In 2017, focus on what's important.

New year. Starting point for change. New reflections. Ditching old habits. Forming new ones.

I've spent a lot of time in the past year enriching myself. Career-wise I've made a solid effort to get to where I'm happy with moving forward, perhaps the first time in many years. Socially I've been making new friends and met very wonderful people, many of whom I still have to work harder at getting to know better. Personally I've kept myself active in once again as many sports and activities as I could muster. And for the past few months I've done a lot of reading regarding personal finances and investing, an area which I felt I was majorly weak and borderline ignorant on. All and all I kept my days filled and my calendar busting. All in an effort to grow myself, it seems.

But what's really important? What really counts? It's time to look back at within. My core values, my spirituality, my relationships. It's time to invest a little more back into myself and in the people around me. My family. My many new friends. My continued pursue to rediscover love, again.

It's time to relearn how to love. To be reborn and discover affections and romance on a new slate. As I sit here, waiting for my dearest friends to join me for an early birthday dinner to mark the occasion, I'm once again wondering, when will it happen again. Have I already found it and lost it, never to have it back again? Is it possible, that there can be different forms of it, equally impactful and perhaps even more intense but sustainable. How shall I open up to enable it to find me?

I know not to look, because it is something that is never found, only arrived. Maybe, with the new year of change, maybe I can rediscover the fire again. It's been too long. I might have forgotten how to start it. But may it come knocking with a might, and hit me when I'm not suspecting, and sweep me away.

Calling for empathy. At 3am.

4pm. Friday. Sunny afternoon in the last week of 2016.

I've finally settled into my comfortable desk, warm slippers and all, in recovering mode after my overnight shift. It's customary for me now to take a snooze a the hospital (about 45 minutes from where I live) after each night shift for fear of dozing off at the wheel on the drive home (almost happened a number of times). But that also eats into my post-night-shift free time. As I finished my work this morning at 9am (official off time was 8am but I'm used to staying an hour or two behind), I rolled into the springy squeaky hospital call room bed and snoozed unsoundly for about 4 hours. Then, feeling as if I'm utterly sick of the hospital by then, rolled out of bed to grab a light breakfast/lunch before driving home. It's usually late afternoon by the time I get to "catch up" on my life at home. Today, I felt the inspiration to restart my practice of blogging my random and impulsive thoughts (hopefully I can keep it up this time). Today the impulse was to write about empathy. Because after every night shift (or even after some quite testing day shifts), I felt I needed a kind reminder of how to be empathetic again as a doctor.

First off, it is intensely easy to lose empathy as a doctor, particularly with a role on the first line, such as myself as an Emergency Physician, as well as (my other hat), as a Family Physician. Your role as the first line of medical assessment means your time with each patient is diluted, because the key in your job is to push through high volumes of patients, efficiently, effectively, thoughtfully, and hopefully, caringly. Why is your empathy tested? It's easy to be empathetic to one or a few people. We all have kindness in us to give. But when you are seeing 20, 30, sometimes up to 40-50 patients a day (the former more in the ER, the latter sadly in the clinic), imagine listening to patients and patients' many questions and concerns, as well as often numerous complaints or expectations, while realizing you are well behind in the waiting times, and often when you are already utterly exhausted, usually more mentally but sometimes also physically. Last night, when I came on shift at 11pm, there were already about 20 people waiting to see me, many of whom have already been there over 2-3 hours waiting (the previous doctors were already working like maniacs to catch up, but holidays seasons has been often an haunting nightmare in the Emergency Rooms). Plus, usually around that time is a new flux of patient coming in to see the doctor, and I was the only doctor on staff from that point on all until 8 am the next morning. Heavy-hearted, knowing that all these patients are in for a long night along with me, scanning their sad desperate eyes hoping that I would call their name next, it is impossible not to want to rush to seem them all quickly. My friends know this. They know it's my nature not to relax until all my work is done. Seeing a waiting room like this literally eats me alive.

