S8E11: Rethinking Self Care in Medical Training

Austen: I think oftentimes it can be . . . Oh my gosh, I just lost my train of thought. I apologize. It'll come back.

Lilly: That happens so much. I feel like I need to have a notepad to write things down.

Hạ: Such a vibe.

Austen: And with that, I guess we'll get started. Welcome back to "Bundle of Hers." For those of us who have been here before, we're glad you've returned. For those who are listening for the first time, we're glad that you're here with us. My name is Austen. I'm one of the hosts. And I am joined by my co-hosts, Lilly and Hạ.

Today, we will be talking about when it's not okay to not be okay. This is an episode where we are going to be focusing on the mental and emotional toll that comes with being a trainee within the medical system. Some of that can come from mistakes that we've made and just kind of the learning process in general.

The act of taking care of oneself is sometimes conflated with needing to be pampered or shirking responsibility. And while this misconception is being corrected, it can still permeate within the clinical space and affect self-care and mental health in general.

Lilly: And before we dive in, I just want to remind everyone that all the thoughts and opinions that we share on this podcast are those of our own and they don't represent any of the institutions that we work for or are employed at. Is that redundant? Whatever.

Austen: So as you both know, and as maybe some of the listeners know, I am currently in my fourth year of medical school, which means that I am applying to and interviewing for residency positions, which has been terrifying and exciting and all the things. But I feel like a question that I've gotten pretty frequently is, "How do you deal with hard things?"

I think it's something that's so common within medicine, and I think it's good to be thinking about how you can kind of . . . not necessarily mitigate the stress or maybe some of the feelings of overwhelming doom, but more so it's good to see if somebody has healthy habits to cope with the stress, to cope with the anxiety, and oftentimes to cope with the feelings of guilt.

But it's been interesting because sometimes I'll talk about going for walks or doing whatever, and everyone seems cool with that. But sometimes when I mention self-care, I see people's eyebrows kind of lift a little bit. And I think it's interesting. It almost feels like a trick question a lot of the times. Maybe not a trick question because they do want to hear a genuine answer, but I feel like using the phrase "self-care" is kind of setting off a landmine.

I don't know if I'm the only one who feels that way, but it seems like there's kind of this image of what self-care looks like, and that doesn't always align with the reality of self-care.

Hạ: I think one of the other things I think a lot about too is I feel like in medicine, we are taught to have to be selfless and to really give up ourselves for the job and to really have this career be everything that is us. So then when you start thinking about, "Oh, I am actually setting boundaries with my clinical work or I'm thinking about self-care," sometimes it kind of . . .

I think even though we rationally know that is great and that is something wonderful to do, a lot of medicine and the environment and what we think we have to be is built in. It makes us really uncomfortable and it makes us feel like we're not doing our job properly if we're not giving our 100% into it.

Lilly: That's a really good point, Hạ. I feel like when I went through residency interviews two years ago . . . That feels like it was just yesterday. But two years ago, they would also ask that question as, "How did you deal with a difficult situation? And how did you kind of debrief that or process it or manage it or whatever?" It almost felt like they wanted to hear this . . . almost martyrizing yourself and saying, "Oh, I experienced this really awful, horrible thing."

For me, for example, I talked a lot about my mom being sick in medical school and talking about how I got over this really difficult thing by focusing on how much I would be able to help others and staying within my studies, not taking a leave of absence, being able to really power through. And it was so impressive to so many people.

They ask, "How are you resilient?" And they want to hear about how you're going to work through really tough times and basically show up even when you're not showing up for yourself.

And so a lot of times I would be talking about how, "Well, I didn't take a leave of absence. I didn't miss work. I showed up. I took the best care of my patients I could, even when my life was falling apart. I was calling patients' families to update them, and I didn't have time to talk to my own family and talk to them on the phone at nighttime because I'm working so much."

And I think that was something that was impressive for residency programs to hear, but in reality, it was actually something that was really toxic to myself and really negative and led to a lot of burnout and wondering, "Why am I playing into a system that didn't even help my own loved ones?"

You sell yourself in this way of, "I can get through anything. And look at how resilient I am," when in reality, you're just causing harm to yourself in order to provide for others.

Austen: And I feel like a lot of the times, that's kind of the expectation, whether it's an overt or covert expectation, is that we need to be prepared to show up and care for others when we literally don't even have the time, sometimes the bandwidth to really care for or show up for ourselves.

