Nitin Agarwal, MD is a resident at the University of Pittsburgh Department of Neurological Surgery, having received his doctorate of medicine from Rutgers New Jersey Medical School. His funded research activities focus on improving patient education to optimize patient outcomes. To date, he has published over 150 peer-reviewed articles and 10 book chapters, and has spoken at several regional and national conferences with over 100 oral and poster presentations. His health literary related research has been published in several high impact factor journals, including JAMA Internal Medicine, and featured by prominent healthcare oriented news outlets such as Reuters Health.

He was appointed as a member of the Young Neurosurgeons Committee of the American Association of Neurological Surgeons (AANS) and serves as the Medical Student Task Force resource coordinator and Top Gun Competition chair. He was also selected as a Council of State Neurological Societies socioeconomic fellow and continues to serve as a past resident fellow mentor as well as an alternate delegate appointee of the Congress of Neurological Surgeons (CNS). Moreover, Dr. Agarwal serves a member of the Joint AANS/CNS Drugs and Devices committee.

He authored Neurosurgery Fundamentals, published in late 2018, as a guide for residents and medical students pursuing a career in neurosurgery. Besides technical information on the basics of neurological surgery, the book distills important socioeconomic topics including training, licensure, credentialing, and advocacy.

 

Tell us about your background and your educational interests.

I’m a resident at the University of Pittsburgh and am pursing an enfolded fellowship in minimally invasive and complex spine surgery there. I plan on completing further training in that subspecialty during post-residency through an approved fellowship with the Committee on Advanced Subspecialty Training (CAST) at the University of California, San Francisco.

I also maintain an active role in organized neurosurgery advocating for medical student and patient education. My article “Improving Medical Student Recruitment into Neurological Surgery” was featured online by the AANS. Additionally, I’m an advocate for philanthropic support and have been placed on the board of directors of both the Neurosurgery PAC, as a young neurosurgeon member, and served as a resident liaison for the Neurosurgery Research and Education Foundation. Besides Neurosurgery Fundamentals, I’m also the co-editor of the book The Evolution of Health Literacy: Empowering Patients through Improved Education.

Outside of neurological surgery, I’m deeply dedicated to martial arts, specifically the disciplines of Taekwondo, Krav Maga, and Jiu-Jitsu.

 

How did you come to write Neurosurgery Fundamentals?

Through collaboration with several colleagues and mentors, we were able to create a concise and portable, but comprehensive handbook for future generations of trainees.

 

What was your impetus for writing it? What did you hope to accomplish?

A limited number of academic resources exist for medical students for the subspecialized fields such as neurosurgery. As such, Neurosurgery Fundamentals provides aspiring neurosurgeons with a roadmap to an academic career. While several chapters are devoted to detailing the key fundamentals any trainee should know, I am most fond of the Advice from Masters section. Mentors have played an integral role in my educational development and, in a similar fashion, the aforementioned section offers readers essential guidance from prominent neurosurgeons.

 

What makes Neurosurgery Fundamentals unique?

The project involved creating a handbook for medical students, residents, and advanced practice providers on the essentials of neurological surgery. Historically, there has been a dearth of information to guide students through the medical school years, residency application, rotations and interview trail. Furthermore, international students, who have no resources whatsoever or mentorship would benefit greatly from this text.

 

 

Neurosurgery Fundamentals

The quintessential guide providing a one-stop roadmap to a neurosurgical career!

Neurological surgery is a complex, highly selective specialty. For medical students and residents, navigating a huge array of neurosurgical information can be overwhelming. Neurosurgery Fundamentals by Nitin Agarwal is a portable reference enabling swift assimilation of neurosurgical care essentials.

LEARN MORE

 

Internal medicine is one of the core subjects of medicine. It covers the internal diseases of a human being. In the past, neurology and laboratory medicine were also part of this specialty. In previous eras, medical professors would also teach pharmacology as part of internal medicine. The therapeutic approach in internal medicine used to be conservative drug therapy. In modern times, interventional procedures, such as stent implantation in constricted coronary vessels or endoscopic polyp or tumor ablation, are gaining importance. This importance also applies to clinical practice and education. We can diagnose and treat growing numbers of diseases due to the wealth of knowledge acquired through medical research and scientific advancement. The use of more precise diagnostic methods, such as CT and MRI, allows us to increase the speed and accuracy with which we can view the body. Newer-generation sonographic units produce excel- lent high-definition images (Fig. 3.9).

 

Fig. 3.9 Plane of section of a transverse scan.

 

Used by an experienced physician, they can deliver valuable noninvasive insights into disease processes. Therapies for many diseases are subject to constant change. For example, the latest generation of chemotherapeutics in oncology and antiarrhythmics in cardiology have become extremely comprehensive, resulting in the growing compartmentalization of internal medicine. Patients benefit from these developments and physicians should respect that. The time required for postgraduate training reflects the enormous range of areas— and an issue that is the subject of ongoing debate. Postgraduate training takes three years in the United States and five years plus subsequent sub-specialization in European countries. It is safe to say that today no physician is likely to be able to cover the entire spectrum of internal medicine but instead must specialize in certain areas.

In Western countries, internal medicine has split into different areas without the official acceptance of the medical community as a whole. It is nearly impossible for any hospital today to provide care in all specialty areas of internal medicine. Generally, there is an internal medicine department that covers gastroenterology, cardiology, and pulmonology. These areas constitute the traditional polyclinic and can provide care for the majority of patients. The word polyclinic is derived from the Greek word polis, which means “city.” It refers to the traditional city hospital. Other medical historians claim that the word polyclinic is derived from the Greek word polys, which means “many” or “much.” This would apply to a hospital or department that treats many different cases and their origins. In modern times, most people die of cardiovascular diseases. Some of the most frequent reasons for emergent treatment include myocardial infarction, cardiogenic shock, hypertensive crisis, and metabolic/endocrine causes of coma. Patients may be referred to specialists for treatments or diagnostics, for example, placing a dialysis shunt, specific blood analysis in rheumatic diseases, treatment for thyroid storm, or cancer treatment. Large university hospitals are the exception to this situation. But even here, as we can see in Europe and North America, not all specialty departments exist in one hospital.

Internal medicine has branched into the following areas:

  • Cardiology/Angiology/Pulmonology.
  • Hematology/Oncology.
  • Gastroenterology/Endocrinology.
  • Rheumatology.
  • Nephrology.
  • Emergency medicine/Internal medicine/Intensive care.
  • Occupational medicine.

Hospitals maintain different combinations of these areas. For ex- ample, many departments may combine nephrology and cardiology or gastroenterology and pulmonology. There is an ongoing discussion about the ideal combination of areas, with no conclusion in sight. What actually matters is that patients receive the optimal level of therapeutic and diagnostic care. The patient should be referred to the proper specialty department when the attending department of internal medicine does not have the necessary capabilities to help them.

While specializing in gastroenterology, pulmonology, or oncology, the physician-to-be learns about diseases specific to these areas along with their highly specialized treatment options. In practice, the physician may not see these types of patients every day because such cases may be directly referred from an outpatient clinic to the specialty center. In my assessment it would be useful to complete the training for general internal medicine at a center for basic and regular care, because these centers usually cover the entire spectrum of internal diseases.

Let’s begin with the technical diagnostic methods before moving on to the different sections. In addition to radiographic examinations, which are likely to include thorax imaging as well as CT and MRI, ultrasonography is widely established. Every internist should be able to handle sonographic equipment. In addition, every physician must be capable of interpreting the results obtained via an electrocardiogram (ECG) (Fig. 3.10).

 

Fig. 3.10 ECG showing hemodynamics in severe tricuspid regurgitation with ventricularization of the right atrial pressure wave.

