One surefire way to start a lively conversation among anesthesiologists is to bring up the ideal timeline children should fast before surgery.

This clinical controversy was the focus of a point-counterpoint discussion at ANESTHESIOLOGY^® 2024. Joelle Karlik, MD, Pediatric Anesthesia and Pain Medicine, Children’s Healthcare of Atlanta-Arthur M. Blank Hospital, Atlanta, Georgia, makes the case that it’s realistic and safe to shorten the fasting time to one hour for many procedures. This article will be followed by a counterpoint from Jerrold Lerman, MD, on reasons to maintain the two-hour window to withhold clear liquids before elective procedures requiring anesthesia.

The 2023 ASA Practice Guidelines for Preoperative Fasting state that the current recommendations are for pediatric patients to strive for clear liquid intake as close to two hours before procedures as possible (Anesthesiology 2023;138:132-51). However, some professionals believe these guidelines are inconsistent with clinical practice, especially in European or Canadian hospitals, according to Dr. Karlik. “A large amount of the research is coming out of Europe in terms of the safety of this one hour clears policy which, per their arguments, is safe,” she confirmed.

The two-hour clear fasting requirement was developed to account for aspiration risk under NPO instructions. Aspirations are an unavoidable risk in anesthesiology, but the argument has always been that ingesting clear liquids just before surgery increases that risk. Some recent research challenges this logic (Paediatr Anaesth 2023;33:1012-19). Dr. Karlik led a small study in which patients were given liquids based on their weight within an hour before the estimated surgery start time and prior to their anesthetic. Once induced, the team measured the patient’s gastric volume to gauge if it was at a level that caused concern for aspiration. Her team concluded that there was no correlation between longer fasting times and increased aspiration risk. However, they acknowledged the challenge of needing a large study population to conduct a proper trial and the reality that aspirations do occur, even with two-hour NPO orders.

After a literature review, what emerged as the most important consideration was the different nutritional needs for the pediatric versus adult patient populations. Growth and nutrition are greater concerns for infants and children, as they metabolize nutrients at a higher rate than adults. The youngest patients are more sensitive to alterations in their nutrition. More importantly, patients of any age tend to fast longer than recommended. “With prolonged fasting, children have signs of hypoglycemia and acidosis. Their blood pressure is actually lower during induction of anesthesia, and, during surgery, they show signs of insulin resistance, which is associated with increased risk. These patients are already fragile and therefore we need a policy that reflects that,” explained Dr. Karlik.

Infertility affects one in eight couples in the general population and one in four female physicians. Many are unaware of these statistics, even in the medical community. When faced with infertility, there is an enormous emotional, physical, and even financial toll. While there is not a lot of data available on infertility in female physicians, a survey of 600 female physicians published in 2016 showed that 53.3% said they would have attempted to conceive earlier and 16.7% said they would have used cryopreservation to preserve their fertility if they had known the statistics of infertility. Meera Kirpekar, MD, Clinical Associate Professor in the Department of Anesthesiology, Perioperative Care, and Pain Medicine at NYU Langone, shared her personal experience with this important topic and her goal of change for the better in workplaces for female anesthesiologists.

Medical school, residency programs, and fellowship training take years and are extremely high stress. In addition to the stress, co-residents are dependent upon each other to be present not only day to day, but also for overnight calls, in a very structured work system that doesn’t leave room for sick days, let alone maternity leave. Dr. Kirpekar explained, “For many, trying for a child during this time can seem almost impossible. Once you are an attending, it takes a year or two to adjust to this new and extremely demanding role, while you are also studying for your board exams. As a result, building your family is put off, which can lead to difficulties later. I did not receive education regarding this in medical school or residency – education such as rates of infertility, how age and lifestyle factors in, how to freeze your eggs, the data regarding egg and embryo freezing, what insurance will and won’t cover, what the cost is, and more. It’s important that female physicians receive this education as early as possible so they can make informed decisions.” While males can face challenges as well, in general, the testing and treatment for infertility is far more invasive in women.

