Embedding Resilience in Medicine

      Half an inch from the first four thoracic vertebrae lie the central nervous system transistors (stellate ganglion) for your fight and flight nervous system. Needless to say, my upper back is constantly aching. I am metabolizing the unique stress of being a brand new doctor/medical student in hospital life. It’s a different kind of stress than the first two academic years: those were crushing content & exams, but they were ivory tower academia. This is the very real medicine that is literally birth, life and death stuff. More visceral than literal, I find myself often crying,  sometimes gagging, and occasionally elated.

The purpose of third year clerkship aka #MS3 is to get a sampling of each major specialty to help us decide on a residency. Its a generic med school formula consisting of: Pediatrics, Surgery, OB/GYN, Internal Medicine Inpatient & Outpatient, Family Medicine, Psychiatry, Community Health. Inpatient, we legally cannot write patient notes. While we can actively participate in patient care,  everything we do needs to be seconded by a licensed doc; therefore, we are mostly shadows, errand runners, and absorbent sponges.

Unfortunately, some throwbacks to fraternal physician hazing rituals are still in place even for third year medical students. For example, my Internal Medicine inpatient rotation, which is already a 6am – 6pm shift 5 days a week (with a 1 hr drive on each side) also requires 6 -24 hour shifts in the 6 weeks. I asked a friend who is a year ahead of me and attended a different hospital clerkship if her rotation was scheduled as such, and she said she had to follow hospitalist hours for that same rotation – roughly 730am – 330pm. If the point is to learn each of the specialty’s roles, it makes sense to follow the professional hours. If the goal is to teach us that Internal Medicine requires an exhausting slog of hospital life, and how to forsake all other aspects of our personal and academic life for our career, then this approach in third year makes sense. Slate Magazine said it best: Third Year Kills Humanity of Medicine.

I haven’t done the above inpatient IM rotation yet and yes, I’m actively worried about my health, my marriage, and my coping skills during that onslaught. I did one 86 hour “sneak peek” week with our Family Medicine inpatient service last Fall.  I did enjoy the steep learning curve and patient contact; however,  I often felt lost and useless as my resident dictated her many notes and ran around the hospital following up on pages and other details. I did get some good studying done and learned some basic inpatient skills but there were hours, especially after the first 8,  that I wished I had something more productive I could be doing in.

In reality, the residents are much more forgiving than the administration and often let us leave early (6am – 10/11pm) saying “there is nothing we could learn at 2am that cant be learned at 2pm.” I am eternally grateful for this ray of grace. And I do understand that night shifts and on-call hours are foundational for many physician careers and practicing them could be relevant.  But why, when 55% of Internal Medicine and Family Doctors report burnout, are we being subjected to these mind numbing hours as third years? How will medicine ever change if the hazing continues to be perpetrated generation after generation?

I accept that being a doctor requires selflessness & sacrifice. I accept that long hours are often required and I like to work – for an income, for a team, and for a good reason. I’m a second career medical student, I study and practice clinical skills because this is what I love! I accept that as a resident I will bear the brunt of hours spent watchdogging and admitting in part because we are the cheap labor force of institutionalized medicine. But, I have 1.5 years of med school left, and 3-6 years of residency/fellowship ahead. What is the purpose of having me work 86 hour weeks now,  and how is it going to benefit my relationship towards medicine?

To embed resilience in doctors, we as a profession and as an academic incubator need to provide time & space for rest, relaxation, and quietude. Only in parasympathetics can we metabolize the soul-rattling experience that comes from facing death and sickness and the burden of chronic disease in North America. Not only are we facing grief/loss/mortality, we are taking on the enormous responsibility of decision maker. A backlog of unprocessed emotion leads to substance abuse, chronic pain, sleep disorders, lack of compassion, and who knows what other organic & chemical dysregulation. We need regular daily time to cook good food, sleep with our loves, be intimate and vulnerable, Netflick and chill, get to the gym or get outside. Only in that space can we emotionally integrate this transformation.

Our clerkship Dean Dr. Taylor sent out this  reaffirming blogpost last month in which an experienced physician Dr. Youngson writes to his younger self. He says:

     “As a medical student or junior doctor, it’s easy to feel powerless especially in a hierarchical medical system that too often teaches by humiliation, punishes those who question the status quo, and grinds people down through overwork and inhuman working conditions…”

Change medical education so that we as medical students (and residents and attendings and all doctors actually) are seen as people who are more than life-saving, problem fixing, chart dictating, disease curing machines. A more gentle, humane practice of time & space for medicine while living life alongside the role of physician has to start at the beginning of the clerkship year when we integrate it’s practice with our academic foundations, or it wont be ingrained as part of the way we approach medicine.