But it is this very notion to get through the list quickly that we, as doctors, must fight to resist. Because rushing though assessments put us at risk of mistakes and errors in judgement. And also, it eats into our empathy.

Some people are totally deserving of being in the Emergency Room. There is usually little difficulty in finding empathy for those people and their families. But many others do not seemingly seem they are in the right place for their concerns. And it is these patients, some of which have waited for hours just to get an question in for you, that you have to dig really hard to find empathy for. I try to remind myself, that if someone has waited 4 hours to see me, even if I truly believe they should not be there in the first place, they deserve at least a good few minutes of my undivided attention and care. More importantly, some of the hardest cases to deal with in the ER are patients to seemingly look well and have no right being in the ER, but yet actually presents with some pretty serious underlying condition that you better not miss and will only find if you are attentive enough. Finally, for both their benefit and mine, I think it is very important for patients to always end their encounters with their doctors on a good note. At the very least, even if I cannot immediately solve their problems (and this happens a lot in the ER), every patient should hopefully feel that they were listen to, that they had a small share of my time and attention, that their worries and their expectations and fears were voiced, and that, even if I have no direct solution, that I cared, and thought about how to help. It's like BayMax in Big Hero 6 (silly reference I know), hopefully they can all feel that they are satisfied with their care, no matter the outcome.

But it's not easily displaying all this, when you are mentally stretched to the limit with multiple things on your plates juggling numerous tasks and often overseeing a mixture of very sick patients to ones who don't seem they need any medical care at all. Those who work with me usually finds that I have a natural friendly and mild manner with patients. But those who know me have also seen me becoming blunt and short with patients when I am stressed. Especially at night, when the wait is long and the light at the end of the tunnel is far from reach, it's very easy becoming the latter. At times like these I try to remember something I learned from a preceptor who always seemed to be controlled and attentive in the most chaotic of environments. I remember asking him how he handed all the stress and distractions. He summarized his approach in one word, "mindfulness" (I actually wrote about this in a previous post I think but it's deserving of a repeated mention). In a zen-like appeal, he explained how he tries to practice mindfulness with each patient encounter, in that, during those brief moments with patients, he allows himself to ignore everything around him, and absorbs himself purely with that patient and his or her problems. It sounds easy, but its exceedingly difficult to achieve in a busy place such as the ED with many problems under your watch. But in those brief moments, I do believe he is able to almost find a little peace within him to reach further to each for each patient. It doesn't seem to take away from his decisiveness and efficiency, and I always remember him as a competent, effective, but very empathetic doctor.

It's easy to lose empathy for patients. It's easy to lose faith in people, when you see patients after patients, many of whom their names and characters get washed out among their medical complaints and symptoms. You start to forget they are people and not just names on charts, with families and loved ones and thoughts and worries and insights. You start focusing on the macro-management of the department, and lose sight of the micro-management of each person. I truly think this is one of the biggest challenge as a doctor. To both be an effective macro and micro-manager. To maintain a certain degree of care, in your voice and in your manners, even if you know truly well that you could care no more. But it's important, not entirely for you in that moment, but for the patient who has so much bottled inside them when they made the decision to come and sit through the hours of wait just to see you for their concerns.

Last night went by, thankfully, with somewhat smooth efficiency. I was mildly rattled by the end of my shift when I was pretty exhausted to have a fresh heart attack patient rolling in at 7:30am (I've not had a break since I started at 11pm, and towards the last hour of your shift is when you really hope nothing "bad" happens so you can quietly tuck into the "night" when your replacement arrives at 8). Thankfully, the nursing staff worked efficiently with me to help manage this patient effectively to get the care that he needed. I don't mind these cases honestly. They are why we have the department open 24 hours a day. I always tell patient never ever apologize for coming to the ER for chest pain. It's what we do and we do very well. Hopefully this man recovers well.

