Failing Up

It as a given that we will fail.  All of us.  Medical or not.  We are all human, which means we make mistakes. So once we accept this as fact, we can then move towards failing better.

When we make a medical error we have a few choices:

 

1. Live in perpetual doubt

Blame yourself and practice defensive medicine

 

2. Ignore the error and do nothing, stop caring

 

3. Failing up – learn from the fail

-       Learning from your medical error takes effort, consideration and time -makes one even more accountable, compassionate and competent.

-       We are all going to fail.

-       When one sweep failures under the carpet, one cannot learn from them effectively and neither can one heal from them effectively

-       Learning to accept this eventuality and incorporating it into our daily life, will allow us to grow as individuals, to more effectively teach others and to take better care of our patients.

-       Strive for post traumatic growth and thriving after failure instead of feelings of shame and isolation.

 

 

Failing up strategies:

-       Find a Failure Friend: An empathetic work friend who understands the context; someone who is your safety net and in return you can be their safety net.

-       Be a good Failure Friend to a colleague: Listen/hear them out and empathize/provide affirmation rather than giving advice or solutions. Use reflective listening like you would with a patient and then come up with a joint plan.

-       Teach from your mistakes: Give talks around your difficult cases that incorporate personal strategies on how to cope after the fact, rather than only concentrating on the medical aspects of the case. Talk with peers, residents and medstudents

 

Watch this excellent FeminEM talk by Dr Sara Gray: https://www.youtube.com/watch?v=aGS6O98p4Q8

 

References:

https://emergencymedicinecases.com/preventing-burnout-promoting-wellness-emergency-medicine/

https://www.entrepreneur.com/article/331332

https://saragray.org/2017/03/07/failure-friends/

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Box Breathing Technique   

Box Breathing Technique   

Next time you’re on shift and get a notification for a baby in arrest or have to prep the neck for a cric take a minute to do some Box Breathing to get you prepped and mentally ready

·      Easy, Quick and Navy SEAL approved

·      Effective in anxiety, insomnia, pain management and even labor!

·      Box breathing with this 4-4-4- ratio has a net neutral energetic effect

·      It’s not going to charge you up or put you into a sleepy relaxed state. But it will, as mentioned, make you very alert and grounded, ready for action.


Box breathing.gif

 

·      To begin, expel all of the air from your chest.

·      Keep your lungs empty for a four-count hold.

·      Then, inhale through the nose for four counts.

·      Hold the air in your lungs for a four-count hold.

·      When you hold your breath, do not clamp down and create back pressure. Rather, maintain an open, neutral feeling even though you are not inhaling.

·      When ready, release the hold and exhale smoothly through your nose for four counts. This is one circuit of the box-breathing practice.

·      Repeat this cycle for at least five minutes to get the full effect.  

 

References

 

Dr Arlene Chung

TIME

https://www.mindfulwellnessrochester.com/single-post/2017/06/02/Box-Breathing-for-Anxiety-Stress-Reduction

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Looking at wellness: "Happiness and Resilience in the Life of an Emergency Physician"

Today’s POTD will be focused on wellness.

I will attempt to briefly summarize an amazing piece on “Happiness and Resilience in the Life of an Emergency Physician” from ACEP Wellness Guidebook. But more importantly the piece is written by our amazing and hardworking wellness advocate Dr. Arlene Chung in collaboration with Dr. Rosanna Sikora and Dr. Laura McPeake.


The first paragraph is talking about defining happiness and resilience. My favorite quote is “Engagement and meaning appear to be the strongest contributors to living a happy life” and that “You can strengthen happiness and resilience by practicing”. But at the end of the day it is very individualized and we, ourselves “ must choose what is most meaningful in our lives along the way to be happy”. 

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The part that I would like to draw your attention to are the suggested specific strategies by the authors that can help to build resilience in the practice of emergency medicine:


Writing a journal or recording oral narratives. 

