Zzzz….

Posted on March 14, 2016 by Amalia Cochran MD

I would start with a few comments about the Daylight Savings Time change that occurred yesterday, though I try to be civil here. Let it suffice to say that I don’t enjoy my dark early mornings that are the “new normal” for a few more weeks again. I always whine a bit about this Spring change, particularly because the bases for it are weak at best. And while I seldom rail about sleep disruption from my travels, the energy drain I tend to experience from the time change is huge. And, of course, that has the potential to really impact my work.

Last month the Harvard Business Review published a terrific summary reviewing the link between effective leadership and getting adequate sleep. I do think that sleep piece is without a question a big piece of it, though I also believe that fatigue in general affects our ability to engage in the four types of leadership behavior that the authors describe. There becomes a domino effect where fatigue directly results in disengagement, and disengagement is intimately related to burnout. While a great deal of the discussion about residents and duty hours has been focused on the impact of adequate rest and safety, the truth is that the impact of sleep deprivation throughout medicine is far more insidious than we’ve previously estimated.

When I was in my 30s I honestly wasn’t as protective of my sleep- perhaps because I spent the first half of the decade finishing my residency before workhour restrictions went into place. As I’ve become a bit wiser (and, in association with that, a bit older), I have learned to better prioritize my rest, though I’m still not as skilled as I would like to be. No matter how much I look at all of the professional advice- get off of your screens, turn the lights down, don’t eat late, don’t exercise late- some of those things simply can’t happen for me all of the time. When I’m not faced with clinical demands I certainly do my best, but it’s a very imperfect best. And while I have been largely successful in creating a 10 + 10 (meditation + free writing, 10 minutes each) morning ritual for myself prior to my morning walks with Olivia , I really wrestle with what my evening ritual could and should look like. I’ve generally stopped sending emails after 830 pm. I’m generally off-line an hour or more before I plan to go to bed. I generally read for 10-30 minutes before bed, depending upon what time it is when I sit down with my book and when the alarm will go off the next morning. Nothing in the evening has stuck for me as well as 10+ 10 + dog walk, however. I’m still working on this concept to figure out what works for me.

I’ll close by saying that I’m a realist. I take call 1 in 3 averaged over the year, and when I need to take care of patients sleep becomes secondary. It doesn’t mean I don’t take a power nap when I get the chance (I love power naps!) or make a conscious decision about managing my energy in other parts of my life (yes, I do skip runs if I haven’t slept well). I’ve made a conscious decision that it’s okay to stop working at some point in the evening, especially because I’ve embraced that my do-to list won’t go away completely anytime soon.

And with that, I should close. It’s after 830 MDT, after all.

Happy resting!

All the cool kids are doing it?

Posted on January 23, 2016 by Amalia Cochran MD

First, a brief apology for my unplanned “break” the last couple of weeks. Travel + a wicked cold (which was at least thoughtful enough to not settle in until AFTER my half marathon last weekend) + life = no blogging. Fortunately I have a backlog of topics so we’ll be good to go for a bit.

Last week Medscape released their annual report on Physician Burnout. For those who don’t want to flip through the whole thing, the report indicates that burnout among physicians is at epidemic proportions. In one sentence, physicians are miserable.

Or are we?

I have many friends who are in medicine, most of us in academic medicine but not all. There are times when our work nearly brings us to our knees; I had one of those call weeks two weeks ago that was both physically and emotionally draining. We share our tales of woe around EMRs and well-intended but poorly executed federal rules that actually impair the care of the patient (Meaningful Use, I’m looking at you). We talk about meeting requirements for MOC and how we’re a little intimidated by taking our recertification exam when we haven’t taken a night of general surgery call in several years.

And yet…I don’t think that most of us can imagine doing anything else because at the end of the day we love what we get to do and we love the people we do it with and for. While there are times when any of us would definitely acknowledge being burnt out, I’m also seeing many of us exhibiting wisdom about knowing when we must have time and space to put on our own oxygen masks first. That’s why I had a crazy-hard week of call nights with tons of administrative stuff to manage during the days…then promptly got on a plane to Louisiana and spent the weekend with friends eating great food and running.

Lest you think I am a paragon of self-care and burnout prevention, I’ll tell you I’m not. I’ve been tremendously burnt out at a few points in my career (twice during residency, once early in my attendinghood), and I hope that I’ve learned from my mistakes. I’ve learned that I don’t like who I turn into when I’m in that place (I become mean- and if you know me personally you know I don’t care for mean people AT ALL). I’ve also come to realize the simple joy in an early morning or late evening dog walk with Olivia; some days our adventures in the neighborhood provide the most effective therapy possible. I realize that time outdoors with a dog won’t help everyone in the same way it helps me, but I provide it as an example of a simple and high-yield intervention.

