How to (almost) never have a bad shift [PODCAST]

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“To understand how to create good shifts irrespective of external factors, I turned to the ancient philosophy of Stoicism. One of its core tenets is that we must focus on what is within our control. Epictetus said: ‘Happiness and freedom begin with a clear understanding of one principle: Some things are within our control, and some things are not. It is only after you have faced up to this fundamental rule and learned to distinguish between what you can and can’t control that inner tranquility and outer effectiveness become possible.’

Too often, we ignore his admonitions, and we focus our efforts on things that are outside our control while paradoxically relinquishing control of things that are within our control. Things within our control, per the Stoics, are our own thoughts, emotions, and actions. We relinquish control of them by allowing our emotions to be unduly affected by external things. ‘That person said something that made me upset,’ or ‘I’m angry because I couldn’t get something I needed.’ On the other hand, we try to control things that are outside our circle of control, such as other people’s actions or opinions, politics, coronavirus, or even the weather. We try to control them in our minds by resisting their presence, continuously wishing them away, or perseverating that they should be different. In order to have the inner tranquility and outer effectiveness Epictetus encouraged, we must give up the fiction that we can control things outside ourselves and maintain better control of ourselves.”

Christina Shenvi is an emergency physician and can be reached on Twitter @clshenvi.

She shares her story and discusses her KevinMD article, “How to (almost) never have a bad shift.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Christina Shenvi. She is an emergency physician, and she wrote the KevinMD article “How to (almost) never have a bad shift.” Christina, welcome to the show.

Christina Shenvi: Thanks, Kevin. I’m excited to share some ideas with your audience.

Kevin Pho: So we’ll get into your article in a little bit, but first off, can you share your story and your journey to where you are today?

Christina Shenvi: Yeah. You know, I have one of the more circuitous journeys, where I really couldn’t figure out what I wanted to do with my life, which I think almost always leads to emergency medicine, because ER docs like to do everything. I actually grew up abroad, then went to college in the U.S., did a PhD, then came to medicine, then came to EM. Now the thing that I love doing most is working with residents and students.

One of my roles currently at UNC is as director of the Office of Academic Excellence, where we help our 800-some students be successful academically. That involves coaching academically, coaching about time management, coaching about a growth mindset, helping students through anxiety, a lot of different things. So that’s what I’ve been spending a lot of my time on, in addition to, you know, working my day job in the ER.

Kevin Pho: Fantastic. And today’s medical students and residents, what would you say are some of the biggest challenges that they’re facing today?

Christina Shenvi: I think everywhere, with everyone, especially with the medical student generation right now, there’s a lot more anxiety, a lot more anxiety than in years past. Or maybe it’s just more talked about, but I think there’s objectively more of that felt. And then the pandemic, where all the students went on lockdown and were now isolated and not able to have that camaraderie with their classmates, that’s been a major stressor. So I think there’s a lot more anxiety that people are dealing with.

Things just keep getting more and more competitive. You know, a Step 1 score that might have gotten you into a good residency 20 years ago is not what it’s going to take now. So there’s a lot more competitiveness. And then there’s also just so much more information out there. If you wanted to learn medicine, you know, 10, 15 years ago when I was in med school, you picked up Harrison’s or you picked up some other textbook, and now there are all these options online. So it can be cognitively overwhelming. Understanding how to curate the information and understand what’s really important and what’s not, that’s become more challenging now.

Kevin Pho: If you could share your number one tip to medical students and residents who may be listening to this podcast, what would that number one tip be?

Christina Shenvi: The number one tip is really that it’s all about managing your own mind. Whether that is understanding how to study when you’re anxious, or understanding how to work hard and study after you’ve failed an exam, or whether it’s dealing with difficult patients, or, especially as a resident when you’re so tired, how do you get going and still walk into the room with a smile, it is all about understanding and managing your own mind.

One of the things that has helped me a lot, and that I wrote about in the article, is the philosophy of Stoicism, which has so many great things to say. One is this idea of Stoic meditation, which is not like Eastern meditation, which is more about the breath and more about emptying the mind. Stoic meditation is a process of actively identifying and managing your thoughts. So as a very first step, just identifying, “I’m feeling anxious because of this,” or “I’m procrastinating and binge-watching Netflix because I don’t want to feel this emotion of frustration when I sit down to study,” or “I don’t want to feel this emotion of anger when I sit down and have to do my charts.”

I know for many physicians, doing charts at home is a major thing that we procrastinate on. So looking at our thoughts, and just first becoming aware of them and then creating distance from our thoughts, can then allow us to manage them, so that we aren’t feeling that overwhelmed constantly or paralyzed by that anxiety.