 

Every physician must recognize dysrhythmia, ischemia, and infarction. The diagnostic area of hematology is divided into three sections: morphologic hematology, immunohematology, and hemostaseology. Morphologic hematology involves the microscopic analyses of blood, bone marrow, and smear preparations, as well as biopsies of lymphatic organs. Subtyping of leukemic lymphoma and leukemia is performed via fluorescence-activated cell sorting (FACS). Risk stratification and prognostic assessment are based on cytogenetic methods (genotyping). The main task of immunohematology is human leukocyte antigen (HLA) typing to assess the compatibility assay in organ transplantation. Hemostaseology is focused on the diagnoses of coagulopathies and thrombocytopathies. Therapeutic hematology offers a multilayered spectrum of interventions, including the substitution of coagulation factors, traditional chemotherapy, treatment with biologic agents, and so-called smart drugs that ide- ally facilitate the specific treatment of malignant hematologic systemic diseases.

In the gastroenterology specialty, the student learns about performing gastroscopy, duodenoscopy, endosonographic procedures, colposcopy, and liver biopsy. Pulmonology addresses the use of fiber-optic bronchoscopy, thoracoscopy, and bronchoscopy with and without biopsy sampling. In cardiology, the curriculum includes the use of the following:

  • ECGs and evaluating long-term ECGs.
  • Echocardiography.
  • Ergometry.
  • Pacemaker application.
  • Coronary intervention via stent implantation.
  • Abdominocentesis.
  • Sternal puncture.

Regular participation in radiographic demonstrations and pathologic/ anatomic conferences, interpretations of laboratory test results, and practicing intensive care, which includes the emergency medicine specialty, are also part of internal medicine training. Particularly in the area of internal medicine—aside from diagnostics and the treatment of internal diseases—technical requirements become ever more important.

 

Based on: Introductory Guide to Medical Training
by Manfred G. Krukemeyer

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An introduction to Essays in Medical EthicsModern medicine suggests omnipotence and an image of life as something that can be perfected at any time. Yet our view of things changes when disease throws us into an existential crisis. Then we seek human answers and feel misunderstood and abandoned in the system of modern medicine.

“Everything cannot be everything.”
(Ingeborg Bachmann)

Who would want to give up the opportunities that modern medicine offers us today? We owe a lot to them, from the very beginning of our life until its end. Indeed, advances in medicine are the major reason why many of us are alive at all and have not had to die of disease or in an accident. Medicine helps us to live our lives in a more unburdened manner. It saves us when we contract a disease that only a hundred years ago would have been a death sentence. To this extent, it is great achievement that modern, well-functioning medicine is available to us. And yet it is precisely this great and indisputable success that bears the seeds of skewed development of other aspects of modern medicine.

What do I mean by this? By skewed development, I mean the observation that medicine, giddy with its success, secretly promises to have everything under control. It increasingly suggests that today, in the age of highly effective modern medicine, one no longer needs to put up with anything. Cutting edge technologies have made it possible to vanquish diseases, extend life, make the body more beautiful, and permanently cure those suffering from hitherto incurable diseases. But does this mean it can really do everything? In the can-do euphoria trumpeted by many areas of medicine, we are increasingly forgetting one thing. Despite all technology, one aspect of being human is that we lack the ability to determine everything ourselves and that the essential things are not in our hands. A consequence of this “forgetting” is that we are increasingly failing to learn how to cope with this finiteness of our ability. The gap between the exaggerated promises of technology and our inability to deal constructively with limits is in no small measure responsible for great moral dilemmas as well as a growing discomfort with “medicine” that is becoming increasingly dominant in our society.

I have not written this book with the intention of joining the ranks of those “critics of medicine” who use this dissatisfaction in society as an excuse for muckraking. Instead, I would like to draw our attention back to the things that humans do not and can never really have under control despite all our technological capabilities. I would like to speak about the limits of what is feasible. Rather than complaining that humans cannot shape everything themselves, I will argue that it may even be good that the essential things remain beyond the grasp of engineering.

Sensitivity to Limits

The increasingly disturbing imbalance in modern medicine demands that we reflect on and question the basic premises of our current approach to the world. This questioning becomes all the more necessary as medicine tends to concentrate only on scientific facts when it deals with human beings. If, in the thinking of large parts of medicine, humans essentially represent only what can be described in scientific terms, then this almost inevitably leads to the attitude that this scientifically describable entity can be changed, manipulated, and transformed. Modern medicine concentrates on changing the external parameters while increasingly losing the ability to distinguish between what must be changed and what one can only react to with the acceptance of something given. Medicine develops entire arsenals for combating disease but offers no guidance in how to deal with and accept what is.

The more we concentrate on doing, the more we lose sight of what lies in front of us, of how important limited entities are for our orientation, and for shaping our lives. Man can only act or produce within the framework of what is given; he does not have absolute freedom to choose this framework. Yet, at the same time, we ourselves are less the result of our own action than an “event” on the substrate of immutable determinants. Modern medicine in particular has long since taken leave of this fundamental insight. The given framework, that which is not doable, that which simply exists—these are concepts that have no place in a medicine oriented toward functionality, programmability, controllability, and efficiency. Just how problematic it can be to banish these fundamental insights is what I would like to demonstrate in this book, which is expressly intended to be an “ethical” book.

Ethics—as a Guide to a Good Life

When we hear the word “ethics” today, we immediately think of the wagging finger, of prohibitions, of restrictions. And when one picks up a book with a title such as this one, one could easily imagine it to be another wagging finger defining limits, demanding we forgo things, and curtailing our options. Yet this is a false understanding of ethics. Since ancient times, the primary purpose of ethical thinking has been to help people lead a fulfilled life. Ethical thinking is thus a guide to a good life. And that is exactly what this book is about.

The following chapters are not about condemnations, prohibitions, and curtailments. On the contrary, they explore the question of how our life can become “fuller.” How can we lead a fulfilled life?

The media often give us very clear messages and very clear-cut solutions. Yet the problems that arise with respect to modern medicine in particular cannot be broken down into shallow messages. Let us look at the limit. It is easy to say that man does not need limits today because he is engaged and should therefore be able to choose everything himself. That sounds good: everyone may choose for himself! Indeed, this expresses the spirit of life in our age, and it was sociologist and philosopher Zygmunt Baumann who expressed this credo in this succinct manner: 

“Postmodern is the exciting freedom to pursue any arbitrary goal and the confusing uncertainty about which goals are worth being pursued.”

We already see here that merely by eliminating all limits we do not automatically come any closer to happiness. This is because happiness does not primarily have to do with feasibility, with the means of our dominion over the world, but with knowing something about the where to and why. Where do we want to go, why do we live, what is important in life, what really matters? These are the central questions that ultimately say something about human happiness. When we lose sight of this goal and simply do everything that is possible, then we subject ourselves to the dictatorship of feasibility. Awash in possibilities, we lose the sense of what is essential, namely the question of who we really are and want to be. If we could do everything and wanted everything we could do, we would be nobody. We can only develop an identity when faced with something we cannot do. Identity arises from and is shaped by the limit, the limit of what is feasible but also the limit of what we can wish for. 

 

Based on: Essays in Medical Ethics
by Giovanni Maio

Professor Giovanni Maio, the eloquent advocate of a new culture of medicine, poses fundamental questions in this book that no one can really avoid: Where are the promises of reproductive and transplantation medicine leading us? To what extent can health be made, and to what extent is it a gift? Does "prettier, better, stronger" promise us greater happiness? Why is the question of organ donation more difficult than is suggested to us? Does being old have its own intrinsic value? How can we acquire an attitude towards dying that does not leave us feeling powerless?

