Wellness Rounds

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This morning we had a group of medical school applicants at Baylor for a “second look”. They asked some very good questions including the question that prompted me to write this post:

“What should I do to get ready to start medical school?

Set up your environment

The amount of material you will be asked to master in your first year of medical school is more than you’ve ever been asked to master before.  You have to approach it with a different strategy than you used in college.  One critical component of this strategy will be to keep up with the material – starting from the first day.

If you try to hook up your cable, organize your electricity and straighten out parking at your apartment during the first week, you will fall behind.  Take the time to come explore your new environment and get settled in at least a week before classes start.  A week doesn’t sound like much to miss, but it’s a significant amount of information in medical school! One of the important tasks to check off the list during the week you are settling in is to set up your study area.  Make sure you have a computer that will meet your needs and an area to study that is pleasant, ergonomic and comfortable.  Most students find a dual screen to be very helpful as you are moving through notes and slides to study.

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You’ll be spending 1-2 hours studying (at a minimum) for every hour of class.  Given the number of hours you’ll spend studying, you might want to think about an “active” desk that lets you stand, walk or pedal as you study.

Develop (or strengthen) an exercise habit

Use this summer to develop a daily exercise routine that you can take into your new (and crazy) schedule.  Your goal for the summer should be to develop a balanced exercise program (cardio, strength training and flexibility) that works for you.  If you’ve never done any strength training, hire a trainer and learn about it. If you develop a balanced exercise routine this summer, it will be much, much easier to continue this once you start medical school or your internship. Commit to doing at least 30 minutes of exercise a day this summer and it will be a lot easier to continue once the pressure of school really kicks in.

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Running is one of the best (and most convenient) cardio exercises for medical students and residents (because it’s cheap, efficient and effective)  Use this summer to become a runner. If you hate running, find another good cardio exercise habit to develop instead – but pick one!

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If you don’t own a bicycle, think about getting one.  There will be places to ride for fun when you have time off.  You can also use your bike to commute to school which is a great way to sneak in exercise and save money.

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If you don’t know how to cook, learn.

Good nutrition is an important part of doing well academically.  It’s hard to concentrate and learn if you are eating junk. There is one simple trick to eat well during medical school: Learn to cook.  This is a skill that will become progressively more important as you enter your clinical work in medical school and then move on to your residency training.

Learn some basic skills to cook simple things.  If you have good cooks in your family, have them teach you.  If you don’t have family members who can teach you, find cooking classes near you and sign up.  Many high end grocery stores and gourmet stores offer classes for beginners – look on line for classes near you.

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Come to medical school rested.

Do not study. Seriously.  We will give you what you need and nothing you can do this summer will make it any easier.  It’s far more important to arrive rested and ready to go than to try to learn material that may or may not be relevant. Take a real vacation (or two). Visit family and friends – take a road trip and connect with people you haven’t seen in a while  Hang out on a beach, go for some great hikes, read some great novels.  Sleep in late, eat well, and just rest!

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New findings about sedentary behavior have real implications for medical students, who spend a lot of time sitting during the first year or two of medical school. This is also an important issue for residents and practicing physicians, particularly those in the more sedentary fields of medicine like pathology, psychiatry and radiology.   However, this problem affects us all, regardless of specialty.  All physicians have become more sedentary due to the time we spend at our computers.

• Harmful metabolic changes happen to muscles that don’t contract for a couple of hours.
• Prolonged Sitting Leads to Glucose and Insulin Spikes
• The more you sit the higher the risk, independent of exercise
• Sitting increases your risk for the metabolic syndrome
• Sedentary behavior is an independent risk factor for a variety of poor health outcomes

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The goal is to move on this continuum from less activity to more… in other words, to become less sedentary.  Here’s some ways to accomplish that goal:

1. Make sure you move at least every hour.   Breaking up sedentary time is important. Although just moving (even a short stroll) is good, if you have time and the inclination do something a little more strenuous.  Walk up several flights of stairs, do 10 squats and 10 pushups, or whatever catches your fancy.  Try to find ways to incorporate more activity into your day on a regular basis.
2. Stand when you can.  Stand when you are reading, working on the computer (with an adjustable desk), or just hanging out.
3. Walk instead of looking up data on the computer on rounds.  I’ve recently discovered I can access our EMR (Epic) on my iPad by installing the Citrix app.  I’ve started taking my iPad with me on rounds, rather than sitting to look up notes, images and lab values.  I’m still not to the point where I write my notes on the iPad, but I’m going to work on it.
4. Walk to meet instead of sitting around a table. Rounds are obvious, but we have lots of other meetings as well.  There are even physicians who have started doing a part of patient visits as a walk.
5. Consider ways to move while you do your “sedentary” work:

Adjustable desks. Although there are a lot of these on the market that are really expensive, there are some that are more affordable, including desks marketed for kids in school.  Or be creative and make your own adjustable desk.

