Good Night, Sleep Tight

(The following article was written for our local church newsletter.)

“Indeed, He who watches over Israel will neither slumber nor sleep.” Psalms 121:4

That statement of the psalmist pertains to God. However, humans in this modern age also try not to sleep nor slumber. With our 24-hour-a-day schedule, and with a society that makes the night the frontier of the next day, people deprived themselves of sleep. And that is not good for our health.

God created men to work, to play, AND to sleep. Though some creatures only require less hours of sleep, like the giraffe who sleeps less than 2 hours a day. But for an adult human, we need an average of 7-8 hours of sleep to stay healthy and to function properly. (Babies and kids need more.) Even though we still not fully understand the science behind it, we know that sleep is needed to regenerate certain parts of our body, especially our brain. Somehow sleep resets our brain to work optimally.

Sleep deprivation has become one of the most prevalent public health problems of our time. It is estimated that in our modern culture we sleep an hour and a half less than people did a century ago. Of course, they don’t have televisions that have programs like “Late, Late Night Show” or computers and internet that is basically 24/7, a century ago.

Rx for sleep deprivation is more sleep, not more coffee.

Our society’s lack of sleep is evident on many mishaps that we had. The 3-Mile Island, space shuttle Challenger and Exxon Valdez accidents were partly blamed on human errors caused by operators who were sleep deprived. The American Academy of Sleep Medicine reports that 1 out of 5 serious injuries from traffic accidents is related to a tired and sleepy driver.

When we lack sleep, it impairs our cognitive function, judgement, reflexes and reaction time. In studies, people who were awake for 17-19 hours and drove, they performed as bad as people who were drunk with an alcohol level of 0.5 percent. That means if you are awake since 6 AM and driving at past midnight, you are as good as drunk! Now what if you even had a real drink too? That will be really bad.

Some people who are always tired and sleepy may have real sleep disorders, like sleep apnea, restless leg syndrome or narcolepsy. They need to see their doctors or better yet referred to a sleep clinic. But many of us who are sleep deprived, are because of our own choosing not to sleep.

If you cannot sleep because of many worries and anxiety, which is by the way the most common cause of insomnia, then maybe you can find comfort in this text: “I will both lay me down in peace, and sleep: for thou, Lord, only makest me dwell in safety.” Psalms 4:8.

Good night. Sleep tight.

Crash and Burn(out)

For the past month or so, I have been reviewing for my Critical Care re-certification Board Exam. In the US, they want us to re-certify every 10 years for our (sub)specialty Boards. So between certifying and re-certifying in Internal Medicine, Pulmonary Medicine, Critical Care Medicine and Sleep Medicine, it seems like I’m taking exams every year or so.

Few days ago, in my reviewer book, I came upon this practice question which made me think. I have never read this topic in any textbook nor heard it in any lectures or review course before. But after a minute of deliberation, I guessed the answer right.

Here’s the  review question:

Which is most commonly associated with burnout among critical care professionals?

A. Conflicts with patients and their families.

B. Conflicts with coworkers.

C. Severity of patient’s illness.

D. Increasing age of clinician.

So what’s your answer? Believe it or not, among the stressors that contribute to burnout among critical care professionals, conflict with coworkers is the most common (choice B is correct). In a survey of almost 7,500 ICU physicians and nurses, conflicts were perceived by 71.6%, with nurses-physician conflicts being the most common. It is also interesting to know that younger intensivists with less experience had higher levels of burnout than their older counterparts. (Source: ACCP-SEEK vol.XX)

I know that working in a critical care environment has a high burnout rate. And I am glad that I have no problems with my co-workers: fellow physicians, nurses, and other medical ancillary workers. This gives me more reason to love, appreciate and always try to get along with my co-workers – not only for the sake of the health of our patients but it is good for my health too.

Being in this line of work for more than 10 years, makes me old, but that is reassuring to know that being experienced makes me less prone to burnout. So there’s actually an advantage of getting old!

If I would give advice or create a practice question, here’s what I will draft:

What will be the best way to prevent burnout in your work?

A. Change career into a less stressful one. (Like, ah…. er….. a professional clown? On second thought, I don’t think a rodeo-clown is less stressful!)

B. Quit your job, and live in a remote place out of civilization, like a hermit.

C. Party every night after work, as if there’s no tomorrow, to release your stress. (Make your motto: eat, drink and be merry, for tomorrow you die!)

D. Start and learn a new hobby……….like blogging!

I guess you know what answer I highly recommend.

I Don’t Know. But That’s Alright.

Not too long ago, I diagnosed a patient with sarcoidosis. She asked me what was the cause of her disease and I offered her that I have two versions of the answer: a short one and a long one. She requested for the short one, which I said “I don’t know”. I went ahead and gave the long answer too, as I can read in her face that she was not satisfied with my short version.

