Sleep is good

Amazing what happens when you get 7 hours of sleep! Yesterday felt very blah just as described in my last entry but today even though I was on call and slept in a call room last night, getting 7 hours feels awesome. I feel energized physically and emotionally and headed home ready to plan some productive and some fun things like planning a Xmas party, sending out some emails, working on some things, going to the beach, working out. I keep thinking of what Dr. Oz says were the four keys to changing one’s behavior to reduce stress eating 

1) Don’t drink in calories – get rid of sugary drinks, juices, milk, it strikes me that the reason I drink juices are that they are easy and cold, one thing worth looking into is an easy cold drink I can make at home. I think having ice readily available (auto ice maker) and something with milk, honey and lime would be excellent if I can make it

2) Sleep! – Ozgur sleeps 7-7.5 hrs a night and if he can do it and still be the Vice  Chair of an academic surgery department, researcher, teacher, surgeon and have his own prime time show and have time to read to his family, what excuse do I have?

3) Keep moving – US Preventative task force recommends 150min of activity per week (half hour a day) – I think for compliance purposes I am going to try for daily activity just in the same way once daily dosing is more effective than any other regimen for drugs

4) Stress buddy – I find that even thinking about Jane before I make bad behavior choices is great, I can hear her voice “don’t do it bear! Its bad for you!” and it replaces the empty calories with a smile

A wedge of lemon, warm compresses and a touch of TLC

First night on surgery call and had an 86yo lady with “frozen bowels” aka postoperative ileus. She had just had her bladder removed five days before and was having a prolonged recovery from surgery. Because her bowels were not moving which is a common condition after surgery, she developed nausea and vomiting and had to have a tube placed in her stomach to drain the vomitus out and we were keeping her “NPO” which means nothing by mouth. I noticed this morning that she had some swelling of her left cheek just above the angle of her jaw. This progressively worsened and became very painful over the course of the day to the point she was grimacing in pain and not moving her head at all due to the pain. After a quick consult with Jane, I thought she might have an infection of one of her salivary glands from lack of salivation due to not having anything by mouth. It turns out I was right and with a little massaging of her cheek, I was able to get a whole bunch of pus (and hopefully a stone) out of her mouth. The treatment is actually something my mom could have come up with: twice daily massages to get the pus and any stones out, warm compresses and wedges of lemon to stimulate the gland to secrete saliva!

Afterwards she felt better and I felt super satisfied! Where else in medicine can a little TLC, some lemon and warm compresses do THIS?? :)

Deadlines help when ur not tip top

So much for being positive. Felt a bit blah/hesitant/pessimistic/tentative/lazy today. Unlikely to be emotional or professional since no real developments in either area in the last 24hrs so I am thinking likely physical. Possible factors may include probably is a combo of poor sleep, alcohol the night before, less caffeine this morning. Interestingly, still had a pretty productive day because I had a deadline to send out Xmas cards in time for the holidays and also had to get some exercise in before tomorrow’s call. Good to know that for days like this, having deadlines help!

Feel great

First day back from Houston. Started surgery today but not on call so got out at 9am. For some reason I feel really good today. Not good in a manic sort of way like excited or on edge but in a really well balanced and positive way. Just totally positive, optimistic, energetic. Even thinking of things that are “downers”, missing Jane, worries about my board scores, loans, etc seem to roll off. Not sure why but definitely worth investigating since things just seem really “up” and would be great to keep it going!

I think I started feeling good after the first three days of vacation when I had to deal with a frustrating transaction at the Chinese embassy.  I finally got on a treadmill on Thursday and Friday of last week which felt really good and gave me some physical energy. I finally finished this frustrating Chinese transaction on Friday just in time to go out with Jane who set up this nice dinner with some friends from Tuck and then drinks with her friends from residency. Then the next day she had the day off, we slept in, went to eat some great dim sum (really good actually) and then went to the Houston Zoo and watched Harry Potter then went home and made some spam musubi.

Had a good plane ride on the way home where I got some reading in Economist and Innovators Prescription by Clay Christensen, thought of some new ideas for my research project, got picked up by my roommate and some other co-interns then had a nice dinner with my roommate at a local hangout.