Kevin Pho: So let’s get into that KevinMD article that you wrote, “How to (almost) never have a bad shift.” Now, for those who haven’t read the article, can you just walk my audience through it and share the story of why you decided to write it?

Christina Shenvi: Yeah. Well, you know, in EM especially, but I’m sure every discipline has its own characteristics of what makes a good or a bad shift. I was thinking about this and wondering one day, “Huh, will this be a good or a bad shift?” And I thought about what it takes to be a good shift, and there are all these things. You know, we need some high-acuity patients that we can help, but not too much, so it’s not overwhelming. We want it to be not too busy, but not too quiet. And I realized that a lot of times, whether something was a good or a bad shift is determined by all these external circumstances, things that are outside my control.

I kind of brought Stoic philosophy to light on this and said, “Well, what would the Stoics have to say about this?” One of my favorite Stoic quotes is from Epictetus, and he said, “Some things are within our control, some things are not. It’s only after you have faced up to this fundamental rule and learned to distinguish between what you can and can’t control that inner tranquility and outer effectiveness become possible.” I kind of reflected on that, and I thought, “You know, that inner tranquility and outer effectiveness, gosh, that is exactly what we need on a busy shift, or in a busy clinic day, or in an OR, or wherever you are as a physician or resident.”

So I started thinking and reflecting on that concept of what’s inside and outside our control, and we paradoxically conflate the two. We take things that are outside our control, like whether I can get an imaging study done or whether I can get a patient back to their nursing facility, and we try to make them inside our control, but we can’t. And so we get frustrated, because we’re continually banging our head against reality and saying, “It shouldn’t be this way,” and yet it is that way. That cognitive dissonance is just us spinning our wheels. We’re not having inner tranquility, we’re not having outer effectiveness. So we need to understand, “Those things are outside my control, and I need to let them go.”

And then the flip side of that is that we do have control over our thoughts, our feelings, and our actions, and yet we relinquish control of those things, especially our feelings, by giving the power to other people. We’ll say, “Oh, that person did this thing that really annoyed me. Now I’m feeling angry because of that person,” when really we have to give that person permission to make us angry. And we do that by our thoughts, by thinking whatever the thought is. If we have a bad interaction with another physician or another caregiver, and then we say, “They shouldn’t have done that,” or “They were mean to me,” or “That made me feel this way,” we’re giving up control of what’s inside our circle of control. So maintaining ownership and agency over what’s inside our circle of control, and relinquishing trying to control things that we can’t, is so freeing and gives you so much more power. So that was the first point.

And then, I’m actually doing an MBA right now, and I was taking an operations class, and we talk about quality control. If you’re creating a product, you want the product to always be the same size or same weight or same quality specifications. And I was thinking, “Well, what would that mean for me if my product is a shift?” I want to have a good shift most of the time, right? Some are going to be terrible, and again, that’s outside your control in some ways. But if I have some mean and standard deviation of good or bad shifts, how can I raise the whole mean? You really have to do that by making the choice to say, “I’m going to make this a good shift. It’s going to be a good shift irrespective of whether people are nice to me, irrespective of whether I can get things done the way that I want to, and I’m going to choose to go into it with that mindset.”

And the third point is that to do that, you have to change your own mind, because shifts are difficult. They’re 8, 12, sometimes 24 hours of a continuous stream of small or big difficulties or frustrations or setbacks. And the Stoics have a lot of really provocative things to say about suffering. One of my favorites is by Marcus Aurelius. So think about a really difficult shift, or a difficult day in the hospital or in clinic, and he wrote, “Ask what is so unbearable about this situation. Why can’t you endure it? You will be embarrassed to answer.” That really struck home with me, because I thought about what really is so unbearable, what can I not endure about this frustration that I’m approaching? And yes, I would be embarrassed to answer.

So we all definitely want to work to improve things. You know, it’s no surprise to any physician listening that our American health care system is imperfect, or that any health care system around the world is not perfect. So we want to work to change the situation. But as Viktor Frankl, who is a Holocaust survivor and psychologist, wrote, “When we are no longer able to change a situation, we are challenged to change ourselves.” So I can’t, at 2 a.m., change the American health care system. I really can’t ever, but I can’t especially at 2 a.m. when I’m on shift. So the only thing I can do is to change myself and change my own mind, and really work to accept things that I can’t control and fully control the things that I can: my own thoughts, feelings, and actions.

Kevin Pho: So I think that all sounds wonderful, and I guess my question is, where can a physician start when we want to incorporate some of these Stoic philosophies into a shift, into our practice, into our everyday life? What would you say is the first thing that we should do in order to get started?

