to the thinking part of the equation of a physician’s day, the service part of the student’s formula can easily be deferred, especially considering our academic priorities. But I want to use this opportunity to urge you that this is the part of the formula that ultimately makes the difference. Taking time to reach out to others has provided me with the motivation to continue through this journey when it is easy to get bogged down by the stress associated with being in medical school. Whether service to you means working at a clinic, spending time at a shelter, tutoring, or helping your classmates, each one of us can serve our school and community by volunteering our time.

But as with anything else in medical school, you don’t have to do it yourself. By learning to work together with the amazingly talented people around you, you will grow as not only individuals, but also as a class. You will become a community with a sense of obligation toward each other, which is essentially a responsibility to help one another manage the trials that lie ahead. Ultimately, our life experiences may shape our practices, but it is our interaction with others and our service for our community that molds our profession.

I’m lucky to have attended DeBakey High School, because it was while I was there that I first became impressed by Baylor’s community outreach initiatives. Whether Baylor is working to eradicate disease on an international stage, supporting its relationships with undergraduate institutions throughout the state, or enhancing education throughout our local community, it is clear that many of our paths have led us here because of Baylor’s very own outreach programs.                                                             

It is in this very sense of community that I urge you to give back as well. You’ll be surprised at not only the inspiration, but also the perspective that you will receive as a result of your efforts. You will realize why you are spending so many hours studying, and you will begin to reevaluate what is truly important to you. In fact, your defining moments in medical school may very well be those in which you actually take a break from studying to reconnect with others.

It’s that very kindness and compassion required in medicine that truly makes our profession an art, one that requires a lifetime of practice. And it is this PRACTICE of medicine that demands so much of us. If there is a secret to doing well in medical school, it is to always keep practicing – practice your studying; practice asking thought-provoking questions; practice your self-care; practice your kindness; practice your service.                       

The Irish poet John O’Donohue wrote that with inspiration, we are able “To enter each day with a generous heart. To serve the call of courage and love.” We are all truly lucky and fortunate that we are here. We have been given an opportunity to learn not only how to help, but also how to heal. Despite the challenges that lie ahead for all of us, please remember that the road we are on is a privilege…so take advantage of it!

Congratulations, good luck, and we are all excited for you and for what is to come on your journeys here!

Advice for New Interns

This is the week that the roughly 16,000 new doctors in the United States will start their residency training.  Even though it doesn’t feel like it, you are ready!  The first year of medical school gave you the “vocabulary” you needed for this new language.  The second year gave you the “grammar.”  Your rotations in the clinics taught you the “language”.  Now you get to actually use it every day!

This year will be one of the most profound transitions you will ever make…. and it will also be a year of intense and fabulous memories.  Take some time to write down the stories, or take some photos (but not of patients unless you have their permission!).  These notes and images will be precious memories in the future.

In talking to other physicians and thinking about my own experiences, here are a few words of advice for you as you start your internship this week:

Learn from every patient.

As an intern, you will need to know a lot of detailed information on your patients.  You’ll need to use a system to keep track of all this information so that when you are asked, you know the last potassium level, which antibiotics were ordered and what the ID consultant said.  If you have a system you developed as a 4th year medical student, great!  If not, start with 3×5 cards. Keep one card per patient, clipped together or held together with a metal ring.   There are electronic systems available like iScut and My scut list.  I haven’t found one that I think is adequate –  but I’d love to hear from anyone who has found good software that works!  Also (very important) – if you are going to have any patient information stored electronically, please make sure it is HIPAA compliant.

That covers the information, but not the learning.  Learning is something that should be actively integrated into your day, not something you do at night when you are falling asleep.   Work on a system that lets you record what you are learning during your daily tasks in a way you can review later.  3×5 cards are a simple, cheap and very effective system for studying medicine, which I’ve described in a previous post. Make a separate card (or use the back of your rounding card) to list something (anything) you learned from every patient you see.

Don’t confuse gathering information with studying information.  Taking notes is a critical part of learning. Don’t just make files of chapters and articles… summarize them to review later by taking notes.

Be the doctor for your patients.

This may sound obvious, but in the everyday world of the hospital, it is really easy as an intern to get lost in the details of patient care… and forget about caring for the patient.  Stop every once in a while and remember that you really are their doctor.  Take a few deep breaths and put yourself in their shoes for a minute to ask something about their family, hold their hand, or just sit with them for a minute.

It’s very easy to get swept away by the velocity of the work most interns experience and lose the “big picture”.  When you are confronted with something you haven’t seen before, push yourself to make a plan before you call your upper level resident or the attending.  What if you were really the only doctor around?  What would you do?  Spend 2 minutes on UpToDate if you have to, but don’t just be a clerical worker – be their doctor.

Part of being a good doctor to your patients is to recognize your own limitations.  You should never feel bad about calling someone with more experience, no matter how “dumb” you think the question is.  It’s the right thing to do for the patient.

Be deliberate about learning your field.

From day one, commit to an organized plan of study to cover everything you need to learn in your field.  Your goal should be to learn (not just read) everything in the primary textbook for your field.