Giovanni Maio's profound plea for an ethics of prudence opens up hitherto unknown perspectives. In this way we could free ourselves from the belief in perfection and find our way to a new serenity as a condition for a good life.

We live in a society in which health is regarded as the highest good—from the perspective of both the individual and the population as a whole. Health today is no longer part of medicine but is increasingly becoming an important economic factor. Empowerment is the new concept: activation of the individual to assume personal responsibility, while the state simultaneously withdraws from its duty to provide for the public welfare. Yet what are the limits and what are the drawbacks when we increasingly bear responsibility for our health ourselves? This chapter raises objection to the insidious notion of sickness as “guilt” and shows that personal responsibility only functions when it is anchored in social responsibility. A healthy person is not one without impairments but one who learns how to cope creatively with his own limitation and his fundamental vulnerability.

Personal Responsibility Is the New Paradigm

The passive patient who consults the expert, the doctor, and is told what to do has become obsolete—at least in political platforms. The guiding principle today is the active patient as an expression of the engaged citizen, one who does not merely follow the doctor’s orders but who sees himself as an expert on his own physical and emotional constitution, contributes accordingly, and makes decisions on his own responsibility. As his own responsibility increases, the patient is redefined as a user, an active player, who on his own initiative obtains the pertinent information and explores the options necessary for managing his health impairment. Not only does he utilize the advice and assistance of the physician, but he also consults other professionals—psychologists, pharmacists, or experts from health insurance providers, self-help groups, and experts from consumer protection associations. The modern patient assumes responsibility for his health himself and makes use of the physician and other health advisors largely as he sees fit.

“Health Literacy”

“Improving the health literacy” of the patients becomes particularly important in this setting. The World Health Organization (WHO) and the European Union (EU) have defined health literacy as the “individual’s ability” to “take decisions in daily life that have a positive effect on health.” “Health literacy,” it continues, “makes people capable of self-determination and of accepting the freedom to arrange and decide with respect to their health. It improves the ability to find and understand health information and accept responsibility for one’s own health.”

Health literacy is thus a concept that explicitly rejects a patronizing health education. It replaces the previous health education, which was primarily geared to avoiding risks, with the emphasis on the competence of each individual. The aim is not primarily to ingrain certain changes in behavior in order to avoid disease but to mobilize one’s own strengths. Thus, this conception relies on motivating a person to control his own behavior. This is referred to as empowerment. The goal of health education would accordingly be to include the world in which the patient lives as well as strengthening his individual problem-solving abilities.

According to Ilona Kickbusch’s definition, health literacy can be divided into five areas:

  • Competence in personal health.
  • Competence in system orientation, meaning navigating the health care system.
  • Competence in “consumer behavior,” meaning the ability to make “service decisions.”
  • Competence in the workplace setting, meaning the ability to avoid accidents and occupational diseases.
  • Finally, competence in health care policy, meaning the ability to become engaged for patient rights and other health-related issues.

This list unmistakably illustrates that health literacy, reflecting the modern aspirations, applies less to the patient in the classic sense than to the user, the “consumer.” It is he who should become empowered as soon as possible, meaning put in the position of being able to autonomously assume responsibility for himself. Yet it also becomes clear that health literacy is not simply a matter of acquiring certain knowledge. Rather, at its core, it is the ability to make many important decisions oneself, including those related to issues of one’s own health, and to acquire a certain practical competence in dealing with these questions. Thus, in discussing in health literacy, it is helpful not only to limit ourselves to only the five areas of competence mentioned—personal health, navigating the health care system, consumer behavior, health care policy, and the workplace setting—but also to differentiate three separate levels of health literacy:

  • Functional competence, referring to the ability to acquire simple information (essentially the ability to read and understand texts).
  • Interactive competence, examining and interpreting this information in a communicative exchange with other people.
  • Critical competence as the ability to question information as well.

Promote and Demand

Naturally, all these goals and aspirations are to be welcomed. Who would not like to determine himself how he deals with health? It is obvious that people do not want to be patronized by experts, and it is a great gain that the old paternalism in which the doctor simply dictated to the patient what he had to do has since disappeared at least from political platforms. Yet it is important to see the modern concept of health literacy in the context in which it was formulated. For health literacy is not simply formulated as a goal in a vacuum but in the context of a new understanding of the state and society. It is formulated at a time when the welfare state, whose duty is to ensure that health care is provided to the population, has been declared obsolete and the call to modernize it is becoming ever louder. What is now called for is for the “activating state.” The modern understanding of the welfare state is based less on providing for citizens than on the concept of personal responsibility. The premise of the political system is thus to promote the citizen’s competences with the ultimate goal of obligating the citizen while simultaneously releasing the state from those obligations. While the welfare state must purportedly be maintained at all costs, it is in fact being dismantled behind the façade of euphemistic concepts such as freedom of choice, engagement, and personal responsibility.

It is not uninteresting to note that the state’s imposition of an obligation to assume responsibility has been coupled with the rhetoric of emancipation, of liberation from patronization. This represents an ingenious twofold strategy. The citizen is to be provided by the state with all the prerequisites for individual success while the state can withdraw from its obligations. We could aptly summarize under the slogan “promote and demand.” The first step is to encourage individual competences with respect to personal health behavior. If this does not suffice, then the second step is to threaten sanctions. But are we not overlooking the fact that the acceptance of responsibility must be linked to certain basic requirements? In other words, must people not first be rendered able to assume responsibility before they are threatened with sanctions? I think it is important to take a closer look here.

The Limits of Personal Responsibility

With the concept of personal responsibility, I feel we forget all too easily that those segments of the population that statistically bear the greatest risk of becoming sick are on average also least able to take health promotion into account in their behavior. Due perhaps to their social status, they often simply have no choice and have neither the financial means nor the freedom of choice that is present to a greater extent among the higher social strata. This means nothing less than that one first must be able to afford health-promoting behavior! The term “prevention paradox” has been introduced to describe this situation. In essence, efforts at prevention approach often fail to produce results because they generally reach those people first who need prevention the least. Conversely, the emphasis on personal responsibility further disadvantages those who are already disadvantaged. This shows that with the pathos of patient competence and personal responsibility we fail to reach precisely the people who would have a vital interest in maintaining or improving health. Here, emphasizing personal responsibility is a strategy that is too one-sided because these people do not lack the enlightenment or good will, rather the inner resources and in particular favorable structural conditions.

In this setting, I find the increasing demolition of social welfare today extremely problematic. The more we reduce social safeguards, the more we rob the already underprivileged social strata of the chance to become individually responsible. The reason why the system is nonetheless structured this way is that we have internalized the economic mindset to such an extent that we no longer notice how greatly it has altered our understanding of justice.

What is now occurring must be described as a shift away from justice based on need toward justice based on merit.

Yet most things in life are not the result of our own failings. In other words, there are social disadvantages that must be first equalized before we can even assume a justice of performance. Today we only look at the fact that in theory no one is denied access to social benefits, yet we fail to recognize that the starting conditions for this competition vary greatly. Under the undifferentiated paradigm of personal responsibility, we are thus on the verge of splitting society into two parts, into laudable healthy people and sick people who deserve sanctions.

We must remember that belonging to a certain social stratum is not the only factor that determines the ability to accept personal responsibility but that all this also depends on a person’s age and state of health. That means that socially disadvantaged people as well as older people and especially sick people have less of an opportunity to attain health literacy. This also has to do with the fact that these groups simply have more difficulty not only understanding information but also communicating about health maintenance issues with other people (experts, family members, self-help groups, etc.) and in communicating with them coming to realize what is important for themselves. Health literacy thus has to do not only with the ability and willingness to read but also primarily with whether a person has reliable social contacts. This is what the “interactive competence” mentioned earlier ultimately refers to. Therefore, relationship structures and not mere reading ability determine whether a person has the ability to develop health literacy.