Once I started thinking about time, resilience and integration as the cure of medical burnout, I began seeing evidence everywhere. I heard a NEJM Interview from 01/03/18 with Dr. Armstrong from Massachusettes General Hospital’s new Pathways program where residents are given time and a scientific team to investigate complex patient-based cases. The 12/26/17 issue of JAMA has an article by Jack Coulehan, MD MPH from the Center for Medical Humanities, Compassionate Care and Bioethics on Negative Capability and the Art of Medicine that speaks to “sustaining the physician through the ‘humdrum routine’ of professional life… [Using]… the power to recognize the ‘true poetry of life'” and of medicine. This is a reflective practice. He says:

In pursuing the steadiness and detachment required to master clinical practice, it is tempting to neglect the more difficult project of nourishing engagement and tenderness in our relationships with patients – and with ourselves.”

The future of medical education is not only about competencies met and clinical acumen. The true scholars of the next generations of physicians will be those who can achieve their best in patient care and scientific fulfillment, while also living a satisfying, integrated and joyful life.


Insomnia is the Worst!

luxury-hotel-rooms-pamilla-cape-townI was on vacation with my sweetheart this past week, and spent two long nights in a hotel room when I could.not.fall.asleep! What to do? It was so exhausting, and of course set my mood and energy levels off for the remainder of the trip.

When I evaluate sleep from an Integrative Medicine perspective, I usually break it into –

  1. unable to fall asleep
  2. unable to stay asleep.

The former tends to have a different set of causes and therefore medications than the latter. Sleep is complex and involves multiple body systems working together including endocrine, neurological, immune, musculoskeletal, and mental/emotional at the very least! Each person with chronic insomnia will benefit most from individualized treatment, but here are some generalizations to improve sleep.

First, as boring and arcane as it sounds, sleep hygiene is important. Hygiene is a strange word to associate with sleep, IMHO. It sounds weird and uncomfortable, but “sleep hygeine” is a general concept that encompasses the environmental and behavioral aspects that are known to improve sleep quality and promote restful sleep. For example, my hotel room was too hot both nights. Maintaining a comfortable room temperature preferably cool with fresh air, is known to improve sleep quality. A darkened room without blinking or other lights within eyesight and a peaceful bedtime routine are also examples of sleep hygiene.

untitled     To fall asleep, sedatives are the key. Valerian is the strongest herb for sleep support. This herb was mentioned by Hippocrates in his writings, and is one of the oldest sedatives known. It has numerous studies supporting its use for sleep. The essential oils in valerian appear to provide its sedative activity, while the valepotriates exert a regulatory effect on the autonomic nervous system.  Although more than 150 constituents have been identified, none appear to be solely responsible for valerian’s effects, suggesting many compounds may act synergistically. Valerian’s mechanisms of action are not completely understood.  Valerian interacts with neurotransmitters such as GABA and produces a dose-dependent release of GABA. Valerian also inhibits the enzyme-induced breakdown of GABA in the brain.

GABA is my other secret weapon for falling asleep. There are two on switch neurotransmitters (dopamine and acetycholine) and two off switches (gaba and serotonin.) When the off switch is stuck on, sleep becomes difficult. Taking GABA as a supplement improves GABA levels in the brain, quieting the mind. Benzodiazepenes like Attivan and hypnotics like Ambian also work to increase GABA levels, as does Valerian. *Don’t use these all together as they can depress respiratory function as a cocktail.

images7OHBNK29Difficulty staying asleep can be more complicated to treat than falling asleep. Taking sedatives at 2 – 4 am can result in morning grogginess. From my experience, early waking (3am) is often related to a dysregulated cortisol clock, or, put simply, stress. Cortisol is the primary stress hormone produced by the adrenal glands. It runs on a 24 hour clock, and should be highest at 8am, and slowly drop during the day and rise at night. With emotional and/or physical stress, travel to different time zones, or shift work, the cortisol clock can become dysregulated, peaking earlier and earlier, creating an too-early wake up signal. Adrenal support is key. I often use herbs like ashwaganda, L-theanine, rhodiola, relora, and more to help regulate adrenal hormone production and heal imbalances. Cortisol is complicated, and balancing requires an in-depth look at ones lifestyle, mental health, stress coping techniques, exercise patterns, blood sugar and more. Therefore, treating stress and adrenal health in relation to sleep is best with an individualized approach, as “cookbook” medicine rarely gives optimized results.