Long post. My apologizes from rambling on in my state of post-night-delirium. But hopefully I'll get in the habit of posting again soon. Mostly, if anything, just as a constant reminder to myself of how to be decent.

One challenge at a time...

It's only been a couple of weeks since returning to work from my short break, and already the intensity and the stress of working in the ER is hitting me.

It's been amazingly busy in the ER lately, at both hospitals where I work. I think that's the expected flow of things in the winter months, particularly at the new year, when doctors are often away, flu bug hits, and patients travel and pick up new diseases.

It's been disheartening and often very discouraging, when I'm already maxed out in my mental abilities, working non stop as fast as I can to move from one patient to the next, while making sure I take my appropriate time and attention with each patient to make them feel like they got their fair share of my care, and to make sure I don't make mistakes or overlook anything in the midst of all this chaos. But the waiting room keeps piling up, and I keep falling behind, and they keep coming. And keep coming. And coming...

This made me think of one of the more favorite movies I watched recently, Matt Damon's the Martian. In the movie Matt's character got stranded on Mars and had to engineer his way to survival and to a eventual unlikely rescue. He encountered endless bad breaks, each one seems insurmountable, but yet he motored through, created a solution, and lived on. Towards the end of the movie he became a professor and answered a question from a student of how he got through his predicament. His answer was, "just focus on solving one problem at a time."

When the world seems crumbling towards you, if you start looking at all of the problems that are coming, you will feel defeated, you will feel there is no way out.

One problem at a time. That's all you can focus on. That is the only solution. Do each problem justice, focus, treat it as the only problem of concern right now, deal with it fully, then move on. That is all you can do. That is the only way to hack away at it.

It's a difficult but high level task to master. As a ER physician, part of your job is to maintain control of your department and manage resources, beds, nursing efforts, and patient flow accordingly. Never must you lost touch with the current activities and demands of your department. It is much like a general in battle. You job is to maintain a pulse on all corners, and be the first to know what to do to keep the department afloat. Having said that, you never lose sight of your primarily obligations, and that is your patients, each and every one of them, when they are sitting before you. In that moment, you learn to shut it all out, even for 5 minutes, and make them feel like it's just you and them then. You give them all of your attention, you try to think of what it is best for them. You deal with their problem.

One problem at a time.

Yesterday I had a very difficult shift. Because I was sick. I couldn't sleep the night before. I woke up with chills and rigors and vomited and almost fainted during my morning shower. I thought about not going in but by that point it was impossible to get a last minute replacement on an early Saturday morning shift. I took 5 minutes to down some warm fluids and half a cup of greek yoguart. Then drove on to work. I thought about the day ahead of me. It felt taunting.

Then I remembered Matt Damon's Martian. One problem at a time. At this point, my first problem is getting to work on time, and arriving safely.

45 minutes later, I arrived at the parking lot of my hospital. I gave a sigh of relieve. First job done. I'm here. On time. I can do this.

I walked in, asked my nurse for an anti-emetic for myself, then picked up my first chart.

I got through the day. Focusing on one patient at a time. Luckily the department was manageable. And I think I did a good job with them all yesterday. I was so relieved when my shift was over. I was so exhausted. But I got through it. Thinking about the Martian.

Today I'm off. Just woke up from a 12-hour sleep. I'm feeling better. Hopefully this will past swiftly before my next shift tomorrow.

One problem at a time.

Anger. Hatred. Resentment. Belief systems.

All irrational mindsets that are deeply rooted in all this.

How we respond will further define this vicious cycle.

But how do we respond? As an international community. As nations. As communities. As individuals.

France has vocalized this was an act of war. Ironic since war is precisely what they want. Is war ever the answer? Or does war only creates more anger, hatred, resentment. And when has war not created a power vacumn that bred more evil?

But. Is diplomacy ever possible with irrational minds? You cannot argue against another's belief system. Especially when it is so deeply rooted that they are ready or seek, to die, from it. If perspectives are different, there is no meaningful conversations.