Like I mentioned earlier, I think that's something that's changing, but I think it's definitely something that's still somewhat pervasive within medicine as a whole and kind of medical institutions.

Just like Hạ said, there's this attitude that we should be self-sacrificing and if we're not giving our all to the point where we have nothing left, then it's like, "Oh, we're not giving enough."

I feel like self-care looks so different to so many people. There are attendings, often older attendings, who hear self-care and they think, "Oh, she means that she needs facials and a pedicure." In my mind, self-care is just, "No, I'm getting enough sleep at night and I am able to see people that I love twice a month. I am eating somewhat nutritious meals just to make sure that I stay alive."

Sometimes, growing up, I got similar messaging that was this self-sacrificial messaging where it's like, "Well, you're going to work until you can't work anymore." I feel like sometimes my parents would be like, "Well, I've worked so hard for my kids and I went without for X, Y, and Z." And it was similar messaging.

And so I'm curious if you guys have experienced the same thing. Maybe since interacting with medical system, it's kind of shifted for you? I don't know.

Lilly: So I wasn't really raised in a household where we were taught skills for self-care or being more selfless, but rather just continue to work for others, and self-care is something that I learned more in college and more in med school, especially from my peers. I didn't really start taking care of my body or exercising until I had a little bit more freedom in med school and I realized I was going crazy and I needed to have an outlet.

So I definitely agree with you. I think that that is a shared experience. And maybe it's amongst more of communities of people of color than others, but I do feel like I hear that frequently where we don't really see that because our parents are living this American dream of rags to riches, grinding 24/7 to try and make something for their kids.

To those older attendings that think we want hour-long meditations and facials, yeah, I do want that, actually. I would love to have that. It's not realistic right now, but that sounds amazing.

I was thinking about that on my drive home the other day. I was like, "Wow, what I wouldn't give to just sit in a sauna for two hours and just pass out and have the biggest nap of my life." Obviously, not realistic. But I think there are small things we can do, and then I think there are also larger things we can do for self-care.

When I'm on inpatient and I'm working six days a week, self-care kind of goes out the door just realistically because of how busy our service is. And a lot of times, because neurology is . . . Almost everyone consults neurology. I spent a day in the hospital and I'll get pages from general surgery, I'll get pages from cardiology, medicine, the ED. We cover a lot.

So small things I do for self-care . . . which I'm still working on, because it is really hard when you're very type A. I'm very detail-oriented and I want to get things done in a certain time frame, and I get impatient with myself when I can't get that done. Then I get anxious towards the end of the day.

But things that I've started to force myself to do, especially on my call days when I know I'm going to be at the hospital for a long time, is after we have our noon didactics, I make sure I go to the bathroom because I know realistically I'm just going to hold my bladder all day and prioritize doing a million other things while I'm giving myself an AKI, which is not good.

But that's just my body going into fight or flight and prioritizing certain things and not others. So now I've made it a part of my routine to be like, "I need to use the restroom. I need to do this, because otherwise I'm going to be so uncomfortable until I go home because I'm just focusing on running around the hospital for other people."

That's a super teeny tiny thing that a lot of people might think is kind of ridiculous, that I have to force myself to put that into my schedule, but I had to because I wasn't using the restroom all day, like 12-, 14-hour days. That might be TMI, but that's just the reality of residency.

And then there are other things like if I have a really stressful day and I have a lot to get done and I haven't eaten lunch yet, one of my seniors was like, "No, you need to give yourself 10 minutes."

It doesn't matter if you have 4 consults waiting in the emergency room and you have 10 notes to write and it's the middle of the night. You need to take a break and eat, even if it's just 10 minutes. Just pull out your lunch, get something quick to eat, and just force yourself to do that.

I really struggle with that because unless I have everything tucked away, I feel like I can't relax. And then I feel bad if there's a consult, even though it's not emergent, waiting for me to see them and this other team is waiting for my recommendations.

So I'm trying really hard to do things like that or just packing more snacks, healthy snacks, because everything we get at the hospital is starchy and carby and makes me want to go to sleep afterwards.

So those are really small things that sound so silly, and if you would have told me in med school that I would need to focus on those things really hard in residency, I would have kind of laughed at you.

