Monday, October 13, 2014

Self-Care Triage

If you've ever had the unfortunate experience of a visit to the ER, then you or your injured party were involved in triage. Maybe you sat there waiting to be seen, wondering why others were called back before you. If your reason for showing up in the ER is less serious than another person's, you will be be seen on a lower priority. This is the concept of triage: the natural prioritization of who and what needs to be addressed first.

With the multiple responsibilities and roles we fill in life during these seemingly shorter and shorter days, it is imperative that we learn how to triage our own self-care. Recently, I was asked by a group of young female medical students to provide some practical tips for self-care. One of them said, "We know we should try to achieve some balance, but no one ever gives us real-life tips on how to do so. I don't know where to start." This prompted me to share some concepts I've had in my head, organized by priority. Following the theme of simplicity in my Four Realms of Balance (Work, Home, Community, and Self), I chose four basic categories of self-care for my triage: Sleep, Nutrition, Exercise, and Leisure Time.


Sleep. Sleep, which arguably could be lumped into such self-care categories as "rest" or "leisure", definitely deserves to be a pillar on its own. It is the base of the pyramid of needs, a most important factor... such that all other attempts at self-care will suffer if sleep is inadequately addressed. Check out this Tedx Talk by Dr. Kirk Parsley on America's Biggest Problem if you don't believe me. The reality is that many of us will suffer periods of sleep deprivation, either due to work or childcare or other personal reasons, at various points during our lives. And during these challenging times, sleep should be priority number one... above proper nutrition or working out or any other self-care items. In other words, it would be better to eat garbage and not exercise but sleep extra than it would be to have nutrition and workouts dialed without good sleep habits.

The goal should be to get at least 7 hours per night. Of course there will be nights, such as on a call shift, that this will not happen. In that event, every attempt should be made to take a decent nap during the day. And no strenuous exercise should take place! This will merely have a paradoxically negative effect due to increased stress levels in the body. What if your profession involves shift work? This is difficult but can be managed. This blog post by night-shift pharmacist Michelle Tam is one of the best I've read about taking care of yourself while regularly working nontraditional hours.

What to do if you must nap at odd hours or have a hard time falling asleep when you should? Make yourself go to bed EARLY. Figure out when you need to wake up and get into bed 8-9 hours before that. Stop looking at the blue screens of TV, phone, or computers at least an hour before you want to fall asleep. If you must look at the computer, install f.lux. Wear a sleep mask. Make your room as dark as possible. Turn up the fan or air conditioner (or turn down the heater).

Nutrition. Without getting into political discussions about food choices or macronutrient ratios, the most broad-based, simple and effective piece of advice I can give here is to eat real food. Basically, 80% of the time you should be eating things that are made at home and/or do not come from a package, restaurant, or vending machine. No matter what your preferred diet (vegetarian, paleo, high protein, low fat, etc.), your food should be as unprocessed as possible. Experiment with some simple meals and go-to snacks that you can bring with you to work. Also have some "emergency" real food on hand for when you get stuck at work late or on-call. Examples of this would be a bag of raw almonds, dried fruit, hardboiled eggs, cans of tuna or salmon, or even an energy bar with minimal ingredients (Larabars are pretty good in that sense).

Exercise. Many people list "exercise" as one of their favorite ways to care for themselves. However, too much or the wrong kind of exercise can actually be detrimental if things like sleep are not optimized. Being in the higher and yet smaller end of the pyramid, exercise should be modulated based on how well you are doing with your sleep and nutrition. Just like you can't fake a good night's sleep, you can't "out-train" a poor diet or poor sleep habits.

Now, some people are just not athletic or do not enjoy to exercise. Nevertheless, I maintain that "exercise" is a pillar of self-care for us all, as long as you re-frame it to encompass a broad spectrum of low-level activity to all-out intense sprinting. What is the type of exercise we should all be doing the most? WALKING. Most of us are capable of it, and if we are not, there exists a similar low-level alternative. And all the walking you do during your day can add up to quite a workout! What if it doesn't because you sit all day at work? Try parking in the remote parking lot, taking short desk-breaks, walking at lunch, taking the stairs, etc. Build your exercise base with walking and fill in the rest with what is appropriate for you. (The topic of exercise deserves its own triage pyramid... a subject for another future post!)

Leisure Time. The rest of "you time" should be made up of things that bring you enjoyment. Not sure what those things are? Well, then you should spend some self-reflection time figuring out what makes you tick! What are your simple pleasures? What kind of personal maintenance activities (baths, massage, creative time, meditation, etc.) do you require to feel good? Take a look back at the Resilient Clinician self-care questionnaire for inspiration and have some go-to ideas.

