Weekly Schedule February 27th – March 5th

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I recently finished my month of nights on labor and delivery. Training was not the best, and most weekdays I was only able to squeeze in one workout. It took me a solid two weeks to fully adjust to nights, and just when I got everything figured out, I went back to a month of days on the pediatric inpatient team. I hope to use the lessons I learned this block on the rest of my night blocks – my residency does two months of nights per year. And, I go back to nights in 4 weeks, so I’ll be able to apply them soon!

My schedule is below. I would work from 7 PM – 7 AM (usually a few minutes later, but rounded) and sleep from 8 AM – 3 PM. It always took me longer to wake up, and I used this time to talk to Richard, hang out with the animals, and pack all my food for the upcoming shift.

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This week was definitely my best of the four. I trained everyday, only missed one workout, and it was my first week back running after taking three weeks off for sprained ankles from Uwharrie. My ankles still feel unsteady on uneven ground, but they are no longer painful when running.

The biggest lesson I learned this block was listening to my body. This has always been important to me, but it has never played this much of a role. I struggled to appreciate how much the schedule drained me. Not only was I working nights (sleeping during the day was never a problem, I always passed out as soon as I got to bed and didn’t wake up till my alarm went off), but labor and delivery is fast-paced and sometimes high stress. As the intern I was seeing all the patients who came in, determining if they were in labor or not, what their pain is from, if they need to be admitted or not, etc. I also delivered almost every baby that month. It requires a lot of list-making and multi-tasking, jumping from room to room and keeping track of which patients need what.

I’m usually fairly quick to warm up, but it took me a solid 30 minutes for my body to warm up on the bike or run this block. I had to build that time into my workouts, and I usually cut down my cool down. Some days, such as Tuesday, my body was just exhausted and I could not physically or mentally give the prescribed workout a solid effort, so I scrapped it and rode easy. By listening to my body, I was able to continue training everyday. My workout on Saturday was also fantastic, reminding me what I can do when I’m rested. As long as I get that one good workout a week, I can keep going during the the off days knowing that I am still working on my fitness. This block has reminded me to not dwell on the poor workouts and to continue focusing on the larger picture.

Weekly schedule January 9th – 15th

I get a lot of questions and inquiries about managing training and residency, usually asking about time management and fitting everything in. I always counter that if something is important enough, you will make the time for it. But that still doesn’t explain how I find time to train. Because of this, I have decided to start a monthly blog post about my training in which I will review the previous 4 weeks. I have chosen 4 weeks because that is how long I am on each rotation.  It will be dry at times, but I hope that by laying out a standard week once a month it will be easier for readers to understand how I fit in training and how I modify training sessions on the fly when I have little time. Each month, I’ll also try to explore a theme that develops as I try to balance work with training.

Note: it takes me about 45 minutes to get ready in the morning. This includes caring for my pets, showering, packing my bags for work and training, and packing my food.

Now, my schedule: This was a down week after a big 9-10 days while on leave.

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This month’s topic is sleep. As shown above, I try very hard to get at least 7 hours of sleep a night. I also try to get one long night of sleep on the weekend, and try to start every shift as rested as possible. I am on a lighter general surgery rotation this month, but I still never know if a surgery is going to go long or not. I like to get one long sleep on the weekend to keep my body from getting too sleep-deprived. My body will build up a deficit, and it takes time to catch up. When I started my week of vacation last month, I was sleeping 12 hours a night for the first three nights, and then was suddenly sleeping 8-9 when my body had caught up with sleep. A common misconception about sleep is that one’s body adapts to decreased sleep over time.While 5 or 6 hours of sleep may come to feel adequate to some, judgement, reaction time, and other functions are still impaired when sleep suffers to this degree. These functions only return to normal with an adequate sleep schedule. It will vary from person to person, but for me it takes about a week of not using an alarm clock while on vacation to bring my sleep deficit to zero.

Sleep is also important because growth hormone is released during sleep, allowing the body to repair itself and reinforce neurological pathways that are created throughout the day. Everybody knows that children need sleep to transfer what they learn from short term to long term memory and to grow, but adults also need sleep for the same reasons. Furthermore, athletes rely on sleep to cement the neurological pathways created during the day through drills, technique work, and other forms of skill development.

For more resources on sleep, you can visit the the National Institute of Neurological Disorders and Stroke, and Arianna Huffington has a great book about sleep, The Sleep Revolution.

