After Match Day

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By Anna Stomberg, MD

Every year the month of march brings a flurry of excitement. For some March means a time to anxiously await the arrival of the first green sprigs of grass marking the beginning of spring, others – to fill out their lucky march madness brackets and accurately predict the years NCAA champion, and to a small, but ever so influential population of brilliant medical students it means finding out where they will train and begin to develop their career as a physician: THE MATCH.

I still remember the day of the match like it happened yesterday. I barely slept the night before finding out my fate and attempted to play off the morning like it was just an ordinary day. I walked through different scenarios and tried to play out how I could react to least subject myself to social scrutiny. Pondering things like “What if I don’t end up where I want,” or “What if I cry?” The uncertainty of my emotional state was terrifying.

Flashing forward to the actual ceremony, I held the envelope in my hand as I thought back to my rank list of locations across the United States….I was likely in for a big change from my comforts of residing in Minnesota my entire life. A change I had made my rank list to reflect.

I anxiously tore through my envelope to reveal the words printed in black and white Times New Roman font: “University of Utah Affiliated Hospitals.” I was ecstatic and now began the quest of moving states a 24 hr u-haul drive across the country.

My intent of writing this blog post was not to walk you through my Match day two years ago, but to provide my top 7 suggestion on moving across the country and what do After the Match and starting the busiest, but most rewarding part of your medical training.

1.) Suggestion number one – Find a place to live and put time into researching! When you’re not at the hospital, you are at home. It should be a place to relax and kick back. Seek out good neighborhoods to look for housing and if you can afford to fly to the city to look at housing it is totally worth it. Evaluate proximity to work, parks, recreation. I got a flight to Salt Lake City for around 100 dollars flying on a Tuesday and back home on a Wednesday. The two cheapest days of the week to fly.

2.) Suggestion number two – Move to your new city AT LEAST two weeks early. I believe this is essential to get all of your belongings settled before residency starts and to do something FUN to explore your new surroundings! I moved to Salt lake City and then spent a rejuvenating week in Moab and then Zion before the grind of the residency
routine began.

3.) Suggestion number three – Make a plan for how you will stay connected with others, skype, facetime, phone calls. Being away from home and friends is difficult and you’ll need them even when they are far away.

4.) Suggestion number 4 – Find a doctor and dentist for yourself. Even though we are in the medical field we are sometimes the worst patients. Take care of yourself and establish yourself with a physician that can be there for you when you need them.

5.) Suggestion number 5 – Make a routine outside of medicine and SCHEDULE it. Your life is at the hospital. Take time to make friends and acquaintances outside of the hospital and take a yoga class, go climbing, to the dog park, skiing, biking…the possibilities are endless.

6.) Suggestion number 6 – Get a financial advisor, and make a budget. But seriously… If you are like me you have spent a lot of time buried in books, but none of them involved vocabulary like “investments,” “retirement,” “disability insurance,” “Roth IRA’s” or “TAXES.” It’s not like we’ve made money in the past 4 years or anything… I was however real familiar with the terms “debt” and “interest” which emphasizes the need for a financial advisor. A tidbit of advice is that many firms offer pro-bono work for residents in hopes of gaining clients for the future – seize the opportunity.

7.) Suggestion number 7 – Look at your weeks of vacation during residency and GET OUT OF TOWN. Adventure out of your bubble to explore your new state outside of the medical circle. There are unique places everywhere. Utilize your new place in residency to explore a new locale.

And Lastly: HAVE FUN. Residency is a great time to develop relationships with people all over the world, from different backgrounds, and different training that we can all learn from. Never forget your roots, but don’t forget to seize the opportunity to learn something new!

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Anna Stomberg, MD is a second year Family Medicine Resident in the Department of Family & Preventive Medicine at the University of Utah School of Medicine.

