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This post was originally going to be a carping vent about other people who’s out-of-context assumptions about my ability to manage my own time hold me back from reaching my full potential. But as I sat down on the patio at a Queen St West pub, cider in hand, the negativity drained right out of me (faster than I could drain my pint glass). So instead, this is a post about the people who enable me.

“When you die, the most important thing you will have done with your life is mentor other people.” – Al Craig (paraphrased)

I just finished an eight-hour meeting of the MedicAlert Board of Directors. This group of 12 women and men are responsible for strategic direction and governance of a Foundation who’s mission is to save lives by providing emergency personnel with critical information at the time of need. During our meeting we discussed what we were looking for in prospective board members, and it got me thinking.

Like MedicAlert, I have a board of directors. It is a group of diverse and intelligent people who all place my interests in high regard. They believe in me even when I don’t believe in myself. They are a diverse group of experts from various fields that directly or indirectly play a role in my professional and personal lives.

One member of my Board once said something that I will never forget. We were at his retirement party at a yacht club and it was all very fancy. He stood up, thanked the crowd, and offered a reflection on his industrious 40 year career of saving lives, transforming systems, making scientific discoveries, and managing a half-billion dollar organization. These accomplishments, he said, were very nice. But the most rewarding part of his curriculum vitae wasn’t his war stories from the medical trenches, his political wins, or his list of publications. It was watching his mentees succeed.

Yep. His legacy, he sincerely believes, is evidenced in those he mentored.

 

As one of those mentees, I felt incredible privilege to have access to his wisdom, insight and investment and horribly responsible for my future endeavours lest I should let him down.

If my Board, which is spread around the globe in at least half a dozen time zones, were to meet in person, he would surely be the Chair.

 
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My Board

Who?  My Board is fluid, but most of the people on it have known me for a decade or two. They know who I am. They know what I am. And they know what I can do. Most importantly, they place my interests above their own, every time they give me advice. They make up most of the very short list of people I trust completely.

Why?  My mentors challenge me to articulate my crazy ideas. They expose weaknesses that could lead to disaster and make connections that lead to brilliance. Sometimes this puts a brakes on my plans, and other times it accelerates my path. In a few instances, it has completely revolutionized my life, putting me on a path I never would have found on my own.

How?  My mentors encourage me when I’m down, pat me on the back when I succeed, scold me when I’m insincere. They keep me honest, demand integrity and never let me forget where I came from.

Sometimes my mentors disagree with each other, but they never force me to pick favourites; I have the autonomy to accept, reject or modify their wishes so that I can choose my own path. If that path ends in disaster, they are right there to help me execute a U-turn, or pave a new way forward.

Life is complicated. My Board guides me through the ups, downs and in-betweens. I am eternally grateful to them for what can only be described as unconditional love. They care. Today’s interactions in the Board meeting opened my eyes to the importance of having a smart, diverse team of deeply committed experts behind you.  I understand what my mentor meant that night at the yacht club when he confidently preached that the most important thing you can do with your life is mentor other people.

As I move through my career, I do my best to mentor others using the examples taught to me by my Board. Those a big shoes to fill, but thanks to them I am on solid footing.

 

Who’s on your Board?

I’ve read nearly every Zombie survival guide out there, and can quite confidently state that when (not if) the Zombies arrive, arms grabbing and mouths gnawing, I will survive. While their dogged determination and sheer numbers have overwhelmed numerous B-rate celebrities in film after film, I have sorted out an algorithm of sorts, a protocol, to survive.

This protocol, the Zombie Apocalypse Protocol for Survival (ZAPS), is secret. I’m sorry – it’s nothing personal, but as you must know from 28 Days Later, displays of compassion during a Zombie Apocalypse will get you killed. I suppose you’re likely to come back from the dead as a human-eating Zombie, if that’s any consolation. Ok, fine, I’ll give you the basic components. You can try to fill in the blanks, and some of you (Brodie Nolan) are qualified to critique and collaborate on improving it.

AN ABBREVIATED GUIDE TO SURVIVING THE ZOMBIE APOCALYPSE
First, there is preparation.
Second, surveillance.
Third, rapid response, which has four prongs:
            1) Alert others as circumstances allow
            2) Evacuate if possible, else:
            3) Hide (for there are good hiding spots and bad).
            4) Fight (neuroanatomic disruption is the key)
And finally: Die heroically *in a fashion that excludes becoming a Zombie       
 *optional, depending on Zombie species.

How To Kill A Resident

With equal preparation to ZAPS, one could learn how to kill a resident. Residents are not Zombies, though if you stared into the eyes of a Resident post-call, you might mistake him or her for a creature from Resident Evil. Residents are, I feel the need to remind some of my Staff Consultants, humans. We have weaknesses, feelings, and insecurities. But since Residents are unlikely to attack you outside of the safety of their dreams, we could use their weaknesses to actually help residents live better, learn better, and be better.

There are four general ways you can kill a resident, none of which involve physical disruption of the central nervous system:

    Disengage them                Undermine their confidence

            Judge them to be incapable           Allow venomous commentary

And so, I present to you How to Kill A Resident, in the hopes that you will help inoculate us from these pitfalls of Mother Medicine and make us as invincible as the Zombies that will one day kill us all. Well, most of us.

How to Kill A Resident #1: DISENGAGE THE RESIDENT

Don’t listen to what a resident is saying.
Teach the resident something they don’t want to be taught.

Words, tone and body (or eye!) language should be listened to. If I am glazing over, staring off into the distance, or mesmerized by an environmental services worker’s mop movement, please stop teaching me how to work up cutaneous T-cell lymphoma. I DON’T CARE. Even if you think I should care, I don’t. So, either find an angle to get me to care or move on.

How do you find an angle? Treat me like an emergency resident, no matter what rotation I’m on. Find something that I need to know. Start your lesson with “here’s something that emerg docs get wrong all the time” or “let me tell you about a tragedy that could have been prevented”. No offence to consultants in internal medicine or surgery, but you don’t know what the Royal College expects me to prioritize in my Oral Board in 2020. What is important to you may not be important to me. Let’s work together to make my off-service rotation result in my development as an emergency specialist.