A quick update

I’ve been meaning to write a blog post for a few months, but haven’t had anything of substance to write about. Residency is the same, week-in and week-out. The service and my duties change some from month-to-month, but I am still gone from home 12+ hours a day and fitting in workouts around studying in the evening.

When I started residency, I thought I would be using my off days for four-hour training sessions. As the reality of my schedule set in, I found myself hoping for the time and energy for even a couple hours of training on my days off. I found that I did not want to plan those 24 hours around training. I wanted to sleep in, spend time with my husband and dogs, talk to my family, go grocery shopping, do some laundry, and prepare some meals for the coming week. Workouts were fairly low on the priority list on my days off.

In contrast, training has become a top priority on the days I work. As an intern, I spend much of my day learning, having my knowledge tested, and facing new challenges. Like many new doctors, my growth in the medical profession has not been perfect;  I may miss an important piece of a patient’s medical record, get a diagnosis wrong, or give incorrect answers to an impromptu verbal quiz from my attending physician. Though I am confident I will become an outstanding doctor, there have certainly been days where I have left work feeling inadequate. Working out is now the one to two hours each day when nobody tells me what I am doing wrong. Training connects me with something that I know I do well, and rejuvenates my sense of self. Even better, I can do it on my own terms. If I am tired, I go easy. I alter hard workouts to fit my mood. I listen to my body. I do what sounds good to me.

Don’t get me wrong; I am not complaining. I love what I do, and although being an intern is mentally exhausting at times, I’ve chosen to embrace the challenges that my new life presents. The medical profession has a high burnout rate, two reasons being that the workload for physicians is so large and it is difficult to stop thinking about patients after leaving the hospital. I have met multiple residents who said, “I use to do X, and then I started residency.” I have also met many attending physicians who stress continuing my hobbies throughout my career and who remind me that the world and my life do not stop simply because I am in residency. I have learned that despite the demanding schedule of the medical profession, I must find a way to balance my professional life with the things I enjoy personally to decrease my risk of burnout.

 

Armed Forces Championships

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Two weeks ago I raced Armed Forces Championships at Naval Base Ventura County in California. The venue, hospitality, and competition were on point, but I unfortunately was not.

While most of my teammates flew out Wednesday morning/afternoon, I could not leave until Thursday evening due to mandatory training for residency. No problem. I planned to catch the 7pm flight out of Fayetteville to DC, and get into LA just after midnight Thursday evening. But DC was having awful weather and my flight was cancelled. So I went home, slept, and caught a flight out of Raleigh Friday morning.

Friday, the day before the race, went well. I got my race packet, biked and ran the course, and had some time to relax with teammates. I stayed on east coast time so I went to bed early, woke up rested, and had plenty of time to warm up for the race.

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I only swam for about two minutes for my warm up because the water was so cold – just long enough to get over the shock but not get numb. Having Raynaud’s, my hands had started to go numb before the gun went off. I had never raced in water that cold (about 60F), and had no idea how much it would affect me. The timing of the gun meant that we had to dive through a wave right as it was breaking. My start was horrible, but I caught up to the group ahead of me after the first lap. Running on the sand around the buoy was tough with numb feet and I lost some time, but I started to gain it back throughout the loop. I came out of the water about 20 seconds behind my teammate and 10 seconds ahead of the next girl. I lost time in transition because I couldn’t buckle my helmet – I ended up using my palms. Knowing that my fingers were useless, I rode the first few miles with my feet on top of my shoes until I got some feeling back and could do the velcro on my shoes.

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My group of three worked well together on the bike. We passed all but the top 3, and even had a Navy girl join us around lap 3 or 4 (out of 5). Unfortunately we took hardly any time out of the top 3. Coming off the bike, I knew I needed the run of my life to defend my title. I took off, going through the first mile in 6:10, but things just went downhill after mile 2 or 3. I lost all the time I had gained on the top 2 as I battled dehydration. The last two miles were survival mode and all I wanted to do was hold 3rd, which I did.

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Immediately after crossing the finish line I was sick, and remained sick for most of the day. I had never experienced dehydration like that. Coming from North Carolina, the weather in California was dry and moderate and I thought I would have a great run. I’m guessing I got dehydrated on the five hour flight despite efforts to drink lots of fluid, and the less than 24 hour turn around did not give me enough time to compensate.

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I am still very happy with my race. I had a strong swim given the circumstances, did a lot of work on the bike, and laid it out on the run. I left knowing that I could not have done anything else. To top it off, Army won the Men’s and Women’s team titles. The men had not won for 11 years, and both teams had not won at the same time in a long time. A write-up on the race can be found here.