When we bear in mind that sick people in particular have difficulty acquiring the required health literacy because they have fewer opportunities to communicate with other people, then it becomes clear that this is where we must begin. Promoting health literacy means not only supporting socially disadvantaged groups but also making an effort to include old and sick people. Yet then it immediately becomes clear that the concept of the “user” or “consumer” of health care services that is currently in fashion represents the wrong paradigm. That is also the greatest weakness of the idea of personal responsibility: it is based on the self-reliant consumer. This is precisely where the activating user concept has its limits. The patient in his role as a sick person is not first and foremost a self-reliant user of services. On the contrary, he is in a fundamentally asymmetrical position because he is dependent. In contrast to the consumer, he as a patient has no choice. He did not choose his illness and cannot choose freely among nonessential goods. He is simply dependent on them. What he needs is not first and foremost freedom of choice but simply someone who will help him. When a person becomes sick, he is initially characterized by helplessness, confusion, and lack of orientation. That does not mean that his freedom should not be absolutely respected! But in order to return to a state in which he is able to decide freely, he first needs someone who feels sympathy for him, who empathizes, who understands him, and who is willing to care for him. Only afterward can we think about empowerment.

 

Based on: Essays in Medical Ethics
by Giovanni Maio

Professor Giovanni Maio, the eloquent advocate of a new culture of medicine, poses fundamental questions in this book that no one can really avoid: Where are the promises of reproductive and transplantation medicine leading us? To what extent can health be made, and to what extent is it a gift? Does "prettier, better, stronger" promise us greater happiness? Why is the question of organ donation more difficult than is suggested to us? Does being old have its own intrinsic value? How can we acquire an attitude towards dying that does not leave us feeling powerless?

Giovanni Maio's profound plea for an ethics of prudence opens up hitherto unknown perspectives. In this way we could free ourselves from the belief in perfection and find our way to a new serenity as a condition for a good life.

Welcome to Exploring Wellness, a three part exploration by Dr. Janet Roseman on how medical students and residents can center their own well-being. This series starts with Part 1: Why Wellness Counts…Your wellness, that is

Whether you are beginning medical school or find yourself in the midst of medical school angst, chances are high that you probably have not considered the topic of wellness. Not patient wellness – your wellness. Although this profession is dedicated to serving others, it is ironic that most physicians in training, as well as practicing physicians, do not make their own self-care a priority. Please read this next sentence aloud: you cannot serve from an empty vessel.

In the next columns, we will explore wellness together in the hopes that, when you find yourself in the midst of stress (and there is no getting around stress without tools), you will pull out these columns as a reminder that your wellness matters not because I said so but because you honor yourself. The mythology that physicians need to ignore their own needs in favor of others has been repeated so long that it has gained traction. However, you cannot help others, and change a culture that has prided itself on ignoring the self, without effort and attention. There are significant and real repercussions that can occur when you don’t attend to your own needs, including poor health, compassion fatigue, anxiety, depression, and even suicide. Reach out to any resources at your medical school or hospital if you find yourself in trouble or if you see a colleague who needs some support. In order for you to be the catalyst for healthy change of this dysfunctional culture, who facilitates compassionate, kind, and heart-based interactions with patients (and others), you need to recognize that offering humanistic interactions begins with you.

 

The emotional strain that medical students and residents experience is real, but it is rare that they receive any type of education that honors their own spirits. Because of the pressures of schooling throughout years of training, young physicians do not always have models that support their need for relaxation and thoughtful reflection during this time. Choose calm over chaos as a lifestyle choice and you will be surprised by its rewards in return. When you slow down and are mindful of your actions, then you can also bring a greater sense of presence to the people you touch literally and figuratively in your life.

 

Granted, medical school, the residency years, and professional doctoring is challenging. However, I remember what one medical student astutely told me: “it’s tough in residency – it can be really awful – but you are a better doctor if you take care of yourself. My mentors are my favorite physicians whom I try to emulate. They are people who, when you are with them, you are with them – even when they are busy and frazzled. You can tell that they have ways of doing it through body language, through eye contact, through silence, or communicating that they are with you.” During medical school training, it’s easy to get into a self-neglectful mode with lack of sleep, poor nutrition, and pressure to be perfect. It can be comfortable to lock yourself up in your room, studying without allowing opportunities for nurturance with family and friends. However, when you value yourself, then it’s a lot easier to value others.

 

How do you do that? It’s actually not as difficult as you may think. Lack of time is the frequent verse heard from most medical students and physicians; however, it doesn’t take an enormous amount of time to tend to yourself. Here is a helpful exercise for you to create your own wellness plan. On a sheet of paper, draw a circle and label three sections: Mind, Body, and Spirit. In each area, write down, without thinking, what you presently do for yourself in each of these areas. Then try to make a list of at least five action-oriented activities you can do for yourself that will take two hours or less. When you are finished, look at your list and select activities in each area that you can easily invite into your schedule. Place at least two activities in your calendar as part of your regular weekly schedule, and keep a diary to record how you felt during this week. It is also encouraged for you to keep a diary or journal during your years in medical school, so you can have a record of how much you have learned and grown not only as a future physician but as a person.

 

Activities that medical students and residents have told me have helped them: visiting the gym, running, walking every day after school, long showers or baths, buying healthy snacks that are available during long study or hospital hours, breathing slowly to help remind themselves that they are centered and in their bodies before taking a test or seeing a patient, sleep, aromatherapy, playing with their animal friends, baking a cake, making dinner once a week for family/friends, swimming, receiving manicures and pedicures, massage appointments, facial appointments, playing basketball, reading a book just for fun, attending religious or spiritual services, meditation, dancing, singing, playing music. What will you do?

 

Remember that the current path you are on is not infinite and that the challenges of medical school and residency will end. You will have a life with more freedom again, and the key is recognizing that you can set the stage for healthy self-care choices that can carry you into your professional career. It just begins with you making the choice that you do matter.

 

 

Dr. Janet Lynn Roseman is an assistant professor in Integrative Medicine at Dr. Kiran C. Patel College of Osteopathic Medicine, Health Professions Division, Nova Southeastern University in Ft. Lauderdale. There she specializes in spirituality and medicine and teaches courses in humanism in medicine. She is the Founding Director for the Sidney Project in Spirituality and Medicine and Compassionate Care™, a unique residency education program.


She was awarded the Presidents Award from Lesley University for her work in oncology and was the second person in the world to be named a fellow in the Spirituality and Medicine fellowship at the Kluge Center at the Library of Congress. Her research on compassion and spirituality has been published in numerous journals, and she edits an ongoing section on spirituality and medicine for the Journal of Complementary and Integrative Medicine.

A published author, her most recent book offers empowerment for people with cancer: If Joan of Arc Had Cancer: Finding Courage, Faith and Healing from History’s Most Inspirational Woman Warrior (New World Library)

Welcome to Exploring Wellness, a three part exploration by Dr. Janet Roseman on how medical students and residents can center their own well-being. Read Part 1 here and Part 2 Stress is your ally, honest. below:

Ok, I want you to answer some questions about stress. Take a moment, and think about the word: stress. What is your reaction to that word? Say it out loud. STRESS. How do you feel? Most medical students and residents believe that stress is a horrible and negative aspect of health. We all know that stress is not beneficial for the body and can cause countless health problems, both physically and emotionally. Well, I would like you to consider that stress can actually be your ally – honest. Stress is not always a negative and can even be a source of empowerment. Remember how much you studied to get into medical school? Well, your stress level was highly motivating, no doubt, so it can have purpose. Some people thrive on stress while others are defeated by it; it can be quite wounding. However, it is difficult to identify your own stress pattern without your awareness of what your triggers for stress are and how it works (or does not work) for you.