How To Kill a Resident #2: ASSUME THE RESIDENT IS INCAPABLE

Use the Law of Averages to think you know a Resident’s needs.
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Whenever I ask to do a procedure, I am asked “What PGY level are you?” My numeric response will determine if I am given what at the time seems to be the penultimate privilege in medical education (when in reality it is your job to supervise and guide me until I am competent in procedures). We all come from different backgrounds and through interest, chance or luck have different capabilities and experiences.

I suggest preceptors rephrase “What year are you in” to a more specific question: “how many times have you done this independently in the past? or “what step do you often have trouble with when doing this procedure?” It’s also totally fair to see if I have done my homework – “What are the contraindications to performing lumbar puncture” is a totally fair question if I ask you to let me stick a needle in someone’s spine.

Now that you’ve decided to give me a chance, I need you to be patient. Running through my checklist and fumbling with equipment takes time. It might even take another tray or pair of gloves if I break sterility. Help me prepare for success; I appreciate that screwing up is type of experiential learning, and I think it has value in simulators, but guiding me to success and following up afterwards with pearls and pitfalls is my preferred way to teach and be taught in a clinical environment.

How To Kill A Resident #3: UNDERMINE A RESIDENT’S (FRAGILE) CONFIDENCE

Show off.
Insult.

Dear Non-ER Consultant: I am a new, junior emergency resident. I am not as smart as you, and I know it. Rather than show off your knowledge, show off your teaching skills. Find my level. Help me raise it a notch. Don’t start with “what’s the FiO2 of room air” and move on to “interpret this blood gas.” If I don’t know something, I am to blame. But the system has also let me get this far without filling that gap. Let’s be practical: fill the gap to accomplish the goal of “me not screwing up again.” This is also known as “teaching.” 

During laparoscopic surgery, you can yell at me for not being able to direct the camera at the Ligament of Treitz (“Did you even go to medical school?”) or you can recognize my limitations and feelings (“Julie, can you take over for Blair? He’s very nice, but they don’t do much laparoscopic surgery in the ER, and I need an experienced camera operator during this critical phase of surgery.”)

A short guide to telling me to kick it up a notch:

My colleagues and MedEd heroes may disagree with this next part, but I think it has served me well as a preceptor of paramedics and as a learner. Save your below-the-belt punches for the end of the day. If my fragile confidence is shattered mid-shift, I might as well call it a day. Teach me what you can, and then sit me down before we part ways. “Blair, for someone who has been on this rotation for three weeks, you seemed to drop the ball quite a few times today. Is there anything you want to chat about?” is a fair way to call me out on poor performance while offering assistance. If I am below the mean, I appreciate being told “I’ve had a few other emerg residents recently, I would have expected your anatomy knowledge to have been stronger.” If I need a kick in the ass, kick me. Be obvious, be quick, and do it once. Please avoid the balls. I’ll do the rest. I am my own worst critic.

How to Kill A Resident #4: ALLOW VENOMOUS COMMENTARY

Allow trash-talking of residents
Give feedback badly

It sounds obvious, but we can forget the basics of humanity when we are working in health care. We are not perfect, but we all want to provide perfect care to every person who we interact with.

We are all learning (and will continue to do so until we retire). We all struggle. We all believe certain dogma that may, or may not, be kind of, or not at all, true. We are all inspired by our love of medicine. So we do not put people down. We seek solutions to our challenges, we reflect on ourselves, and encourage others to reflect on themselves. We feedback to each other, we feed back to ourselves.

Feedback is mandatory if we wish to fulfill our central purpose: to deliver perfect care to people in need. Please give me feedback. It can be positive feedback, or it can be negative feedback. It can be filtered, refined, or blunt. I love it all. But please give it in a constructive manner with one objective in mind: to influence my practice so that I can be an excellent physician.

Give me feedback with the intent of hurting my feelings, undermining my confidence, or disabling my curiosity, and you will be attempting to extinguish the burning fire that gets me out of bed each morning. Without that fire, I will be, by definition, burnt out.

Burn me out, and you will have killed a resident.

//

What do you think of my ideas? Please like, comment, share, tweet or use your rotary phone to dial your friends and tell them the URL of this page.

Feeling burnt out? Feel free to get in touch with me, the Doc Help Line 1800-851-6606, or check out this post here: Thoughts: On being less sad

 

For all intents and purposes, I am 24 hours away from finishing my internship. For those of you lucky enough to have never done an internship, it can be succinctly described as this:

Imagine running through a forest fire, trying to save as many rabbits and deer as you can, through acrid black smoke, without any idea where the oft-rumoured safe meadow of competence is.

Maybe that is a wee bit dramatic. Since the end of August last year, I have been assigned to work as a junior doctor in various departments of various hospitals doing various tasks that I know next to nothing about. Now, it is true that I am a doctor, but I am not a specialist. It is true that I am experienced in emergency situations, but I am not much of a discharge planner. It is true that I am a good communicator, but I am no social worker. Yet, as an intern, I must be all of those things (at three o’clock in the morning).

Emergency residents rotate through various specialties in their first year of residency. We tell ourselves we do this because other specialties have important things to teach us that will prepare us for a life in the trenches that is an emergency department; we will see post-operative complications following bowel resections, overdoses of psychiatric medications, extraordinarily complicated airways, sick neonates weighed in grams (not kilograms), broken bones exposed to air, and women who may or may not be in labour but are certainly in a heck of a lot of pain.

But the second reason (or perhaps it’s the first, and all that other stuff is the second) we do this is to “staff” services. Hospitals rely on junior doctors to consult patients in the emergency department, care for patients on the wards, discharge patients to make space, and coordinate community care, follow ups, and tests. We also provide night coverage to a hospital otherwise desert of physicians. Working up to 80 hours a week (or, as my dear friend on the surgery recently confided in me, 140 hours), we often work 24, 26 or 30 hours in a row with little to no sleep, running from ward to ward putting out fires.