Transforming your traumatic experiences into a written or recorded piece will not only help you to cope with difficult emotions but also put the situation in perspective and even learn from it. 


Meditation or mindfulness exercises. 

Mindfulness can be as simple as taking in a deep breath and exhaling very slowly, resulting in a parasympathetic charge of feeling peaceful and settled.


Peer mentoring.

Discussing stressful events with a supportive and empathic colleague is some of the best medicine that we have, and if our emergency medicine atypical humor is involved, all the better. Humor is a great coping strategy. 


Niche development. 

“Research has demonstrated that physicians who have developed a niche within emergency medicine have lower rates of burnout, better career longevity, and more career satisfaction.” This one is specifically very important for the senior class. Thinking about what can improve your clinical practice after graduation (and I am not only talking about fellowship) but rather looking into different areas of interest that can potentially become your niche.

Education. 

I’ve heard teaching is rewarding and improves doctors satisfaction :)



Personal coaching. 

Develop a mission statement and a career plan and the examples that authors suggest: personal organization, time management courses, and learning to say “no” to obligations outside your mission statement.



Focus on empathy. 

Consider books, workshops, and podcasts. Connect with your family, friends, and co-workers outside of the fluorescent lights of the emergency department. 




Take care of your own needs. 

We need to take care of ourselves before we can care for others. Remember to MOVE your body: “A jog a day keeps depression away.” Make time for what you enjoy. Place it on your calendar and treat it like a shift.


Limit stressful downtime.

Balance your high-stress activities with low-stress activities. 



Please read the full article at ACEP emergency physician-focused wellness guide 



https://www.acep.org/globalassets/sites/acep/media/wellness/acepwellnessguide.pdf




Wellness Wednesday POTD: Imposter Syndrome

As the academic year is coming to and we all adjust to our new roles within our residency programs or as new attendings or fellows, I thought this would be a good time to talk about this.

Imposter Syndrome

Originally described by psychologists Suzanne Imes, PhD and Pauline Rose Clance, PhD in the 1970s, it is defined as an "internal experience of intellectual phoniness". Essentially, this means that people with imposter syndrome feel that their achievements are undeserved and worry about being "found out"that they are less than adequate despite evidence indicating success and/or competence. 

Dr. Clance described six potential characteristics:

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  1. The imposter cycle
    The cycle starts with a task, which is then met with anxiety, lead to either over-preparation for the task or procrastination (which is over-compensated with frenzied preparation). When the task is completed, there is relief, but this is short-lived despite positive feedback. Instead, the person believes that their success is either due to their hard work or luck, but not due to their ability

    The result is a feeling of self-doubt, depression, and anxiety and a tendency to overwork

  2. The need to be special or the very best
    Those with imposter syndrome are secretly comparing themselves to others, which leads to a feeling of inadequacy.  

  3. Super(wo)man aspects
    Related to the need to be the best, people with imposter syndrome set unrealistic goals for themselves. 

  4. Fear of failure
    This can also be identified as the main motivational factor for most people with imposter syndrome. 

  5. Denial of competence and discounting praise
    Adding onto feelings of inadequacy, those with imposter syndrome have difficulty internalizing success and will even make excuses about why praise is not deserved. 

  6. Fear and guilt about success
    Although people with imposter syndrome crave success, they also fear it because it makes them feel isolated in their success. They also fear taking on more responsibilities as they're more likely to be "found out" with higher expectations. 