I told her that sarcoidosis results from a specific type of inflammation involving lymphocyte and mononuclear cells forming caseating granuloma, which in some theories said could be triggered by occupational or environmental exposures, while other theories implicate infectious agents, some think it is an auto-immune disease, and some believe it has genetic association — but all theories are not proven, so we really don’t know. I think I made her more confused after that, but she was satisfied with my answer.

There are so many things in this world that we still don’t understand and we don’t have answers to. Of course there are more things that have answers, but you and I, as an individual, may have not just learned it yet. And I think there’s nothing wrong to admit if we don’t know them.

I have been asked by patients questions that I don’t know the answer, and I tell them so, but promised to looked them up and study to provide an explanation for them. I also have been asked by my medical residents and students during hospital rounds, questions that I don’t know the answer and I admit to it. So I tell them I’ll read up on it, or better still, I tell them to research on it, and give us an informal report the next day, so they could learn it better (we tend to retain information better when we read it ourselves rather than hearing it from somebody else) and so I could learn from them too (students can teach their teachers more ways than one, you know).

I remember our Principal during my high school days saying: when we finish high school, we think we know everything; when we graduate from college, we find out that we know something but not everything; after graduate school, we realize we really know very little, but so does everybody else. I find that statement very true, for the more knowledge we gain, the more we discern how little we really know.

Einstein explaining how to draw circles and squares?

I don’t think we show our weakness when we admit that we don’t know. But we show our strength when we do something about what we don’t know. We show our true ignorance when we don’t admit that we don’t know, and worse if we don’t do anything about it, or even pretend that we know.

So what is that theory of relativity again? I don’t know. But I’ll look it up (though it does not guarantee I’ll understand it!).

Lesson From A Limping Deer

It was a lazy weekend afternoon. I was just relaxing sitting by the window, and my thoughts were wandering beyond the confines of my dwelling. In fact, one of my favorite form of relaxation (aside from blogging), is just staring blankly beyond the blue. It’s transcendental daydreaming.

My quiet musing was disrupted by the sight of familiar visitors intruding and frolicking in my yard. Even though I’m used to seeing deers in my lawn, something was quite different this time.

As I observed them more closely, I noticed that one of the deer was limping. I hurriedly grabbed our camera, and zoomed in to see closer.

I was surprised that one of the hind legs of the limping deer was rotated backward. It appeared that it was dislocated from the hip or fractured above the knee. (Maybe I’ll have a career in veterinary orthopedics.) Perhaps she had a close encounter with a speeding car: got mesmerized with its headlights and did not move out of the way quickly enough. But she lived and did not become a roadkill. And she had the evidence to show of that tragic encounter.

My first reaction was I felt sorry for the deer. That must be a painful experience. And perhaps more painful to struggle with everyday existence with her injury.

Deers are agile animals. They are fast runners and strong leapers. Thanks to their powerful hind legs. But with only one good hind leg, this deer was in a great disadvantage. How could she survive in this cruel world?

I thought of giving her food by bringing it out in my porch. However, something stopped me. First, I may just scare them away when they see me go out. Second, my wife would probably get mad at me, as I know she really hate those deers, for they massacre her flowers. And besides, by providing food for that deer, would I help her situation or just make it worse?

That deer did not asked for my pity. What she asked for is time and chance, to show me and the other creatures, that she is fine and that she can rise above this tragedy and survive on her own (three) feet.

How about us? Do we gripe that life is unfair and cruel? Or maybe we already had been wounded and injured. Do we give up and wallow in self-pity? Do we continue to parade our open wounds so people would show us mercy? Or do we lick our wounds and rise to the occasion and overcome the adversities that life had dealt us with?

I noticed that the deer was moving with ease and had no apparent distress despite of her injury, telling me somehow that her accident was quite a while back already. As she scurry and bounced away gracefully, albeit with a limp, somehow she showed me, that she had learned to adapt to her condition and that she had already conquered her disability. She had three good legs left, and that’s all she need to survive.

Slow Place, Quick Opinion

I drove to southern Iowa a few days ago to my new outreach clinic, which is about 70 miles (1 hour and 15 minutes drive) from Des Moines. After seeing all my patients there in the morning, I headed then to my other outreach clinic (still in southern Iowa) for the afternoon, which is about 30 minutes away from the first one. I visit these satellite clinics, outside of Des Moines, once every other month. (Most specialty clinics from bigger cities in Iowa reach out to many surrounding small towns to provide services.)