And then kind of trying to do that for the med students. We have this weird mentality where it's like, "No, they're tricking us. They want us to stay." But I actively push out my med students. I'm like, "It's 3:00 p.m. You need to leave. You have better things to do. Go study, go work out, go be with your family. Please, for the love of God, you're not getting paid to be here and you've done all the learning you need to for today. We'll see you tomorrow morning." So those are small things we can do to try and change the system a little bit.

Hạ: I think one of the things that they talk a lot about is this Maslow hierarchy of needs thing. And basically, you think about it as a pillar of the survival things at the base and for you to finally reach . . . What is it?

Austen: Self-actualization?

Hạ: Yeah, self-actualization. You have to have those core needs at the get-go. But one of the things that I sometimes keep thinking about is Maslow's hierarchy of needs is great and all, but how do we kind of turn it on its head? I think everyone deserves self-actualization regardless of what they're struggling with and where they are at.

In terms of basic needs, I think self-actualization is really important. And it comes into also thinking about self-care in that way. And part of self-actualization is understanding yourself and understanding your needs.

And so for me, when I think a lot about self-care, I also really center it onto this introspection and understanding that self-care can mean so many different things and it can also really matter in the moment. And sometimes self-care is realizing, "I need time away from this." So that means calling out to take a mental health day.

In my experience, I actually had two instances, first in my intern year of residency where I was actually really struggling studying for Step. So I actually had to work with my program to figure out a way to give myself dedicated study time and dedicated mental health healing time.

And then the other part of it is when I was a second-year, I was also going through a lot of things and I had to take a leave of absence to sort out my life.

It's really hard because when you do it, also depending on the size of your program . . . I think you two in neurology and OB-GYN are much smaller programs than me in pediatrics. But it's hard because when you do it, you know that that means you're asking someone else to come in and to cover your slack and there's a lot of guilt about it.

But I also needed to reflect and recognize, "No, this is my breaking point and I need to prioritize myself because then I'm able to come back and actually do the work that I want to do."

And so when I now reflect each day when I'm like, "What is the thing that's going to get me through this day?" I kind of try to reflect on it in that broader scheme of things too.

Austen: That's something that I think is interesting about this concept of self-care and whatever form it takes, whether it be making sure you can go to the bathroom so you're not giving yourself an AKI or advocating for yourself and asking for more time so you could focus and study.

I think, at some point, you realize that you need extra help, whether it be from programs or from people around you. And I feel like so much of surviving life and medicine alike is kind of bound up with this idea that we never go it alone and that we have people around us. But sometimes when we're in the trenches, when you are feeling guilty, when you're feeling overwhelmed, it can feel hard to not feel guilty about needing help.

It can feel difficult not feeling . . . I don't say like a burden because that might be a little too extreme, but it can sometimes feel like, "This is just one extra thing that I'm adding on to somebody else's plate."

I feel like I naturally lean towards feeling guilty about things, and that's something that I'm actively trying to combat. I feel like sometimes there's only so much that I can do on my own to kind of change my frame of mind and change how I'm thinking about things.

I was curious if you guys have any insights for me as far as ways that you can reach out for support without feeling so guilty for it or almost feeling like you've fallen short in some way for needing support.

Lilly: I honestly struggle with this because neurology is small. I saw a primary care doctor for the first time in seven years and it took almost a year because every time I would get to my appointment, my clinic would run late or my sign-out would run late and I would have to push it back. And then, of course, it takes another three to four months to get in with a PCP.

But when I finally did see them, they told me, "Are you using all of your sick days?" And I was like, "No." And she was like, "You have to. That is a form of self-care. They have those in place for you to utilize them."

It was so interesting because I was like . . . And I love my PCP. She is wonderful and amazing and a wonderful human being. But I knew realistically that just isn't the case, because we're such a small program.

Actually, our program is pretty decently sized. We're a little bit on the bigger side compared to most other neurology programs, so I can't even imagine what this would be like if there were half the number of us, which other programs have that situation.

But I just know if I did do that, if I were to pull someone else, especially if it's a weekend, I'm taking away a weekend and that means they might not have a weekend for two months, basically. If they're doing a four-week block, and then they have that weekend that I pulled them for, and then they have their next four-week block.