Stress does not have to be the saboteur; by understanding the wisdom of your body, you can decipher its messages. How? By listening to your body and learning its language. This language will also help you understand the language of your patients’ bodies as well. Look. Listen. Learn. Ask yourself: how do you deal with stress now? How did you deal with stress when you were a child? It’s not unusual for stress patterns to be repeated, especially during the rigors of medical school training. Pay attention to your somatic clues: lack of sleep, fatigue, irritation, depression, headaches, gastro-intestinal problems, insomnia. In one residency program where I taught, over 90% of residents scored in the moderate to high-burnout range in terms of depersonalization or loss of empathy. This type of dehumanization in interpersonal relationships can lead to decreased empathy in the patient-physician relationship. It is easy to understand how the stress of residency reveals heartbreaking patient encounters to young physicians. Often, because of that stress of witnessing acute suffering and even patient deaths (that are not usually discussed), physicians can find themselves with blunted emotional responses to patients and friends as a protective mechanism. Over 58% of medical students I have worked with told me that they never received any type of wellness curriculum during their years in medical school, which is very alarming.

 

Only you can recognize your stress triggers and know how to relieve those triggers. Stress is beholden to the beholder and the key is to work with your stress rather than struggling against it. Imagine that your stress is not only your ally but your friend, and it has an important message to convey to you. It is here to let you know what you need to pay attention to in yourself before you are overwhelmed or suffer ill health. The foundation for this recognition is knowing what sets you off into a stress spiral. The word ‘stress’ is derived from the word ‘distress’ from the 16th century, which itself comes from the Latin word ‘districtus,’ or divided in mind. This division is a main culprit for stress and you may feel that you are unable to handle a multitude of problems. When you feel that you cannot handle your stress alone, seek out professional guidance at your medical school or at the hospital where you work. Tell a friend or trusted family member. You don’t have to deal with your stress alone, especially if you feel that you can’t. Honor your feelings at all times.

 

The root word for healing is “healen,” or to become whole. Balance is essential, and that balance, no matter how small, is important. Decide that your wellness is your priority, not because someone tells you so but because you acknowledge that you matter, your time matters, and your health matters. When you provide that affirmation for yourself, then you can offer yourself the compassion you require. Professional competence includes compassion for self, and hopefully this self-compassion will carry you through the humanistic interactions you will provide for others.

 

What can you do? Set realistic standards and decide to make self-care a priority. Remember to eat well, exercise, get outside every day to let the sun shine on your face and body, and surround yourself with family and friends who support you. Remove negative people from your life. Take breaks. Find the beauty in whatever form it takes. Find a way to bring your “soul” into your daily life. Don’t forget who you are. Learn to say no. Most importantly, appreciate your position to help another human being in need.

 

Maintaining a practice for recognizing and ultimately reducing stress (when it does not work to your advantage) is key. However, making stress a familiar and even welcomed ally can preserve your abilities as a humanistic physician..

 

 

Dr. Janet Lynn Roseman is an assistant professor in Integrative Medicine at Dr. Kiran C. Patel College of Osteopathic Medicine, Health Professions Division, Nova Southeastern University in Ft. Lauderdale. There she specializes in spirituality and medicine and teaches courses in humanism in medicine. She is the Founding Director for the Sidney Project in Spirituality and Medicine and Compassionate Care™, a unique residency education program.


She was awarded the Presidents Award from Lesley University for her work in oncology and was the second person in the world to be named a fellow in the Spirituality and Medicine fellowship at the Kluge Center at the Library of Congress. Her research on compassion and spirituality has been published in numerous journals, and she edits an ongoing section on spirituality and medicine for the Journal of Complementary and Integrative Medicine.

A published author, her most recent book offers empowerment for people with cancer: If Joan of Arc Had Cancer: Finding Courage, Faith and Healing from History’s Most Inspirational Woman Warrior (New World Library)

Welcome to Exploring Wellness, a three part exploration by Dr. Janet Roseman on how medical students and residents can center their own well-being. Read Part 1 here and Part 2 here. Below is Part 3: Prescription: Creativity.

You may have a creative hobby in your life that you love, such as listening to or playing music, dancing, writing, painting, crafting, or even an art exercise as simple as coloring. You may be surprised to learn that a recent analysis of over 100 studies on the impact of art on health and the ability to heal found that, for patients battling chronic illness, the arts (painting, drawing, dancing, pottery, photography, writing etc.) had an overwhelmingly positive impact on the health of patients.

The researchers found that art was a helpful and healing distraction that patients could use to cope with their illness because it improved well-being by decreasing negative emotions and increasing positive ones. It also reduced stress, anxiety, and depression. So, what does this study have to do with you? Creativity in all its forms can help you not only during your medical school training but as a healthy outlet that offers relief from the medical mind. In addition, it isn’t just that the art making activity and the creative expression are healing but also that art making (or any creative endeavor) offers you a chance to immerse yourself totally and align with the sacred forces of creativity. It’s easy to get lost in the process of creativity, and that is one of its myriad gifts. When you experience these gifts, then you truly know how healing a creative activity can be. There are literally hundreds of studies that show how effective the arts can be, particularly for oncology patients (but that is only because the researched populations were oncology patients). All of your future patients can receive its benefits. It is not unusual for patients who turn to creativity during a health crisis to find that this was what helped them through the difficult path of illness. It is immensely beneficial for patients to be able to connect with their creative side, a side that is not injured even though they may use their art to depict their pain. Creative pursuits can aid anyone who is injured (mind, body, or spirit) to recover loss of self-confidence, an integral part of any health challenge.

 

Creative activities also give you a chance to quiet your mind, to be still and engage only in the activity at hand, whether it be art making, dance, working out, gardening, or meditation. Even walking in quiet can be a creative activity, for it allows your mind to rest and you to concentrate on the beauty of breath while you walk. Remember, it is not just the activity and the freedom of creative expression that are healing but the chance to immerse oneself in that activity and align with the creative forces. I believe that, if more physicians encouraged their patients to utilize this creative and sacred process in the therapeutic interaction, the healing process could be much richer. For example, journaling, drawing, recording dreams, yoga, meditation, and mindfulness training can help bring you into the present moment of creativity and function as stress relievers. Asking yourself where your current pain or stress is in your body and drawing that visually can help you pinpoint where your anxiety lies. This exercise may sound silly, but it really works, and it is also quite useful for patients who may not be able to speak with you about a traumatic event that is affecting their health.

 

Ok, you may not think of yourself as an Artist with a capital “A,” but you don’t need any specific talents to engage in a creative endeavor. All that is required is the intention to create something. For some, a driving force to “make art” stems not only from an exploration of personal creativity but from an attempt to fix, to change, to process, or to understand one’s personal story. This personal story often contains aspects of pain, depression, or woundedness, and those elements are where the creative powers reside. Often, we flee those feelings because they are uncomfortable and anxiety producing. In an attempt to mask the truth, we search for outlets such as drugs, alcohol, or other destructive patterns. However, if we changed our perspective to understand that these so called “negative” feelings are really where the knowledge lies and made these feelings our allies, then they wouldn't hold the same power over us. This is not to say that all creative or artistic ventures must be triggered by pain; however, when you give yourself permission to delve deeper into your feelings—especially during the difficult times in medical school—it can be a potent healing prescription, more potent than any pharmaceutical intervention.