On the way to my afternoon clinic, since it was lunch time, I decided to get food. I passed a small rural town (estimated population: a couple of thousand people) and searched for a place to eat. I looked for something familiar and a restaurant that I knew would be accepting credit card, as I had only a few dollars in cash. Come to think of it, I rarely carry more than $20 in my wallet, as I exist by the swipe of the card.

small Iowa town (photo from New York Times)

I saw a Subway franchise restaurant and stopped there for lunch. The place is quite small and I thought to myself, since it was a small town, it must be a “slow” place. I wondered how can this franchise survive in this “remote” place. Sure enough, when I entered, there was no body sitting in the tables, though there were 2 people in the counter placing their order to-go, ahead of me. That would be OK, I would be eating in my lonesome, but at least a quiet meal.

After I got my order, I sat by the window in an empty restaurant all by myself.  However, I soon observed that one after another, cars started pulling up in the parking lot. A wave of people came trickling in non-stop. In a short period of time, the restaurant was bustling and full of people, and I felt like I was in a crowded downtown joint. Must be a popular place to eat. What did they do, invite the whole community for a lunch party?

As I left the place, there were several people seated in the tables, and there were 42 people (yes, I counted them!) in line, waiting to make their order. A “slow” place huh?

How many times do we quickly form our opinion and judgement on many things, just based on our first impression? And many times it turns out to be wrong.

Treasure in the Junk Mail

buried in junk mail

Few days ago, my wife cleared out all the letters, and junk mail in our table. As we received a lot of materials in the mail, most of them junk mail, they just piled up in our counter. Most of the time, I will separate the bills from the rest of the mail, and put it to my important mail pile. (Yes, all I am searching for in the mail are bills!) How funny that the only “important” letters we receive nowadays are bills.

As there are some personal information on the letters and even in the junk mail, my wife decided to shred them before she toss them away. As she was sorting the pile of papers and envelopes, she found an envelope with a check inside that amounts to more than $1,500 named to us. Yes, more than $1500! The check was sent to us more than 4 months ago. It was from our previous bank lender and it was given back to us, when we refinance our home to a new lender. We have mistakenly stacked it in the junk mail pile.

I cringe at the thought that we almost shred  and throw away  a nice sum of money. We have never thought that there’s something precious buried in that pile of junk letters. And we never even knew that we had it.

Sad to say, there are also other precious things in our homes that we are not aware of, or worse, pay no attention to. Treasures that are buried in the clutter of our busy lives. Valuable moments that are stacked upon by our preoccupation and distraction to “junk mails.” Constant deadlines, overtime at work, games and amusements, TV, computers, and other forms of entertainments heap over and bury this simple treasures.

A quiet family meal time together, a moment reading with your child, tutoring them with their homework, or time just playing with your children — these are the treasures I am talking about.

My son just entered the room with a chessboard in hand. I think I should finish this piece and heed my own advice.

Failed New Year’s Resolutions

Today is already the end of the first month of the new year. We blink and time will pass us by.

How long does a new year’s resolution last? A lifetime? The whole year? How about a few days to a few weeks.

Yesterday, I went to the gym. It was notable how different a couple of weeks made. It was not as crowded as it was a few weeks ago as I wrote in a blog before. Does that mean the people with resolutions to go to the gym and exercise, fizzled out already?

This is a classic example of human endeavor. We just cannot sustain our initial enthusiasm, nor can we finish what we started. Are we doomed to fail? Maybe this is the very reason why some people (that may include me) don’t make new year’s resolution at all: the fear of failing.

However, if we don’t at least make an effort to commit ourselves to change or make resolutions, then I believe that it is more dangerous, for we will not care at all. For me, it is better to make a resolution and fail, than not make one, or not care to change at all. I know no one can claim that he/she has no more room for improvement. For we all do.

Go ahead, try to quit smoking for the thousandth time. Try to exercise more regularly instead of once a year. Try to live more healthy. Try to stop chewing your fingernails. Try to blog everyday (I’m still working on this). Try to take a bath everyday or at least once a week (you have to, for the sake of the people around you). Try to be more patient and loving. Try to make more time for your family. Or just try to be a better person.

If we fail? There’s always the next year. We only really fail, if we completely quit trying.

By the way, who said you can only make resolutions during new year? Start one today.

Walk Fast, Live Long

(The original article is written for a local church newsletter.)

Fish were created to swim, birds were created to fly, and men were created to walk (although some are born to run). Even though most of the land creatures crawl or walk in all fours, human beings stand upright and walk on their two feet. From the dawn of history – from evading our predators, to the present – to strutting on the catwalk, moving on our feet is key to our survival.