Dr. Kirpekar became interested in the topic of fertility preservation both due to her patients’ experiences and her own. As she treats pelvic pain, many patients also struggled with infertility and invasive treatments, which exacerbated their pain. On a personal note, Dr. Kirpekar struggled with infertility for two years, during which time she experienced multiple miscarriages and invasive testing, followed by several egg retrievals and IVF embryo transfers. Now the parent of a baby boy, she added, “During this time, I continued working, never taking any time off, and not even letting on about the physical, mental, or emotional toll I was facing. I only ever alluded to the struggle if I had to take a day off for an anesthesia procedure, for example. I know of many women in medicine who faced similar challenges and continued to do their jobs and live their lives in silence. We all had something else in common – we just didn’t know there would be a possibility of facing infertility because we received no education on the subject during our medical training.”

When discussing fertility preservation with other women in medicine, Dr. Kirpekar noticed how the discussions turned to the multiple obstacles women in medicine face because of the differing life cycle of females vs. males. For example, females endure massive swings in bodily changes throughout their lifetime, which contribute to their physical, mental, and emotional health. They also experience menstruation and menopause, and, possibly infertility, pregnancy, and lactation. After putting it all together through a collaborative effort with colleagues, the ASA panel on “Women’s Health Issues During Their Careers as Anesthesiologists and How to Support Women in the Workplace” was born.

Dr. Kirpekar’s presentation at ANESTHESIOLOGY^® 2024 focused on objectives such as reviewing current data, discussing the toll on female physicians, choices for fertility preservation, and support options for the anesthesiology departments. A study out of Hungary with over 3,000 women physicians showed that amongst the group, infertility, high-risk pregnancies, and miscarriages have been associated with burnout, which can increase medical errors, risk of malpractice, and poor patient outcomes (BMC Womens Health 2014;14:121). As for the physical toll, enduring infertility often means rounds of testing, frequent blood work, ultrasounds, painful daily injections, and uncomfortable procedures, which causes stress to the body. Finally, the cost of IVF is extremely high, so the financial strain is significant, particularly if you must undergo multiple rounds of treatments. And if women need time off, there could even be loss of work and lack of support from their jobs. Dr. Kirpekar made it clear how all three of these factors (emotional, physical, and financial) all play a part, and how significant each stressor is depends on individual situations such as the type of testing and treatment they are undergoing, insurance coverage, workplace accommodations, stigma they may face, other personal life factors, and more.

As it relates to fertility preservation, many female physicians may not be aware of the most common options. Egg freezing, also known as oocyte cryopreservation, is a process in which eggs are extracted, frozen, and stored. For women 38-40 years old, freezing 25-30 mature eggs gives them roughly a 65-75% chance of at least one live birth. Another option, embryo freezing, is more involved and requires eggs retrieved from a woman combined with a partner or donor’s sperm, allowing embryos to grow, and mature for freezing. Dr. Kirpekar then addressed what three key strategies can be put in place to manage physician fertility.

1. Early education on fertility preservation beginning in medical school, continuing through residency and early years in practice, with access to discussion groups and other resources.
2. Full access to a reproductive endocrinologist and insurance coverage, to ensure fertility assessment and management.
3. Workplace support to reduce stigma, increase psychological well-being, and increase time coverage. Time coverage is significant as women anesthesiologists, both residents and attendings, need time while undergoing fertility treatments for doctor visits, breaks from the operating room to administer injections, and even days off for procedures.

Dr. Kirpekar noted that medical schools and residences are starting to briefly incorporate fertility preservation into the curriculum, but not universally, nor comprehensively yet. She clarified, “I hope that the more we discuss this topic openly, the more commonplace it becomes to ask for and expect an increase in education and in workplace accommodations, and a decrease in stigma.” Anecdotally, because of discussing this topic openly with others, she’s also noticed more women feeling comfortable asking for accommodations to undergo treatment, such as time to go to appointments, more quick breaks from the operating room to inject fertility medications in a timely fashion, and even a day off to undergo a procedure. The hope is for this to become commonplace in the future and a part of institutional policy.