Can anger ever be contained? Don't think so. Not when technologies and information exchange created a world with no boundaries. Not when the risk of lone wolf outliers further threatens the lack of predictability when they may not even adhere to the mandates of the central organization.  Not when the thread is irrational.

So how do we respond.

As usual, there probably is no single optimal answer.

There is likely some grounds for continued containment. To limit their resource. To limit proliferation of their extreme ideals. But to think they can be extinguished is likely naive.

There is likely some grounds for diplomacy, even if only to achieve an ongoing presence of international pressure against such thread. Form some form of unity. Better information sharing and security efforts could probably lead to, well, more security.

And there is probably grounds to continue to breed tolerance and compassion, to diffuse further anger, hatred, resentment. Continue to learn about our differences. Continue to find similarities.

At times like this, the natural reaction is an instantaneous radial aggressive angry response. It is probably better to carefully evaluate the options and potential implications. Answering anger with anger never works. When has that argument ever turned into a productive resolution?

This is an opportunity to grow closer as a people. Thread will always be among us. I see that all the time in my work. Most of it is unpredictable and irrational. Be vigilant. Form effective safety nets and protective mechanisms. Seek and diffuse potential threads. Show compassion and care.

And carry on.

Never sit on an opportunity to express myself or to show others what I am capable of.

Otherwise the next day days will just be filled with regrets of missed opportunities.

Don't have to be rude about. But also no need to be too polite. Maintain respect, but seize the chance if it's there for you.

Doors don't open by themselves.

Resist the urge to sit back especially in the midst of a downward spiraling mood.

Stand up and sing. Take the ball to the net and take the shot. Speak up. Call for the puck.

Nobody will thank you for being a bystanders.

Winners are not made that way.

Never sit on an opportunity to express myself. To show others what I am good at.

Otherwise, people will never know.

And what good is that?

I passed.

I didn't expect the results for perhaps another week. I was expecting the worse, actually. I wasn't a very pleasant exam. I didn't feel that it tested the knowledge and clinical skills we worked so hard to get. I was more flustered at whether I had interpreted their questions properly or whether I gave them the very answers their templates wanted me to give. I had never felt this poorly after an exam before. After the morning of the first part of the exam, I walked out feeling stunned. I'm sure I looked pale and ghostly. I wanted to cry. Christine kept asking me if I was ok. I didn't even care to look at her and answer her. I was sure I had failed it. I would be "the one" who failed it from our school in something like 10 years. After that terrible weekend, I was ready to accept the embarrassment, and had resolved to letting whatever happens happens. I'd be okay, I told myself. I have many options going forward. I'll just live with the shame for a  little while. Then it'll all be gone. And we'll live. Whatever happens.

So this morning when I saw my friends posting their happy news on facebook, I sat there, cereal in hand, wondering if this should be the moment that I meet my fate. I took a deep breath, thought to myself 'what the heck, might as well let it be', then opened the email link...

Whew. What a relief.

Is it joy? Is it excitement? Not really. It was very anti-climatic. I texted my family. Texted a few friends. Posted it on my facebook religiously as we are expected to do so with other major milestones of our lives. And waited for the congratulatory statements to flow in. Great. Now the world knows. I'm officially a certified Emergency Physician.

That last statement took some time for me to absorb. In fact that moment had hit me that morning when I prepared to leave for my flight to Toronto for my exam. Certified Emergency Physician. Seemed a tall order and actually took more a lot longer than expected to get here. I took many detours, many of which my own doing, for I had other ideas in life, other career paths at various points, other desire than medicine alone. But it's always been a floating target. I remember some of the most impressive teachers I've had when I was a medical student were Emergency Physician. As biased as it sounds, ER docs really are some of the most highly trained, knowledgable docs who really are expected to be able to do anything on the fly. Now in reality, they are really not that spectacular, and sometimes relies very heavily on good support from other colleagues and consultants. But from a skill set they are really the most comprehensive. When I was a medical student, I look to the core skill contents of the ER docs to be the set of skills that I must obtain to make a competent doctor. It took so many years to try to acquire those knowledge and skills, and I don't even feel I'm really there yet. But being board certified is a marker of at least getting there on the most basic level. It gives me a certain level of credibility, even though the exam itself really don't mean much of anything. But it's a symbol. There after many years of trying to get there, I think from a credentials point of view it means I have finally gotten here.