Up next I have a two month block of training, adjusting to life as an intern, and studying for Step 3 boards!

Tying up loose ends

It has been a very busy month for Richard and I. On April 24th I raced St. Anthony’s Triathlon. It was not the race I was hoping for and I felt flat the whole race. The one positive is that I completed my first race in the elite division and felt I belonged there. Racing against the best in the sport was incredible.

A couple days after getting home from St. Anthony’s, I drove up to New York to visit friends and some old college professors. Richard and I then closed on our first home together on May 4th. The next week was graduation. We had family in town for five days to see me graduate from medical school and promote to Captain. It has been a long road, but I am so excited to finally start doing what I’ve been training to do for many years. I start residency June 3rd!

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The week after graduation my mom and I drove to Knoxville to compete in the REV3 Knoxville Olympic Distance race. My stress from the previous weeks showed when I forgot to pack my sunglasses and bike computer. The sunglasses are actually a crucial part for me because otherwise my contact lenses dry out on the bike. A volunteer graciously lent me her sunglasses for the race – thank you Muna! I decided to not worry about the bike computer and just race off of feel.

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I had an alright swim, but lacked focus in the middle and came out of the water two minutes behind the main pack. I knew I had a lot of work to do and decided to go for it on the bike. At the turnaround, I was about 90 seconds behind the next person. While I had made up ground, my legs were starting to feel the aggressive pace I set and I lost some time in the back half of the bike. On the run, I was making up time to the two girls ahead of me but I ran out of steam with less than a mile to go, finishing thirty seconds behind fifth. While I am nowhere close to the front of the races, I still feel that I belong in the elite division. I also have to remind myself that my progression will take longer due to my limited training time.

In two weeks I race Ironman 70.3 Raleigh, but in the meantime, Richard and I are moving house this weekend and I start residency in a week!

Out in the Open

It is difficult to write about a bad race – I don’t want to give excuses, but race reports for subpar performances often sound like a list of excuses. A string of good workouts capped by a strong performance at Ukrop’s Monument Avenue 10k (for my current fitness) gave me the push I needed to write about Ironman 70.3 Puerto Rico and the Cooper River Bridge Run.

Puerto Rico

I went into Ironman 70.3 Puerto Rico with a good winter of bike fitness and promising swim fitness. My hamstring was finally healthy and I was confident I could do well. On the bike, though, I had severe cramping in my glute and piriformis and decided to drop out half-way through the bike. While this was not the outcome I expected or wanted, I know it was the right decision. Soon after the race, I had the following conversation with another guest at my Air BnB:

Her: How’d you do?
Me: Not good.
Her: Oh, everyone says that, I’m sure you did great.
Me: No, I didn’t.
Her: Oh, well, you finished, didn’t you?
Me: No.
Her: Oh, well, there’s always next time.
Me: Bye.

Sorry for my rudeness, you caught me at a bad time. A note to people interacting with racers: if they don’t seem happy, keep a wide berth; or else you might have a similar conversation.

Upon returning to Richmond, my poor performance made me hesitant about my ability to make it in professional triathlon. The first week back I had a string of bad workouts and was shying away from the bike more and more. I found excuses in my schedule to not get in all of my workout or to not ride outside. After another episode of cramping on a long ride, I had a bike fit with Dave Luscan. We changed a few things about my fit that placed less stress on my glute, and I felt good. It took another week of making myself ride to finally have a good session. I put it off for a day because I was dreading the hard intervals. If I was still struggling to hit decent watts, was the bike fit successful? Is there something else going on? I placed too much importance on the workout (in retrospect) and stressed myself out about something I looked forward to three weeks ago. The first interval was mediocre, and I decided to just go for it on the last three. By the end, my all-in approach paid off with top power numbers for the winter. Although I hadn’t gained all my confidence back, I was moving in the right direction.

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Three weeks after Puerto Rico I went to Charleston, SC for the Cooper River Bridge Run with USMES teammates. A week before the race I did my first hard run workout consisting of 20 minutes of tempo. The tempo showed me that I had maintained most of my run fitness through the winter with easy runs and bike and swim workouts. The race, though, did not go well. I had forgotten how hard a 10k is and I let my pace slow too much in the middle. The two positives from the race were that I had no pain in my hamstring and I got to meet some more teammates.

