Evolution

Over the past few weeks, I have reflected in great detail about the way I live my life: as a man, husband, friend, trainee, physician. Challenges inevitably stimulate growth, even if the new growth requires the burning away of old habits and beliefs. The past year and a half of my new career as a physician has provided numerous challenges, and accordingly I must find ways to change and grow. With the turning of the year, there are three areas of improvement that call upon my resolve.

Energy

As a senior at Harvard College, I took a course taught by Psychology professor Tal Ben-Shahar on the Psychology of Leadership during which a key theme was the cultivation of energy. A number of researchers in the business realm studied the habits and behaviors of high-stress/performance professionals (Olympic athletes, FBI hostage rescue operatives, trauma surgeons, etc.), and they found a unifying principle: that time is a limited resource, but energy can expand and grow. Performance failures are often attributed to the lack of time, but a significant part of the effectiveness of performance during a finite time period is related to the energy levels of the performer. This intuitively makes sense: at the end of a long work shift, every task, no matter how simple, takes longer and is more prone to error. Accordingly, improvement in performance should focus more on maintaining, growing, and effectively using one’s stores of energy and less on “time management.”

However, cultivating energy in the setting of medical residency training is very difficult. Over the past year and a half, part of my psychological programming has centered on self-preservation through protection of apparently limited energy stores. Time for sleep became more precious than ever. Forgoing social engagements for quiet nights at home became the rule. A constant reminder of the burden of fatigue played out in the form of a memory of a previous teacher’s only slightly hyperbolic experience: “After residency, I slept for three months.” A premedical advisor, a resident at the time, told me, “When you train in medicine, you can only bring one other thing with you, such as a hobby. For me, it was my marriage.” After each thirty hour or more on-call shift, my first priority was to sleep and allow my brain to heal, expecting that any deviation from this would result in worsening performance during subsequent work days and overnight shifts with accompanying demoralization.

Now, I am reevaluating this world view. I know there are physiologic bases for energy and fatigue. If nothing else, I have certainly performed enough Neurology consults for “weakness” that end up being medical evaluations for severe fatigue. There are limits to what the human body can routinely do. However, is routine the operative word? Can you change the human body’s routine to gradually require more and more energy mobilization and expenditure? Perhaps fatigue and chronic “sleep debt” are less a function of a depleted pool of energy, but rather, they represent a diminution of the means to quickly access energy stores. Am I still suffering from fatigue accummulated during my intern year, or am I “out of shape” with regards to acquiring energy? If so, what is the physiologic basis by which the body can be trained to more quickily mobilize stored energy? Can it be traced to an enzymatic process? At this time, I am managing to exercise on my elliptical machine almost every day, even if only for short bursts, yet even a fifteen minute session can keep me awake for hours in the evening working on projects and having meaningful conversations with my wife when otherwise I would sink deep into the couch and watch television.

Granted, there is a distinction between energy and willpower that I will not discuss in detail now. For the time being, my resolutions follow:

Abstract
[ ] Learn to cultivate energy
[ ] Train to mobilize energy stores

Concrete
– Exercise on the elliptical machine daily
[ ] for 7 days, [ ] for 14 days, [ ] for 1 month, [ ] for 3 months, [ ] for 6 months, [ ] for 1 year

Serenity

Many people find benefit in learning the art of meditation. It is not hard to see why this might be useful: we are constantly bombarded with information and sensory stimuli. For example, I can count seven electronic screens in the room where I am writing this entry, four of which are within my range of peripheral vision, three of which having shifting/rotating images. In addition, our interconnected world is filled with strong emotional stimuli: sensationalist news reports written to inspire a passionate response, Facebook photograph uploads of parties and weddings and gatherings that you wish you could attend, and status updates whether through social networks, e-mails, text messages, or more frequent (and incredibly inexpensive) cell phone calls. As with sleep, there is a strong desire to disconnect with the world and find a moment and place of peace.

As for me, I am terrible at meditation. Closing my eyes, counting, and other mind tricks are not enough to quiet my brain. When I wake up in the middle of the night, my mind immediately jumps to the tasks for the next day, including orders I need to place in the hospital, patients and colleagues I need to call or e-mail, and measures I need to take to make the day slightly more manageable. During intern year, I spent both my waking and asleep hours at the hospital: my dreams often involved walking the hospital corridors and running to Code Blues.

Nonetheless, I would like to find ways of calming the mind. One way I hope to do this is by rediscovering hobbies and pasttimes and exploring new ones. One disheartening development related to medical school and residency training was the loss of hobbies, including music and sports. And yet, a great deal of the benefit of these activities is the switching of focus from agitated and worrisome thoughts to a singular purpose, whether to create beautiful melodies, perfect a form or dance routine, or win a game.

One unexpected activity I have adopted is woodcarving, specifically whittling. For some time I have longed for an activity that uses the fine dexterity of my hands and also one that can produce something. One game I used to play as a younger man was to peel the skin of apples in a single uninterrupted spiral. I find much charm in this quote attributed to Michaelangelo: “Every block of stone has a statue inside it, and it is the task of the sculptor to discover it.” There is a beautiful simplicity in the art form: a block of wood, a knife, and a very small repertoire of cutting techniques that can be learned intuitively. So far, I have spent the past week gradually carving away at a small block of basswood to make the traditional first project which requires that one learns a few basic techniques: an egg. While I have only aspired to carve for ten minutes each day, I find myself cutting for longer periods of time as my mind quiets, relaxes, and finds some serenity.

Abstract:
[ ] Find serenity

Concrete:
[ ] Learn basic techniques of whittling/small woodcarving
[ ] Carve an egg
[ ] Carve a set of calipers
[ ] Carve a scholar’s rock
[ ] Carve a cheese knife
[ ] Carve a rabbit

Focus

For most of my life, I have followed the path of the jack-of-all-trades. I have often enjoyed the ability to learn new skills quickly, but mastery has not often been part of my trajectory. This has partly been due to having a wide variety of interests and a limited amount of resources (e.g. not having the money to have music lessons at an early age). Nonetheless, my career trajectory is moving me towards subspecialization, most likely in the field of Vascular Neurology, the field that is concerned with the treatment of stroke. Part of my passion for stroke comes from the fact that I have interest in many aspects of it: the disease pathophysiology (the many etiologies), the emerging and changing acute and neuroprotective treatment modalities, the need for better public health methods to get people to the hospital faster, the variety of care delivery strategies that different centers have established, and the great deal of research going into stroke rehabilitation and adaptation to post-stroke disability. Nonetheless, as my training progresses, it will help if I can explore this field with the aim to find a point of focus for my energy and intellectual desire. As such, my resolutions this year are:

Abstract:
[] To develop a point of focus

Concrete:
[ ] To find a concept of stroke that is not well understood and prepare to study it
[ ] To find an aspect of stroke care that can be improved upon and develop a means to achieve improvement

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