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Floating in the Bathtub of Medicine

Posted on 24 April 2015 by Erica Hoe (Meds 2016)

 

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Having recently finished my psychiatry rotation, I have become more attuned to the importance of mental health in our profession. It’s been estimated that rates of depression are about 15-30% higher in medical students and residents compared to the general population. Adopting a healthy lifestyle can help us to stay afloat in a profession that demands much of our sanity.

I picture myself as a rubber duck. I don’t physically resemble one, at least not usually, but I think it’s a good analogy. I am floating along, happily in the bathtub. I feel weightless. I meet a few bubbles here and there. All’s good.

Once in a while, though, I have patient encounters where I find myself not only empathizing with their struggles, but also bearing their burdens. In the end, it’s like a couple of small bubbles have been added on my back, and I must carry them around on my journey in the bathtub. I carry around these bubbles, and I sink a little lower down in the water. That would be fine, however, in addition to my patient bubbles, I also have “improve your hand-writing and stop losing pens” bubbles, “don’t lose your cool at the anti-vaccinators or the crying babies” bubbles and “smile-and-nod no matter what your preceptor says” bubbles, etc. All as to say, at some point, I have taken on too much. I am expecting myself to stay afloat, when I physically cannot. I have to make some sort of change, or I sink.

 

There are three ways I can help myself from sinking:

  1. Inflate myself with more air and act like a floatation device.
  2. Increase my surface area so I can hold more bubbles.
  3. Just let the bubbles roll right off my back.

 

Let’s start with #1: Inflate myself with air.

 

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This means, I’ll need to breathe more and increase my tidal volume. What better way to do that than through exercise?

A recent JAMA article and 2013 Cochrane review show that exercise causes a greater reduction in depression symptoms than placebo or other interventions like relaxation or meditation.1 Depression has also been found to be associated with lack of physical activity.2

Exercise may provide physiological effects such as increases in endorphin and monoamine levels, and reduction in cortisol levels.2 Exercise stimulates the growth of nerve cells and the release of brain-derived growth neurotrophic factor (BDNF), which is important for learning and memory.2,3 Exercise has the ability to improve executive function and increase neuroplasticity. In fact, neuroimaging studies show that there are changes to areas involved in higher-level cognitive functions such as the prefrontal cortex and hippocampus.3 This improvement allows for a sense of mastery, positive thoughts, and enhanced self-efficacy which all improve mood.3

Even a small amount of exercise appears to be helpful, as there is no indicated type, intensity or frequency that has been associated with alleviating depressive symptoms.2 There is even some small evidence to suggest that exercise may work as effectively as pharmacological or psychological therapy, however more studies are needed.2

Needless to say, do anything active, and your mood will be uplifted. You may even lower your risk for developing depression.4

 

#2: Increase my surface area.

 

 myplate

 

No, this does not mean I physically increase my surface area. Though it would be fun and delicious to binge on junk food, I actually want to increase the proportion of healthy foods that I eat. By eating the right proportion of foods, we gain the energy to power through the day. A good guide is to follow these 5 tips from the Dieticians of Canada5:

  1. Go for whole grains.
  2. Load up on veggies and fruit. Making a smoothie is a good way to get 2-3 servings at once.
  3. Have 2 cups of milk or fortified-soy beverage per day. The Vitamin D is not easily found in other foods.
  4. Choose lean meats or meat alternatives (chick peas, lentils, kidney beans).
  5. Limit saturated and trans fats. Healthier unsaturated fats are found in: avocados, nuts, seeds, oils (olive, flaxseed, nuts, canola)

More tips here: http://www.dietitians.ca/Downloads/Factsheets/5-Tips-for-Healthy-Eating.aspx

 

I was also recently made aware of the positive effects of Vitamin D on depression. A meta-analysis published in 2013, revealed that lower serum 25-OH Vitamin D3 levels were associated with a higher risk of depression.6 In fact, another recent study found that depressed older persons had significantly lower 25-OH and 1,25-(OH)2 Vitamin D3 levels compared with non-depressed counterparts.7 Another study found that lower levels of Vitamin D3 were associated with increased severity of depression and an increased risk for depression.Proposed mechanisms for this association include that vitamin D: 1) has receptors that are distributed in neural areas involved in emotional processing and affective disorders, 2) regulates serotonin synthesis, and 3) impacts the production of pro-inflammatory cytokines that influence mood by activating the stress response.9