For really tough sleep cases, NeuroScience labs makes a neurotransmitter panel to assess what is causing the night time wakefulness. Blood sugar disorders, sympathetic nervous system activation, cortisol dysregulation, hormone imbalance, anxiety, depression, grief, and more can all be part of the “perfect storm” of insomnia. Find a Naturopathic Doctor in your area to unravel the depths of your sleep mystery.

Umbrella_GraphicFinally, energetic medicines like acupuncture and homeopathy can be invaluable for unlocking sleeps depths. We are quantum physics humans, we do not operate in straightforward paradigm. Sometimes sleep issues go back to childhood dysregulation or other “never been well since” life events. These more energetic medicines can work to correct these deep imbalances by integrating unresolved issues that plague your subconscious when your guard is down. Psychotherapy and cognitive behavioral strategies can also be used to unravel sleep and stress mysteries.

I was lucky: once I was able to come down from the stress before my trip, and relax into my holiday my sleep improved, and I even got to sleep in for a change! What do you need to get that beauty sleep you so desire?


Eat, Sleep, Wait, Repeat.

glycogen-and-intermittent-fastingI recently read an article that most Americans eat for 15 hours a day. Apparently, the body needs a 12 hour fast daily to clear liver glycogen, thus switching metabolism to utilize the body’s stores (fat) to fuel the basic metabolic rate. Without this 12 hour fast, the liver does not get to ever fully utilize glycogen stores, and food/fuel aka glucose gets stored as fat.

Ive been tracking myself, as I always do when I am trying out a new metabolic theory, and I usually get about a 9 hour fast in. I’m one of those people that likes to eat at night, and with my new academic schedule, I need my 7am morning toast to soak up the coffee that makes my 6am wake-up call possible. Also, beverages counts as food/fuel in this context. Therefore, the last drink of alcohol, milk or juice you have before bed also counts towards the fasting timeline.

The 12 hour fast biochemistry is probably the source of the “dont eat after 7pm” dogma. That, and most of the snacking that occurs after dinner is high calorie and high deliciousness.But what if, like me, you are someone who likes to graze after 7am, eat dinner late, and/or cant sleep with an empty belly?

The moral of the story is: if you are trying to lose weight, make it a priority to fit in a 12 hour fast that includes your hours of sleep (hopefully 8+. Read how more sleep helps you lose weight here.)

For example: If you snack until 10pm, don’t have breakfast, coffee with sugar or cream/milk, juice,  or anything over 5 calories or sweet tasting until 10am. (Ps. Even artifical low calories sweeteners may be linked to weight gain says Harvard med.) This will allow your body to “empty” its reserves, making room for a day of metabolic synergy and a delicious, satisfying 12 hours of food after your overnight fast.

blackHint: learn to love black tea or coffee, green tea, and/or hot lemon water before your 12 hour fast is over if you are honestly wanting to lose weight. If, like me, you are too busy to make changes right now, just think about it, watch your patterns, and see if you can do it every once in awhile or on weekends.


How to Survive Influenza

Herbal medicine is wonderful for any kind of cold and flu. The key to successful use of herbs is to take them early and often. I began with Gaia Respiratory Defense capsules 2 caps every 3-4 hours with lots of watered down juice. I also drank an entire bottle of Apitherapy Wild Cherry Cough Syrup at 1 tbsp every 2-3 hours for the first 36 hours – this is a New England centric product but any herbal wild-cherry or horehound based product would do. If you live in a bigger city Nin Jiom Pei Pa Koa is an awesome Chinese cough syrup available at many health food stores. Mix 1 tbsp of the Nin Jiom thick syrup with hot water for a soothing tea/cough syrup 3-4 times daily.With these two products I was successful in clearing the lungs, and ended up with only some minor sniffles.

“Feed a Cold, Starve a Fever” is an old saying. When you have a fever, your body does not have energy or attention to pay to the digestive system. Most people do not have an appetite anyways, so it its Best Practice to focus on fresh fruit, juice, water, and soup broth. Apple sauce, popsicles and crackers are also good choices. Follow your intuition when it comes to food. Herbal tea with fresh lemon and honey is also healing and soothing. Echinacea tea, or any “throat tea” or “cold tea” will be beneficial. Don’t be afraid to *not* eat if you are not hungry; however make sure you maintain some caloric intake so your body has fuel to fight (unless it is a stomach flu.) Your appetite returning will be a sign of health.