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Under the desk pedals are inexpensive, and are particularly effective if you are reading and studying.

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Put a desk on your stationary bicycle. Work while pedaling on your stationary bike.  If you have a bicycle, you’ll need to by a trainer to convert it to a stationary bike.  I recently bought  a desk (FitDesk Pro) for my spin bike and it really works.  If you don’t want to spend the money, there are other ways to use your laptop or read while you are on a stationary bike like using an ironing board, or putting your bike under an adjustable desk. I particularly liked this idea of a bicycle rack that doubles as a desk.

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Fit Desk.  If you don’t own a stationary bike, and don’t mind spending $200, look into the Fit Desk.  Friends who have tried this say it is very stable while pedaling.

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Treadmill desk.  This is the most expensive option, but for practicing physicians is not at all a reach.  For students and residents, if you can find an old treadmill, you can build this for $39.

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I was looking at my beeper then other day and realized it looks exactly like beepers looked 25 years ago.   Think about it.

Here is what mobile phones looked like 25 years ago…

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 Who invented beepers?

There are some conflicting stories about who invented the first “beeper” (because they only made a noise)

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“More than 20 million people in the United States today are connected by an invisible, ubiquitous wireless link, originally developed in 1949 by a hospitalized radio engineer. Charles F. Neergard was annoyed by the constant, loud voice paging of doctors on his hospital floor, and reasoned that there must be a way to quietly inform only the intended recipient that a message was waiting. The first commercial pagers were deployed in St. Thomas Hospital in London England and were the approximate size and weight of today’s two D-cell Mag-light.”  from llinoissignal.com

“In 1921, the first pager-like system was in use by the Detroit Police Department. However, it was not until 1949 that the very first telephone pager was patented. The inventor’s name was Al Gross and his pagers were first used in New York City’s Jewish Hospital. Al Gross’ pager was not a consumer device available to everyone. The FCC did not approve the pager for public use until 1958.”  from inventors.about.com

Timeline of history of the pager

In the era of nothing but landlines, pagers were necessary to contact people who were moving around. Which leads to the next obvious question:

Why do we still have pagers in medicine?

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Most physicians preferentially use texting as a method to communicate with each other (when we can).  But, we all still have pagers, too.  There are several reasons:

1) You can turn off a pager (when you aren’t working).  It’s harder to turn off your cell phone.

2) Pagers don’t interfere with medical equipment.  (Unlike some cell phones).  (Although there are some who feel that the benefit of improved communication outweighs the potential risk of interference. )

3) Pagers work in the basement and in steel reinforced buildings (like hospitals), places that limit cell phone reception

4) You can dial one number to reach a group of people (important for codes, etc)

5) The battery life is much better than a cell phone

6)  In a disaster situation (like a hurricane) pagers still work when cell phones don’t

Where are the new solutions?

There are systems now that allow you to use special mobile phones within the walls of the hospital.  Some systems, like Spectralink, use proprietary phones that work only within the hospital.  Others, like Vocera, use software to allow the use of iPhones for the same purpose.  Apple has acquired a patent for a similar system which suggests they may be working on new technology.

Making a new product for the almost 1,000,000 physicians in the United States would seem to be a market big enough to warrant some creative ideas!  How about the most obvious one – Why can’t the full function of a pager be added to a cell phone? 

Any engineers and/or entrepreneurs looking for a new product to develop?

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We recently finished interviewing for our pediatric surgery fellowship.  We always have exceptional candidates but this year was amazing.  I started jotting down some of the comments made during the interviews because I found them so encouraging.  The future of medicine is in good hands!