 

Creativity can be your prescription, and, once you find your specific creative calling, stick to it. Challenge yourself and learn a new skill, even while you are studying. You would be surprised at how helpful this can be. In the long run, once you find your own healing prescription, it will be easy to suggest to your future patients that they engage in some type of creative activity in the midst of their illness. Even if they have limited mobility, these activities will help restore their creative voice. I am reminded of the wonderful artist Frida Kahlo who painted compelling self-portraits as her own therapy while she endured over 40 surgeries as a result of a tragic accident when she was a teenager. Kahlo wanted to be a physician, and, if you study her work, you will see her knowledge of the human anatomy in each picture she painted. I paint self-portraits because I am so often alone, because I am the person I know best. Kahlo understood that the creative process offers opportunities to be alone, to spend time with yourself, and to learn about yourself.

 

Probe deeper into your own creativity and share your insights with others so they can share their own creative adventures as well. Find your creative voice and reveal it, if only for yourself. You are worth the exploration.

 

 

 

Dr. Janet Lynn Roseman is an assistant professor in Integrative Medicine at Dr. Kiran C. Patel College of Osteopathic Medicine, Health Professions Division, Nova Southeastern University in Ft. Lauderdale. There she specializes in spirituality and medicine and teaches courses in humanism in medicine. She is the Founding Director for the Sidney Project in Spirituality and Medicine and Compassionate Care™, a unique residency education program.


She was awarded the Presidents Award from Lesley University for her work in oncology and was the second person in the world to be named a fellow in the Spirituality and Medicine fellowship at the Kluge Center at the Library of Congress. Her research on compassion and spirituality has been published in numerous journals, and she edits an ongoing section on spirituality and medicine for the Journal of Complementary and Integrative Medicine.

A published author, her most recent book offers empowerment for people with cancer: If Joan of Arc Had Cancer: Finding Courage, Faith and Healing from History’s Most Inspirational Woman Warrior (New World Library)

Competence in the sense of strengthening the patient’s autonomy is something that must first be learned. This goes beyond the mere accessibility and processing of information and primarily has to do with fundamental attitudes: How can I face changes? Am I able to experience myself as dependent without seeing this as a loss of my self-determination? I am convinced that a person can only be competent when he has learned to be so adept at coping with his illness that he no longer insists on complete restoration of his ability to function and can become so accustomed to what is irreversible that he can discover his own creative potential even in sickness.

This includes the ability to experience having become sick not as an affront and the dependency on others not as the end of one’s own perspectives. Sick people achieve the best competence when they are not only “activated” but when they receive so much assistance and support that they are able to learn to live well with their illness.

Time and again, I see that severely ill patients in particular, for example, cancer patients, tend to trust their doctor’s judgment and delegate their decisions to their doctor. Here, as in so many other places, one must recognize that one cannot lump all people together and that it is not simply a matter of writing informative brochures about certain medical findings and then leaving the patients alone with these brochures. One only does justice to the patient when one also feels responsibility as a physician. Patients have a personal responsibility but overemphasizing this responsibility could tempt the health care professions to neglect their own responsibility as helping professions. This would be the result of the cult of personal responsibility: that in this way all responsibility would rest on the individual and the health care professions themselves would no longer genuinely internalize their own professional responsibility. “‘Responsibility’ is a scarce good,” notes the Frankfurt sociologist Helmut Dubiel, who himself contracted Parkinson’s disease at the age of 46, in his book Deep in the Brain which arose from his struggle with the disease. “It cannot be placed on someone without taking it away somewhere else.” The overstretched responsibility of the individual, as he indicates, could have “its downside in the new ‘irresponsibility’ of institutions such as the state and the health insurance and health care system that has found its way into all hypermodern societies in recent decades.” Especially in the face of the insidious advent of structural irresponsibilities, physicians and patients should learn to see each other as partners.

Competence in Dealing with Limitations

What do freedom and responsibility mean and what does health literacy mean in this setting? For the person who has become sick, it means that the appeal for personal responsibility must never mean simply leaving him to his fate. On the contrary, I feel that all the health care professions must unmistakably show their willingness to assume responsibility for their patients. And society should not be allowed to withdraw from its responsibility to those in distress but should do everything in its power to be alert to any hasty overextension of the activation model. Additionally and not least, this means recognizing that the state with its concentration solely on activation and personal responsibility is secretly submitting to the classic laws of the market and has assumed a market-economy mindset that can have catastrophic effects for sick people in particular.

For the healthy person, health literacy could mean not pursuing the ideal of complete wellbeing but learning to live with the limits. It could mean not feeling powerless but realizing even in a precarious situation and under poor initial conditions that every one of us has potential. Using this potential does not depend solely on money but also on the inner attitude, on the feeling of being able to find joy simply in the fact of one’s existence. The French physician and philosopher Georges Canguilhem (1904–1995) defined health in this sense as a sort of safety reserve of response options:

“The healthy person measures his health by the ability to survive the crises of his body and establish a new order.”

I think health is not a state characterized by the absence of disease but one in which the disease risks and disease conditions can be taken into account as an integral part of life. Therefore, I would advocate describing health as a person’s ability to behave toward his limitations and even functional disabilities in such a manner that they can be integrated into his own concept of life. A healthy person is not one without impairments but one who has found out how to cope creatively with his own limitation and his fundamental vulnerability. A healthy person would therefore be someone who is not determined exclusively by his disease and who does not see himself as powerless even if not everything “functions” equally well. Viktor von Weizsäcker (1886–1957), the German physician and founder of psychosomatic medicine, put it very succinctly when he said: “The secret of health is not capital that one can exhaust, rather it is only present where it is produced at every moment of life.”

We live in a society where health is highly prized, yet it would be tragic if people did not realize that they can live a full life even in the presence of functional limitations insofar as they succeed in reflecting on their inner potential to overcome these functional limitations. In any case, it is of paramount importance that we realize that health is nothing that we can simply make or be certain of keeping with good will alone. Health is ultimately a gift that we receive without having earned and that we therefore should protect joyfully, maybe even thankfully, every day.

Personal Responsibility through Care

And what does that mean for medicine? Medicine has long based its self-image on the unshakable ethos of being on the patient’s side and offering him help without question. This unquestionable aspect of helping has been the basis for the trust in the humanity of medicine. Indeed, it is what has made all of medicine appear as a guarantor of humanity. Today, this unquestionable aspect of helping is gradually being rescinded, and this is being done very subtly. For this reason, physicians must unmistakably show that they will never withdraw from their core task, which consists in giving patients the indissoluble commitment that they as patients need: you will not be abandoned! Only in the deep awareness that medicine is on the side of the patient without reservation will patients feel strengthened and able to do something for their health.

Thus, the greatest danger of an excessive cult of personal responsibility lies in the fact that our society could be tempted to give up a social achievement with reference to the responsibility of the individual, namely the achievement of solidarity. A too one-sided pathos of personal responsibility could ultimately lead to erosion of public spirit, the collapse of the binding forces within our society, and the breakdown of a sense of community among all people. Each of us can only act autonomously when he feels supported by the reliability of social bonds, when he knows he has a stable frame of reference. The cult of personal responsibility has rendered this community-oriented frame of reference increasingly fragile and forces many people into an atmosphere of intimidation and fear, namely the fear of social indifference. Fear and intimidation are not a good basis for motivating people to take individually responsible action. Therefore, the concept of activation and individual responsibility must be pursued with a sense of proportion. It must not be so overstretched that what is basically a good idea ultimately leads to disastrous consequences, namely to social disintegration. Today there are shared values that cannot be framed in the entrepreneur’s slogan for himself. There are values that go beyond the value of personal economic success. And the awareness of solidarity with those who are worse off is such an incalculable value. I am profoundly convinced of this!