Despite these findings, a meta-analysis published this year in March, looks at 9 randomized controlled trials and found that there was no significant reduction in depressive symptoms after Vitamin D supplementation.10 However, these authors do identify that perhaps the duration of follow-up was not yet long enough to determine any effect.10 And, even though Vitamin D was not shown to have a significant effect in those who are already depressed, lower levels are associated with depression, and thus supplementation may play a role in prevention. Given the low cost and limited issues with toxicity, it cannot hurt to take extra Vitamin D supplementation and to incorporate foods that contain Vitamin D into our diet.9 Perhaps this is also a perfect excuse to bask in the sunlight more often.

 

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The Family Medicine Practice Guidelines recommend 800-2000 units of Vitamin D per day in adults.12 The Canadian Cancer Society recommends 1000 units of supplementation to all adults who live in Canada, especially in the fall and winter months. The daily upper limit is 4000 units. Supplementation is contraindicated in hypercalcemia and hyperphosphatemia.12

In addition to taking big gulps of sunlight whenever you get the chance, there are some foods that have Vitamin D. These include: fish like salmon and tuna, liver, fortified milk or soy beverage, fortified orange juice, margarine, egg yolk.11 One glass of fortified milk or soy beverage has about 100 units of Vitamin D. Fish can range between 100-700 units.

For a full list of foods and number of units associated with serving size visit: http://www.dietitians.ca/Downloads/Factsheets/Food-Sources-of-Vitamin-D

 

#3: Let the bubbles roll off.

 

sleepbaby

Finally, what better way to shake it off, than to sleep it off. A meta-analysis of 21 studies showed that non-depressed people with insomnia have a two-fold chance of developing depression compared to people with no sleep difficulties.13 Treating symptoms of insomnia may help to prevent subsequent development of mood dysfunction.13

I mean, just look at that baby.

In order to get good sleep, it’s important to practice good sleep hygiene. This includes not doing any stimulating activities 1 hour before bedtime: no exercise, no big meals, and no TV-watching or use of electronics. Limiting fluid intake before bed can help to decrease the occurrence of nocturia. It’s also really important to decrease caffeine intake especially later in the day.

Going to bed at the same time every night, and waking up at the same time every morning can help, too. Yes, even on weekends. Avoid naps if you can, they throw off your sleeping schedule.

The best way to wind down before sleep is with a good book. Not a reader? Then find another activity to help you relax, whether it’s meditation or listening to music. The worst thing is to think about all your worries before bed. Forget them, or write them down an hour before you decide to sleep. Then, let your body know it’s time to shut down, and let all your problems roll away.

 

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And that’s it, the three ways I’m going to stay afloat in medicine – exercise, healthy eating, and sleep.

  1. Any little bit of exercise counts.
  2. Eat more healthy foods and get enough Vitamin D.
  3. Follow good sleep hygiene.

I think it’s a simple enough concept; sometimes it’s just hard to do. But when I don’t prioritize these things, I sink deeper into the bathtub of medicine and I gradually neglect my own mental health.

After all, if we don’t take care of ourselves, how can we manage to take care of others? And so, today I’ll be going for a run in the sunshine, whipping up a smoothie, and rewarding myself with a plentiful night of sleep. Every minute counts.

 

So, what will you do to stay afloat?

 