This was further elucidated by Dr. Valerie Young who broke down the syndrome into five different personality types in her book The Secret Thoughts of Successful Women:

  1. Perfectionists: people who set unrealistic goals and feel like failures despite the level of completion of these goals

  2. Experts: people who need to know every piece of information and will overeducate themselves. They are also afraid of looking stupid and will hesitate to assert themselves

  3. Natural geniuses: people that are used to achieve success effortlessly, which leads to feelings of inadequacy when any effort is needed

  4. Soloists: people who feel that asking for help is a sign of failure

  5. Super(wo)men: people who need to work harder than everyone else around them in order to succeed in all aspects of life

How to deal with imposter syndrome

As with any problem, the first step is identifying and recognizing the problem. From there, overcoming imposter syndrome requires a lot of self-reflection and much of this comes from reframing your mindset on what qualifies as success. Some potential methods:

  • Seek help: this can be found in a mentor, a friend, or a therapist. Vocalizing feelings and concerns can help in several ways. First, it can help identify characteristics that are typical of imposter syndrome, which can lead to increased self-awareness. Talking can also help with the realization that imposter syndrome is not an uncommon occurrence, which helps to normalize the condition. 

  • Lean to internalize validation: people with imposter syndrome tend to dismiss positive feedback. Learning to reframe your mindset by resisting this response to positive feedback can help put things into perspective.  

  • Be realistic about expectations: the expectations that those with imposter syndrome set for themselves are unrealistic. It is important to realize that nobody is perfect and to properly reflect on one's own successes. Likewise, it's important to recognize that everyone has strengths and weakness and to reflect on one's strengths and not to see weaknesses as failures. 

  • Figure out your true goals: it's possible the goals that you've set for yourself would not actually ones that would make you happy. Take stock in what really matters and that may also help to redirect your ambitions. 

Sources:
Abrams A. Yes, Imposter Syndrome is Real. Here’s How to Deal With It. Time Website. http://time.com/5312483/how-to-deal-with-impostor-syndrome/
Roche J. 10 Ways to Overcome Imposter Syndrome. The Shriver Report Website. http://shriverreport.org/10-ways-to-overcome-impostor-syndrome-joyce-roche/
Sakulku J, Alexander J. The imposter phenomenon. International Journal of Behavioral Science. 2011;6(1):75-97.
Weir K. Feel Like a Fraud?. American Psychological Association Website. https://www.apa.org/gradpsych/2013/11/fraud
Wilding M. 5 Different Types of Imposter Syndrome (and 5 Ways to Battle Each One). The Muse Website. https://www.themuse.com/advice/5-different-types-of-imposter-syndrome-and-5-ways-to-battle-each-one

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POTD: Wellness. You Do You.

As we residents, ED attendings, medical students know, finding time for wellness can be a challenge, especially in the face of contiguous shifts, conferences, and multiple inversions of our sleep schedule. It can feel like the weight of Atlas’ world is resting on your shoulders. My intention with this POTD is to reflect on the lessons I have learned navigating self-care in residency, in the hopes that it will prove helpful to someone.  

After perusing articles by wellness gurus and our own PD, Dr. Arlene Chung, I realized that what I do for wellness is different that what many people do. At first, I thought that the difference between my experience and experts meant that I wouldn’t have anything to contribute, but then I realized that wellness is personal, and maybe my experience will prove helpful for someone who reads this POTD. The following are my tips for wellness: 

GENERAL:

First and foremost, approach all advice regarding wellness with curiosity and skepticism, including my own. It might be right for you.  It might not. My intention is not to write you a to-do-list, but to help you examine some areas of your life that may have potential for exercising self-care.  Experiment and see what’s right for you.  

FOOD:

Some residents don’t eat on shift. If this is a choice, either as an intentional approach to intermittent fasting, or because you don’t need to, then that's great. However, it needs to be a choice. Experiment, and learn who you are and follow what’s best for you. If you need to eat regularly, then prepare for this need. 

I bring hydration and food from home and eat before coming to shift. There is not always time to go out and grab something and I enjoy bringing food from home. Waking up early to prep food for myself is a form of self-care. I feel prepared, and loved by myself, when I can grab a frozen Tupperware meal from the fridge. The same is true when I can enjoy a nutella sandwich. I also enjoy prepping a meal/snack for my loved one.  We can go a few days without seeing each other on a long stretch, and knowing that we have that connection through a prepared food is like a lifeline to connect us when we can’t physically be together.