The current era of economization, individualization, and ebbing solidarity is a great challenge for the social character of medicine because it is to be feared that medicine has fundamentally changed and moved away from its genuine social task of helping to mutate from a helper into a judge over the patient. Helping the patient attain a health-promoting way of life remains a key requirement of medicine. Yet at the same time we should maintain the awareness that medical aid for sick people must not be linked to the discussion of possible personal guilt—even in the occasional case where it may appear obvious. For good reason, the physician’s actions have always been guided by the ideal of the unconditional helper. Attempts to weaken this paradigm shake the very foundations of medicine as a social practice.

For medicine to remain the patient’s advocate, it also needs a framework that allows it to invest in relationships with the patient without immediately having to produce evidence that this investing in relationships has directly paid off. The investment in promoting personal responsibility through the relationship with the patient is a golden investment in the future and should also be respected by the system as a value in itself even in the absence of an immediate expected return. It is this relationship with the patient that offers the opportunity of engendering a capacity for responsibility, a capacity that can only ripen into personal responsibility with social support. Therefore, the ethical motto for the future is: not personal responsibility instead of care, but personal responsibility through care! And medicine has no greater commitment than to this unconditional care for the person in need.

 

Based on: Essays in Medical Ethics
by Giovanni Maio

Professor Giovanni Maio, the eloquent advocate of a new culture of medicine, poses fundamental questions in this book that no one can really avoid: Where are the promises of reproductive and transplantation medicine leading us? To what extent can health be made, and to what extent is it a gift? Does "prettier, better, stronger" promise us greater happiness? Why is the question of organ donation more difficult than is suggested to us? Does being old have its own intrinsic value? How can we acquire an attitude towards dying that does not leave us feeling powerless?

Giovanni Maio's profound plea for an ethics of prudence opens up hitherto unknown perspectives. In this way we could free ourselves from the belief in perfection and find our way to a new serenity as a condition for a good life.

One of the big problems we usually confront when we make the transition from plan to action is that we avoid starting. We want to avoid the unpleasant workload that is ahead of us. We often fall into the habit of “procrastination,” thus avoid doing a task that needs to be accomplished. There are usually two correlated reasons for this behavior:

  • Lack of motivation (remember when you postponed to study until the night before the exam?).
  • The inertness to start, because you have no idea how to start.

Let us skip from the car-driving paradigm to mountain climbing. Imagine that you are in principle capable to perform complicated rock climbing. You have decided that one of the important goals of your life is to climb the Matterhorn (Fig. 4.1).

Just looking at this mountain might intimidate most of us and induce a severe bout of procrastination: “this is not manageable, not today, maybe tomorrow, I have an urgent appointment with my coiffeur and so on ….” If this project is not really important for you, then walk away from it: no harm done. However, if the project is important, then you are in big trouble by walking away. The urge to accomplish and to deliver will catch up with you and will add to the many nagging voices in your subconsciousness. Eventually, the pressure might become so overwhelming that you start climbing. There are several drawbacks with this procedure. First, you went through a tough time with the nagging voice constantly accusing you of your insufficiency. Second, your pressure-generated motivation might make you blind for weather problems and you are climbing under less than optimal conditions.

The Stepwise Approach

A very efficient way to overcome this “procrastination problem” is to transfer this huge, monstrous project into manageable portions (actions). Fig. 4.2 shows you the subdivision of this monster climb into manageable steps (at least for the few mountain climber capable to do this), so that your perspective is a now and immediately manageable action (Fig. 4.3). Therefore, after defining a goal, you need to sit down and define the subsequent steps that you need to make (Fig. 4.4). This is a crucial point. You need to translate the goal into manageable steps (= actions).

The Need to Define the First Action

Take extra care to design an easy first action. Once you have started, things often become easier and are carried by the momentum that develops after successfully climbing the first step.

Forward and Backward Organization

By subdividing a complex problem into manageable steps/actions, it is essential that you:

'

  • Identify all necessary actions.
  • Put them in the right sequence.

One of the very effective ways to do this is to walk through a timeline. It is often useful to start with the end point. Imagine that you organize a meeting. Think at the closing session. What is needed at this point? Brainstorm the actions that come in mind: flowers for the organizers, certifications, in which location, date of next meeting, transfers to the airport, time the meeting stops, time for the transfers, etc. Note all the actions that come in mind and repeat that exercise with a forward approach. You will end up with long list of items (actions). Now sort them into a logical sequence: according to time frame, importance, etc.

 

Based on: Time and Life Management for Medical Students and Residents
by Michael Sabel

As grueling as medical studies and training are, with appropriate discipline and time management it is possible to stay afloat, maintain one's sanity, achieve one's goals, and still enjoy a fulfilling life. It is the purpose of this book to stimulate thought processes that nurture a healthy attitude toward organizing one's time and life so as to improve one's own quality of life as well as the patient's well-being.

Imagine that you are sitting in a small boat. It is stormy, it is raining, and it is cold. Your boat (your position) is subject to waves, wind, and current. This is altogether an unpleasant situation that you want to change.

You start to row: initially you are not used to the movement, but with time you are improving—you concentrate on every stroke and eventually you become an efficient rower. After some time, you start to get tired; finally, you have to stop because you are exhausted. You suddenly become aware of your surroundings: the storm is getting worse, it is even more unpleasant than before, and you realize that you are very far away from the land. Thus, despite your (per se efficient) efforts to improve your situation and your motivation (you pushed yourself to complete exhaustion), your situation is even worse now. Had you applied your rowing skills in the right direction (thus had defined a goal before starting to work out like mad), you would be safe and sound on stable ground.

Ideally:

  • You would have defined your goal before jumping into action.
  • You would have performed efficiently.
  • You would have self-regenerated during your journey.

I think it is already obvious from this simple example that you need to define your goal first. I also introduced other important concepts: motivation, efficacy, and regeneration. Do you agree that they are secondary to defining goals? So let us work on goals first.

As shown in the example with the jungle road and the rowing boat “incidence,” being highly motivated and very efficient in performing is completely useless (and you will still be a loser) if:

  • You have no defined goals.
  • You have defined the wrong goals (which maybe even worse and very dangerous), that is, unrealistic, too ambitious, too understated, and so on.

We can safely assume that you have goals in your life. It is, however, amazing that many people do not consciously work on this very central hit list of their life. Are you completely aware of your goals?

The “You Can Make It If You Want” Nonsense

I suspect that you are very eager to start on your journey to reach the goal(s). However, the decision to go for a goal is a very important decision and can have huge consequences on virtually all aspects of your life. It is therefore almost essential to understand the underlying mechanisms, which determine your success or failure. Before jumping in, put your goal to a reality check.

The difficulty in choosing a goal is to avoid underestimation of your capabilities. On the other hand, overestimation is problematic as well. A huge part of success and motivation literature is filled with witty little statements such as: you can make it if you really want. No, actually you cannot, if you choose to run a marathon under 2.03 hours or plan to become a commercial pilot with poor eyesight. Therefore, perform a reality check by evaluation of the available logistics of your life. In a schematic drawing (Fig. 1.1), I set your goal in the context of a timeline (x-axis) and work required (y-axis).

This simple model shows that you need to invest work to reach your goal: the more ambitious your goal, the more work you need to invest. Note that the position of your goal is also within a time frame. The shorter time you plan to reach your goal and the more ambitious your goal is, the more energy you need to invest (area under the curve). If you plan to reach a less ambitious goal in a longer time period you will need to invest lesser energy (Fig. 1.2). Another important point: if you have reached your goal, you have (according to our rather crude mechanical model) acquired a certain potential energy (Fig. 1.3). In terms of physics, there are two consequences:

  1. You need to spend energy to stay on this level.
  2. If you do not, you will fall. The higher you climbed, the deeper you will fall.

