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.


The Longest Night of the Year

December is not always mistletoe and gingerbread. It can be one of the hardest times of the year for many people. People aren’t supposed to die on Christmas and relationships aren’t supposed to end around the holidays…. but they do. The myth of the happy family is only a reality for a portion of the population; and even those who do celebrate Christmas with family can have significant stress and sorrow around money, relationships, and more.

So, for those who are alone this month, or in the midst of tragedy or change or trauma, I wanted to offer some self-care advice. From a metaphysical perspective, no matter what your religion is, this time of year IS about the miracle of returning light. The first few weeks of the month bring ever increasing darkness. Light some lights in your own home, whether they are candles or Christmas lights, reflecting your own inner flame. No matter how dark the world appears, each of us has the light of our soul to guide us. Connect with yours.

broken_heart_remedy_compoundFor those with heartache, there are many botanicals that offer gentle physical and emotional support. Avena botanicals makes a Broken Heart herbal tincture and a lovely sweet Rose Petal Elixir. The elixir is in a glycerin base and is used to gently lift the spirits and open the heart. It tastes like a rose smells on a hot summer day! Many herbalists make their own rose petal elixirs at the summer solstice, in preparation for this dark time of year. Herbal medicines like these affect our body, mind and spirit. By using self-care medicines we are making a commitment to our Self to move through this time of change with as much gentle strength and internal fortitude as possible. http://www.avenabotanicals.com/rose-petal-elixir.html 

Many people have seasonal affective disorder (SAD) or just simply hate the cold. We have had a particularly cold pre-winter here in Maine, which makes getting out to enjoy our gorgeous local landscape more difficult. Prevention is key for SAD – once it takes hold it is harder to manage. Adequate levels of Vitamin D3 are especially important. I generally recommend 2,000-5,000 IU daily depending on your body weight and Vitamin D reserves. Have you had your blood levels of Vitamin D checked yet this fall? High quality fish oil is a good adjunct to Vitamin D, enhances its absorption and can help with mental health. Fish oil contains two chemical constituents – EPA and DHA. The EPA is the part that helps with depression. Aim for a minimum of 650 mg of EPA daily, taken with your D3.

Saint Johnswort is another classic treatment for SAD. This herb affects the metabolism of many medications. Therefore, I only suggest using St Johnswort if you are not on any other meds. Dosage must be 900 mg per day, taken *every day.* This herb acts like SSRI antidepressants in that it takes about 4 weeks to get the full effect, and it needs to be taken daily for best results. This herb has evidence of use back to 400AD by Hippocrates. It is an ancient and magical herb with an association to light. It is no mistake that it is useful for SAD! If you do take medications like birth control, daily pain medication or blood pressure medication but would like some mood support you can consider 5-HTP. This is a serotonin precursor that is naturally produced in the body, and is available in supplement form. It can be helpful for anxiety, depression, insomnia and “the blues.” It is quite safe in general, although it should not be taken along with antidepressant medications unless specifically advised by an Integrative Medicine Dr. Typical dosage for 5-HTP is to start with 50 mg twice a day, and increase to up 150 mg twice a day as needed.

Exercise and meditation are two other valuable tools for getting through hard times. Exercise releases endorphins which simply make us feel good! It can be a walk around the block or a cross-fit class or hot yoga. The type of exercise does not matter as much as the act of getting into your body and out of your head. Meditation offers ways to step outside the constant chatter of our ego. I recommend a guided meditation for beginners. I use this Buddhist body-focused beginner set by Reginald Ray, but there are many more available! http://www.soundstrue.com/shop/promotion/1047.pd

At the end of the day, we each need to get through our darkest times in the ways we know how. Alcohol, television and drugs are all effective in their own way, but they also exacerbate the feelings of isolation and despair. Connecting to your inner light source and fanning your fires of spirit and confidence and strength will help grant you the courage to move through these difficult times. Some of us need more help than others to connect to our strengths, and supplements like herbal remedies, vitamin D, fish oil, St Johnswort and 5HTp can be great support systems. I love the rose petal elixir for its sweet uplifting taste of summer in these harsh cold days of winter.

For personal support on transforming your own journey or connecting to your inner strengths, book an appointment with Dr. Wright. She is available for consults during the month of December including December 27, 2013.

Call 207-774-1356 now.


The ABC Clinical Guide to Herbs. American Botanical Council, Thieme Publishing 2003. Currently out of print.

Encyclopedia of Natural Medicine. Michael Murray ND and Joseph Pizzorno ND. Prima Publishing, Rocklin, CA 1998