I have a few plausible theories behind the current epidemic of physician burnout, and I’m not sure which is correct- or if all are:

Physician burnout really has increased (question, related but unrelated: What about burnout rates in other high-stress, long-hour fields?)
The stigma around physician burnout has gone away, so people are owning it (but the true incidence isn’t any different)
Surveys are being worded in a way that if someone had a bad day last week they may be described as having burnout, when it’s really just a bad day
We’re saying we’re burned out because we think we’re supposed to be burned out. We’re busy! We’re working hard! We’re supposed to be exhausted and maybe something is wrong if we’re not.

I suspect the truth lies somewhere in the spaces between these ideas; what I do know is that regardless of the actual incidence of burnout in medicine that a focus on wellness is both merited and deserved. The pace that our world runs at simply isn’t sustainable and the demands placed upon us by our patients, our teams, and the healthcare system are huge- much less the demands of our “normal person” lives. We both need and deserve time and space to do those things that heal and restore us if we’re to sustain our roles as effective healers, team members, friends and family, and humans. The challenge, of course, is prioritizing that time. The reality is that if you don’t prioritize if for yourself, no one else will do that for you.

What’s your wellness today? What do you need to sustain you? Sitting still with a cup of coffee? Yoga? A snowball fight? I challenge you to pick something, then revel in that- even briefly.

Pushing the reset button

Posted on December 4, 2015 by Amalia Cochran MD

Today’s post is driven by a conversation with a respected colleague whom I spent time with this morning, when we became immersed in a conversation about how surgeons fail ourselves in terms of wellness. Although I pride myself on my ability to set limits, this week has been a whirlwind.

Let’s recap:

Sunday night- burn call, 1 pre-bedtime admission

Monday- orientation of a new group of medical students, meetings, annual trip to the veterinarian for my cats, during which I get the opportunity to observe my usually Zen boy cat have a complete and total meltdown (also an annual event)

Tuesday night- helped host the first-ever Association of Women Surgeons tweet chat, a new way for us to network that I hope will grow. Committee conference call just after.

Wednesday-resident interviews, quick clinic visit with a lovely patient, then off to the airport for an evening flight to Edmonton, AB

Thursday/ Friday-Visiting professor at U of Alberta

I’m writing this post somewhere in the skies of Canada or the northernmost parts of the US as I head home from that visit. Now, to give myself credit for things I did “right” from a wellness standpoint in the midst of this wild week, there were quite a few. I went a got a pedicure on Sunday since it wasn’t too close to next weekend’s half-marathon. I did core and weight work on Monday and Wednesday and ran on Tuesday and Thursday. And this weekend…tomorrow morning run with my fabulous running group, afternoon haircut (sorely needed!), evening at the Symphony. And Sunday…a facial in the morning and Restore yoga workshop in the afternoon. Did I mention restorative yoga? Because it’s really amazing and restorative.

Why am I rambling to you about the minutiae of my week and weekend (hey, I didn’t catalog my meals for you!)? Mostly to make a point that even in the midst of tremendous busy-ness I managed to hit the “reset” button a few times, and I plan to hit it repeatedly this weekend. I do these mini-resets regularly because I learned my lesson about not doing them, resulting in those times when you need to do a hard reboot. While hard reboots are still beneficial, the reality is that it’s better for us at an individual basis and for those who love us the most that we not achieve a need for one.

It’s Friday evening and there’s a weekend in front of all of us. While I recognize the demands of our profession mean that more than a few of us are working (I am on call Sunday night), I hope that I can encourage you to stop for just a moment…and push the reset button. Do something, even for 15 or 20 minutes, that is just for you and recharges you. Don’t do it because you “should.” Do it because you can.

Thanksgiving, 2015 edition

Posted on November 25, 2015 by Amalia Cochran MD

(Slightly edited and cross-posted from the November 2015 AWS Connections)

I started an active gratitude “practice” a few years ago in which every week I sit down and document at least one thing for which I am grateful. Granted, there are some weeks that gratitude is easier and more obvious than others, but that practice really does help keep me focused on the good things that are present in my life. I also find that it helps me turn challenges and frustrations on their head.

So, what am I grateful for in November 2015? Plenty of things.

I have a home that I love in a city that I love that I share with amazing rescue animals who I love.

Good coffee.
My Mom lives 1½ miles away from me and is always here when I need a hand or an ear…or a hot meal that I didn’t have to cook.
Yoga.