Also, I get hangry. Nutella keeps the Bruce Banner version of Allie in the ED, so no one has to get their rapid strep test from the 8 month pregnant Hulk version of Dr. Kornblatt.  

MEDITATION:

When I come home, I often will feel my brain racing and have thoughts of patient tasks zipping in and out, causing me to stress and have dreams about patient care. So before bed, I actively try and clear my mind to think of nothing at all. Sometimes if I’m having a rough time with this, I use a body scanning meditation technique so that I can focus. I recommend the free first ten guided medications on the app “Headspace.” (I am not paid to endorse Headspace, or a meditation expert at all). The more you practice, the easier it gets and I find in stressful situations, I can clear my mind so that I focus on the task at hand.

SCHEDULE ACTIVITIES IN ADVANCE:

If you see you have a weekend off, schedule something in advance. In my experience, if you wait until that weekend itself, you’ll just sit at home and not do anything. If you do need that time at home to recharge, then plan that, ahead of time. Planning for a weekend under the covers can make it feel intentional, and relieves any guilt associated. 

FINAL TAKE HOME THOUGHTS ON WELLNESS:

We often think of our accomplishments in numbers: test scores, numbers of procedures/requirements completed, class rank, etc. Sometimes this is helpful—comparison to our peers let’s us know if we are falling behind, or in a position to act as a leader and help our colleagues succeed. Not so with wellness. 

Wellness is not comparable, it is not a competition on who is the most well. Experiment and find what’s right for you. If you try to compare or adopt the habits of others, you are destined for disappointment.

So, go be well, whatever it means to you.

Your friendly TR this month,

Allie

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POTD: Sleep Hygiene

The term “sleep hygiene” refers to a series of healthy sleep habits that can improve your ability to fall asleep and stay asleep. These habits are a cornerstone of cognitive behavioral therapy, the most effective long-term treatment for people with chronic insomnia. CBT can help you address the thoughts and behaviors that prevent you from sleeping well. It also includes techniques for stress reduction, relaxation and sleep schedule management.

Here are some general tips for good sleep habits from the CDC:

  • Be consistent. Go to bed at the same time each night and get up at the same time each morning, including on the weekends (this one is admittedly hard for the ER doctor, especially as a resident!)

  • Make sure your bedroom is quiet, dark, relaxing, and at a comfortable temperature

  • Remove electronic devices, such as TVs, computers, and smart phones, from the bedroom

  • Avoid large meals, caffeine, and alcohol before bedtime

  • Get some exercise. Being physically active during the day can help you fall asleep more easily at night.

If you’re still having difficulty falling asleep, consider keeping a two-week sleep diary to analyze your sleep trends.

In our modern-age of electronics, here are some tips to effectively manage electronic screen time in preparation for sleep:

  • Set your iPhone to “Do Not Disturb”

    • This will prevent your phone from alerting you with text messages or phone calls while you’re sleeping. Critical calls will still make it through if you toggle the “repeated calls” setting (i.e. a second call from the same person within 3 minutes will not be silenced)

    • You can also have automatic message replies if people attempt to call you when “do not disturb” is turned on

    • You can schedule when “do not disturb” is turned on

    • You can ensure that certain phone calls will always go through

    • Essentially there is NO REASON why this button shouldn’t be turned on!

  • If you have an Apple Watch, in addition to “do not disturb,” you can place your watch on “theater mode”

    • This will prevent your watch from lighting up with movement while you sleep

  • Download sleeping apps:

    • Sleep tracking apps

      • Sleeptracker

      • Sleep Watch

      • Sleep Cycle

    • Sleep sounds:

      • Relax Melodies

      • Sleep Sounds by Sleep Pillow

      • White Noise Deep Sleep Sounds

What about melatonin?:

Melatonin production in humans has a pronounced circadian rhythm; nocturnal plasma melatonin concentrations are at least 10-fold higher than daytime concentrations. The nocturnal rise in melatonin secretion plays an important role in the initiation and maintenance of sleep.

