Wednesday, February 20, 2019

Retrospective wellness advice for my pre-clerkships self

Two plant pets being raised by Andrew

Currently I am taking an East West Medicine elective, which has been a fascinating way to learn about complementary and alternative medicine (including Traditional Chinese Medicine), and to think about my own wellness state and changes I would like to make.  In many ways it is a formalized continuation of my efforts in making some habit changes as a third-year medical student on the wards.  As I blogged about previously, some of my reflective writing last year is focused on these habits, which I have more or less continued during my fourth year, so here is the promised second post.  Nothing here is revolutionary, and in fact most—if not all—of this is common sense, but I think common sense is often arrived at by circuitous routes.

In the spirit of trumpeting common sense:

1. How to survive [at least one year of] medical training as someone who doesn’t tolerate sleep deprivation well  |  One of my biggest fears about MS3 was whether I would be able to function effectively when sleep-deprived on hospital rotations, especially on surgery, with its frequent 5-6am start times (and sometimes even earlier).  Many older students and residents told me that while their sleep deprivation was real, it was something they got used to, and that falling asleep while actively doing work wasn’t really a concern.  They were right: it’s quite difficult to doze off while walking around the wards, making phone calls, or checking lab results.  Sitting in one place during lectures is more challenging, but that’s where coffee is particularly helpful, as is the collective understanding – or so I told myself – that everyone nods off occasionally.  The overnight calls I took also turned out to be more manageable than I expected, in part because my expectations were dire to begin with, and in part because many of my supervising residents were kind and would tell me to go sleep for a couple hours if nothing was happening.   I could only sleep fitfully, afraid that I would somehow miss a text message or a pager beep, but even a 20-minute snooze helps. I did eventually learn what it feels like to be awake and almost constantly on my feet for 28 continuous hours, plus the time spent getting to and from the hospital: not good, but indeed I survived, and the most exhausting night I had also turned out to be a highly educational one in terms of both the surgeries and patients I saw. 

TL;DR: Sleep when you can and trust that you’ll get through it.  Or, to adapt something one of my early mentors told me, the night always ends, and the rotation always ends.

Brief detour on the topic of studying: Though this is without any kind of formal sleep log, I think I averaged about 7 hours of sleep per night over the entire MS3 year.  I certainly envy those people who truly need only 6 hours or less of sleep each night, but for better or for worse, 7 hours is the minimum I need to feel alert and productive.  Accordingly, I learned early on during MS3 that in the choice between going to bed early enough to get 7 hours of sleep vs. staying awake and studying for the shelf exam, I should go to bed.  I certainly didn’t ace every exam, but I was satisfied with my performance.  Also, on most rotations there were daily episodes of “down time,” such as waiting for new consults, or waiting for a patient to be rolled back to the operating room. I found that fitting in a couple practice questions or reading a few pages during each of these breaks could result in a significant amount of studying being done by the time I headed home.

2. How to exercise when you are prioritizing getting enough sleep  |  I started running during college and eventually discovered that it could in fact be inherently pleasurable, but for me the most important benefit of exercise is that it improves both my mood and my sleep quality.  Between 2.5 and 5 miles is my preferred distance range; any more than that on a regular basis, and I am likely to meet twinges in my knees or hips, not to mention that the workout requires close to an hour

  • Walk to/from work and take the stairs whenever possible. This is obviously some of the most common and boring lifestyle advice ever.  During MS3 most of my rotations were at UCLA’s main campus, which is a 20-min brisk walk from my apartment, so I benefited from 40 minutes of walking on many days.  Follow that with sometimes climbing hospital stairs up as far as the 6th or 7th floor (while wearing a backpack), and that is a pretty respectable mini-workout.
  • Set reasonable expectations for exercise frequency and duration.  I had at least one day off a week, so that allowed me to go for at least one run per week. Sometimes I would get sent home early, and so that would allow for a bonus workout.  Even a 30-minute run was a great way to clear my head and somehow reset my body for the week ahead.  During my surgery rotation at the very end of the year, I started using the Nike Training Club app and found that I like the bodyweight workouts, which are often just 15-30 min long. Occasionally I would tack one on to the end of a short run, but often I would do a short workout on a yoga mat in my apartment.  It’s not as hard to talk myself into a 15-min workout if I can then literally walk 10 steps into the shower.
  • Speaking of yoga, exercise classes are cool, but it’s ok if they’re not your thing.  I have tried both barre and yoga classes, both of which are innumerable in LA.  One of my friends is a SoulCycle devotee, and another loves Pure Barre.  The classes I’ve tried have been nice, but ultimately my preference is to work out on my own for less than an hour at a time.  I also like being able to start and end workouts at my apartment instead of having to walk or drive to a studio.