So there is a lot of guilt, just to be honest, in my situation where I don't want to pull my colleague because I know that I'm disrupting a large portion of their self-care and having that time to decompress and be with their families and things like that. So I do struggle to pull.

Obviously, if you're so sick that you can't leave your home . . . When I was in my intern year, I had norovirus and I absolutely couldn't leave my home. I would not have made it through rounds. And that was unfortunate, but I had to pull. Obviously, medicine is a lot larger, so they had a little bit more leeway.

In my current residency now, I have to be very thoughtful of that. And there are other things that you can do to try and recuperate that time that you feel like you need that doesn't always involve pulling. And it really depends on if you have very good seniors and co-residents.

So, for example, if it's not as busy of a day and you were there super late the day before, and your patients are pretty tucked in, I do feel comfortable asking my colleague or my co-resident, "Hey, is it okay if I sign out early to you? I was here until 11:00 p.m. and I just need to get some rest before my next call shift."

They're always so agreeable because we all have been there. We've all had that really bad shift. We all have had that time where we just don't even know how we're operating anymore.

And so those are small things that you can do. Or if I'm on a different rotation where we have clinic and call, sometimes our seniors will say, "Hey, we actually have enough patients to providers, so we would be overstaffed if everyone came in. You can decide amongst yourselves if someone wants to take the afternoon off."

I think, at that point, you should feel comfortable advocating for yourself and being like, "Hey, can I please take this day off? Can I please not come in this afternoon?" or whatever.

There are small things like that where you don't have to fight the whole system to make those changes and feel like you're totally impacting others, but still being able to prioritize your own care.

If, for example, an attending's clinic gets canceled that you were supposed to rotate in, great. Take the afternoon. Don't feel guilty. Take it off. Sleep in. Enjoy.

I will feel guilty and be like, "Well, can I come help with this service? Do you think that this team needs help?" And my seniors will be like, "What are you doing? You're crazy. Don't volunteer yourself for additional work."

And so learning those kinds of boundaries while still recognizing that we work in a system, I think, has helped me a little bit. But at the same time, if you really need it, someone else at some point will need to pull you. So you should feel okay pulling someone else. That's why those systems are in place, is so that we have that extra safety net if we need it.

Hạ: Yeah, it ends up that we have to recognize that it is very systems-dependent and situation-independent. Pediatrics is a bigger residency. Per class, we have 25 to 30 people. So there's just a lot more coverage that is available.

But the thing that I've also recognized is . . . I don't know. I think when I started residency, I thought a lot of times it meant that I had to give up a lot of things. But what I then realized is there are things I have to give up and schedules are never going to completely click the way that you want them to, but you never know until you try and you ask and you try to see how things work.

Last year, I was able to make six weddings, which I never thought I could make a wedding in residency. I thought that was done. But just because I asked around, I figured out shift swaps, and I worked with people, it was amazing the things that you can do.

And so for me, in trying to navigate systems, I think about it and trying, "What system do I have? And how can I play the game to get what I need?"

There is always going to be guilt. That's just the natural part of, I think, how I was raised. But what I work with a lot in therapy and things like that is also feeling that guilt but not letting that define you, and letting yourself be able to let go and give yourself love and acceptance that, "This was a shitty moment, I feel guilty about it, but I'm going to move on from it."

I think that is also a really big mindset shift for me that I have figured out. Well, not completely figured out, but that I'm trying to practice in residency.

Lilly: It's like a jigsaw puzzle you have to put together, because even with my small residency, I have also been able to make a quadruple swap with my co-residents in order to make it to my cousin's wedding.

If there's a will, there's a way. If you individually text people and say, "Hey, please, please, please, can you cover this day for me? I'll cover this day for you. What can I do?" people are like, "Let's make it happen." I literally had four different residents coordinate with me on my call schedule so that I could go to my cousin's wedding. So you can make it happen. It just takes some extra effort.

Austen: Oftentimes, my perception of residency is that is the time where you have the least amount of time for yourself, the least amount of control over scheduling, and all of that kind of stuff. And I think I've been afraid that I would kind of lose myself in residency even if it was for a short amount of time, that I'd have to just kind of forgo the things that fill my cup, the things that help keep me grounded and centered.

And so I think it's great to know that those things can still be a part of my life, they can still bring me joy and make me happy. And we're supposed to be happy even on this crazy journey. It'll be okay, and we're never going through it alone.