So now what? Well it really doesn't change anything. I've already started working in the ED since July. All this means is that I don't have to face the embarrassing possibility of having to tell my department that I had failed the exam and they have to reschedule all my shifts. As for what it means for my future, I haven't decided that either. I'm still trying to find a comfortable balance in where I'd like to work, what type of practice I want to be in, whether I want to keep some clinics going, and what else in my life I want to be thriving for going forward.

But one thing is more clear. I want to get back to my own life a little bit. After years of pondering my medical career, and a year of intense studying and residency work, I feel like I've really left myself behind. Sometimes when I come back to my empty apartment after a series of shifts, I'm not really sure what I want to do with my time anymore. All my hobbies had been set aside. My natural curiosity in anything other than medicine has been smothered. It's so easy to go from day to day just carrying out my work and errands in a robotic manner. My soul hasn't grew much the last few years. I haven't evolved much as a person. I've been lacking a lot in time for self-reflection.

Which is why I'm back here, on my blog. My last entry was almost 5 years ago, about the time when I first finished my Family Medicine residency. I'm not even sure if I'd be publishing my blog online at this moment. But I wanted to write. Writing makes me self reflects. Writing triggers my emotional self and allows me to dig back into my values a little bit. Writing makes me feel more in touch with myself again. It brings my world back to me, through my own eyes, my own mind. Keeps me in control a little better in a life (and now a career) with very fast moving parts.

Hope I can keep this up. Hope this keeps me up.

Newleaf. Now officially Newleaf, CCFP (EM).

Enough already.

Enough already.

All these years I've learned to view life with a critical eye. It's served me well. I'm great at identifying problem areas that can often lead to solutions. But when it's my own life, I'm been identifying too many problems and haven't yet discovered too many solutions...

Perhaps being naturally critical is becoming a major downfall. I have yet to learn to count my blessings and enjoy life a little.

I should be glad. I should be thankful.

If I learn to just stay positive in life, I might find there to be not as many issues that require fixing, or that, even if I choose to fix so many issues, they can be fixed more enjoyably.

I am rather glad, actually, of what I have become. I just need to learn to be prouder.

I'm mighty thankful to be in a job where my natural curiosities carries me through my tasks. I'm forced to read and learn things I would happily enjoy learning anyways. I get to be extremely practical in my work. My knowledge applies to all my surroundings. I have worked for years for a set of skills that has enabled me to handle almost any health question with an approach. And I am mightily thankful to have achieved that.

I am thankful my work doesn't kill me. I have a rather routine schedule, extreme flexibility, and can choose to work as hard or as little as I feel like. I make enjoy to make life comfortable, and enough to allow myself to be generous to the people around me whom I am so indebted to.

I am fortunate have so much opportunities to spend quality time with family at an age when we are all young enough to enjoy each others' craziness. Trips, home rennovations, goofing around. I'm lucky my work has not taken me away from them, allowing me to cherish every moment of every day with them.

I should feel good about what lies ahead. I am in a lucky position that allows me to give as much of myself as I wish into my career. There will be opportunities for furthering career aspirations, and I already have a great job to fall back on. It doesn't matter which decision were correct, or which future decisions is the best. All options have the positives and negatives, but I will always hold the control in the kind of work I wish to do. Finding the positives in whatever I am doing will always yield a happier process. And as we all already know, the secret to happiness is to enjoy the process of life, not the destination.