Volume 39

January - 2023

Cover: Majesty of the Mountains

Building Healthy Habits - By: Jonathan Warren, MD

It’s January, which means that it’s that time of the year when we are all making new resolutions, striving for healthier living, and attempting to reach balance and wellness in the coming year. It’s an admirable goal, but getting started is heavily reliant on developing strong, healthy habits. This month we’re going to take some time to review how that can be achieved. 

Habits are easy- we’re often unconsciously doing them every day in our life. However, that morning cup of coffee isn’t something that became a habit right away. It took weeks of you waking up, deciding to make coffee, and developing a routine. Nir Eyal describes the difference between routines and habits: routines are those activities that will require conscious effort while habits are those that you can complete mindlessly (even a zombie in the morning makes their cup of coffee). (1) Routines can become habits, but not all do, and it’s not easy. It’s not impossible to turn a routine into a habit, but one must realize it will not be a comfortable process and those routines which require significant thought (studying daily, writing your notes before sleeping, conducting research) will not make the transition. 

Now, making healthy choices and improving wellness are things that can become effortless through habit formation. Previous studies have shown it can take anywhere from 18-254 days. (2) This can be a grueling amount of time to feel uncomfortable through this transitioning process, but ultimately is worth it and that’s the first step. Prepare yourself for months of delayed gratification and establish your reasons for developing this new habit. Keep this as your guiding focus as you get started. 

Now how do you start? Small, infinitesimally small. Attempting to turn a difficult routine such as doing 100 push ups a day or doing 50 Rosh Review questions per day is difficult. BJ Fogg describes the “motivation wave” where people at baseline have the energy to meet goals only some of the time. (3) Setting a small goal that can be met at motivational level may lead to long term sustained performance. James Clear from Atomic Habits provides the idea to break larger habits into chunks and increase slowly over time. Instead of starting with 50 Rosh Review Questions, perhaps starting with 5 per day is an achievable goal that can grow until meeting your overarching goal. (4) As you achieve these small goals, you maintain momentum and make goals that are realistic and increase small amounts. You’ll be amazed how rapidly it adds up. 

Some might say these small goals aren’t enough, but that there should be some guiding support or reward to guide and build your motivation. Charles Duhigg proposes the idea that all habits, both good and bad, develop in a cycle of cue, routine, and reward. (5) Think back to the habit of making coffee: you are tired (cue), you make coffee (routine), you’re more awake and energized (reward). The reward helps to change the way your brain thinks about completing your goal. There are studies to support this as well. Both intrinsic motivation and pleasure independently improved the relationship between repetition and habit. (6) To build on this, Dr. Milkman recommends “temptation bundling”: couple something you enjoy with the activity of the habit you are trying to form. (7) Going back to our Rosh Review question example, consider having a snack or special coffee that you only enjoy for the time you are studying, and do not have access to it otherwise. 

Rewards may help, but you can also go one step further. Remove barriers that prevent you from successfully completing your goals. Pre-plan your schedule time to prevent you from “being too busy”. In the instance of working out, lay your clothes out the night before. Studies have shown that even small barriers in routines may cause people to deviate from their standard practice. (8) Taking the time to remove these barriers not only makes you goal more attainable but serves a cue to prompt you to complete them.

You’ve developed a great routine, but you’ll need to maintain it to develop a habit. Now you’re at the step to find ways to make this happen. Consider performing your routine at the same time of day every day. “When I wake up and make coffee, I will do my 10 Rosh Review questions”. Studies have shown that providing context stability to routines allows them to more rapidly approach automaticity (habit) and goal attainment. (9) As you become successful, you will want to rapidly grow in your habit, but it is important to make progress, but keep it sustainable. As your habit grows in requirements of time, thought, and energy, it becomes easier to fall out of your habit. Grow slow and set upper limits to your growth. (10) Finally, don’t forget to look back at your progress with an app tracker! Using an app like Forest (I like the fact that actual trees are planted for your progress) and you can visualize your progress growing into an entire forest on your phone. (11)

Finally, be kind to yourself. Developing new habits is difficult and uncomfortable and you won’t be able to maintain it 100% of the time- even the most successful can’t. Forgive yourself and get back on track the next day. Have a plan to maintain consistency whether it is accountability partners, scheduling, or finding other tricks that may work better for you. 

Keep these thoughts in mind and if you want to read more from the amazing minds that helped to inspire this article, please look at the references at the bottom of this page. Best of luck in developing your new routines for 2023!

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Reach out to us through out contact form and we would love to work with you to make this a reality!