References

  1. Cooney G, Dwan K, Mead G. Exercise for Depression. JAMA. 2014. 311(23):2432-2433. <http://jama.jamanetwork.com.proxy1.lib.uwo.ca/article.aspx?articleID=1881295>
  2. Cooney G, Dwan K, Greig C, Lawlor D, Rimer J, Waugh F, McMurdo M, Mead G. Exercise for Depression. Cochrane Database of Systematic Reviews. 2013. <http://onlinelibrary.wiley.com.proxy1.lib.uwo.ca/doi/10.1002/14651858.CD004366.pub6/full>
  3. Erickson KI, Gildengers AG, Butters MA. Physical activity and brain plasticity in late adulthood. Dialogues in Clinical Neuroscience. 2013;15(1):99-108. <http://www-ncbi-nlm-nih-gov.proxy1.lib.uwo.ca/pmc/articles/PMC3622473/>
  4. Mammen G, Faulkner G. Physical Activity and the Prevention of Depression: A Systematic Review of Prospective Studies. American Journal of Preventative Medicine. 2013. 45 (5): 649-657. <http://www.sciencedirect.com.proxy1.lib.uwo.ca/science/article/pii/S0749379713004510>
  5. 5 Tips for Health Eating. Dietitians of Canada. <http://www.dietitians.ca/Downloads/Factsheets/5-Tips-for-Healthy-Eating.aspx>
  6. Ju SY, Lee YJ, Jeong SN. Serum 25-hydroxyvitamin D levels and the risk of depression: a systematic review and meta-analysis. J Nutr Health Aging. 2013. 17(5): 447-455. <http://www.ncbi.nlm.nih.gov/pubmed/23636546>
  7. Voshaar R, Derks W, Comijs H, Schoevers R, Borst M, Marijnissen R. Antidepressants differentially related to 1,25-OH2 vitamin D3 and 25-OH vitamin D3 in late-life depression. Translational Psychiatry. 2014. <http://www.nature.com/tp/journal/v4/n4/full/tp201414a.html>
  8. Milaneschi Y, Hoogendijk W, Lips P, Heijboer AC, Schoevers R, van Hemert AM, Beekman ATF, Smith JH, and Penninx B. The association between low vitamin D and depressive disorders. Molecular Psychiatry. 2014. 19: 444-451. <http://www.nature.com.proxy1.lib.uwo.ca/mp/journal/v19/n4/full/mp201336a.html>
  9. Kerr D, Zava D, Piper W, Saturn S, Frei B, Combart A. Associations between vitamin D levels and depressive symptoms in healthy young adult women. Psychiatry Research. 2015. In press. <http://www.sciencedirect.com.proxy1.lib.uwo.ca/science/article/pii/S0165178115001080>
  10. Gwoda U, Mutowow M, Smith B, Wluka A, Renzaho A. Vitamin D supplementation to reduce depression in adults: Meta-analysis of randomized controlled trials. Nutrition. 31 (3):421-429. <http://www.sciencedirect.com.proxy1.lib.uwo.ca/science/article/pii/S0899900714004857>
  11. Food Sources of Vitamin D. Dieticians of Canada. <http://www.dietitians.ca/Downloads/Factsheets/Food-Sources-of-Vitamin-D>
  12. Guideline for Vitamin D testing and supplementation in adults. Toward Optimized Practice. 2012. <http://www.topalbertadoctors.org/uploads/102912_Bzds37w2W3fC57Vz_92317.pdf>
  13. Baglioni C, Battagliese G, Feige B, Spiegelhalder K, Nissen C, Voderholzer U, Lombardo C, Rieman D. Insomnia as a predictor of depression: A meta-analytic evaluation of longitudinal epidemiological studies. Journal of Affective Disorders. 2011. 135(1-3): 10-19. <http://www.sciencedirect.com.proxy1.lib.uwo.ca/science/article/pii/S0165032711000292>

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Dine While You Dash!

Posted on 02 January 2015 by Erica Hoe (Meds 2016)

How often do you want to eat a full breakfast, but have absolutely no time to make it, let alone sit down and eat it? For me, that’s every morning. That’s why I’ve taken to making smoothies in the morning. I use my trusty blender, toss in the ingredients, press “blend” and then start getting ready for the day. By the time I’ve gotten dressed, my breakfast awaits. How perfect. I’m living the life.

Seriously though, you can guzzle it down in the car, on your walk to work, while you’re waving to passersby, or cleaning your stethoscope. Whatever. The point is, it’s the fastest breakfast and it has all the right nutrients.

The idea is to pick some of your favourite fruits (you can freeze them before they go bad so you can use them instead of ice cubes), pick a vegetable like kale or spinach, add some honey if you want it sweeter, invest in some chia seeds and almond milk, and toss them in the blender until it’s smooth. Here are a few of my favourite smoothie recipes.

 

Monday:

Let’s start off simple. Like they say, the first five days after the weekend are always the hardest. So, let’s not get ahead of ourselves and make too many elaborate smoothie plans. This one is super simple, and you can pretend you are still out having a drink with your friends. The weekend’s not over, I refuse to believe it!