• “”How I talk to individual parents matters.  With a few extra words you can change their reality.”
• “Teaching is a big part of why I went into medicine.”
• “To make a difference.” (why he chose to go to medical school and why he chose surgery as a field)
• “I’ll know I’m a success at my retirement if my wife and children are happy and my colleagues show up.”
• “It was something not verbalized, but always known.” (why he went into medicine)
• “I tell people not to worry about being a good parent as a doctor.  When I was a kid and my Dad was on call it was really special – we got to go to the hospital cafeteria for dinner and they had ice cream bars. ”
• “I want to move the field forward and be a steward of our profession.”
• “What do philosophers do?  They think and write.” (The link between his undergraduate degree and his academic career goals)
• “I want to train in an environment where the important people are humble enough to come to you to shake your hand and find out who you are.”
• “My primary goal is to be a good pediatric surgeon.  If I can be sure that I’m trustworthy  and that I’m the person who should be doing this child’s operation, I will be a success.”

When you first start going to professional meetings, it’s easy to feel a little awkward.  If you are a student or resident, you will hopefully be with a faculty who will be able to act as a guide for you.  But, if the attending doesn’t make it (or isn’t really helpful) you may find yourself on your own… so I thought some guidance might help.

Go to the meeting. 

This might seem a little obvious, but if your department or school is paying for you to attend a meeting, you should attend the meeting.  If it’s your own money… you should still attend the meeting. This is part of being a professional. Your peers have put a lot of work into their presentations.  Put yourself in their shoes – and stay to hear their talks. Stay engaged during the sessions.  Don’t be the person in the back row surfing the web on a smart phone during the entire conference. Listen actively and ask questions.  If you ask good questions, people will notice and it will reflect well on you.  However, be gracious.  Always thank the speaker for what they said, and don’t be antagonistic when you ask your question.  That will be noticed, too, and not in a positive way.

Look like a professional.

No matter where you are in your training or practice, you will be making a first impression on people who may play a role in one or more of your future position(s). Start off with a suit and tie (or the equivalent for women) the first day.  If you are a woman, make sure you dress as if you are going to an interview – not a party.  If everyone else shows up in jeans the first day, move to more casual wear… starting the second day.  Don’t dress down too much – even if everyone else is doing it.  It’s never wrong to look professional at a professional meeting.

Take advantage of the social events.

Even though it is tempting to sneak off with a couple of our friends and skip the evening reception, don’t do it.  The social events are where you meet the important people in the field.  If you have time, do a little homework about who is attending the meeting and where they are from – just to be able to start a conversation.  Most of the “celebrities” in the field are delighted to talk to people in training, so don’t be intimidated.  You’ll also meet peers at your level at these meetings who will become lifelong colleagues and friends. Introduce yourself to people you don’t know!  If you are invited to dinner or if there is a formal banquet associated with the meeting, you’ll feel awkward if you don’t know the basic rules (like what to do if there is more than two forks).   If you aren’t familiar with formal dinner etiquette, here’s a great site to learn what to do:  Dining Etiquette Guide.

Be fiscally responsible.

Just because someone else is paying shouldn’t mean you pick the most expensive restaurant and order the most expensive items. If you come in under budget people will notice. If you turn in receipts over budget, they will really notice. Save all your receipts, and turn them within a few days of returning.  It’s always a nice touch to thank the people who paid for you to attend the meeting, either in person or with a note.

Reading maketh a full man; conference a ready man; and writing an exact man  -  Francis Bacon

Attending Professional Meetings for Beginners (a previous post on Wellness Rounds)

Handy hints for attending national meetings from KevinMD.com

The USMLE Step exams are important.  Even though they weren’t designed for this, many residency programs use these scores (especially Step 1) to decide who to interview for the NRMP match.  By far and away the best way to decrease the stress associated with this exam is to be prepared when you take it.

The best way to study for Step 1 is to start the process early.  As soon as you can (now, if you are in the first year!) look at examples of Step 1 questions.  This will give you an idea what to expect and will guide you in how to organize your studying.  The strategy for Step 2 will be similar.   Do this systematically – keep notes on your computer or in a notebook, or use the 3×5 card technique to make cards to organize and review later.  Whatever system you choose to use, be consistent.  You really can’t “cram” for the Step exams – it has to be a review.

In addition to developing a systematic approach to preparing for Step 1, it’s a good idea to spend dedicated time reviewing for the exam.  If your schedule allows, taking a full month or two to prepare for this exam is probably a good idea.  If it doesn’t, spread it out over more time, but devote the same amount of time.

The following recommendations are from two 4^th year students on how to review for Step 1.   Use specific ideas that fit you, leave the ones that don’t.  There are many ways to succeed and not all of these recommendations will apply to you.