I have this tribe of people in my life who have huge hearts and huge vision and huge hopes for the future. Those kindred spirits are who pull us through the tough days, aren’t they?

Dark chocolate.
My professional life has reached this beautiful point where I am able to spend a great deal of time focusing on mentoring and giving people a hand up.

One of my mentors, and two of my mentees

Running (especially running with friends).

My personal life has reached this beautiful point where I am able to spend a great deal of time focusing on giving back, both financially and personally.

Winter retreat plans in Montana.

Because of my academic activities and my role as the AWS President and within the ACS this year, I have incredible opportunities to reach out regarding the continued relevance of diversity in surgery and healthcare.

Summer vacation plans in the wilderness in Alaska.

ANWR, 10 years ago. It's time to go back! — ANWR, 10 years ago. It’s time to go back!

Have I mentioned my Burn Unit Family/ team/ tribe? Because I can’t step back without mentioning these amazing people. We love BIG. We do hard things. We take care of the people. (And I don’t have a recent photo of us…so the one below is the best exhibit I can give. We apparently need to get a new family photo.)

Even if times are hard for you right now, it’s my deepest wish for you that you will be able to find something, no matter how small, as a source of gratitude today. And tomorrow. And each day following.

Do it for the love of it

Posted on October 21, 2015 by Amalia Cochran MD

Those of you who read my blog and know me personally know that I am a runner. I routinely refer to myself as the World’s Okayest Runner, a title I have embraced with enthusiasm. I have a long history of running that dates back to elementary school, though I can’t remember exactly when I started running. It’s more that I don’t remember ever not running and when I was in junior high and high school it was a way that I could get time with my Dad. I know that I ran my first organized 5-miler when I was 10 and that when I was 12 I beat the Governor of Colorado in a 10K. Unfortunately, I also have a history of overuse injuries that accompanied years of my life when it was my “addiction” and I didn’t moderate my running as I need to since I am not built on a traditional runner frame (see: med school and residency). I took a few years off from running in my late 30s and early 40s, then decided to get back to it with some “rules” a few years ago that involve moderation. So far those rules have been successful: I’ve had no stress fractures, at worst a couple of minor tweaks with the IT bands that correlate directly with wearing heels, and I managed to run 4 half marathons injury-free and with only one toenail lost between May and September this year.

And, of course, as I mentioned last Spring, I did acquire a running coach last April. The first thing that she did was give me some form adjustments that I know have contributed to running without injury this summer. What she best provides for me is a training program that I don’t have to think about (she’s the expert!), encouragement even when I have a “meh” run, and wonderful wisdom. I like to think that I am also learning some coaching behaviors from her that I can translate to my work life. I know that her guidance has made me an overall stronger runner, and I am faster than when I started with her almost-6 months ago.

So, why the rambling about running? Here’s the thing: I love running. I love how it makes me feel. I love the accomplishment I feel after a solid run, and I really love that my half marathon in late September I was able to describe as “tactical” in terms of how I ran it. I already mentioned that I refer to myself as the World’s Okayest Runner, and I am. I get out there and have fun and find JOY in moving and being outdoors, particularly when I get to do that with friends. While I may be running for a PR in some of my races, I am not running because I expect to win my age group, much less the race. I’m not going to the Olympics and I’m unlikely to run a Boston qualifying time (in part because I continue to have little to no interest in running a marathon, and in part because I’m a really okay runner). My relationship with running is that it is something that I am doing it for the love. Or, as I have said more than once, I run because I get to.

Please understand that I’m not saying that everyone should go out and start running- I know that some people simply can’t for physical reasons (my Dad is now amongst them thanks to his Parkinsonism and he’s why I often run wearing a yellow flower that symbolizes running because I get to). I know that some people hate running with a fire-breathing intensity, and that’s okay. What I am using my own running to describe is the idea that we should each have something in our lives- and preferably something that has absolutely nothing to do with our vocation- that we do for the love.

To quote Michael Franti, “Do it ‘cuz you love it and it makes no sense.” It doesn’t have to make sense to anyone but you.

Conserving energy

Posted on October 13, 2015 by Amalia Cochran MD

If you’re considering skipping tonight’s post because you’re afraid it’s going to be all about tree hugging and turning your heater down, please don’t. It’s not about those things at all (but they are important if you believe in climate change, which I do). I’m talking about YOUR energy and how we live our lives to manage that energy. While time is something that is finite and that you can’t simply “recharge” to get more, energy is instead a precious resource that varies for many reasons. Energy is what allows us to keep going, keep doing, keep being at our highest levels, sometimes in spite of those time limitations.