 

Strawberry Pina Colada Smoothie

Erica Hoe - 1

 

 

 

 

 

 

 

  • A handful of strawberries
  • ½ frozen banana (keep them in your freezer, and snap them in half when you want to use them)
  • 2 tablespoons of coconut Greek yogurt
  • 1 tablespoon chia seeds
  • 1 cup coconut almond milk (or just almond milk)
  • 1 tablespoon shredded coconut (in the smoothie and for garnish) – you fancy huh?
  • Ice cubes
  • Honey

 

Tuesday:

Monday was tough. Tuesday isn’t going to be any better, so let’s just make a smoothie filled with all the most delicious berries.

 

Very Berry Smoothie

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  • A handful of blackberries, blueberries, raspberries, and strawberries
  • ½ frozen banana
  • 2-3 kale leaves (use the leafy green part) – The bitterness of the kale is masked by the berry medley; also the colour of your smoothie won’t be that scary green colour!
  • 2 tablespoons of Greek yogurt
  • 1 tablespoon chia seeds
  • ½ cup coconut water or orange juice
  • A few mint leaves
  • Ice cubes
  • Honey

 

Wednesday:

It’s the middle of the week. That means you’ve been working really hard for the past two days and you deserve to celebrate with a tropical drink. Yes, that means mangoes. This is one of my favourites.

 

Mango Coco-Loco Smoothie

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  • 1 mango
  • 1 frozen banana
  • 1 tablespoon coconut Greek yogurt
  • 1 cup almond milk
  • 1 tablespoon chia seeds
  • Ice cubes
  • Honey

 

Thursday:

You might not have time to bake a cake, but this tastes just like it. It might even improve your vision without expanding your waistline.

 

Carrot Cake Smoothie

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  • 1 frozen banana
  • 1 carrot (chopped)
  • 1 tablespoon chopped walnuts
  • 1 tablespoon shredded coconut
  • 2 teaspoons pumpkin pie spice (cinnamon, nutmeg, ginger, cloves)
  • 1 teaspoon vanilla extract
  • 1 tablespoon chia seeds
  • 1 cup vanilla almond milk
  • Ice cubes
  • Honey

 

Friday:

It’s Friday, treat yo self. Indulge in this chocolatey goodness. Lather your intestines in sweetness. Too visual? Too bad. This smoothie is THAT badass.

 

Chocolate Almond Smoothie

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  • A handful of spinach
  • 1 tablespoon almond butter
  • 1 frozen banana
  • 1 cup chocolate almond milk
  • 1 tablespoon chia seeds
  • 1 teaspoon vanilla extract
  • Cocoa powder (optional) – if you want it even more chocolatey or if you’re using plain almond milk
  • Ice cubes
  • Honey

 

I hope you like these just as much as I do. May you now power through the morning without your stomach growling with hunger. Bottoms up!

 

Erica

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Post-call R&R

Posted on 30 November 2014 by Erica Hoe (Meds 2016)

Okay, I admit it. I love post-call days. There’s nothing better than knowing that while everyone else is driving to work and experiencing morning struggles, I get to drive home and snuggle under my warm blankets. I get to finally shut my brain off.

It’s really tempting to enter the door of my apartment, throw my things down, run to my bed and flop, face-first into the covers. But I find that when I do that, I don’t wake up as refreshed. I actually feel even groggier sometimes.

Recently, I’ve been trying a new thing where I take 30-60 minutes to give my body a little R&R (rest and relaxation) before I shut it off completely. Kind of like a gradual entrance into the serenity of sleep. Here is my recipe, feel free to add your own ingredients and modify as you please!

Ingredients:

  • 1 scented candle
  • 1 playlist
  • water
  • cucumbers, raspberries, mint or clementines
  • pen & paper
  • yoga mat
  • lacrosse ball/tennis ball
  • 1 wall

 

RELAX (2 minutes):

Erica - Pic 1First, I light a scented candle. Yeah, it sounds cheesy, but believe me – once you smell that citrusy aroma or lilac infusion, you’ll forget all about those stale hospital sheets and the scrubs you wore all night. I try to stay away from sugary scents (Bath & Body Works, I hate you) because then I’ll just abandon my routine and search my shelves for chocolate or candy and spend the next 15 minutes eating them.