Saint Mary Lake

In between hikes at Glacier National Park we stopped along Going-to-the-Sun road to enjoy the view of Saint Mary Lake. The stark, jagged mountains contrasted beautifully with the serene lake and wild flowers.

is another way of saying i am about to give up. when i was

small the trees would shake a stubborn shake

   refusing to shed

their coats even the cold would sit     a seat between teeth

i moved east years ago

to find a ballet in leaves falling

     without an audience     they had a faith

i found only in the books i loved musicians by trade

    thought my job as student   was bearing witness to music

not to shake the trees

to start a fire

to wear a methodical blue

and pull colon taut so long i might avoid following it

home

Tension

This is a piece on burnout I started as a medical student, and reworked as a junior resident. In some ways, poetry has allowed me to process what we do when we otherwise have so little opportunity to.

Specialties as Flowers

Before medicine I worked for 8 years as a youth worker and camp counselor. I later became a middle and high school teacher. When entering medical school pediatrics seemed to be a great fit. However, as I learned more about other specialities I found myself falling in love with so many. These collections of flowers represent all the specialities that I considered. I finally landed on one: Emergency Medicine.

Untitled

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References:

1. Eyer N. Stop Confusing Habits for Routines: What You Need to Know. Accessed January 16, 2023. https://www.nirandfar.com/habits/

2. Lally P, van Jaarsveld CHM, Potts HWW, Wardle J. How are habits formed: Modelling habit formation in the real world. Eur J Soc Psychol. 2010;40(6):998-1009. doi:10.1002/ejsp.674

3. MotivationWave-BJFogg-2012.Mp4.; 2012. Accessed January 16, 2023. https://www.youtube.com/watch?v=fqUSjHjIEFg

4. Clear J. How to Build a New Habit: This is Your Strategy Guide. James Clear. Published July 18, 2014. Accessed January 16, 2023. https://jamesclear.com/habit-guide

5. Duhigg C. The Power of Habit: Why We Do What We Do in Life and Business. Random House Trade Paperbacks; 2014.

6. Judah G, Gardner B, Kenward MG, DeStavola B, Aunger R. Exploratory study of the impact of perceived reward on habit formation. BMC Psychol. 2018;6(1):62. doi:10.1186/s40359-018-0270-z

7. Ross M. Medium: Use Temptation Bundling to Create Better Habits. Center for Health Incentives and Behavioral Economics. Published June 21, 2019. Accessed January 16, 2023. https://chibe.upenn.edu/news/medium-use-temptation-bundling-to-create-better-habits/

8. Houten RV, Nau PA, Merrigan M. Reducing Elevator Energy Use: A Comparison of Posted Feedback and Reduced Elevator Convenience. J Appl Behav Anal. 1981;14(4):377-387. doi:10.1901/jaba.1981.14-377

9. Stojanovic M, Grund A, Fries S. Context Stability in Habit Building Increases Automaticity and Goal Attainment. Front Psychol. 2022;13:883795. doi:10.3389/fpsyg.2022.883795

10. Clear J. Do Things You Can Sustain. James Clear. Published May 22, 2014. Accessed January 16, 2023. https://jamesclear.com/upper-bound

11. Forest - Stay focused, be present. Accessed January 16, 2023. https://www.forestapp.cc

This Months Featured Artists:

Amina Ibrahim

My name is Amina Ibrahim. I was born in Mogadishu, Somalia and raised in Ottawa, Ontario, Canada. I currently live in Chicago. I am a 4th year Medical Student that aspires to match into an Emergency Medicine Residency. My teenage brother once joined my mother and I to my kindergarten "Meet the Teacher" night. I proudly showed my artwork to them. My brother laughed and called it scribbles. I knew it was better than scribbles. I obsessively practiced to prove him wrong. I eventually did! Like most kids I loved to draw, I just haven't stopped.

Elaine Hsiang, MD

I am an emergency medicine resident at UCSF. I started writing after going to my first spoken word show. It was a time of a lot of change in my life and I found I could be my most authentic self through poems. Other things that have long made me happy: coffee, time with loved ones, games, and the excitement of trying something new. View more of her work on Twitter.

Giuliano DePortu, MD

I was a professional photojournalist and went to medical school at 33. Currently still doing imaging for fun! You can see more images at www.giulianodeportu.com.

Tyler Kirchberg

I am a 4th year medical student applying into Emergency Medicine. I have always loved the outdoors, and I use photography as a fun and rejuvenating way to capture some of my favorite places to be outside. In my free time I also enjoy swimming, biking, surfing, skiing, camping, and reading.

You can learn more about the artists featured in this and other volumes at our contributors page!