I feel like that is something that I'm reminded of over and over again, is medicine is the greatest, craziest team sport that you could ever play. It's hectic and chaotic and there are a million things going on. And in the middle of the game, someone breaks an ankle and you have to run and help them while still playing.

But you're part of a team, at the end of the day. You're part of a team where you have people who are in the same position as you, who understand what you're going through, and who are ultimately looking out for you. And that's something that brings me a lot of peace. There will be a time when I'm worrying about all the other things in life.

Lilly: We're all trauma-bonded.

Hạ: Don't let the system win, Austen. Protect your peace. Protect your joy.

Austen: Normally, I'm fine, but every so often I just look at how much you guys do as a resident and I'm like, "Oh, man, they're doing the damn thing." And I think that I have moments of self-doubt, but generally I'm doing okay.

Lilly: Even sometimes when we're doing the damn thing, I feel like even as a resident, sometimes I black out and I disassociate and I'm like, "Wait, am I actually doing this?" It's kind of crazy.

Hạ: There are days I go through and I'm like, "That was not great work. You could do better, but you're so tired and things outside your control are conspiring against you." But it's okay.

Lilly: Oh, always.

Hạ: It just matters if you come back each day, get your little sweet treat, and keep coming forth.

Lilly: I was going to say one thing that we do is we'll go on hot girl walks with our teams, like med students, resident seniors, sometimes fellows, sometimes attendings, especially if they're going to pay. But we'll go get a coffee or a sweet treat, and it's so nice to just . . . That's the tiniest thing you do, is just leaving the workspace, going on a nice walk, getting a sweet treat, coming back. We call it our hot girl walk. And every gender is involved in this, but we just call it that because it's fun.

Hạ: It's the little things. Yesterday, a crew of us . . . conference was canceled, so we all grabbed lunch and just sat outside. I'm in California, and we're having some really good weather right now, uncharacteristically, and so we were just sitting outside enjoying the sunshine and eating food. It's the little moments that count.

Lilly: Yeah, I saw that. That was so cute.

Austen: At some point during the conversation, and I lost track of when, but someone mentioned . . . We talked about reaching out to friends, setting good boundaries, going on hot girl walks, having this kind of connection, and then also we mentioned therapy as well. I feel like with therapy, it's nice because you have a clear boundary and you know your role and it feels like a safe space to go and kind of process everything. But I feel like sometimes with friends and even with peers, those lines can get kind of blurred.

And I feel like I've found myself blurring those lines and kind of . . . not necessarily overstepping my bounds, but I never want to turn a friendship into a pseudo-therapist/patient relationship. I never want to do that.

Have you guys ever found it difficult to not overstep and, I guess, not necessarily rely too much on peer support? But how do you approach peer support so that you never get to the point where you feel like instead of bonding and forming connection and everybody leaving the situation feeling relieved and uplifted, you have someone instead who feels like, "I'm now carrying all of your emotional baggage in addition to my own"?

Hạ: In the past, I feel like there have been moments where I think I've probably unleashed too much on one person, or vice versa. And in working on peer support and getting through this wild thing called medicine and medical education, one of the things that I have reflected a lot on is I've kind of figured out I have different little groups. I'm thinking of a network now. I have these little dots of groups of people.

And sometimes for something, I will talk about it with this person and process that with them. But then another time, a different issue comes up, and I'll process it with a different person. Creating a network of different processing is helpful.

And also, sometimes in the processing, giving room for joy and other fun things to do outside of just processing is helpful. There have been moments where friends have been like, "I'm really sorry that I'm dumping all of this onto you." And the way that I always phrase it to them is, "If I am at my capacity, I will let you know. And it will be not because I don't love you, but because I'm at capacity and I don't think I can support you."

I always give them that understanding, and I'm pretty consistent with it because then that way I feel like I've been setting a boundary from the get-go. Even preemptively before, there's a moment where I might feel that way.

I think it's also been helpful when those friends are also similarly processing in a group chat. So if I don't have the capacity at that moment to help them process, there are other people in that group chat to help, which I think is a good way to do it.

Not that profound, but practical and has worked for me.

Lilly: Obviously, we all have our village, but having smaller villages amongst that to talk about certain things with or without. I'm close to my co-residents, but I don't unload all of my super-intense feelings on them. We'll talk about things that frustrate us at work.