In an era marked by evolving biothreats and emerging infectious diseases, the U.S. biodefense apparatus has become a critical component of national security. As key players in the health care system, anesthesiologists have a pivotal role in this complex landscape. Understanding the broader biodefense framework, including the mechanisms in place for research, surveillance, response, and policy, is crucial for anesthesiologists.

The U.S. biodefense system is a multifaceted network designed to protect the nation from biological threats, including pandemics, bioterrorism, and emerging infectious diseases. This system integrates federal, state, and local efforts and encompasses surveillance, preparedness, response, and recovery. Critical agencies involved include the U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID), the Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH), the Department of Homeland Security, and the Biomedical Advanced Research and Development Authority (asamonitor.pub/4h07A9r).

This article explores the U.S. biodefense apparatus, its components, and its relevance to anesthesiologists, offering actionable recommendations for improving preparedness and response.

A 20-year-old man presents to the emergency department with a severe headache. Upon evaluation, he is found to have a large intracranial mass and is scheduled to undergo craniotomy for resection. According to a recent meta-analysis comparing scalp nerve blocks, scalp infiltration, and placebo, which of the following statements is MOST likely true regarding regional techniques using ropivacaine for 24-hour postoperative pain control?

• □ (A) A scalp nerve block was more effective than scalp infiltration to control pain
• □ (B) A scalp nerve block was only effective to control pain if performed preoperatively versus postoperatively
• □ (C) A scalp nerve block increased opioid consumption compared to placebo

Craniotomy frequently causes moderate to severe pain and chronic headaches. Although opioids are the primary pain relief option, their adverse effects can complicate neurological assessments and hide potential intracranial problems. The adoption of regional techniques such as scalp nerve blocks and scalp infiltration has introduced new strategies alongside opioid analgesics for pain control. Scalp nerve blocks encompass the blockade of superficial sensory nerves across the scalp at multiple locations, whereas scalp infiltration involves the subcutaneous administration of local anesthetics at a specific incision site. Many randomized controlled trials and meta-analyses have analyzed scalp nerve block or infiltration separately but have not compared the various methods and drugs used.

A recent systematic review and network meta-analysis compared scalp nerve blocks, scalp infiltration, and controls in adult patients undergoing craniotomy. In these studies, control groups received saline-mimicking scalp nerve blocks, scalp infiltration, or intravenous analgesics. Various local anesthetic doses and timing (i.e., before and after surgery) were considered. The primary outcome was 24-hour postoperative pain scores (0-10). The secondary outcome was opioid consumption within the first 24 hours postoperatively (intravenous morphine equivalents).

A systematic database search was conducted from inception to February 18, 2022, and updated on March 5, 2022. The mean difference, 95% CI, and 95% credible interval were used to estimate the efficacy of different treatments. Overall treatment ranks were estimated using surface under the cumulative ranking curve (SUCRA) scores. The SUCRA score allocates one number to each treatment score, ranging from 0% to 100%, with a higher SUCRA score signifying the treatment is likely to be more useful and a lower SUCRA score signifying the treatment is likely to be less useful. The overall quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) guidelines.

Of 24 eligible studies, 13 studies with 718 patients compared scalp nerve blocks to controls, seven studies with 428 patients compared scalp infiltration to controls, and four studies with 215 patients compared scalp nerve blocks to both scalp infiltration and controls. In terms of timing, scalp nerve block or infiltration was administered before surgery in 11 studies, after surgery in 12 studies, and both before and after surgery in one study. A total of 23 studies reported 24-hour postoperative pain as the primary outcome. These trials consisted of 51 treatment groups distributed across 10 distinct nodes representing various treatment options.

