• Rosalind Kaplan, MD

Self Care

by Rosalind Kaplan, MD

At 60, I am finally figuring out what it is to actually take optimal care of myself. It's so much more work than I ever wanted to do, but is also proving worth it. My news feed has been full of articles on self care ever since the pandemic took hold, and each one has a different take on what 'self care' actually means. I think each of us can only define it for ourselves, and each of us must make a decision on how we invest in our own physical and mental health.

As a primary care physician who has advised thousands of patients on care, both medical care and their own care of self, I have certainly always had a good handle on how one ought to go about pursuing well-being. I also always believed, in theory, that I should serve as a good role model for patients. Externally, I think I managed to look like a paragon of health. I've always exercised, so there I did a good job. I maintained my weight in the normal range, which was easy when I was young, due to a naturally good metabolism, but became more of a challenge with age. I had a doctor and was regularly screened for high blood pressure and cancer, and I kept up to date on vaccinations (working for hospitals would have forced that, anyway). I even went to the dentist regularly.

Still, underneath I was stressed out a good part of the time. I was a natural worrier, tending to anxiety, and I took home lots of stress from work. In the last couple years of primary care practice, I was also frustrated and angry much of the time about the constant barriers to providing care, like the prior authorizations for medicine and pre-certifications for tests, the constant time suck of the EMR and the data entry I was forced to perform, and the lack of support for all these activities due to understaffing, poor staff training, and a general disregard for physician well-being by administration.

All the stress and time crunch meant inadequate sleep, which added to the stress, and often inadequate nutrition (no time for lunch or healthy snacks, dinner late in the evening) and consequently shoving whatever was easy and convenient into my mouth when I was truly starving for real nutrition. Caffeine and sugar served as ways to bypass the need for sleep and actual food, and crashes from the caffeine and sugar led to migraines on a majority of days I worked. I'd take my migraine medication and then rebound off of it, since I wasn't addressing the underlying causes of the headaches- and then need more medication. And forget about drinking enough water- that causes the need for bathroom breaks, and who has time for that? Long work days and fatigue meant less time for exercise, so exercise had to be concentrated on days off and weekends, or I'd have to get up even earlier or stay up even later to fit it in on work days.

I still looked healthy enough, and managed to do what I had to do. They trained us well in medical school and residency: your needs don't really exist. Your patients need care but you can manage without sleep, without food, without bathroom breaks. Grab a cup of stale coffee and something sweet and you'll be fine.

I tried to look alert and present, to avoid seeming harried during patient visits. Up to the last year or so of primary care practice, I think I managed to maintain that facade. I kept up the external appearances, getting my hair colored regularly, keeping my nails manicured, and dressing neatly--but underneath I was a mess. By the end, my patients were commenting on how tired I seemed, or asking me if I was okay. Even the less-tuned-in patients would ask me, 'what's going on in this office? It's so chaotic!" or note that I looked unhappy. I was still able to give good medical advice, to make a diagnosis and write the proper prescription, but I was a terrible example of what self care looks like. In fact, the inattention to my general well-being had resulted in depression by then, and there was no way to truly correct that except by stepping out of the situation that was driving the problem.

It has now been a full three years out of primary care, and I've bumbled around with how best to manage my health, both physical and mental. I attacked the depression directly with medication and therapy, with good success, and my time spent in my creative writing MFA program was therapeutic on many levels. Sleep and eating got better, overall, though when I started working in Urgent Care, I had trouble figuring out how to wind down to go to sleep when I got home at 9:30- sometimes it took me hours-- and I fell back into missed meals and uneven exercise patterns at times. A herniated disc in my spine in January of 2020 made regular exercise difficult for months. Then the pandemic hit, and, like most people, I sometimes needed a crutch during periods of isolation and existential angst. Mine was sugar; I'm not a big fan of recreational drugs and alcohol gives me a migraine, but I really like sugar.

The upshot was that by the spring of 2021, though I was back to regular exercise, I felt sluggish and tired and had gained a few pounds. Though technically I wasn't overweight, my lousy nutrition pushed my hemoglobin A1c into the pre-diabetic range. That was my call for action. I let my smart doctor mind take over and started doing the right thing for the patient--who this time is me.

I bumped the exercise up and enlisted a friend who has similar concerns. We keep each other accountable. I revamped the food shopping and started planning meals and snacks more carefully. I started carrying a water bottle everywhere. And at work, I decided that, unless someone is in such bad shape that I can't leave the patient room, I would eat regularly, hydrate and take regular bathroom breaks. If someone has to wait 5 extra minutes, so be it. After work, I make the effort to decompress and shake off the day with yoga or breathing exercises and by talking through any worries with my husband or a friend, so I can get to sleep at a reasonable time. At home, I'm prioritizing time outdoors, and rest when I'm tired, and time with friends and family, instead of seeing all this as a 'break' from work.

I remind myself constantly that I am a human being with human needs, and that I deserve to have those needs met. Not just for a day or a week, or while I'm on vacation, but every day. All the time.

A few weeks into this, I am feeling considerably better. I'm getting stronger with exercise, and have energy and stamina for my daily activities. I'm sleeping a lot better. As someone who has lived with low-grade chronic anxiety and depression, I am finally seeing what 'normal' feels like emotionally- at least most of the time. It's a work in progress, but I feel like I am finally making consistent progress.

I try not to think about the fact that I spent six decades in a less healthy place. I wish there had been some consideration of physician wellness when I was in training, at the time when habits were forming and I was choosing a lifestyle. I also wish that the lip service being paid to physician wellness could be morphed into real action now, so that med students, residents and young faculty had an opportunity to practice real self care. I have no doubt that healthier doctors would translate to healthier patients. But what I see is that the reason I can do this now is that I work much less than I used to, and I have the time and other resources that I didn't when I was younger. It's going to take a big culture shift in medicine for physician self care to be the norm, and I hope it happens in time to help all those who are dragging through their days, telling themselves that it will somehow get better soon.

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