 

Based on: Time and Life Management for Medical Students and Residents
by Michael Sabel

As grueling as medical studies and training are, with appropriate discipline and time management it is possible to stay afloat, maintain one's sanity, achieve one's goals, and still enjoy a fulfilling life. It is the purpose of this book to stimulate thought processes that nurture a healthy attitude toward organizing one's time and life so as to improve one's own quality of life as well as the patient's well-being.

The path through medical training is long and arduous. Most enter medical school with a sense of idealism and purpose. There’s been a lot written about how over time, that feeling can be tempered by the stressors of the field and exposure to some of the less glorious realities of medicine.

Some of this hardening process is necessary for survival. Experience teaches you how to deal with the loss of a patient, the reality that patients may not appreciate what you do or things may not go as smoothly as hoped despite your best efforts, and the fact that some problems don’t have easy solutions. Establishing some defense mechanisms is healthy, since you’re exposed daily to a wide roller coaster of emotions.

I remember distinctly one of my first shifts in the emergency room as a student. In one night, I saw a woman who had been struggling with infertility for almost a decade come in with nausea and find out she was pregnant, a patient with abdominal pain find out that he had widely metastatic cancer, and a homeless patient come in for a bite to eat and a dry place to sleep. There were also two codes that night, with two very different outcomes. By the end of the night, I had spoken to families who were elated and families who were devastated, had picked up tips from social workers and hospice workers, had been yelled at by a consult service, had been hugged by one patient, and had to run away from another patient who tried to hit me with his cane. I left the hospital the next morning emotionally and physically exhausted, with a slightly different view of my role as a physician than I had the night before.

Every day of your clinical rotations teaches you new and unexpected lessons, both clinically and about your role in the healthcare system. Every physician could tell you countless stories that have influenced how they practice medicine. Some of these stories chip away at our idealism and can even lead to cynicism, but hopefully there are also a proportionate number of stories that reignite passion for medicine and patient care.

I’ve always loved to write, and one thing I did during training was to journal as a way to process my thoughts. From time to time, I look back on those journal entries. Particularly when I’m frustrated with medicine, this has been invaluable in reminding me of the reasons that I went into medicine. It’s also been a wonderful way of charting my evolution as a physician. I love going back to it and reading about my perception of my first day on the wards, the first time I delivered a baby, and many other experiences. To those of you in training, I would encourage you to occasionally write down yours, both positive and negative. I guarantee you’ll treasure it later.

 

Nisha Mehta, M.D.

Dr. Nisha Mehta is a physician and writer with interests in physician wellness, medical education, and health policy. Follow her on Twitter @nishamehtamd or on Facebook at www.facebook.com/nishamehtamd.

I’ve written before about my medical student journal, and how looking back through it reminds me of the reasons I went into medicine and highlights some of the experiences that have had the biggest impact on me. There is one journal entry I go back to more frequently than others. Everyone has certain patients that stick with them forever, and over ten years later, this patient’s experience continues to influence how I practice medicine on a daily basis.

During my inpatient medicine rotation, I had a patient that I took care of for almost an entire month. I remember his face and voice so clearly - he was a patient with metastatic lung cancer in his late 60s, who had decided to forgo most medical treatment. When I rounded on him daily, there wasn’t much to do medically except control his pain, so I would just chart his vitals and then sit down with him and talk. Every morning when I came in, he would be sitting there with a cup of coffee and the newspaper, and would talk to me about current events, life in the military, his career, his daughter, and his rationale behind deciding against further treatment.

I cherished those conversations, and would often go back in his room to talk during moments of downtime during the day. He had no visitors, and had so much to say, and I wanted to give him a chance to say it. I enjoyed his sense of humor, and learned so much from his perspective as a patient. He was brutally honest, and shared with me everything that he thought we as a society did right and wrong in healthcare. As someone entrenched in learning how to provide care, it was eye-opening for me to really see the other side of that from the patient’s perspective. As the month progressed, so did his condition, and during his last few days, I found myself unwilling to leave the hospital, worried that each conversation would be the last. I stayed late, and then went home and spent most of the night wondering what was happening at the hospital and whether he was scared or in pain. I was terrified of when I would walk into the hospital and find that he wasn’t there.

Of course, one day, that happened, and I was devastated for days. My attending physician and residents shared their stories about the first patient they lost that had meant a lot to them, and I slowly came to terms with the fact that this would be a part of life in medicine, and that I had to develop coping mechanisms that allowed me to function in my life outside of medicine.

I moved on, like we all do, but that patient changed who I was as a physician, and I look back on my memories of him with a lot of fondness and a sense of gratitude. In addition to teaching me how to deal with the loss of a patient, he is my reminder that behind each patient and their medical condition is a lifetime of stories and relationships that impact their health and their medical decision making process. He is my reminder to see the patient as more than a chart and test results, and approach each interaction with empathy and an opportunity to learn. Most importantly, he is my reminder that it is a privilege to be a part of a patient’s life. On my harder days in medicine, I remember him, and am so thankful for my role as a physician.

 

Nisha Mehta, M.D.

Dr. Nisha Mehta is a physician and writer with interests in physician wellness, medical education, and health policy. Follow her on Twitter @nishamehtamd or on Facebook at www.facebook.com/nishamehtamd.

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I came across a picture the other day which in my eyes, summarized the way a lot of people view their time in training. It’s an image that asks you to check a box indicating your relationship status, with the options being single, in a relationship, ‘it’s complicated,’ married, and ‘in medicine.’ While it made me laugh, I also found it telling. So many trainees voice a sentiment that their personal lives are on hold during training, whether it be in regards to relationships, hobbies, or other interests. I don’t think it needs to be that way, and in this era of burnout, actually feel strongly that it shouldn’t be this way.

In medicine, we learn quickly that we will make sacrifices for our careers. Having night, weekend, and holiday responsibilities means that we won’t always make it to weddings, reunions, or other social events. Patient care is unpredictable, and we (and our significant others) know all too well that promising we will get out of work at a certain time is a setup for failure and disappointment. We know that entire months at a time will be dedicated to studying for a particular exam or all-consumed by a demanding rotation.

That being said, it’s important to keep in mind that training occurs during some of the best years of your life, and as we know all too well in medicine, the future is unpredictable. Don’t put everything else on hold for a later point. I would be willing to bet that most people who have crossed the threshold into attending-hood would agree with me when I say there’s no such thing as perfect timing for the other things in your life. If you really want to make a relationship work, make a commitment to that in the same way you make a commitment to passing an exam. They should be viewed as being equally important. If you want to have children, same thing. If you’ve always wanted to explore a certain interest, experience a particular bucket list item, fulfill a certain goal, or learn about something outside of medicine - again - same thing.

Forgetting who you are or what you want will only lead to dissatisfaction in the long run. Don’t be afraid to ask for accommodations that allow you to do the things that mean something to you - the worst anybody can do is say no (and sometimes they will). But sometimes, they will surprise you, and maybe even support you. Don’t be afraid to think outside the box. Coming up with unconventional solutions such as extending residency by a few months so you can take some extra maternity leave, taking a year out at some point in training to pursue a passion project, travel, or gain some perspective on the pathway you are on - these are all good things. And, perhaps surprisingly, they will make you a better physician. Life in medicine is evolving, and the personality traits necessary to have a fulfilling career are changing with it. We need this next generation of physicians to be brave, well-rounded, and creative.

As the saying goes, life’s a journey, not a destination. I wish you well during your journey, and encourage you to carve out the life in medicine that you desire. Don’t let anyone tell you how your path should course. You are first and foremost an individual, and staying true to that will help you to be the best version of your physician self.

 

Nisha Mehta, M.D.

Dr. Nisha Mehta is a physician and writer with interests in physician wellness, medical education, and health policy. Follow her on Twitter @nishamehtamd or on Facebook at www.facebook.com/nishamehtamd.

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