Make a plan to read (and then study to learn) a textbook every year.  Make notes that are easy to review, so you don’t have to go back to the textbook to review the material.    Whatever system you use, make it easy to integrate the notes you are making in the hospital (i.e. the 3×5 card on each patient) with your organized study system.  Adding articles into the mix is fine – but only after you have mastered the basics.  Don’t let reading the latest finding take the place of really learning the material in the textbook.

Be kind and be part of the team.

Hard work is made easier when it’s done with your friends.  You will all be tired, you will all be stressed, but be kind to each other.  Staying 5 minutes more to help out a fellow intern is an investment that will help both of you.  Look for ways to apply the golden rule of internship:  “Help others the way you would liked to be helped”.

Make your bed.

Do this simple act every morning to remind yourself to take care of yourself.  Find time to consciously take care of your emotional, physical and spiritual health. Take good food to the hospital for your nights on call.   Find ways to get stress reducing exercise into your weekly schedule, or at least find ways to increase your activity while you are at work. Watch your weight – if you are losing or gaining, it’s a sign that you need to focus on your own wellbeing by improving your nutrition and working on your fitness.   Nurture your relationships – make your family and friends a priority.  Take care of your spiritual needs in whatever way is best for you, but don’t ignore this important aspect of self-care.

Smile!

You have the enormous privilege of caring for other people and learning the art of medicine.   Take a little time every day to notice the moments of joy in this work and, if you can, write them down to look at on the days you are tired.

Congratulations to you for all you’ve accomplished thus far!  Enjoy this incredible journey!

The Perils of Perfectionism

Last week I attended a wonderful lecture in Baylor’s Medicine and the Art of Compassion lecture series entitled  “The Perils of Perfectionism”.  It was presented by Dr. Glen Gabbard, who is a psychiatrist and author with great expertise in physician wellness.   I can’t do justice to the entire lecture, but there were a few key points that I wanted to share:

Compulsion is one of our our greatest assets as physicians, but it can become one of our greatest liabilities.

One of the key personality traits that physicians need to have (and/or develop) is to be compulsive.  In fact, many of us choose medicine because it’s a good fit for our basically compulsive personalities.  Unfortunately, as Dr. Gabbard pointed out, unbridled compulsiveness can lead to “excessive devotion to work and productivity to the exclusion of leisure activities and friendships.”   How do you tell if a good thing (caring about patients, being compulsive) has become an unhealthy behavior?   Here’s some warning signs that he pointed out in his lecture:

  • A reluctance to delegate tasks or work with others unless they submit to exactly the way you want it done
  • Rigidity and stubborness
  • Perfectionism that interferes with completion of the task (checking the reflexes 10 times on rounds instead of once or twice)
  • Self-doubt
  • Guilt
  • An exaggerated sense of responsibility
  • Failure to take vacation
  • Cynicism
  • Chronic fatigue
  • Emotional outbursts
  • Headaches
  • Increased alcohol consumption
  • Marital “deadness” or discord

It’s dangerous to look at the issue of physician stress with an “us-them” mentality

It’s easy to think that discussions of physician stress and impairment apply only to “other doctors” (or “other” medical students).  Unfortunately, the stress that comes with out of control perfectionism can lead to suffering for any physician.  In extreme cases, it can lead to physician impairment, destruction of relationships, burnout and physical illness.  As Dr. Gabbard pointed out in his lecture “impairment is the endpoint on a continuum.”  Every physician, when exposed to the right combination of stressors, can become impaired.  The key is to realize that all physicians are susceptible, that it’s important to watch for warning signs, and that’s it’s even more important to seek help when its needed.

“The desire to excel must be differentiated from the desire to be perfect.”

I thought this was a wonderful rule for physicians to remember.  We all want to do our best, and we all want our patients to do well.  We want to excel, but we can’t ever be perfect.  Physicians don’t have control over many outcomes – some patients will develop complications or die despite our best efforts.  And… we are human.  Mistakes will be made.  The goal is to minimize them, learn from them, and forgive yourself.

“A physician that treats himself has a fool for a patient” (William Osler)

Every physician should have a personal physician.  As much as possible, the relationship should be as “normal” as possible i.e. even though you are a doctor, you should be treated just like any other patient.  That’s not as easy as it sounds, but it’s the right approach for both you (as a patient) and the physician treating you.   Why go to the trouble of finding a personal physician?  If you become ill, it’s nice to have an established relationship with the person who will be treating you.  It’s also nice to have someone you can talk to if you are feeling burnt out.  Depression, stress, and impairment can all be treated.  It’s really no different than going to the orthopedic surgeon if you break your arm.  If you need help, talk to your primary care physician or a mental health expert.

Some of our greatest lessons come from dying patients.

Anyone who has had the blessing of caring for a dying patient has learned from them that there are only two important things in life: to live wisely and to love well.  Our family and our friends are our greatest treasures.   Learn to spend time taking care of yourself  and nurturing these important relationships.  It’s easy to fall into the trap of putting off this important work… but don’t.    “The fool with all his other thoughts has this also:  he is always getting ready to live.”  (Epicurus)

Wellness for Emergency Room Residents

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

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