Scalp nerve block with ropivacaine, compared to the control, reduced 24-hour postoperative pain scores (mean difference, -2.04; 95% credible interval, –3.13 to –0.94 [low quality]). Also, 24-hour postoperative pain scores were reduced with scalp nerve block with ropivacaine compared to scalp infiltration with ropivacaine (mean difference, –1.77; 95% credible interval, –3.04 to –0.51 [low quality]) and scalp infiltration with bupivacaine (mean difference, –1.96; 95% credible interval, –3.65 to –0.22 [low quality]). Scalp nerve block with ropivacaine was found to be the most effective approach for pain reduction (SUCRA, 91%). Based on the comprehensive SUCRA rankings, the scalp nerve block appeared to be more effective than the scalp infiltration and control methods.

In addition, a subgroup analysis considering the timing of block or infiltration administration revealed that, compared to the control group, both preoperative and postoperative scalp nerve blocks with ropivacaine lowered 24-hour postoperative pain scores (preoperative mean difference, –2.07; 95% credible interval, –3.61 to –0.46; postoperative mean difference, –1.96; 95% credible interval, –3.74 to –0.13).

For the secondary outcome, opioids consumed within the first 24 hours postoperatively were analyzed in 19 studies with 41 treatment groups that were assigned to nine different nodes representing various treatments. Compared to the control group, scalp nerve block with ropivacaine reduced opioid consumption (mean difference, –11.91; 95% credible interval, –22.42 to –1.40 [low quality]). However, scalp infiltration did not show a reduction in opioid consumption compared to the control group. The addition of epinephrine did not influence opioid usage.

In summary, the authors of a recent systematic review and network meta-analysis found that scalp nerve block with ropivacaine, compared to other methods such as scalp infiltration or no intervention, was likely the most effective method for controlling 24-hour postcraniotomy pain and reducing opioid consumption. However, the overall quality of the evidence was low, primarily because of study heterogeneity and limitations such as lack of blinding or incomplete outcomes.

In the high-stress world of medicine, physicians’ mental health and well-being are often overlooked. Physician/provider health programs (PHPs) were established by physician and health care worker regulatory boards and were introduced with the noble intention of providing support to struggling doctors. They also serve as objective assessors of competency to oversight boards. Unfortunately, this has led to a reported lack of trust among clinicians and an apprehension to voluntarily seek assistance from PHPs.

There is a better way forward: medical societies. Medical societies can offer earlier intervention and confidential mental health and well-being resources, fostering trust and support within the health care community.

A 3-month-old infant with an unspecified mitochondrial/metabolic disorder underwent general anesthesia for cardiac catheterization for VSD. The anesthetic administered was 200 mcg/kg/min of propofol for three hours. The child subsequently developed severe metabolic acidosis, circulatory collapse, myoglobinuria, and renal failure concerning for propofol infusion syndrome (PRIS) vs. metabolic crisis. Unfortunately, he progressed to multiorgan failure and death.

Dealing with rare diseases in the OR or the interventional and imaging suite is perhaps a more common occurrence in pediatric anesthesia, as these children often require anesthesia for multiple procedures, including those for which adults can tolerate sedation, local anesthesia, or being awake. Even the most experienced pediatric anesthesiologist cannot be intimately familiar with the thousands of conditions that potentially affect the conduct of an anesthetic. Mitochondrial disorders, often thought to be exceedingly rare, may, especially in their less profound expressions, be more common than generally suspected. These alternations in cellular energetic pathways have profound implications for anesthetic pharmacology (Paediatr Anaesth 2013;23:785-93). In this brief report, we will examine an adverse event from the database from two perspectives: first, to discuss this case itself, and second, to describe specific strategies and resources for the anesthesiologist to use when confronted with these patients.