I do think venting is therapeutic. Obviously, you don't want to only spend all the time every single day venting about an issue because it can become toxic the more you dwell on it in this work environment. So sometimes you have to just let things go that you cannot control that frustrate you.

But I do think that in talking about these things with your peers, they can relate with certain aspects of your frustrations with triaging patients or trying to coordinate getting outside records from a hospital. Things that are very niche to our hospital systems, I think they're things that I can talk to with my peers.

When it's deeper things in my personal life, I think I tend to go back to the villages I've had outside of medicine, like my family, my cousins, friends I've had since grade school and high school.

It's kind of full circle because we're going back to the thought of self-care. I've always really enjoyed getting my manicures and pedicures done, mostly my manicures because my friend does them and I've known her since college. We've been friends for a decade now. It's our little yap sesh where we just debrief our lives. And it happens very sporadically whenever I have a random day off and her schedule is open.

But as she's doing my nails, I'll just update her about all of these things. And I'll vent about something happening in my personal life, something that happened at work, talking about something else. We have that one-hour block where we both just vent to each other. And you're not getting insanely deep into the nitty-gritty details, but you're at least unloading.

I do think it's important that you're able to talk about this with different people because different people also have different perspectives, whether they're in or out of medicine, to validate your feelings, and then also, if you want them to, help you think of other ways that you can cope or resolve the situation.

And then I think being able to talk to different people also doesn't burn out just one person that you're constantly overloading on, especially if you don't have a lot of rapport with them, like if you've only known them for a year or two at work mostly.

I think those are the things that I try and do. And then sometimes I will also just talk to myself, which sounds kind of crazy. But I'll process my feelings by just talking through the situation in my head, whether I'm driving home from work or something. I'll be like, "What else could I have done to deal with that situation?" or whatever. I think some people do this in journaling, and that seems more sane, but I don't have the energy to journal.

Hạ: That's what I do.

Lilly: Yeah, I don't have the energy to sit down and journal, but I do it in my head and I just talk to myself sometimes. And I think it also is a little therapeutic, although I probably sound nuts now.

Austen: No, I love that. I will full on sometimes be in the shower going through things in my head, like, "Oh my gosh, that was insane," or, "I could have done things so differently." I love a personal play-by-play of my [inaudible 00:31:08], so I get it. That's invaluable advice.

Well, ladies, I feel like self-care and mental health, in general, are huge topics to discuss. And this conversation has been helpful and it's reminded me of a few key points.

I feel like, first and foremost, no one thrives alone. It's so important to create a community that you can then rely on, and then also that you can be relied upon by. I feel like every relationship that we have should be reciprocal. And so in being a good friend and being a good source of support, I think that enables us to have better friends and better support as well.

Also, I feel like this has been a good reminder that self-care can look like many different things, and each one is valuable as long as you're checking in with yourself and evaluating what your needs actually are.

So, yes, self-care might include facials and manicures, but I think also, just like we mentioned earlier, self-care can include making sure that you're getting snacks, making sure that you're going for walks, making sure that you have time to feel like a human being so that you could come back the next day and give your patients your all.

Self-care is valuable. It's not a frivolous need. It's a way that we can demonstrate commitment to our craft and a commitment to ourselves as well. I think that's important.

So thank you, ladies, for sharing your pearls with me, pearls of wisdom. I'm glad that we could chat.

For our listeners who have joined us for this episode, thank you for sticking through it with us. I guess leaving you guys with just some things to reflect on. Hopefully, you'll have time this week to check in with yourself and kind of think about a potential small step towards support that you could take this week, whether that be reaching out to friends, scheduling an appointment with a therapist, going for a walk, or maybe just making sure you get a good night's sleep.

We want you guys to, hopefully, check in with yourselves and maybe check in with somebody else after the episode. Not necessarily to fix anything, but simply to connect and to see where you're at.

Lilly and Hạ, before we sign off, is there anything that you want to say?

Lilly: That was a beautiful send-off, Austen. I think we just need to be gentler with ourselves and remember that we're people in process.

Austen: Love it. Well, thank you for joining us. And remember to subscribe, share the episode if you want, and join the conversation on Instagram. You can find us @bundleofhers, and you can listen anywhere you podcast.