After this, I also flip on my favorite playlist to set the mood. I usually try to go for some slower beats – some R&B slow jams do the job quite well.

 

HYDRATE (3 minutes):

This is the most important part. I grab a tall glass of cold water and drink the whole thing. Sometimes two, if I’m feeling dangerous.

Too often, we don’t drink any water while on call. Our bodies are aching to be hydrated by the time we get home.

A tasty cucumber carbonated water beverage
I love slicing up some cucumbers and splashing them in the water. I also pre-make trays of ice cubes frozen with mint, raspberries or clementine slices and add them to the water. It just adds a little extra zest, and I can pretend I’m getting  more vitamins.

 

REFLECT (5 minutes):

Erica - Pic 3This is the second most important part. I write down two things:

1) One thing that I learned from the night

2) One thing I did well

The objective is to do some reflection and identify what the previous day meant to me. Writing down things I did well, also encourages me to improve for tomorrow. If you don’t encourage yourself, who will?

 

STRETCH (5-15 minutes):

Okay, I lied. This is equally important. I unroll my yoga mat and do 15 minutes of easy yoga. Sure, downward dog seems impossible at first, but once I get started, I find that it’s exactly what my body needs.

A good resource is Sadie Nardini’s youtube videos. She has a bunch of yoga videos online. This 15-minute one is my favorite: https://www.youtube.com/watch?v=e6Wt9CFb-4s

She also has a good 5-minute morning one if I’m feeling lazy and I just want to stretch:

https://www.youtube.com/watch?v=KT7VOYhk9Zk

 

RELEASE (15-30 minutes):

Now I grab my lacrosse ball and find a wall. A friend recently gifted a lacrosse ball to me, but you can also use a tennis ball. This thing is glorious. It’s an easy do-it-yourself myofascial release and releases your trigger points.

 

Start with your upper traps.

Erica - Pic 4After spending a night slouched over hospital charts and patient’s bedsides, it is impossible not to have tight shoulders. This routine can help you prevent upper-crossed syndrome. Put the lacrosse ball between upper back and the wall. Work the ball up and down your back. Keep your arms folded in front of you, moving your shoulder blades out of the way. Here is where the R&B slow jams really start to make sense – yep, you’re grinding with the wall, but hey, no one’s watching and it feels great.

When you find a point in your back that is more sensitive or painful – stay there. Don’t move and add some more pressure against the wall. This is a trigger point. Breathe into it for several seconds. Even though it hurts at first, you’ll find that after some time, you relax into it. Do this for any points you find throughout the routine.

Now finish your entire back.

I probably don’t need to tell you to do this because you will naturally want to. Roll the lacrosse ball all the way down your back on one side of the spine. Repeat on the other side. This releases all your spinal muscles and your lats.

Don’t forget your pits.Erica - Pic 5

The idea is to work the lacrosse ball where your lats insert and improve lymphatic drainage. Place it under your armpits, and with the same arm behind your head, roll the ball up and down against the wall.

Release your IT band.

Erica - Pic 6Lie on your side on your yoga mat and place the lacrosse ball between your hips and the mat. Now roll so that the ball slides down the side of your thigh. Tight IT bands can cause a lot of injury and knee pain. So keep it nice and loose by doing this.

Staying on your side, work the lacrosse ball in circular motions around your hip joint. Your glutes insert here, so you want to get them good.

Release your lower extremities.

After standing all day and night, you want to release the main muscle groups of your legs and your feet.

Erica - Pic 7Lying supine on your mat, work the lacrosse ball on the bulk of your glutes and your hamstring insertions. Work in circular motions around your ischial tuberosity.

Now move the ball down the back of your thigh to get your hamstrings. Work it down to your calves.

Erica - Pic 8

To get your hip flexors, sit in kneeling position and roll the lacrosse ball across the front of your thighs. It’s easier than trying to lie prone in plank position (nobody needs abb work at a time like this!)

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In standing, put the ball under one of your feet and move it up and down. It feels amazing, trust me. Your clogs are no match for this.

 

Finally, it’s time to hit the sheets! My body feels like jello, but the best kind.

See you on the other side!

 

Erica

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