Propofol is, of course, one of the most ubiquitously used drugs in anesthetic practice and is often used as a continuous infusion for anesthesia in the cardiac catheterization laboratory. However, there are several effects of the drug on cellular metabolism that, under rare circumstances, can cause metabolic decompensation that can be irreversible in some patients. Propofol has two effects that may destabilize cellular metabolism, resulting in a crisis of cellular energetics. First, it interferes with the transport of long fatty acids into the cell, starving the cell of substrate (Lancet 2001;357:606-7). Second, it disrupts electron transport in the mitochondria, specifically at complexes I and IV, and possibly at complex II, leading to a breakdown in the critical mechanisms of energy production of the cell and metabolic failure (Paediatr Anaesth 2013;23:785-93). Thus, it is prudent to avoid propofol in patients with mitochondrial disease, although an induction dose alone (without subsequent infusion) might be safe in some patients. Total intravenous anesthesia with remifentanil and dexmedetomidine has been used successfully in these patients. It is also important to provide a dextrose infusion during surgery, both to provide an energy substrate and to suppress fat metabolism. Minimizing fasting times is similarly important.

The effect of succinylcholine in patients with mitochondrial myopathies has not been thoroughly investigated, and although malignant hyperthermia and mitochondrial myopathies are genetically and biochemically distinct disorders, there are at least two reports of them occurring in the same patient. It is probably best to avoid succinylcholine in any of these patients.

Propofol-related infusion syndrome (PRIS) was first described in children in the early 1990s but has since been reported in adults. It is characterized by otherwise unexplained metabolic acidosis, hyperlipidemia, rhabdomyolysis (which in turn results in acute renal failure), hepatomegaly, dysrhythmias, and rapidly progressive cardiac failure. Without early recognition and institution of supportive care, it is often fatal. Prolonged use of propofol (>48 h at infusion rates >65mcg/kg/min) has been identified as a risk factor, although it is suspected (but unproven) that undiagnosed mitochondrial cytopathies, even mild ones, might be predisposing factors (Crit Care Med 2018;46:e91-4). Indeed, it is unknown whether patients who developed PRIS during much shorter timeframes, such that occur with propofol-based anesthetics, might have subclinical underlying mitochondrial defects. There are indications that even in “normal” children and adults without overt PRIS, evidence can be detected for subtle effects on both mechanisms of disrupted energetics (Crit Care Med 2018;46:e206-12; Anesthesiology 2007;106:1134-8). Certainly, the defining line between these two conditions in some situations is blurred, yet the physiological and clinical courses coalesce as full-blown metabolic crisis ensues. It also must be noted that in some mitochondrial disorders, exquisite sensitivity to volatile anesthetics can be present, and deep levels of anesthesia can be seen with very low end-tidal concentrations of sevoflurane (Anesth Analg 2021;133:924-32). The use of a processed EEG monitor can be very helpful in avoiding relative anesthetic “overdose” in these patients.

In this tragic report to the AIRS database, both diagnoses were correctly considered in the differential diagnosis after metabolic decompensation and organ failure developed. Although we cannot make a definitive diagnosis based on the limited information that the anesthesiologist reported, the existence of an uncharacterized mitochondrial defect suggests that this patient was likely at some increased risk for metabolic decompensation and failure.

When confronted with a patient with an unusual genetic or metabolic condition, where should one turn to for easily accessible information? There are three textbooks and two websites that anesthesiologists might find most helpful. The classic text in the field, “Smith’s Recognizable Patterns of Human Malformation,” is focused on anatomic conditions, but many of these have physiological consequences as well (Smith’s Recognizable Patterns of Human Malformation. 8^th ed, 2021). The virtues of this book include its many photographs and an outline format notable for both brevity and ease of reading. There are two indispensable anesthesia-specific texts. The first, by Baum and O’Flaherty, “Anesthesia for Genetic, Metabolic and Dysmorphic Syndromes of Childhood,” is organized alphabetically, with concise and clear entries (Anesthesia for Genetic, Metabolic and Dysmorphic Syndromes of Childhood. 3^rd ed, 2015). The second, “Syndromes: Rapid Recognition and Perioperative Implications,” by Bissonnette, Luginbuehl, and Engelhardt, is more encyclopedic and expansive (Syndromes: Rapid Recognition and Perioperative Implications. 2^nd ed, 2019). Because online resources are easily accessible, there are two web-based databases that anesthesiologists should add to the favorites tab of their browsers. Frances Veyckemans and Jean-Louis Scholtes have detailed the anesthetic implications of thousands of syndromes and congenital conditions (asamonitor.pub/3U1zIiP). It is up to date and referenced, although the references are not hyperlinked. The Mendelian Inheritance in Man compendium began as an encyclopedic textbook by McKusick but is now available online – and it is the most comprehensive information site about syndromes and congenital disorders (omim.org). It contains links to every paper ever indexed and published on each condition, and you can search by findings as well as the syndrome’s name. Click on “clinical synopsis” for a concise outline of the critical aspects of the syndrome. Although extraordinarily complete and continually updated, it offers less anesthesia-specific content.