That sounds crazy. Placing someone who is not a surgeon in a surgery ward to assess sudden drops in hemoglobin, or someone who is not an internist adjusting electrolytes levels, sounds very crazy indeed. However, I must say, the last 8 months has been one of the most fun times of my life. Scary, also. And stressful. But so much fun.

Thanks to WIFI, iPhones and really smart nurses, the junior doctors I work with deliver exceptional, if not confident, care 24/7. We’re pretty crafty people, and unfamiliar with a disease or procedure or situation as we may be, we are trained to find the answer, consult each other, consult our bosses (who we wake up when we are really unsure of what to do) and figure it all out. And in doing that, we learn.

Now, I’m not saying this is the best way to teach me how to be an emergency physician, or the best way to provide care to hospitalized people, but it’s the system we have, and I think it works pretty well. We can, and must, do better, and I’ll write about how another time. But on this, the eve of my finishing internship, I just wanted to express how much fun it has been, and how much I have developed and matured as a physician.
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Sure, there was that morning I was so tired I didn’t notice I put moisturizer in my hair until I had slathered my face with hair gel.

There was that time I’m 100% sure I was 99% responsible for someone dying.  That time I was yelled at by a family member, and uncharacteristically yelled back.  Times of gloom, sadness and tears.

But then, there were all of the other times. The time I picked up on an anastomotic leak at 3am. The time I influenced “flipping the plan” towards palliation for an elderly man who had the ultimate altered sensorium. The time I laughed so hard with a patient I snorted, and then they snorted at my snort, and then their neighbour, separated by a curtain, began snorting at snorts.

And then yesterday, when a nurse overheard I was heading back to the ER and offered me a make-shift going-away card.

Residency is hard. But when I look back on the last year where I played trauma team leader, paediatrician, obstetrician, anesthesiologist, internist, and general surgeon, I wouldn’t give it back for the world. There are many pejorative words we use to describe the first year of residency. But if I had to sum it up with just one, that would would be FUN.

In Part 2, I’ll discuss some of the ups and downs in more details, share a few stories I probably shouldn’t, and try to give you a good sense of the life of a resident doctor.

In Part 3, I’ll speak to the privilege of caring for people in a large, tertiary care hospital, and the wonderful people who make the monstrosity that is a Hospital function.

Thanks for reading. Have a beautiful week.

This is a rant. It is not a thesis; it is tangential and confounding and confusing. I hope you either love it or hate it so long as you read it.

One of the core beliefs that I (try to) maintain always is that every person has equal value. This means that each person has equally valid beliefs, different from mine as they may be. This, of course, causes me a great deal of cognitive dissonance. Do I truly believe that this is true, or is it some self-serving phrase meant to portray a fictitious altruism all doctors purport? While I am challenged daily to live this belief through actions at work, nothing has tested it more recently than the rise of Trumpism in America, and to a lesser degree, the rise of Ford Nation prior to the late mayor’s passing.

Let me start by saying that I am friends with people who think Donald Trump is the answer to all of America’s problems, and that Rob Ford was the answer to all of Toronto’s problems, and in this phrasing, for those of you who don’t know me, you can tell where my bias lies. And yet, if I am truly to believe that we are all beautiful human beings of equal value, which I think (no, I know… I think) that I do, our respective perspectives also hold equal value (though not necessarily equal truth).

While avoiding a discussion about morality and how my own morality is but a construct of my environment, and is thus nothing more than a set of thoughts applicable only to me, it is important in the discussion of Trump and Ford to at least respect opinions I do not agree with. The challenge comes not so much from the ideological gaps between “left” and “right” (which I could sum up, quite unfairly, as “we are one” and “I am one” respectively) but from the failure of both sides (but mostly the right) to accept evidence counter to ones ideology.

And now I am getting to my first point. Recent controversy over an anti-vaccination film scheduled for debut at the Tribeca film festival highlighted the oddly-present mainstream question of vaccine use. The world is a better place because vaccines were invented and implemented as a matter of public policy and medical marvel. The fact that Trump (and, quite shockingly, pediatrician Ben Carson) feel that the science of vaccines is somehow a subject of question, is beyond baffling.

Yet, I don’t quite put my foot down here. Free speech is something I very much value. If someone wants to screen an anti-vax film, go ahead. For the record, I think that person is an idiot with idiotic views, but, and I understand if you aren’t following me here, those idiotic views are equally valid to my own. See, I like vaccines because I grew up in a household that valued vaccines, with parents who believe in vaccines, and then (skipping ahead) I became a doctor and was taught that vaccines are medical marvels. In other words, I believe in a construct. Now, I believe very strongly in that construct, as do nearly all Canadians, but if you don’t I can’t rule out that your construct is right and mine is wrong (although I’d bet good money that you’re construct is wrong, and mine is right).

The millions of Americans who are supporting Trump have a perspective that deserves respect; Trump himself has tapped into a group of people deeply committed to his cause (which, to be honest, is a bit unclear but certainly involves wall-building). Ford had so many supporters who felt disenfranchised by the political body that runs Toronto he got elected as mayor. And these people, who include friends of mine (who are not stupid people by any stretch), are to be heard.

But here is where I must put my foot down (my second point):

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If you are going to vote for Mr. Trump because you want a wall built along the Mexican border, vote for him. I’ll try to respect your values. But if you vote for Mr. Trump because you believe he will make America great again without any plan articulated, without any shred of vision, because he yells the loudest and fights the toughest, my cognitive dissonance will overwhelm me and I just might end up joining the “I hate politics” camp that you must be in right now.

But, and here is where I am really just writing a letter to myself, we can have politics or we can have a dictatorship. We can have debates about our “leftist’ and “right-winged” values, or we can have someone else’s values shoved down our throats. We can compromise on a solution, or end up with a problem.

Politics isn’t perfect. But the alternative, what Mr. Ford brought to Toronto and what Mr. Trump is selling to America, is far worse. Rob Ford popularized the very worst in us: misogyny, racism, homophobia, and the general belief that government is nothing more than a drain on personal wealth. His legacy, if one can call it that, was to uncover our own ugliness, revealing it starkly in the mirror, revving internal mechanisms in each of us to simply rise above what is now known as Trumpism and care deeply for one another.