• First week: Read quickly through First Aid cover-to-cover
  • This reminds your brain of everything you’ve ever studied and gives you the book’s lay-out
  • Read complicated or new information out loud
  • By reading out loud or skimming/reading quickly, it should take  about 6 days

• Second week: Start UWorld as arranged in First AID
  • 46 “randomized” questions per set (2 methods of organization below)
    • Choose the organ system on the right hand side of the menu screen but not any subset groupings;
    • Alternatively, do biochem, behavioral science, and micro questions separately (everything for which there is a section in FA)
      • Then move onto organ system and the associated anatomy/physiology/ path/pathophys
• Don’t worry about time at first, but ultimately you should be well under an hour/block
  • Practice good test-taking strategies
  • Read the last line of the question, skim the answer choices, read the full question for necessary buzzwords/data
  • No phone/gmail/chatting etc. during this time (it’s your “exam” time)
• Take a 10 min break after answering all 46 questions
  • Do all the activities you put off – check your texts/email, go to the bathroom, read ESPN/NPR per preference, etc.
• Review the answers from the 46 q block
  • Keep the 45-50 min “ON” study time (no distractions! No phone/email!) & 10-15 min “OFF” (see above)
• Look up anything you don’t know / can’t explain to yourself
  • Make sure you really understand the explanation, but don’t get bogged down
  • Annotate any crucial information into First AID, using First AID as your primary textbook & notebook
• Repeat above cycle until you have completed all q blocks for that organ system
• Review associated First AID chapter (cardio, GI, etc)
  • Go over your freshly annotated chapter by yourself or with a study partner
    • “I sat down with my BFF and we took turns explaining each page & our annotations, covering details the other might have missed and adding mnemonics/stories.”
    • Review related annotations from other sections (micro/biochem/BS, etc)
    • Optional: listen to the related Goljan section while driving/exercising/etc
• Repeat: Q-Block –> Review –> Annotate –> Q-block…etc… until you have completed all organ systems
• Arrange some question blocks by topic (biochem/micro/etc)
  • You will already have completed all of these questions, but it is easier to review the First AID chapters for biochem/micro/BS if you take a couple question blocks to focus your mind
  • If you are consistently performing poorly on a non-organ based section, you can always interrupt your “organ based learning” and focus on your weak area for a couple of days using the above format (qs, review, annotate)
  • Identify weak areas based on score data & personal comfort
    • Retake question blocks, answers & related First AID chapter

• If you have time during the last 2 weeks, as you go through First AID and your annotations in FA, write down everything you don’t know (don’t get stressed out if you end up writing a lot of stuff down…I think I had 1-2 pages handwritten front and back per section at this point). Then study only your notes and stop looking at First AID. The rationale behind this is that you don’t want to spend too much time rereading the stuff that you are 100% sure you know at a time when you should be focusing on what you don’t know. Note: you may need to start this while you’re still going through UWorld questions, but I think it’s worth your time.

• Last Week:
  • Review First AID from start to finish with emphasis on weaker areas
  • Continue with random blocks of questions or NBME purchase exams to keep in “practice question shape”

• Last couple days
  • 2-3 days before:  review behavioral sciences, write down any formulas for memorization, cram “regurg” factoids/formulas/graphs, cram the things in your notes that you still don’t know
  • Day before: NOTHING
    •  Hang out, relax, distract yourself, go to a movie…
    • You’re not going to change your score for the better by studying/stressing now (but it might make you fatigued the next day)
    • Pack your bag with all your documents, directions, First AID, notes for the next day (& lots of food) so you don’t have to worry in the morning
    • Try to sleep (you’ll be nervous but do your best!)

     

PRACTICE EXAMS

• There are many opinions on how to best use practice exams.  The timing of them is as much an emotional consideration as a fact-based or practice based benefit.  Here’s one way to organize the practice exams that has worked for some students:

• 2-3 Weeks into studying: Free NBME practice exam
  • Get a sense if you are on track, this score will underestimate you’re final score
    • If close to your goal, the score can be reassuring that you should keep doing what you’re doing
    • If significantly lower, the score can be motivation to pick up the pace/cut out distractions

     