Rare metabolic diseases require special care and management; however, even “normal” patients might have subclinical variations in the function of the respiratory chain enzymes that place them at risk for increased sensitivity to anesthetics. The more we learn about the biochemical effects of the agents we use daily, and about the many genetic polymorphisms that affect cellular energetics, we can expect that we will uncover a multitude of subtleties in the cellular responses to anesthetics that can have sometimes profound effects on their outcomes.

Each month, the AQI-AIRS Steering Committee abstracts a patient history submitted to AIRS and authors a discussion of the safety and human factors challenges involved. Absence of commentary should not be construed as agreement with the clinical decisions described. Reader feedback can be sent to airs@asahq.org. Report incidents at aqiairs.org.

Each health care professional reacts and copes differently to stress, especially when their patients don’t do well clinically. Everyone must find a method to manage their emotions when stressful events occur, whether in one’s personal life or professional life. I have spent many years helping my colleagues cope after experiencing poor outcomes in patient care. Each time a devastating unanticipated patient outcome occurs, I am still significantly impacted both mentally and physically. I will share with you the practices I have found that bring some sanity into my life as a practicing critical care/palliative care anesthesiologist who consistently cares for patients at the edge/end of life.

In my opinion, one’s practice environment can be instrumental in helping to ease the burden on a colleague who has experienced an unanticipated poor patient care outcome. First, early relief from clinical duty can give one the opportunity to focus on/process the patient care events that just occurred. Second, I appreciate when other members of my group check in to see how I am doing and if there is anything they can do for me. Third, I appreciate when the quality process is expedited to allow me to learn if there was anything I could have done differently. When this quality review process is extended over weeks to months, I have found that time frame less helpful and more burdensome in my own efforts to manage my reaction to the unanticipated outcome. The first point of early relief can be problematic given that many of us are experiencing significant staffing shortages, but if possible, it is very important and helpful. As for the second and third points, I offer support to my colleagues and trainees after each poor outcome. The quality committee for my practice group tries to expedite quality reviews and provide feedback to our anesthesia colleagues.

The medical literature does not offer much direction when it comes to dealing with a health care practitioner’s reaction to a patient’s death. What is available seems to revolve around: acknowledging your emotions, using reflective practices, focusing on self-care, and seeking professional development (asamonitor.pub/3TDrEo6; asamonitor.pub/3ZA6bA7; Innov Clin Neurosci 2012;9:22-6). Acknowledging your emotions is one thing – managing them is another. If you are one who can intellectualize everything that happens to you, then stoic philosophy might work well for your continued well-being. I have enjoyed the insights of contemporary author Ryan Holiday and his many books (along with his daily podcast “The Daily Stoic”) on stoicism. For further reading, one should seek out the works of early stoics like Epictetus, Marcus Aurelius, and Seneca (make sure to find a contemporary translation). For others who do not intellectualize events as a means of coping, managing one’s emotions after the death of a patient can be a bigger struggle. When I have a bad patient care outcome, my emotional and physical reactions take longer to manage. When reading books on resilience, anger management, self-control, discipline, emotional intelligence, palliative medicine, and understanding destructive emotions, two common themes predominate as methods of coping with and reducing stress: practice in mindfulness and practice in self-compassion.