So to all of my dear American friends:

Think the way you want. Vote the way you want. I’ll respect it. Just as long as you put a little bit of thought into the values you hold dear.

 

 

 

I’m not a hippy, but I kinda think like one. I’m a committed practitioner of yoga, believe strongly that mindfulness is core to saving the world from itself, and believe in a poorly-defined yet strongly-felt spirituality that is a strangely-woven tapestry of the dozens of religions and philosophies I’ve encountered during my travels. These characteristics give me a mind-over-matter view of my life.

Yet, I’ve been pretty down for the last few months. Most of my friends have been too, and not just the residents I spend an uncanny amount of time around. At times it’s been easy to sink into a couch and feel sorry for myself, though I can never quite label what it is I’m sorry about. Working hard? A decade of life indicates that’s something I thrive on, not wallow over. Being single? Despite my frequent whining, I’m a diagnosed commitmaphobe who enjoys things the way they are. Winter blues? It’s the mildest winter I’ve ever experienced, and a good chunk has been spent in Australia, Bolivia and Cuba…

While I can’t put my finger on what it is that’s been suppressing my usually (annoyingly) cheerful self, I do know that there are tricks I can use to turn around my mood and get my ass in gear. I’m fortunate to have these tools at my disposal: there are friends of mine, patients of mine, and strangers of course, who just can’t. I wonder if I’ll ever be like them, and worry a little over the unknown characteristics of a disease called depression. But, on this first day of spring, I thought I would share what my friends and I have been discussing quite a lot recently: how to stay positive in an increasingly busy, complex and tragic world.

Our Reptilian Brain: Helpful or harmful?

I’m a firm believer that I should respond, rather than react, to every stimulus around me. Reactions bypass the frontal lobe; they reside in the reptilian brain and amount to being on autopilot. They are easy to have, because they happen without doing anything at all. They are executed by the base of the brain, the same brain parts shared by alligators and owls and, I presume, a tyrannosaurus rex. But a response is different; responses are considered reactions. They are a bit slower, a lot more taxing, and infinitely more useful (unless you’re being attacked by a saber tooth tiger!).

Our reptilian brain, responsible for our survival, is where our primitive drives reside: the three F’s they taught us in medical school (fight, feed, and f…ornicate). They are reactive, emotional and often flood our bodies with hormones and neurotransmitters that jack up our heart rate, blood pressure, and sense of sight. They are prehistoric, intended for survival. They have not evolved to take into account an 80 hour work week, QEW traffic, instant messaging, or my resident pager. And yet, these “modern” stresses have the ability to activate our reptilian brain in much the same way as a bear attack does. This is maladaptive; adaptation takes time.

How do we regain control over this maladaptive reactivity? We practice responding rather than reacting.

When others say or do something, we can slow down my reception, respond to the stimulus, and have a considered output that is more useful than a quick reaction would be. Allowing others to bring me down, I would argue, is immature. It shows a lack of perspective and control over my world. Attitude is relative, of course, and it’s hard to stay positive when surrounded by negativity. And so, I work hard to spend time with positive-minded people. When I start to get into that cycle of negativity, I always ask myself three questions:

• Do I have any control over this situation?
• Is my perseverating motivated by anti-kindness?
• Is there a fresh lens I can view this situation through?

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And finally, when all else fails, I simply say “Can I let this go?” Easier said than done, this often involves using physical activity to stimulate the difficult mental work that goes into letting go. A run, a swim, a yoga session… sometimes, I literally need to sweat it out.

Energy Leadership: Part of the solution

I was recently introduced to the concept of “energy leadership” which I found rather enlightening. It basically outlines different “levels” of response to emotional stimuli. By adjusting your own response to stimuli, you can lead and motivate others around you. Here’s the jist of it:

You can respond to a stimulus with catabolic energy, which is negative, or anabolic energy, which is positive. Anabolic energy is constructive and growth-oriented, while catabolic energy is draining and blinding. Without boring you with research, it seems to be based in science.

Leadership, or the ability to influence someone through an interaction, can be knowing or unknowing, positive or negative. In other words, your own output can affect the output of others, and vise versa. You can also lead yourself, which I find I’ve been having to do more and more these days to maintain my same level of happiness and productivity.

Here are the energy levels:

1. Apathy: “I’m losing. Everything is against me.”
2. Anger: “I want to win, so you have to lose. I will beat you.”
3. Forgiveness: “I win, and hopefully, you win too.”
4. Compassion: “I want to help you win, even if I lose; I am here in service.”
5. Peace: “Everyone wins or no one wins; let’s make lemonade out of these lemons!”
6. Joy: “We always win; everything happens for a reason.”
7. Passion: “Winning and losing are illusions; they are false constructs. We are just being.”

Most health care workers live at level 4 when they are with patients, and in level 2 when they are in the break room. We have bursts of success where levels 6 and 7 are displayed, and tragic loses where we spend time at level 1.

I find I can be very hard on myself, as well as others. This often involves judging my actions and decisions on data that I didn’t have at the time those decisions were made. For example, a CT scan comes back normal and I say “Ah, I shouldn’t have ordered that test, it’s normal!” when really, at the time I ordered it, by pretest probability for X supported ordering the scan. I rarely say “Yes, the CT is positive! Ordering it was such a brilliant move!” Here we can see that I perseverate on the “bad” rather than admire the good.

I don’t want to bore you with what may sound like frilly theory, but I’ll leave you with my assurance that I have viewed my world through a different lens since being introduced to the concept of energy leadership. I find I keep things in perspective, forgive myself and others more often, and take more joy out of the work I do. Energy leadership has joined my self-control repertoire, along with mindfulness techniques and yoga and my strange definition of spirit so that I can be just a little less sad.

If you have techniques that work for you, I’d love to hear about them in the comments below or by phone, email, twitter or facebook. We’re all in this together… to win. (For now, winning is still a construct I very much strive for, but I’m a work in progress.)