Moving from Illness to Wellness

By Jessica Jones, MD

yoga

Many people, mental health professionals and patients alike, are curious about the growing movement of lifestyle interventions promoting brain wellness.  There is growing scientific data on how behaviors like mediation, exercise, nutrition, and even time spent outdoors benefit mental health and increase resilience to stressors.  The traditional interventions of psychiatric medication and psychotherapy remain essential for individuals struggling with severe psychiatric conditions, however questions about how to optimize treatment outcomes to prevent subsequent morbidity abound. Whether this is a reaction to disillusionment with big pharma or part of the bigger movement toward wellness, it seems like common sense that improving our daily habits could impact our long-term mental health, but these lifestyle changes prove difficult to put into practice for most.  In my experience, shifting the therapeutic focus from finding the ‘right medication’ to finding a healthy mixture of lifestyle interventions, psychopharmacology, and psychotherapy has been key to improved quality of life and sustained recovery in the face of difficulties in many of the patients in my practice. The way to move toward a practice addressing lifestyle changes involves not only the ‘what’ of behaviors to change but the ‘how’ of making changes to promote wellness. This leads to the question: What are the best ways to start a new habit and maintain it?  If we do decide to address lifestyle changes with patients, what are some helpful resources for education on evidence-based interventions to improve mental health?

Habit-Forming:

To start any new behavior, it takes intention, energy, motivation, reinforcement, and a way to out-smart the barriers standing in the way of maintaining the new behavior. Individuals struggling with depression, for example, find that there is a scarcity of energy for even self-care, let alone new behaviors like meditation, taking medication, attending therapy, or taking a walk outdoors.   Here are a few quick tips that have been useful in promoting behavior change:

  1. Helping the patient identify the reasons they would like to start a new behavior, like taking a daily walk outside, is much more effective than telling them all the reasons it is good for them. I often give a menu of evidence-based recommendations for lifestyle changes to address their concerns and ask which one appeals to the patient most, or which one they think would be easiest to incorporate into their daily lives. Seeing progress on self-selected goals is a strong motivator to keep going.
  2. Identify the smallest first step toward the new goal, something they can do immediately. If possible, we do that step together in the office. If not possible, we specifically plan for the soonest possible time they can do it. For example, if it is ‘taking a walk’, we will plan the time, place, gear needed, and a brief check-in via message once they have completed the task. Again, getting the momentum rolling for a new behavior is difficult, so exaggerating these first steps is often critical in helping someone get started. Other tricks that are useful are visual cues, i.e. a note on the bathroom mirror, placing the pillbox beside the toothbrush, taking walking shoes and clothes to work and going straight to the park afterward. Think ‘nudge’ theory, positive reinforcement and indirect suggestions equals effective behavior change.
  3. Use positive reinforcement. I am always surprised at how rarely adults use this for themselves to maintain a new behavior. It turns out it works time after time. The secret is to find something really rewarding to that individual. The rewards we often overlook include: positive social interaction, improvement in social status, unscheduled free time, and a sense of achievement. While tasty treats, or a new gadget are nice, they are not all we have in our quiver of goodies to help keep a new behavior going. Tracking behavior daily on a chart, app, or smart watch with a social media function is known to regulate the behavior in the way the individual intends. Programs that provide built-in social incentives are very useful in changing behavior.
  4. Plan for barriers. This is where your creativity as a clinician comes into play. There are as many barriers to starting a new behavior as there are people who want to change their behavior, probably even more.  Taking time to do a little speculation with the patient about what might get in the way of starting the new behavior is helpful. Make a plan for how to deal with that problem. It models resiliency to the patient and normalizes the struggle of overcoming barriers to reach a goal.  One underlying theme to many barriers is emotional decision-making. Essentially, it’s ‘I don’t feel like it after… (insert work, in the morning, today, ever, etc.). Discussing this barrier ahead of time is often necessary. Placing the behavior on the calendar like an appointment can help reserve time and serve as a reminder. Planning meals, exercise dates, trips to the mountains for the week ahead during times of lower stress, such as on the weekend, is extremely useful. Actually writing the plan down and having it visible can be helpful to stay on track and reduce the energy it takes to get started. Decision fatigue occurs after a day of making choices and shifting our attention among many things, making it difficult, and irritating, to make another tough decision. This is not the time to try to decide about whether to have salmon or a hamburger for dinner. Shift that decision to Sunday after you have had a nice meal, some time to relax, and can more clearly think about your goals.
  5. Check-in on progress. Have the patient send a mid-month message through the EMR portal. As a clinician, this allows you to cheerlead progress, trouble-shoot barriers, and help the patient refocus on the goal in real-time.

Resources:

Here are a few helpful resources for incorporating healthy lifestyle changes for improved mental health.  These are resources I often provide to patients depending on their goals.