Looking at the above there is nothing really that strikes me as mindblowing. Perhaps its just feeling good about my mind and body with some physical activity and endorphins kicking in as well as mental stimulation with my research project. I guess one other note is that I finally watched my first episode of Dr. Oz and felt like it was really inspiring to see a legitimate doctor really translating concepts and evidence based medicine into lay language in a really expert way and then tackling some tough issues around behavior change such as weight reduction, preventative health etc. Also seeing him as an example of someone who is centered who can be involved in multiple things (practicing CT surgeon, academic researcher, administrator, TV celebrity, dad) and still have time to sleep 7-7.5hrs a night was quite inspiring.

Once again no solutions, we are complicated beings, but good once again to document happiness. One of these days I will crack the code to what makes me happy!

Flexplans for MDs

I have become convinced that when it comes to work-life balance in medicine, you can structure the hours however you like shift work/call, but ultimately it comes down to how many patients you can comfortably manage as a provider which should be up to each physician to determine for themselves. Interestingly this goes to a huge area of cost on the hospital financial side namely the tension between every increasing demands of hospitals to churn more volume and “decrease” costs and efficiency by working the docs harder which leads to hospital turnover and decreased continuity of care. What if we had a system where physicians could adjust how many patients they see? I suppose this happens already in primary care. And from at least one of the studies looking at physician job satisfaction, it certainly seems like office based practices where it may be easier to titrate ones cases rather than high paying high volume practices (hard to turn down emergency room volume, trauma surgery cases) lead to less job satisfaction

http://www.medfriends.org/job_satisfaction.htm

Maybe pain medicine is starting to look a bit better!

On Self-motivation

You know that feeling you get in the morning when you just don’t wanna get out of bed. Maybe you had a late night, maybe you’ve been deprived of sleep all week. But you know you have to because 1) you gotta get your day started 2) you are getting out of shape 3) its fun (once you get going).

This sense of universal inertia is a fundamentally human part of all of us. It struck me today (as I finally got myself on the treadmill this morning) that overcoming this “mental inertia” is the fundamental challenge underlying much of leadership, marketing, medicine, economics. I mean, if you can’t motivate yourself how can you claim to be able to motivate others? If you can’t get yourself to take the pills four times a day, how are you going to market this pill to docs/patients?

It strikes me that this inertia is fundamentally a neurochemical problem. It is no coincidence that Apathy is a characteristic symptom of depression, schizophrenia and many other extreme psychiatric disorders. Overcoming this in a non exogenous way really then lies in altering both our long term neurochemical balance (days and week) as well as our short term balance. I think the best polypharmaceutical here are things like exercise, meditation, a positive state-of-mind and things that give one positive bolus of endorphins. I wonder if things like 10 jumping jacks or relaxation breathing in lieu of long term maintenance stuff may be efficacious as well? I also believe that negative modifiers such as self threats “if I don’t do this now”, poor mood, bargaining are helpful to a point but do not work by themselves to steel the will to act.

The moral of this story is not new nor mindblowing, we need to be happy and balanced in our lives and in our neurochemistry and that will do wonders for us in the short term. In the meantime, beating oneself up has its limits, perhaps a little jolt of energy from short term versions of neurochemically modifying activities can be helpful?

Cool quote to describe the problem of applying technology in medicine

The paradox is that hospitals have 21st century needs, 20th century technology and 19th century budgets.

Walking with both legs

I recently watched the North American premier of Zhang Yimous new film Under the Hawthorn Tree. During the post screening Q&A, Zhang commented in response to a question about the tension between art films and commercial films that as a Chinese filmmaker today one must “Yung liang tiao tui zou lu”. In other words, he went on one must help China protect it’s market for filmgoers the young 20-30s who want to see Hollywood style movies while at the same time making films for filmmaking or “arts” sake.

I found these comments to resonate deeply with me. In the face of conventional wisdom and social pressures to package each of us neatly into one single career or passion, I’ve always thought of my own career as one in which I am constantly balancing several interests for which no single professional activity alone can optimize. I keep coming back to the three I’s impact, independence and income. I must optimize all three in my mind to be successful. Impact in my view has to do both with personal sense of accomplishment as well as social approval. One should not only feel a sense of satisfaction at the purposefulness and meaningfulness of ones work as well as achieve some socially determined recognition of success. Independence, having a loved and loving family behind ones career is vital. The support that my family and Jane provide me is critical to my ability to function at a high level. Finally income, how good is money at measuring the impact of ones work? I’m not sure but I do believe it is an important measure whether you are a nonprofit attracting donors and donations or a large consumer goods company tracking sales or an investment bank managing a portfolio of assets, the more dollars your work affects the more value you create and the more risk you bear ie the more impact you have. Income is at least a part and in my opinion a big part of the picture.