Thanks for reading this rather long post… I’ll keep it shorter next week.

It’s been 16 hours since I started my call shift. I’m sitting at the nurses station on 6 Surgical as one of them walks in carrying a take out container. Greek fries. She’s brought extra forks. I think of my upcoming trip to Cuba. Then she opens the lid. Irresistible smells waft upwards and I unwrap the plastic from around the cheap hospital fork. On-call calories don’t count, I tell myself, painfully aware of my diet these past eight months as I try to stay alive during my rotating internship. I haven’t cooked a real meal since December, in part because I haven’t been grocery shopping since Christmas. We sit there, 6 of us, and chow down, laughing about the state of US politics and wondering if Cuba will decide to boycott America right after America un-boycotted Cuba. 8 more hours.

Beep-beep-beep-beep. Fake enthusiasm draws laughter as I punch in the 5 digit call-back. It’s the stepdown unit, for a patient I don’t know, operated on by a surgeon I’ve never met. A mild fever. “Just want you to be aware!” Well shit. Being aware on a night shift is a curse. Being aware means being responsible. I leave my loaded fries and new friends and hit the stairwell. (Residents don’t use elevators, because elevators are slow, and because we eat Greek fries on call, and because deep down inside we know that on-call calories DO count).

Fevers can be nothing. Tylenol makes them go away. But fevers can also be canaries, subtle hints that badness is brewing. I check in on the patient. She’s recently had major surgery, and now has a fever. I note a heart rate of 98 – technically within the normal range (60-100) but only just. She says she’s fine, so I ask again, and she admits to some shortness of breath. Fevers can be nothing, but fevers can be blood infections, abscesses, pulmonary embolisms, or necrotizing fasciitis. Once I’m aware of a fever, I need enough evidence to calm my neuroticism before I squash it with Tylenol. No Tylenol, this time. I order an x-ray and labs and make a note to check them later. 7 more hours.

This is how the night will go. Chatter with nurses, picking at foods I tell patients to avoid, answering pages of vague significance, and meeting patients I have never met before, who’s lives the consulting surgeon has placed in my hands until 0700h. Read a chart, review a scan, order some blood work, hang some fluids. Don’t kill anyone.

Beep-beep-beep-beep. Less enthusiastically I pick up the receiver. The emergency department has a patient who I discharged yesterday. Ooops. I head downstairs and the wife assaults me with a venomous tongue. I take a deep breath. 6 more hours.

No one likes to wait. It’s been five minutes since I was paged, and this woman is irate. Her husband, she says, is dying. Gently, I explain he is not. Her husband, she says, has been mistreated. Kindly, I explain we do our best. I assess his surgical site. It is red and painful and oozing blood. Because we just did surgery on it. When you cut skin, it tends to get red and it tends to hurt and it tends to ooze blood. I sense my persona has shifted, like the tides shift with the apogee and perigee of the moon. I’m getting tired; enthusiasm is being replaced with sarcasm. I discharge the patient home, tell him the trochar site will heal, and thank the wife for her graciousness before walking away, rolling my eyes. It’s not that I don’t understand her, or him, or human nature. I get it. But rolling my eyes makes me feel better, if not a tad bit immature. I head back upstairs, knowing the fries won’t be the same cold and soggy.
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It’s 0200h and there are 5 hours left. I realize that my Sunday post will now be a Monday post as I sit down at my laptop. The Tim’s closed at 11pm and there is no coffee here overnight. My Red Bull does the trick. I write a blog post about the only thing on my mind, which is the Greek fries. Cuba… shit, my abs…

I check the bloodwork of The Fever (yes, I know, I should call her Mrs Whatever-her-name-is, which for this blog post I would change to Mrs Whatever-her-name-sounds-like-but-isn’t, but I don’t remember her name). She’s sick. I call the nurse. I start fluid, antibiotics, and order a CT scan. I call the radiologist. I get up, obliged by my own philosophy more than any real occupational requirement to go see The Fever with my own two eyes. 4 more hours. When I come back, I’ll lay down. My eyes will close, but my mind will race. At some point, I might drift into a zone of semiconsciousness I can’t really describe, but which every resident knows.

Until beep-beep-beep-beep.

 

 

It’s 6:19pm, and I’ve been awake for a little over two hours now. Despite having had a (relatively) quiet call shift on the Acute Care Surgery service, I still found myself waking up well past my self-imposed noon deadline. Seems like I’m getting old – I remember doing a busy night shift as a paramedic and then going straight into the office and working all day, then partying all night. As my body starts to require more and more horizontal time, I jeopardize my ability to say yes to – and deliver on – tasks I want to do. It’s reminded me to be efficient and disciplined with my time, a challenge I’m often asked about.

The ability to create a 25^th hour in a day, or an eighth day in the week, continues to elude me. Over the last decade, however, I’ve tried just about everything else to create time to work hard and play harder. Keeping balance in the foreground as I plan my weeks, months and years ahead, there are a number of tricks that I use to maximize my time-on-task, and thus my productivity. Here’s a few of the tricks that help. The first five are principles and the second five a visual tools.

#1: I don’t have cable or Netflix. Don’t get me wrong, I have a few TV shows that I try to stay up to date on, but I tend to binge-watch a season (HOUSE OF CARDS COMES OUT THIS WEEK!) rather than follow along on a network’s schedule.

#2: I minimize my time on social media. We’ve all gone to check our Facebook wall only to regain consciousness four hours later with a youtube video of a baby monkey riding on a pig playing. Avoiding the trap of clicking link after link of entertaining but not-so-useful media means more time to read, write or sleep. Going to bed early instead of surfing aimlessly through the infinite web world means I can wake up earlier and start my day rested.

#3: I get out of the House. House has Bed and House has Toys and House has a million other distractions. When it’s time to work, I grab my satchel and head to a coffee shop, where I grab Java, plug in, and get to work.