We may not think of it much, but there is a lot of science, physics and physiology in standing and walking upright. How a creature can remain vertically steady against gravity without tipping over is already a marvel. And to move by shifting our weight from one foot to the other like an inverted pendulum and remaining perfectly balanced and straight up while walking is really amazing. Sometimes this equilibrium malfunction, like people who suffered stroke, and walking becomes a challenge. Indeed, we are fearfully and wonderfully made.

The most physiologic way of going from point A to point B for humans is by walking (not Segway). It is estimated that an average human being will walk 65,000 to more than 100,000 miles in his lifetime depending on his level of activity. (65,000 miles is almost 3 times the distance around the world.) The thing is the more we walk, the better. Unlike cars, humans last longer with higher mileage.

Studies have showed that the more active we are, the healthier we become, and the longer we live. In one study, researcher analyzed more than four decades of data from the Framingham Heart Study. They found that life expectancy at age 50 for people with medium activity was 1.5 years longer than those with low activity, while the high activity people live 3.5 years longer.

For most people, the optimum walking speed, that is the speed where our kinetic energy  is balanced with our potential energy, is around 3 miles per hour. We may not consciously think on how fast we walk, but our walking speed can be a simple reflection of how healthy we are, or how well our body systems are doing.

In a recent study that was published in Journal of American Medical Association this year, it stated that walking speed predicts life span and health. It was a meta-analysis of 9 separate studies of individuals 65 years or older. The study measured the walking speed of more than 34,000 seniors. They found that for every one-tenth of one meter per second increase in walking speed, survival rates for additional years increased exponentially.

Thus walking faster just not make you reach your destination earlier, or just make you appear that you are a man with a mission. It is also an indication of your longevity.

Let’s walk. And a little bit faster please.

Ang taong naglalakad ng matulin, (kung matinik malalim)………..buhay nama’y mahaba ang aabutin.

Winter Driving

Driving in the winter, especially in snow and ice, can be very challenging. There is no scarier moment in driving than when you turn the steering wheel to one direction but your car heads the other way, or when you hit the brakes but you continue to skid forward, or worse you start to spin. (I have experienced all of the above.)

We had snowstorm again yesterday and today, and the roads were dangerously slippery. There were few minor accidents in the road, that it took me more than an hour to drive to my work both days, a distance that I usually cover in 20 minutes. (I should not complain too much, for in Manila it takes an hour drive, a distance you can walk in 10 minutes.)

In one particular icy stretch of the highway today, I saw several vehicles that have fallen into the ditch. I have noticed that most of the vehicles in the ditch are either pick-up truck or SUV, which is counter intuitive. You would think that these type of vehicles will have an advantage in the snow. I guess the drivers of these vehicles had false sense of security and invulnerability and were driving at speed limit of normal road condition.

In my opinion, in winter driving, more important than the high ground clearance (like in truck and SUV), or the 4 x 4 or all-wheel drive, or by being equipped with winter tires — is using some common sense and a bit of caution.

Retiree’s Regrets

Few nights ago, our group had dinner with one of our former partners who retired a couple of years ago. He appeared healthy and fit than ever and he sounded like he was really enjoying the retiree’s life. After being in practice for over 30 years, he is content for what he had accomplished. When we asked him for some advice, he stated that he had only one regret: that he did not build better and deeper relationships. More meaningful relationship not just with patients, but with partners, other doctors, co-workers, employees and others.

Relationship. This got me thinking. How profound is that advice. Very true, that in our busyness, we don’t really take time to know people that we work with. We don’t know them enough nor we do care enough to know them. We are driven by our productivity, our deadlines, and accomplishing our jobs, that we have no time to build relationships with people.

I don’t think anybody at the end of their career would say, I wish I could have work more days in the office, or submitted one more project on time. Nobody in their deathbed would say, I wish I could have earned another hundred dollars, or another million for that matter. Our regrets would be something much deeper than these. When we are in our deathbed, our 401K, our financial portfolio and even our estate does not mean anything. It will be the relationships we establish with people, that will be treasured.

definitely not my estate

And it is not just the relationship with people at work that is suffering with our busy lives. Even the relationships that really matter, the one we have at home. Many times we forget why we work, and that is to provide for our family. Work is the ‘means’ to support the ‘end’ – our family. But sometimes the ‘means’ becomes the ‘end’, and the supposed ‘end’ (our family), becomes “the end.” How many families have broken because of too much work? Somehow our priorities are mixed up.

I know I will never be the best doctor in the world. I may never be the best doctor in our group. I may not even be the best doctor in our home (who knows if any of my kids will become a doctor someday). But I can be the best husband to my wife, and the best father to my children. And that is what I will strive to be.

I am thankful for the advice of an old and wise doctor. I wish at the end of my career, I will not have the same regrets that he had. Maybe mine would be: I wish I could have played more golf. But I don’t even know how to play golf!