Other things that help fight off influenza – elderberry syrup has tasty evidence based antiviral capabilities. Taking a minimum of  5,000IU of vitamin D and 2000 mg of old fashioned vitamin C will both speed recovery as well. This years flu is highly contagious – please don’t “be brave” and work/shop/be out and about unless you absolutely need to. Ask a friend to pick you up something and drop it off, take time off work, and REST! Everyone else will thank you for it, and you will recover faster in the end, with less complications than if you have suffered through it publicly.

I haven’t had the flu…. ever before. And I had not had a fever since I was a child. Boy, together they make an awful combination! I spent most of the week between Christmas and New Years Eve lying in bed with a face-headache, sweating, chilled, sniffley, and unable to do much more than lay with my eyes closed.However, I did recover rather quickly, without losing more than a couple days of work and a few pounds. During my fever induced vacation, I had time to consider fever medicine, and to mull over how many people have actually died from influenza over the course of history.

Curious as to how this self-limiting virus induced illness could literally wipe out generations, I took to Medscape to better understand why the flu can have such devastating effects.  From the article “Christmas 2009: Years Like This: The Spanish Influenza Pandemic Seen Through the BMJ’s Eyes: Observations and Unanswered Questions” by Tom Jefferson, Eliana Ferron BMJ. 2009;339:b5313 it is clear that it was not a simple case of influenza that killed so many people, but rather a combination of factors including environment, hygiene, medical practices of the times, and a lack of immunity to the European microbial ferment that wiped out staggering numbers of  people. The article states:

” The causes of the high case fatality rate are still unclear, but modern research suggests that the pandemic was a lot more than just a “one germ-one disease” affair. [19] … Agents other than the influenza virus probably played a part. Above all, the environmental explanations of the high [Samoan and Lapp] mortality rates indicate the peril of generalizing across contexts and simplifying causation models. “

In other words, early pandemics were about more than just a flu virus. They were complicated environmental scenarios where subsequent (fatal)  infections developed. Therefore, most of us in modern times are highly unlikely to die from influenza. This is of course, a more serious condition for people who have a defective immune system and for individuals on either end of the age spectrum who are more fragile. So, knowing that one is unlikely to die from the flu or fever, are you more willing to suffer through the symptoms if you knew it would be over sooner?

I was raised with the belief that a fever is an opportunity for “cleansing” on a spiritual and physical level. Fevers up to 102.5 are still considered safe and effective for a healthy person. The heat in the body serves as a natural autoclave, killing bacteria and viruses quickly and effectively. In my upbringing, it was also “burning karma” and an opportunity to cleanse oneself from spiritual burdens. This is what I focused on as my fever climbed from 101.5-102.5. I felt awful and was miserable and in pain. But, I kept telling myself I was in the process of transformation! It seemed to justify the misery in a way. There is of course, a limit to pain and suffering and modern medicine has much to offer. Therefore, I would return to my 400mg of Ibuprofin at night to help me sleep and reduce my pain and fever for the night. After all, sleep is as important in recovery as anything else is. Thus, I do suggest when you or a loved one has influenza, to allow a fever to burn within a safe range up to 102.5 F (Technically a fever is safe up to 104.5F) . Fever reducing medications can always be used as needed when the tolerance level of suffering is reached. Belladonna 30CH is a homeopathic fever reducing medication that can be used safely in children and adults as needed. It acts as a trigger to the body to reduce its thermostat, without actually suppressing the fever like NSAIDS do. This is a great medication to have in your home first aid kit. I was happy to dig mine out at 2:30 am on my second night sick – anything for relief in those sick midnight hours!

A final thought on cold medications – allergy pills, Dayquil, and other daytime cold and flu medications are most likely going to fail in the face of influenza. You are better off lying in bed and letting your fever burn while you try and watch some tv. However, night time is  when I believe some medication can be necessary as most people worsen in the night. No natural cough syrup is going to be as effective a pharmacy brand one. If I am hacking in the night with a cough, I use a pediatric cough suppressant as they contain less alcohol and chemicals than adult ones. Using Nyquil, or Ibuprofen/Tylenol at night to sleep is perfectly reasonable if it actually works for you. (If it doesn’t work, stop taking it and call your Naturopathic Dr for more treatment support.)

In summary – Rest, liquids, soups, belladonna 30ch, wild cherry cough syrup, vitamin C, vitamin D, elderberry, and a herbal formula that treats your constellation of symptoms are all components of successfully navigating a bout of influenza. Allow the fever to burn, whether you view it as a natural autoclave or a spiritual cleansing (or both) is up to you. A cough that lasts more than 7 days, fever above 102.5, or consistent vomiting for more than 36 hours are all good reasons to call your primary care provider and check in.