#4: I automate my life. I’m not great with technology, and a million resources can tell you better than I how to maximize technology in your life. But basically, if I’m supposed to do something that my phone or computer can do for me, I make that happen. Bills are set to automatically withdraw, cheques are set to automatically deposit, and whatever else can be automated, is.

#5: I outsource. It’s expensive, but having a cleaner, an accountant and a mechanic means I don’t blow a much-needed day off vacuuming, shuffling papers, or changing oil. I also hired a trainer – it maximizes my hour at the gym, motivates me to show up, and he’s super hot.

 

Now, I’m a visual person, and I’ve developed (or, to be more accurate, stolen) a number of tools that help keep me on track and prevent me from becoming overloaded.

#1: Categorizing with domains. I’m a bit of a scatterbrain. If I could, I would be an air traffic controller, a doctor, a lawyer and a zookeeper. Sadly, my brain isn’t smart enough for all that. I’m a firm believer in being really good at what you do, so I work hard to develop specialty in the things I care most about. Stealing the CanMeds graphic that presents the core competencies a physician should possess, I have 12 of my own domains that I try to constrain myself to. Of course, nothing is set in stone, but it does help me focus on what I want to do with my life.  Red items are firm commitments.  Green items are exploratory.  Don’t bother trying to interpret the acronyms – I can barely remember what I’m trying to tell myself half the time.

 

#2: The Long Term Planner. Using my domains as the X axis and 3-month periods as the Y axis, I can generally keep track of my commitments a few years down the road, making sure I’m neither bored nor overloaded. I only peak at this every few weeks, but it keeps me focused on where I’m going and what I need to do to get there. It also helps me evaluate if a domain I think is important actually is. Domains occasionally drop off the planner or sneak their way in.

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#3: The research tracker. It’s easy for a research project to disappear into thin air. Research can be frustrating and complicated, and sometimes a phase can be roadblocked for months or years. This tracker motivates me to make progress, keeps deadlines on my radar, and of course provides a disproportionate amount of satisfaction when I can delete a completed project.

#4: The weekly planner.  Let me explain this, because it changed my life. In box one are things that are both important and urgent. Things like going to work so you don’t get fired. These have to happen or your mortgage doesn’t get paid. In box three are things that are urgent, but not so important. Submitting a grant for that study you accidently said yes to helping with falls into thi category. You’ve said yes (mistake #1) and now you have to do it. But you don’t want to, and it probably doesn’t do a lot to advance your interests. Box three fills up with things that stress me out, but don’t help me out. I’m nice, usually, so I say yes to lots of things. But saying no to box three items frees up more time for box two, things that are important to me (like reading, writing and having brunch with friends) but don’t have to happen. They are deferrable if I don’t have the time or the energy to do them. Going to the gym or to hot yoga belongs in box two, but often gets sacrificed as I struggle to complete urgent tasks. My minimizing nonimportant urgent tasks, I can focus on box two. When box one and three consume too much of my time, I don’t have the energy to attend to box two. That’s where box four comes into play. Box four is where I go when I’m tired. Youtube holes, Family Guy binges, and laying in bed reading about US politics all belong in box four, the box I wish I never spent time in.

My goal is to keep box three empty so that I can have the energy and time to focus on box two.

1          2

3          4

#5: The personal accountability calendar. This was another life-changer. Using this tool, I score every day before I go to bed as green (a good day), yellow (an ok day) or red (a day I shouldn’t have survived). Red days are rare. But as you can see, I’m pretty critical of myself, assigning a yellow as a form of punishment when I don’t meet a daily goal. It may be simple, like going to the gym or finishing an assignment or reading about Tylenol overdoses. It may be more substantial, like responding poorly to a stressor, making an egotistical or selfish decision, or failing to help someone when I could have. Regardless, I find myself in positions where I say “If I make Decision A, today will be a green day, but if I make Decision B, today will be a yellow day.” It might sound silly, but for a competitive person like me, it works. It also offers me a chance to track patterns. A series of yellow days indicates I need to change things up – contact a friend, get to a yoga class, or even book off work and take care of myself. By acknowledging that I’m falling short, I can come up with a self-prescription to get back on track. I also use this calendar to track with little codes my diet (three checkmarks means three healthy meals) and my fitness endeavours. Note the lack of running in January 🙁

 

These, of course, are a work in progress.  Residency is a busy time, and I’m continuing to learn from those who have been when I am now.  If you have any tricks or tips please share them in the comments… I need all the help I can get to squeeze every minute out of every hour.

In another post, I’ll share some of the on-the-job tricks I have to stay productive, safe, and sane.  Thanks for reading this blog.  See you next week!

This is an article written for my friends who are also residents.  However, I suspect it applies to many of my other friends who are nurses, paramedics, EMTs, firefighters, police officers, staff physicians, respiratory therapists… well, pretty much all of my friends.  Even those who aren’t in healthcare!  Ones worth these days seems to be measured by productivity, which makes all of our lives stressful.  I hope some of the tips in this piece can help you stay calm and carry on.

“When the lines-to-limb ratio is >1, the patient is sick”- Blair Bigham, 2015

Last year, a resident died by suicide. It wasn’t the first time a resident died this way. Another resident commented “well, clearly there was something going on”. This phrase was intended to excuse the death, to make it an anomaly, and to say “it happened to them – but it can’t happen to us.” It was, I think, a form of self-talk, a way of saying “don’t worry, that was them – I’m ok.” Any resident worth his or her salary knows that ignoring our own fallibility and blowing off alternate diagnoses is a good way to end up in trouble.   This got me thinking about my own psychological wellbeing and the techniques I use to protect it.

Psychological wellbeing is something we preach. We’ve studied the DSM, interviewed PTSD patients, written exams where C) was “vicarious trauma” and we’ve talked with real people with real problems. And yet, despite the current shifting of tectonic plates (even the Armed Forces and their stoic ways of being are evolving to recognize that “suck it up” is not often a valid response to personal suffering), healthcare workers often view themselves as psychologically invincible.