Christina Shenvi: There are a lot of great resources out there. One of my favorite entry-level books is by Donald Robertson, called How to Think Like a Roman Emperor, and it’s actually really a biography of Marcus Aurelius’s life and philosophy and how he applied it in his struggles, or how Aurelius applied it. So that would be a great entry-level book. I blog. My website is timeforyourlife.org, and I put out different concepts drawing from Stoic and other philosophies and other educational psychology literature and things like that. So I write about this topic, but if you were to pick up one book, I would say that How to Think Like a Roman Emperor is a great one.

Kevin Pho: And in terms of actionable tips, if we want to incorporate some of these philosophies into our life, you know, before picking out a book, what would you say are your top actionable tips?

Christina Shenvi: The top actionable tip is to start writing down your thoughts. Start when you’re feeling your wheels spinning, you’re feeling yourself getting angry, anxious, or just frustrated, and you can’t figure out why. It’s almost like there’s kind of a cloud or a swarm, there’s like a miasma of negative thoughts, and you can’t manage a miasma, right? You can only manage one discrete thing. So try to drill down to, “OK, this is what I’m feeling. What is the thought that is creating that feeling?” Because it’s always a thought in our minds that’s creating the feeling, whether it’s frustration, betrayal, anxiety, worry, etc., or just fatigue. What is the thought that’s causing that feeling?

So drill down and really be honest with yourself to say, “This feeling is being created by a thought in my mind. Let me find that thought.” And then the action is to say, “How do I want to feel in this moment? Maybe I want to feel optimistic or engaged or determined or confident. And what is the thought that I will have to use?” You can use this thought like a tool, like, “OK, I need to put a nail on the wall, I need a hammer.” OK, if I want to feel this feeling, what is the thought that I need to make that feeling happen? And then actively and intentionally choose your thoughts.

Kevin Pho: So you talked a lot about Stoicism, but for those who aren’t familiar with it, can you just give us a short background on what Stoicism is? You talked about some of the major tenets, but if you’re going to summarize, what are some of the major philosophical pillars of Stoicism?

Christina Shenvi: Yeah. Stoicism dates back a little over 2,000 years and is attributed first to Zeno. Stoicism with a lowercase s has now come to kind of mean, “Oh, you just suck it up and stiff upper lip,” but that’s really not what the philosophy itself, capital S Stoicism, is. The word comes from the term “painted porch,” because they used to stand and philosophize and discuss these matters on the painted porch. And some of the biggest players, in addition to Zeno, are people like Seneca, Epictetus, Marcus Aurelius. Those are kind of the most well-known.

The central tenet is that you want to pursue what’s called, in Greek, eudaimonia, which means perfect human flourishing. That means living in alignment with nature, so not trying to bang your head against reality, living in alignment with nature and pursuing virtue. The highest virtues are things like wisdom, justice, courage, and temperance. Those are kind of the four cardinal Stoic virtues. And the way that you do that is by saying things are either good, they promote virtue, or bad, they detract from virtue, or indifferent.

And this is where we get our lowercase s stoic view. One of their goals was to view most of life as things that are not good or not bad, you know, either promoting or detracting from virtue. Everything else they approached with what’s called a Stoic indifference, or a studied indifference. So if I can’t get someone exactly what they need on my timeline, when I want to get it at 2 a.m., that isn’t really a virtue-related issue. I’m going to work hard to do my best, but otherwise I’m going to approach that with a studied indifference. If somebody says something to me that I perceive is mean, or I don’t like their tone, that’s not promoting or detracting from my pursuit of virtue. I can approach that with a studied indifference.

And that’s a very powerful way, because often we amplify our own grief and our own suffering by layering on additional things that we make it mean. If this person speaks to me in a tone that I don’t like, it’s not just that, “Oh, they made air molecules vibrate, and it impinged on my eardrum.” That’s really all that happened in the physical world. But we make it mean, “They think I’m a bad doctor. Maybe I am a bad doctor. Everyone in the hospital thinks I’m a bad doctor.” We kind of amplify, and we catastrophize, and we layer on more grief than we actually need to experience in most situations. So approach it with that pursuit of virtue, of eudaimonia, the perfect human flourishing, and then other things we can handle with a studied indifference.

Kevin Pho: We’re talking to Christina Shenvi. She’s an emergency physician, and she wrote the KevinMD article “How to (almost) never have a bad shift.” Christina, what is your take-home message that you want to leave with the KevinMD audience?

Christina Shenvi: I would leave with a challenge, and that is to maintain ownership over those things that you’re in control of. Choose your thoughts intentionally. Raise your mean. Decide to have a good shift, and measure the goodness of your shift not by those external circumstances that happen, but by your own attitude and how you overcome those circumstances. Because then, and only then, will a good shift be something that you create and not something that you hope for.

Kevin Pho: Christina, thank you so much for sharing your time and insight, and thanks again for being on the show.

Christina Shenvi: Thanks, Kevin.

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