So where does that leave me? What are the two legs of my walking success story? One is as a Doctor, I am more sure of this every day. The next well we shall see, I have a feeling it will have to do with the business side of healthcare. Stay tuned . . .

Motivation

What is motivation? According to wikipedia the word is defined as “the activation of goal-oriented behavior”. As I sit in my house looking at my google calendar, at all the meetings later this week, putting the final touches on my vacation schedule, noting the 7 overnight calls i will start the following month, I feel a mild anxiousness. Its not a full blown dread at the work that is forthcoming or even an anticipatory nervousness or performance anxiety. Rather is a dull agitated feeling in my gut that I am not doing what I should be in life. Its an uneasy sense that I am not going the right direction coupled with a mild frustration at not being able to find the right direction combined with a paradoxical nihilism of why finding a direction even matters. Either way I feel particularly lazy, unmotivated, stagnant.

So why is it that I feel like I am procrastinating even though I have nothing really to do? I suppose even though I am still undergoing my medical training, have made a ton of friends in my new program, I have gotten into a routine of having extrinsic goals set for me over the last 5 years to the extent that I have lost a lot of intrinsic motivation to set and execute my own goals. Its interesting, even doing laundry or cleaning my room as gotten to be a chore whereas presenting at a conference or turning in IRB proposals and setting up meetings for research have become routine.
It doesn’t help that in the midst of all of this, I am feeling my attention span get shorter and shorter as I get tired, have even less time as a resident and feel the pressures of the mid 30s modern day life start creeping up.
Hmmm, we’ll keep thinking bout this one

as I think back to why I decided on medical school now 7 years ago and the last time I had this uneasy feeling

Habits of the mind

President Kim likes to talk about “habits of the mind” in his speeches to the undergraduates. I recently read a piece at convocation for the entering Dartys (Class of 2014):

http://now.dartmouth.edu/2010/09/convocation-address-by-president-jim-yong-kim/

It hit me when he discusses his example of procrastinating . . . I mean “writers block” while writing his own PhD thesis which he overcame by doing exercises he called “morning pages” in which he just woke up in the morning and wrote about anything.

It is interesting to map this onto my own experience in which I have developed since b-school the habit of being a little hypomanic in order to improve my productivity. For example, to overcome my own procrastination, I use deadlines both real and artificial and set them closer together so that my time being productive can be maximized.

The unusual problem which I have encountered with this method though is that I end up having to “pay the price” of this adrenaline and hypomania with some subclinical depression when I feel like I must just lay around and do nothing for as long as a night to a few days and as long as two weeks.

For example, during my last 3 months at Dartmouth, I organized the Dartmouth Summit on Healthcare Delivery, matched at Hopkins Anesthesiology, got two business job offers and started a business while finishing my last term of business school. After this, I had about two weeks to finish packing and say good bye to friends, instead I lay around sometimes feeling so disinterested I literally did nothing or perseverated playing video games etc.

I had an interesting conversation with Ji Soo who I just saw for the first time in 5 years. We discussed the advantages and disadvantages of focus vs the approach I have been taking to a dual track life and career. On the one hand, defining success as creating something valuable, achieving something prestigious which is what Ji Soo suggested involves spending 110% of one’s time on one thing. Especially as he describes when everyone else competiting with you is doing the same. However, I simply love being involved in multiple things. I think there is a synergy for me in climbing up the first 80% of my attention and focus curve and once my productivity/attention/focus/effectiveness plateaus moving onto another project so that I can constantly stay on the steep part of my learning and passion curve. For example in bschool I remember spending one term focused completely on school then the next term doing 2-3 things while taking classes and noting that I sometimes did better in the classes despite doing other things. I suppose if you assume my grade reflects what I actually learned in the class then this means that somehow I can get a “twofer” by doing more things at once. Either way, this may just be a habit I cannot change. Something tells me that I am destined to a life of throwing on multiple hats and loving every minute of it. ;)