As the world has changed, so too has the experience of “growing up”. Information is easier to access than ever before, and with that, distance has died. Constant media presence means we live vicariously through radio, TV, Facebook and our smartphones. Scary things that rarely happen berate our senses, and before you know it, it’s not safe to walk to school alone or play in the park after dusk. Parents take freedoms away, and without those freedoms, experiences are never had.   If parents benevolently navigate our worlds for us, we have limited capacity to learn and develop, and this in turn leaves us vulnerable to psychological trauma. Without the freedom to play, we lose out on developing strategies to cope when things don’t go our way.

This may explain why young adults today have rising rates of mental health illness. As health care providers we residents think of ourselves rather highly, and why shouldn’t we? Most of us have been in university for a decade, we’ve dropped hundreds of thousands of dollars into tuition and textbooks, and most of our friends already have houses and kids and dishwashers while we wallow alone in our studio apartment with a sink full of dirty plates. We’ve sacrificed, and we know how to be tough. However, we are human and although great, some even brilliant, resilient, caring and extraordinarily hard-working, we have breaking points. In fact it’s often our brilliant, resilient, caring and extraordinarily focused nature that keeps us from reaching out.

Suicide rates amongst medical students, residents and staff physicians are inordinately high. Depression, substance abuse and marital disharmony are also prevalent amongst our ranks. Despite these evidenced truths, our own mental health is the elephant in the room. We are Type A personalities, we succeed at all costs, and we are stronger – stronger than everyone else.

The signs and solutions to this are well known to you. Today, give yourself permission to apply these principles to yourself. Learn to recognize the red flags, and have a management strategy at the ready should you need it.

This is hard: most of us are Type A personalities and view struggling as a weakness. But everyone needs to talk about their experiences as a resident, because being a resident is stressful. A lot of us frown on “touchy-feely crap” and suck up both small and large stressors. This is akin to having chest pain on a run, ignoring it, having chest pain at rest, ignoring it, getting sweaty and pale while having chest pain one morning, ignoring it, and then… yep. “I’m clear, you’re clear, we’re all clear!” There is no strength or intelligence in waiting to fall apart and develop PTSD, compassion fatigue, depression, or worse.

We are all nice people. When we stop being nice, something is going wrong. It starts a process that leads to hypo and hyperarrousal during crisis situations and results in underperformance. Compassion fatigue makes us susceptible to vicarious trauma, PTSD and ultimately suicidal ideation. Some of the signs of compassion fatigue include negativity, diminished tolerance for frustration and ambiguity,,intrusive thoughts of difficult patient situations, dread of working, anger, depression, absenteeism, or organic illness. Separating work and personal lives becomes difficult, and home life becomes impacted.

Time does not heal all wounds – its what you do with that time that aids healing. Cumulative stresses build up over time, and any one event can be the straw that breaks the camel’s back. Don’t stop using what already works for you – I’m a roller blader – but perhaps a few of these tips can be added to your toolbox. In other words, “if it ain’t broke, don’t fix it… but if you’re stuck in a hole, stop digging” (Steve Miller, 2004).

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Change your Physiology in Two Minutes: Inhale through your nose; exhale through your lips as if they were wrapped around a straw: Inhale (4 counts) + hold (4 counts) + exhale (6 counts) + hold (2 counts). Repeat.

Shift your thoughts: If you shift your attention to a different thought, the chemicals connected to any emotion naturally subside in ninety seconds. Sometimes negative self-talk can take over. Call a friend and try to laugh or talk about something fun or interesting, or search for cat videos on YouTube

Take in the Good : Consciously experience a good feeling by absorbing it into your body and letting it expand for twenty to thirty seconds. One way of doing this is to use your senses to remember a really good time.

Practice Gratitude : Seek things to be grateful for; take a moment to reflect on and embrace the feeling of gratitude for something or someone in your life. The research shows that if you have gratitude it is much more likely that you will have happiness.

Exercise humour! Humour is essential in all health care environments.

Journaling: not for everyone, I admit, but put pen to paper, and you just might run out of ink. You can save the piece of paper or burn it, I don’t really care, but the exercise can be eye-opening.

Call it as you see it: If you think a colleague is struggling, call them out on it in a sensitive way. A phrase like “you’ve been snappy recently, what’s up?” can give someone permission to talk about the stress they are feeling and how it is negatively manifesting.

Your mental health is extraordinarily important; refresh your memory of the services available to you through your employer (such as employee assistance plans, extended health benefits and wellness services), University (such as resident affairs offices and social supports), and associations. Residency should be an enjoyable and healthy part of your life and lead you to prosper in your profession, your relationships and your own sense of wellbeing.

So, to all my fellow Type A’s – be the BEST at self-care. Or nothing else will matter.

FEB 19 2016, Toronto CANADA

The Ontario government yesterday introduced legislation to help paramedics and other first responders who are diagnosed with post-traumatic stress disorder (PTSD). The Promoting Ontario’s First Responders Act, if passed, will amend existing legislation to create a presumption that first responders diagnosed with PTSD have a work-related illness. This will allow first responders to more quickly access benefits and treatment and hopefully prevent catastrophes like divorce and suicide amongst front-line caregivers.

Paramedics crowded the Ontario Legislature ahead of the announcement, and some cried as the legislation was tabled. “Given all that we ask of our first responders it is only fair that we support them when they need us most” said Minister of Labour Kevin Flynn, adding claims will be allowed up to 24 months after the diagnosis instead of the usual 6.

For Natalie Harris, a paramedic and PTSD survivor, the moment was many years coming. After responding to a scene in 2012 where two women were murdered, Harris became depressed and required hospitalization for addiction and PTSD. “It’s life-changing” says Harris of the new legislation, while acknowledging it’s “gutwrenching as we all remembered those peers we have already lost.”  Harris, a PTSD advocate, credits “how powerful collective, passionate voices can be.”