I choose meditation as my form of mindfulness, reflection, and awareness in managing my emotions. In the beginning, I was not a meditator. I had more important things to do with my time than sit and breathe. During the COVID pandemic, I needed an outlet for what anesthesiologists and critical care physicians were experiencing. I read books on meditation but found that I needed more guidance. I tried online mediation classes, but I learned that I needed to do things on my own time rather than on a class schedule. I tried many meditation apps but finally settled on one called Calm (many others prefer Headspace). Calm requires a subscription, but it has a 30-day mindfulness meditation program. I had to listen to and practice some of the lessons 10 or more times to grasp the concepts. Over these years since the pandemic, I have settled into a stable mindfulness meditative practice, and I recognize how it has impacted me. I’m calmer, less reactive, less angry, more mindful, less prone to road rage, and more content. But I have to be honest that it has taken years to achieve this state. Mindfulness meditation helps me cope after poor patient care outcomes. As time went on and my continued needs for mindfulness meditation were not being met with the Calm app, I explored other avenues. I settled on the work of Jon Kabat-Zinn. His books and teachings have aided my continued growth in mindfulness meditation. Mindfulness meditation practice is how I decompress and reflect on the events of each day. I think of the following: If I could do this day all over again, how would I do it differently? When patient care outcomes were unanticipated and poor, I do the same reflective meditative mindfulness practice, and I continue to encourage professional colleagues to consider this same practice.

Self-compassion was more difficult for me. Historically, I have been very critical of myself when I have fallen short of my (and others’) expectations. That self-critical nature of not living up to high standards did not make it easy for me to cope with bad health outcomes in my practice. One of the foundational elements of self-compassion can be found in the following question: Why don’t you treat yourself as you would your best friend or loved one? Why would we not treat ourselves in the same way we would treat a loved one? I again went into the literature to explore this aspect of managing emotions. I decided to focus on the “Mindful Self-Compassion Workbook” by Kristin Neff, PhD, and Christopher Germer, PhD. This book offered a nice step-by-step method on how to treat myself in a more compassionate manner. I’m now more forgiving and understanding of my emotions, and I am far less critical of myself than in the past (but I am still working on this).

Self-care is tricky and denotes different things to each person. For my physical health, I had to change habits. But to successfully change one’s health, you must measure it. I changed my sleep, my nutrition, how I exercised, how I used any free time, and with whom I would spend my free time. I have read several books on making my sleep quality as good as I can make it. I chose books whose authors had either PhD or physician credentials (just my choice). I now track my sleep using a fitness tracker. I’ve found that one alcoholic drink will reduce the quality of my sleep significantly, so I now drink alcohol only when socializing and limit drinking to weekends. I target seven hours of sleep a night, and this alone has improved my mood more than any other change in my physical health. I’m at a gym with a trainer several times a week and took up swimming. I now cook, prepare my own meals to avoid fast food and hospital food, and focus on the healthiest options I can find. I don’t get sick as often. I put more effort into hobbies and focus on nurturing relationships and friendships that matter. I now have fewer acquaintances and a very gratifying handful of valued friends. This is my version of self-care. Yours may be different.

From the professional development standpoint, I have been managing patients at the edge/end of life for many years. While providing a patient a dignified and comfortable death, I learned that every patient, every patient’s family member, and every professional colleague experiences death and dying differently. My interests in bioethics and disclosure have only further helped me manage very difficult and dynamic conversations with patients, their families, and my health care colleagues. I recommend that all physicians gain additional training on how to disclose adverse and unanticipated outcomes to patients and their families.

Each of us is unique in our experiences and emotions. Each of us must find a way to cope with stress. The things I have considered for my own emotional management have been slowly working, but it has taken years to achieve. Some of these things might work for you if you are struggling. We are all (including myself) a continuous work in progress, but if you don’t try to work on yourself, nothing will change!