Before you read on, I would like for you to stop and to consider what your energy level is right now while you are reading this. Has it been a long, chaotic day, and you’re feeling like a 2/10 who needs a nap or an early bedtime? Or are you coming off of an activity that completely charges your batteries- be it personal or professional- and you are a 10+ out of 10? And how many of you who were exhausted and drained acknowledged that to yourself while thinking, “And I have a billion things to do!”?

Here is a truth: We are all busy.

Here is another truth: We each have 24 hours in a day. The difference in what happens lies in the choices we make about their use.

I’ve become much more conscious over the years of the things that help me recharge, and while I’m not always able to do them perfectly (that whole “doing the right thing for the patient” does come first), I certainly do them to the best of my abilities. I know that walks with Olivia make a huge difference for me, and our morning walk is an absolute- even if it only ends up being 10 minutes. I know that running is important to me and helps give me additional reserves to draw from. Yoga, same. I’ve also learned to commit one day a week to as little work as I can reasonably do- if on-service, patient care only, and if off-service, no work stuff at all- and I do take at least a few days a year off the grid where I may or may not be reachable. Since those times also typically involve being in nature somewhere, they are tremendously recharging for me. And the key question I find myself asking more and more is how something aligns with my priorities, if it’s a high-value activity. That answer can certainly vary depending upon context, but it also helps me to decide if I’m going to the opera at the end of a long day or coming home for a home-cooked dinner and some time with animals. While I love opera and value cultural activities, I will tell you that at the end of yesterday’s 12 hours of Burn Unit madness the best choice in that moment was home for dinner and a dog walk. It’s a value choice, I recognize, but both yesterday and today it served me well.

In the Buddhist tradition, the last of the Six Words of Advice may well be the most important- “Relax, right now, and rest.” Sometimes our greatest work is to not do any work at all by simply being in the present moment.

The bare necessities

Posted on August 23, 2015 by Amalia Cochran MD

Okay, maybe that’s not exactly where I was going, but the levity is a perfect opener for tonight’s blog.

We’re in the process of starting a wellness program for our residents, and last Wednesday I met with several of our residents one-on-one to help them establish wellness goals for themselves. I’m not sure that I’m entirely qualified to do this, other than I do know what has failed dismally for me in this realm, and I’ve previously confessed to having experienced full-fledged burnout at least twice during residency and once as faculty. I suppose since I think I am getting it right more days than not, that makes me reasonably well qualified. And since my biggest vices are designer shoes/ clothes and half marathons, an argument could be made that I have mostly functional coping mechanisms. Confession: This has not happened without a LOT of work and a LOT of introspection.

About 3 1/2 years ago, I was introduced to the work of Jennifer Louden and was particularly drawn to her concept of “minimum requirements for self care.” Her concept inspired me to make a list that I divided into multiple categories- daily, weekly, monthly, and yearly. The great part is that the list isn’t full of complicated things, at least not until you get to the monthly or yearly portions of it, and those lists are much shorter. For example, the daily list:

Walk with Olivia Ann
Movement- workout, yoga, running, wiggling, whatever
Reflection- meditation, writing, prayer
5+ fruits and veggies
6+hours of sleep (this being the least-controllable when on call)
Time to just “be” with Olivia, Tucker, and Belle!

If you look at that list, it’s all pretty simple. There’s nothing terribly time-consuming on it (the sleep doesn’t count on that basis), and they are simple, measurable things I was able to identify that help me stay at my best. Even the weekly list isn’t onerous:

Dedicated time outdoors
1:1 time with a friend
Reading fiction
Learning something, teaching something
Making music
Finishing something, starting something

Again, nothing that requires huge amounts of time, and all things that I know help keep my work choices and life choices at their best.

What I’ve been most proud of in the context of these lists is how little they have shifted over the last three years (meal planning has come off of the weekly list, bless you creators of Blue Apron), and how grounding it is to go find my list when things are completely hectic. At core I’m not a list person- much more of a visualizer- but in these lists there is some inherent comfort and that gentle reminder to have a salad or to just shut things down and go to bed because it’s what will help me the most.

And, of course, there are all of the things not on the list. I’m the first person to admit a love for social media, but FB, Twitter, and Instagram aren’t on the list for the true basics of self-care. Neither is Inbox Zero. And by virtue of their absence I’m reminded what my priorities would be when it’s incredibly easy to forget them.

What are your bare necessities- your minimum requirements for self care? And how can you put them to work for you? There’s your challenge as we move into Fall…I would love to know how it goes.

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