My triage may seem a bit daunting, but it's actually very simple. When faced with a choice over how to fill a particular period of time, think of the pyramid. I use it constantly in my own practice of balance; I may have planned to weight train or go bouldering after work, but if I woke up from a bad night's sleep or work was particularly stressful, I will skip it... or maybe just go for a walk! How about you? How do you prioritize self-care?

Monday, September 29, 2014

Busting the "Hidden Curriculum"





The medical school at my hospital is now offering a structured Wellness Lecture Series for the first and second year students during their lunchtime break, and I was proud to be a part of it last week. I was the first presenter this year with my Heal Thyself talk. It was an honor to share with them my personal experiences in wellness and stress management, and I hope to continue doing it ever year!

The planned lectures to follow include more detailed information about some of the things I discuss in my talk, namely nutrition, exercise, mindfulness practices, etc. So it seemed perfect that my lecture started things out this year! I'm curious what detailed advice the other experts will be providing.

I also recently hosted some female junior medical students at my home for a potluck, and I asked them what kinds of information they would like to see in the Wellness Series. They said that they wanted concrete examples and details of how to take care of themselves. I found this questionnaire from the book The Resilient Clinician, and I thought it might be worth sharing here too. Take it and see if it helps you identify some new self-care strategies!  

In last year's NY Times expose Medicine's Search for Meaning, the "hidden curriculum" of medical school is described as one that teaches future doctors to be self-denying, push emotions to the background, and cover up parts of themselves for the sake of work. We have to undo this type of thinking early in their training, before the bad habits set in. We need to be able to uncover ourselves and families. Different institutions have a variety of ways that they deal with this, including entire courses such as The Healer's Art, which is now taught nationwide at more than 70 medical schools. So glad to be a part of an institution that's trying its own methods for raising self-care awareness!

Check out the talk slides and the questionnaire and let me know what you think!

Monday, September 22, 2014

Taking Time to Enjoy the Raspberries

(My hand, my raspberries)

We have a couple of raspberry bushes in our yard, and our neighbor has a tall one that hangs a bit over our side of the fence. While none of these could be considered copious producers, each bush steadily makes daily raspberries - a few at a time - from mid summer to early fall. At this point in September, their bounty is fleeting... which made me think about how much pleasure I get from the unassuming plants each year.

Every day, I wander past the bushes. Oh look! A few more berries! Sometimes they are dark and perfectly soft. Sometimes the white buds are just starting to turn pink, and they are too hard for picking. No matter; they'll be ready for me to eat them soon. A few berries might be shriveled and drying because I didn't notice them soon enough (always a sad sight). I might glimpse, for the first time, a little droopy, leaf-covered clump holding a cluster of perfect, yet-to-be-picked berries. How did I not notice them until now?

It is rare to collect more than a small handful in a day. Depending on my mood (and hunger level), I might just pop them all into my mouth at once and savor the juicy burst of flavor. If there are only a few, I may eat them individually in succession, experiencing their distinct berry-ness one by one. In the case of a nice handful, I will carefully take them inside, balancing delicately in my hand, to eat with some yogurt or pudding later.

In the midst of our complex lives with daily conflicts to resolve, work duties, roles as doctors (or patients), as spouses and parents and caregivers and friends, it is a treat to find so much pleasure in something so simple. The equivalent of less than a dollar's worth of raspberries that are home-grown and fresh, perfectly tasting and yet with slightly different characteristics each time, gives me immense happiness. Which is something I need lately in the midst of life's challenges. I'll be looking forward to their arrival next year!

This recent Huffington Post piece talks about the often forgotten act of noticing and points out some things in our lives that deserve to be noticed. One of them is "simple pleasures". What's your simple pleasure? Share it here!

Sunday, September 7, 2014

PracticeBalance Again Featured on KevinMD!

My recent post about the challenges of NORA was picked up by the Medpage Today's popular medical blog KevinMD.com. This was a timely release, given the recent events surrounding Joan Rivers' death. To be honest, I hadn't heard about her death being a possible result of an endoscopic procedure until I started reading some of the comments to my post. (Shows you how much TV I watch)!

Of course at this juncture, it is difficult to know the details of how she suffered cardiac and/or respiratory arrest during an elective procedure at an outpatient medical center. She could have been receiving moderate sedation or something deeper, and there may or may not have been an anesthesiologist present (I cannot piece it together from the conflicting reports I have read).

The thing to note is that she was 81. She may have had lots of plastic surgery that made her physical appearance belie her age, but sedation or anesthesia on an 81 year old is never without risk. And sedation or anesthesia of any type on anyone is not without risk. 

Anyway, here is the link to the syndicated post. If you can't stand to read the post again but are curious about the comments, those can be found here.