Meditation:

Apps- for guided meditation
Headspace (Lite version is free)

Smiling Mind 

Insight Timer

Nature Melody 

 

Podcasts

Meditation Oasis 

Mindfulness + with Thomas McConkie

 

Books

Full Catastrophe Living by Jon Kabat-Zinn, PhD

10% Happier: How I Tamed the Voice in My Head, Reduced Stress Without Losing My Edge, and Found Self-Help That Actually Works–A True Story by Dan Harris

Getting Outdoors/Exercise:

The Nature Fix: Why Nature a Makes Use Happier, Healthier and More Creative by Florence Williams. A well-written book incorporating the latest research in the benefits of time spent in natural settings and exercise. It turns out our own backyards, not to mention the abundant parks and outdoor recreational opportunities in our community are huge benefits for our mental wellness.

Nutrition:

Eat Complete: The 21 Nutrients that Fuel Brainpower, Boost Weight Loss, and Transform Your Health by Drew Ramsey, MD. He is a psychiatrist at Columbia University and has written several books about improving diet through whole foods and improving the microbiome of the gut.  The information is straightforward, easy to incorporate into your life, and presented with a focus on wellness.  His nutrition mantra, ‘Seafood, greens, nuts and beans…and a little dark chocolate’, is a good start to a grocery shopping list.

There is also a nice interview on the podcast, The Splendid Table, for those who prefer an audio format.

The Confidence Gap: A guide to Overcoming Fear and Self-Doubt by Russ Harris.  This is a great self-help book for individuals who struggle with anxiety as a barrier to behavior change.  It is based on the psychotherapy Acceptance and Commitment Therapy, which is an evidence-based psychotherapy for anxiety disorders and depression. It incorporates many helpful exercises to teach a new way of relating to strong emotions. This would be a useful tool for individuals who are stuck due to anxiety.

jessica jones md

Jessica Jones, MD is a Private Practice Psychiatrist with Utah Center for Evidence Based Treatment. She is also Adjunct Faculty with the Dept. of Psychiatry at the University of Utah.

 

One in Five

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By Vanessa Galli, MD

Nearly one in five women have reported experiencing rape in their lifetime according to the most recent data from the CDC. Statistics never mean as much to the reader as an “n of one” or a personal testimony. I myself am the one in five, a survivor of rape. That is not the point of this article, but rather serves as a context for a larger conversation.

I bring this all up at the beginning of this article because it shouldn’t be any different than talking about any other part of one’s life story. The shame and the embarrassment that these events are shrouded in stops us from having open conversations and prevents survivors from seeking the help that they need. I also bring this up to challenge your stereotypes about rape trauma survivors and for any of you reading this who share my experience to remind you that you are not alone in this journey. One in five means that many of you reading this unfortunately share this part of my life’s story.

Sexual assault can come in so many forms, both big and small. I have always been aware of gender biases in conversation, although have become increasingly aware of these throughout medical training. Each time I was called “Sweetie”, “Honey”, and “Angel” and told that I “looked like a Barbie Doll” by patients, it became harder to just shake it off and walk away. I attempted gentle correction, changing the subject and removing myself from the conversation. I never found a “good” solution and was left feeling guilty on some level. I found myself asking the question, “What did I do to bring this on?” I was experiencing some form of survivor’s guilt.

I also began see how often we do this to one another in the work environment. I began to notice that my female colleagues are frequently addressed collectively as “ladies” or automatically by their first name in conversation, while their male colleague sitting next to them may be addressed in the same breath as doctor. In the hospital setting, I have overheard staff complementing male providers for their “bluntness” and female providers with a similar communication style accused of being “harsh and unapproachable.” We live in a world of micro-assaults that are committed innocently in the work place every day.

So what exactly do we do about this? I do not believe in being overlying politically correct as that doesn’t further the conversation and leads only to frustration and tip-toeing around the true issues at hand. I believe in being direct and open in communication, a style that was born from my Northeast roots. So on that note, I challenge each person reading this to question your own preconceived notions and stereotypes. We are in a line of work that relies on solid skills in pattern recognition and judgement, although sometimes we need to leave that judgement at the door. We need to have open conversations with each other. We need to feel comfortable and safe correcting one another, whether it be a patient or a co-worker. Only then, will we create a work environment and a patient care environment that is safe for everyone.

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 Vanessa Galli, MD is a Chief Resident in the Family Medicine Residency Program in the Department of Family & Preventive Medicine at the University of Utah School of Medicine.