Nocturnal melatonin plasma concentrations decline with age; many older adult individuals develop age-associated insomnia (eg, waking up during the night, diminished sleep efficiency). Physiologic doses of melatonin may be beneficial for these individuals. Exposure to light suppresses the normal nocturnal rise in plasma melatonin concentrations. Can use low, physiologic doses (0.1 to 0.5 mg) for insomnia or jet lag. High-dose preparations raise plasma melatonin concentrations to a supraphysiologic level and alter normal day/night melatonin rhythms. 

In a randomized, double-blind, replicated crossover trial performed on EM residents in 2018 regarding melatonin vs placebo in regards to sleep efficiency, it was found that there was essentially no difference in sleep quality between the groups, although a minor decrease in drowsiness was found in the melatonin group.

My take away is that good sleep hygiene practices supersede any supplements to promote healthy sleep.

References

https://www.cdc.gov/sleep/about_sleep/sleep_hygiene.html

http://sleepeducation.org/essentials-in-sleep/healthy-sleep-habits

https://www.uptodate.com/contents/physiology-and-available-preparations-of-melatonin?search=melatonin&source=search_result&selectedTitle=1~108&usage_type=default&display_rank=1

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6117540/ 

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And a Happy New Year of Wellness

Today's pearl will be brief and focus on Wellness. We are often super busy on our shifts and in our lives, but it doesn't take much time to stop - pause - and add a little wellness to your day. 

Here are 9 ways to have less stress in under a minute.

  1. Breathe. Take a big breath in and feel your stomach muscles relax. Hold it for a moment. Purse your lips, and blow your breath out slowly as if you are blowing out candles on a birthday cake. Feel your stomach muscles tighten as you empty your breath. Do it again 2 times or more if needed.

  2. Smile- even if you don’t feel like smiling! Smiling has been shown to decreases stress response, and even shown to lower heart rates during a stressful situation. So maybe every so often a little  "grin and bear it" can help reduce your stress!

  3. Relax your Mouth. Open your mouth, let your jaw and tongue relax, or try a jaw massage. Often times stress will lead to jaw clenching. Relaxing your jaw helps signal to your brain to reduce your stress response. 

  4. Laugh! Laughing decreased your stress levels and long-term may even boost your ability to fight sickness.

  5. Give others or yourself a hug. Hugging help reduce stress for both the giver and the receiver!

  6. Shrug your shoulders. Bring your shoulders up to your ears for a slow count of 5, then release.

  7. Exercise. Do some quick squats, jumping jacks, running in place, walk across the street to grab some tea or water, etc.

  8. Peel an orange – seriously! Then inhale the smell. Research shows that the smell of citrus relaxes people.

  9. Say Thank You. Really. Think of things you are grateful for. It is another great stress reducer! 

Wishing you a safe, happy, and healthy New Year!

References:

https://www.smithsonianmag.com/science-nature/simply-smiling-can-actually-reduce-stress-10461286/

Simply Smiling Can Actually Reduce Stress | Science | Smithsonianwww.smithsonianmag.comA new study indicates that the mere act of smiling can help us deal with stressful situations more easily
https://exploreim.ucla.edu/wellness/stressed-it-may-take-a-toll-on-your-teeth-explore-an-integrative-approach-to-managing-bruxism/
https://www.mayoclinic.org/healthy-lifestyle/stress-management/in-depth/stress-relief/art-20044456
https://health.usnews.com/health-news/health-wellness/articles/2016-02-03/the-health-benefits-of-hugging
https://nihrecord.nih.gov/newsletters/2006/02_24_2006/story03.htm

https://www.ncbi.nlm.nih.gov/pubmed/22071630
https://nycwell.cityofnewyork.us/en/coping-wellness-tips/less-stress-in-under-a-minute/
https://www.psychologytoday.com/us/blog/what-mentally-strong-people-dont-do/201504/7-scientifically-proven-benefits-gratitude

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