Ontario Paramedic Association president Geoff McBride was in the legislature at the time of the announcement. “It is no secret that first responder have a higher incidence of PTSD and we must take the proper steps to prevent and treat those that need it” he said, supporting the actions of the government. “We are pleased to see this type of legislation announced in Ontario and hope that other jurisdictions will follow suit” added Chris Hood, president of the Paramedic Association of Canada. Albert and Manitoba have similar legislation, and Nova Scotia is considering presumptive causation legislation. That makes Ontario the third province in Canada to recognize PTSD as a workplace illness.
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The proposed legislation covers police officers, firefighters, paramedics, EMTs, correctional officers, and 911 dispatchers and includes claims currently under appeal. It also requires EMS employers to implement and publish plans to prevent PTSD.

Some Ontario EMS Chiefs didn’t wait for legislation to proactively address the epidemic of first responder suicides that have recently been reported in the media. York Region Paramedic Chief Norm Barrette has been addressing mental health stigma amongst his paramedics for years. “York Region Paramedic Services has a wide variety of supports in place for paramedics dealing with operational stress” says Barrette. Launched recently, the York Peer Support Team includes 20 paramedics nominated by their peers with special training provided by the Tema Conter Memorial Trust are on call 24/7. Staff have recently been trained in additional supports that are available, including reimbursement for private psychological counselling, confidential access to municipally-funded counsellors, and immediate post-event debriefings.

Vince Savoia is the director of the Tema Conter Memorial Trust, and for years has been tracking first responder suicides and advocating for change. His organization, which last year tracked 39 first responder suicides, offers various training programs like the one York Region employs. New this year is a postgraduate training certificate offered online. He hopes that through training, first responders can better utilize tools to stay healthy, recognize when they are suffering, and feel empowered to ask for help.  “First responders now have the peace of mind to know that they can get help without jumping through hoops” he said of the Government’s announcement.

Being on call is about not killing anyone. But people don’t live forever. 

Dave didn’t ride his bike to work that December day; that’s how bad the storm was. Of the seven doctors training to become emergency specialists, he was the sportiest and cycled everywhere. The blizzard had dropped a foot of snow in just a few hours, and the forecast wasn’t promising. I arrived for my 26 hour internal medicine call shift in boots and a Canada Goose parka that masked my slender build. Dawn hadn’t yet broken, a symptom of northern winters. I walked through the dark parking lot, falling snowflakes glistening in the twilight.

After a decade of working as a flight paramedic caring for the sickest of the sick, internal medicine was a synch. Between the chronic diseases and deteriorating bodies, I rarely responded to emergencies. A bit of insulin, a bit of saline, and I could fix just about anyone. Internal medicine is not emergency medicine; instant gratification is never the rule, and dramatic therapies tend to do more harm than good. Rather, small adjustments followed by periods of observation are the key to being a good internist.

Being an adrenaline junkie, found the work boring. An eighty year old was considered to be young, and a work-up could easily take 2 weeks. I longed for the chaos of the emergency room, where diagnoses were made in seconds and electric shocks restarted dying hearts. But as all junior doctors know, we must bid our time and staff the internal medicine service. I did not expect to learn anything profound on the medicine wards. Until, that is, I met James.

James was 93, but didn’t look a day over 85. Normally steady on his feet and sharp with his wit, James came to the emergency room after a “gravity mishap” – he had fallen at his retirement home. Despite not breaking his hip, he couldn’t walk very well and was admitted to my team. A shadow on the x-ray – a hypodensity, the radiologist called it – prompted a CAT scan of his hip.

It didn’t phase me one bit when I read the results: “metastatic cancer invading the pelvis and hip, secondary to prostate cancer.” When you’re 93, I just assume you have cancer. Lacking excitement for this explanation of his pain, or sorrow for his dismal prognosis, I apathetically noted the diagnosis and listed the options for treatment. Chemotherapy, radiation, and drugs to dull the pain were on the list of offerings. Metastatic cancer is rarely cured, but medical advances can prolong and improve people’s lives by months or years. With a plan in mind, I headed to ward E3 to meet with James and his daughter Connie in a stale, semi-private hospital room.

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James glanced downwards nonchalantly. He face barely reacted. Connie’s eyes filled with tears and she bit her bottom lip. She was too tough to sob, yet any attempt to speak would open floodgates. I looked back at James. I laid out the options, and he matter-of-factly asked questions. Could the chemo kill me? Possibly yes. Will the radiation stop the progression? Probably not. Will the pain medicine make me drowsy? Sometimes it can. If I had spoken any more generally, I might have been saying nothing at all. Reflecting on this useless council, I question my vocation of choice. So often as doctors we are grasping at straws, straws that can break our patient’s backs.

James didn’t want any therapy. “I just want to be around” he declared. Connie’s facial expression reacted viscerally to her father refusing treatment. Sensing the tipping point, I offered her a hug. She accepted, clinging to me like Velcro, her tears flowing down my shirt. I couldn’t quite grasp James’s choice: it seemed as though he had given up, that tomorrow didn’t matter to him anymore. I didn’t judge him negatively, but rather felt disconnected. When Connie released me, I left to call the palliative care team, who would plan James’s pathway to dying.

It was nearly two o’clock in the morning when my pager went off. I walked briskly through long, dark hallways to the ward on E3 to attend to a patient. Crisis addressed, I checked in on James. I found him pushed to the far right side of his hospital bed. Connie was snuggled up against him, her head resting on his chest as she slept. She had regressed from school principal to passed-out kindergardener. At first, I thought he was sleeping too. He must have heard me; he opened his eyes without moving a muscle (well, except for his levator palpebrae superioris). We looked at each other and smiled. His grin was unmistakable: it conveyed total peace and absolute joy. James was living exactly as he wanted at that moment. His glaze shifted to the window of his hospital room, where snow was still falling.

It was then that it struck me, obvious now but profound then. As we age, our priorities change; we no longer look for tomorrow’s adventures, but cherish what we love most today. With that change in priorities comes a change in what we need most from our doctors. It becomes not about saving a life, or even prolonging one. It becomes about helping people realize the moments they desire most.

I knew then what James needed from me. I stepped forward and gently pulled the blue-striped flannel blanket up over Connie’s shoulders. I am indebted to him for imparting a lesson he may not even realize he taught. I became a better doctor in that moment; standing in the dark, snow swirling outside on that cold December night.