After Cooper River, all I wanted to do was train. The excitement of my last week of medical school and having an article I collaborated with Julie Patterson, my training partner and PharmD/PhD candidate, published helped push me through some awesome workouts across all three disciplines. My confidence was coming back.

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Photo Credit: Jesse Peters / Sports Backers

I then raced Ukrop’s Monument Avenue 10k, and it was a very different experience from the Cooper River Bridge Run. I felt strong the whole way round, negative split the course (helped by the headwind on the way out), and competed with the people around me. I think the photo above sums up the race.

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One thing that I have learned from this string of races is that when I transitioned to racing in the professional field, suddenly my results were much more visible. Everybody looks at the professional results, and it is easy to see a DNF or a poor time when there are only sixteen racers. As an amateur, my poor results got buried in the 2000 competitors, but now my results are out in the open. I’ve had bad races before, but suddenly a bad race means I’m last in the field, and there is a level of humiliation I have yet to overcome with finishing last. When you are racing in the amateur field, it is harder for spectators to tell you are having a bad race, but in the elite field, you are on your own and everyone can see you moving backwards. I equate the feeling to transitioning to medical school. In undergrad and the amateur field, I was a big fish in a small pond – I was always one of the best. In medical school and the elite field, though, I am a very small fish in a big pond. I overcame the transition by ignoring what everyone else in my class did and continuing to do what got me into medical school – hard work, perseverance, and consistency. I am working on implementing the same plan to successfully transition to the professional field of triathlon.

A difficult but important conversation

In the Medical ICU, medical students are part of a team that manages patients with serious and complex medical problems, including learning how to have difficult conversations with patients and their loved ones. There are frequent family meetings to discuss patient prognoses, recovery timelines, and goals of care. The team aims to do everything that the patient would want, be it everything, nothing, or something in between.

This is where issues can occur – healthcare providers and family members may be unaware of the patient’s wishes and the actions taken on behalf of a patient.

Triathletes, runners, and cyclists are fit and healthy individuals who expect to live for many more years. Unfortunately though, accidents happen, and the unexpected can force family members to make difficult decisions about the care of a loved one.

During my time in the ICU, I have seen families struggle with making these decisions. The stress of making a life-changing decision for someone else is very difficult. These decisions can be made much less difficult if the patient has a very clear written living will that allows the family members to make decisions in accordance with the patient’s wishes. In the situations I’ve seen, families derive a great deal of comfort from knowing that the decisions they are making reflect what the patient would want in that situation, even if the patient cannot advocate for him/herself at the time.

I encourage you to have a conversation with your loved ones about what you want if you are not able to make medical decisions for yourself. Do you want a breathing tube? Do you want to be on life support? If so, for how long? Do you want a feeding tube? Do you want CPR done? This is called a living will, and it helps your loved ones and physicians make the decisions you would want. Having a succinct and clear written living will also decreases disagreement among family members.

Another important designation to make is your power of attorney, also known as healthcare proxy. The appointed person will make the medical decisions for you if you are incapacitated. If no power of attorney has been established, there is a set order created by your state of who will be responsible for making healthcare decisions for you. Some states also limit how far their decision-making power goes. In contrast, a healthcare proxy can make all of your medical decisions, including end-of-life care. It is important to have this in writing (links for forms and more information at the bottom of the post) because you may not be able to share your wishes due to stroke, severe injury, neurological status, etc.

As an example, because I am healthy, I would want CPR done. I want everything done that can be done for me. If I need life support, I will give it 7 days. If I do not start to improve after 7 days, I want to be taken off life support. Why 7 days? It seems like a solid number – enough time for my body to heal some and make some progress, but not that long of a time on a ventilator. As I grow and change, my living will will also change. I expect at some point to not want any heroic measures done. The good thing about a living will is that it can be updated by the creator to meet the changes in his/her life.

Below are good resources for how to establish a living will, designate a power of attorney for when the need arises, and how to have this important conversation with family members. Most hospitals, nursing homes, and home health agencies are also required by federal law to provide information about and the necessary forms for living wills and power of attorney.

The Mayo Clinic – The basics on living wills and different methods of resuscitation

National Hospice and Palliative Care Organization – Advance Care Planning – Good resource on how to talk to family members, your state’s requirements for advance directives, and how to prepare one.

National Caregivers Library – Good resource for everything about power of attorney.

American Bar Association – Good resource from the lawyer perspective. If you scroll about half-way down, there is a box called “Featured Resources.” These PDFs are very good resources for the patient and the proxy, and also includes financial guidance information.