3. How to eat for health and pleasure when you really just want to eat for pleasure, because you are tired and stressed and cookies are good  |  I have always been an enthusiastic eater who loves trying restaurants and bakeries, reading cookbooks and food writing, cooking, and baking.  I particularly love desserts, though I hesitate to call it a “sweet tooth” because I prefer desserts that are minimally or moderately sweet, and as I get older my tastes are sometimes veering toward the savory.  I am also cognizant that being slim doesn’t make me less prone to diabetes; in fact I have multiple risk factors, being East Asian and having a family history of diabetes.

As my stress level ran persistently high at the end of grad school, I started using food as a source of comfort.  This pattern of stress-eating and fatigue-eating persisted through the start of MS3.  It can be difficult to eat healthily while working in a hospital.  Salads take more time to assemble in the cafeteria and then to eat, compared with sandwiches or pizza.  Bagels with cream cheese are a traditional fuel for medicine teams after an overnight call, and when you are tired, it’s amazing how easily bagels (yes, sometimes more than one) can be tucked away in the blink of an eye.  Afternoon seminars or conferences often include a plate of cookies, and it is so easy to mindlessly grab one on the way to your seat.  I also found it hard to resist the pastries frequently lying about the residents’ workroom during my medicine rotation.  It didn’t help that sometimes these snacks included fresh gourmet donuts from Sidecar Donuts or even cake from Sweet Lady Jane, brought by a particularly generous attending.  

During my second rotation, ambulatory (outpatient) adult medicine, I spent one afternoon shadowing the clinic’s dietitian, who enthusiastically described to me just how many servings of carbohydrate (four!) are in the typical American bagel.  After a visit to my own doctor I realized that my hemoglobin A1c, a marker of blood sugar levels for the prior three months and a useful marker of diabetic status, was creeping close to the pre-diabetes threshold.  Yikes!  In addition to developing a sustainable exercise routine as already discussed, I resolved to make some dietary changes, namely:

  • Reduce intake of starchy carbs during the day and pair carbs with protein whenever possible, to prevent spikes and crashes in blood sugar.  If I choose a lunch of salad with chicken, tofu, or chickpeas, or a protein entree with vegetable side dishes, with perhaps half a serving or less of rice/pasta/bread, I feel a more consistent energy level during the afternoon.  If a sandwich is what is available, I’ll eat less of the bread.  For snacks I like fruit and nuts, or no-sugar-added bars like Larabars.
  • When possible, eat more slowly to reach satiety but not over-fullness (or drowsiness).  Most of the time I try to eat something every couple of hours.  That said, I learned during my surgery rotation, when certain surgeries were very long, that it takes quite a while (over 6 hours) before I actually feel strong physical sensations of hunger.
  • Pay more attention to your actual level of hunger and desire for food; take a moment when faced with convenient but unsatisfactory desserts.  Many of the pastries that are frequently available at work are in fact not that great—a doughy or dry croissant is a sad thing—and I don’t even enjoy them while I am eating them, but it is easy to forget that when standing right in front of the tray.  I am trying to first ask myself if I am actually hungry or actually want that particular dessert.  I also try to remind myself that I am perfectly able to either buy or bake myself a delicious dessert that I can fully enjoy at a later time.
  • Food is for both enjoyment and nutrition, but it’s not the end of the world if you eat a crappy cookie. The frequently touted rule of eating healthily 80% of the time has been somewhat useful for me.  It helps to have that 20% of self-compassionate room: sometimes a middling seminar cookie or slightly stale Danish just has to be eaten.  Conversely, good food will always be one of the most important aspects of my personal wellness.  During a delicious dinner with good company, I love sharing the bread basket, ordering a glass of wine, or trying dessert, and occasionally if I want all three and I truly enjoy all of it, then that is awesome.  Ultimately, I have come to believe that mindful eating, in all its forms, is the most nourishing of all.

4. How to care for your own mental health the way you want your patients to  |  Other than general good health, the biggest blessing in my life is that I have a supportive family and set of close friends.  Living with Andrew was particularly important during MS3, and though our time together was more limited because of my early-to-bed and early-to-rise schedule, we tried to spend intentional time with each other whenever possible.  These days so much of our lives also involve our phones (for better or worse), and I also found that being able to text with my husband, family, or friends during moments of “down time” helped create much-needed mental breaks and moments of levity.

Another enormous blessing in my life is psychotherapy, and I would be remiss if I did not mention in this piece the positive impact that therapy has had in my life.  I started seeing a therapist during my last year of grad school, and continued to work with him on and off during MS3.  We focused primarily on emotional mindfulness and the process of fully experiencing emotional reactions when they occur, actively allowing them to move through me instead of suppressing the thought and storing the emotion for later, often for reemergence at unexpected times.

In an important step a few years ago, my med school established a Behavioral Wellness Center, where medical students, graduate students, and resident physicians can all receive psychotherapy and psychiatric care, fully covered by our student/trainee insurance.  The providers offer early morning and evening appointments to accommodate clinical work hours.  This Center is an amazing resource, one which has benefited me and so many of my colleagues.

In summary  |  I unexpectedly found that I ended my MS3 year in a healthier state than when I began, and with better habits that could continue to fit into my life.