• 1 week before the exam: 2x 4 block UWorld practice exams
  • I took all 8 blocks back-to-back to simulate the exam experience (timing of breaks, fatigue, etc)
  • Do NOT review the answers on the same day, in fact, you should probably take most of the next day off to recover
  • Use the results as a comfort that you are on track (my actual score was 1 pt off my practice exams —- and despite fatigue & feeling like my second block of 4 was worse, I actually got identical scores throughout)
  • Look at the stats and focus on any weaker areas (my weakest areas became my strongest by the actual exam)

   

• Last week: fee based NBME Exams
  • I paid for NBME 7, which tells you your estimated score, your percentile in each area, and reproduces the questions you answered incorrectly (but does not give you the correct answer) – again, within 1-2 pts of my final score
  • I worked through many of the exams (some easier, some harder than the my step) during the last week as a way to practice the random mix of qs….I found it helpful
  • Some of the questions on the NBME practice exams were on my REAL Step exam

BALANCE!   You’re job is study and do well on this exam —- but it can be very stressful, even just on a subconscious level.  For most people it works better to really structure your time.

Keep work hours:  go to a library/coffee shop/school on a regular schedule

• 8 am – 5 pm (5/7/8 pm…whatever you decide)
• Taken an hour off for lunch & hang out with friends
• Go home & be DONE until the next day (get good food & sleep!)
• Keep a life
  • Partner, work-outs, family, etc. should be in your life every day
  • Take at least one day off a week at the beginning

RESOURCES

• First AID & UWorld: you must use & love these, everything else is just bonus

• Others (Wiki, BRS, textbooks, Goljan, etc.)
  • Resources other than FA and Uworld will not help your score significantly.
  • Use them to explain specific questions or concepts from UWORLD or FA that you don’t understand or can’t remember
  • Use them if for some reason you have a ton of extra time and already know FA and Uworld like the back of your hand
  • If you choose to use external resources, BRS physiology and the first part of Goljan Rapid Review Path (through the neoplasia chapter) might be worth your while, but seriously don’t worry if you don’t have time to get to them.

Traci Fraser and Natalie Gwilliam, Class of 2012, Baylor College of Medicine

I’m always looking for good websites for recipes that are healthy, simple and easy to make.  In other words, the kind of food that makes it easy to avoid eating fast food when you are on call.   Kalyn’s Kitchen is a fabulous website for delicious, healthy, and often low calorie recipes that meet the “pizza rule” for medical students and residents (i.e. recipes that take less time to prepare than it takes to order a pizza). She also really goes out of her way to teach each step in the recipe, so if you are new in the kitchen, this is a fabulous website for you!

Tuna Salad Lettuce Wraps with Capers and Tomatoes

Not-so-Dumb Salad with Cucumbers, Tomatoes, Onions, Avocado, and Balsamic Vinegar

Mediterranean Tostadas with Hummus, Feta, and Kalamata Olives

Crockpot Double Lentil, Sausage, Brown Rice, and Spinach Soup

I recently spent the night in the hospital with a friend who underwent a minor procedure.  It was a fascinating experience to watch the hospital “from the other side”.  Overall, I was very impressed  – the nurses, patient assistants, technicians, clerks and food service personnel were universally professional and kind.

But then we went to sleep…. or tried to.  Vital signs, meds, and necessary events were more or less over for the day by 10pm.  The unavoidable noise in the hall, unfamiliar bed, and the events of the day made it difficult to get to sleep, but we both drifted off around midnight.

At 4am there was a cheery “Sorry to bother you, but I’m here to get your weight”.  She couldn’t have been nicer but when I asked why my friend had to be awakened at 4am (!) for a weight (!) she responded, “We have to have the weights, labs, x-rays and vitals all completed before the day shift starts at 6am.”

Not too long after this experience, I admitted a long-term (and adored) patient of mine for an elective procedure.  Her parents reminded me that last time she was admitted I wrote an order to forgo the middle of the night vital signs so their daughter (and they) could sleep.  Coming on the heels of the night I spent with my friend, it made me think about how we manage sleep in the hospital.

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Why do we wake patients up to weigh them?

There are patients who absolutely must be woken up for medical reasons.  If you are admitted for a hypertensive crisis, you need to have your blood pressure checked during the night. Waking patients up in the middle of the night for things that could easily be accomplished during daytime hours is done for three reasons, none of which are medically necessary:

1) To distribute work to the less burdened night-time staff from the day time shifts

2) To have the data available for morning rounds.

3) Because of pressure to get the patient out of the hospital at a certain time

Is there really no way to off load the busy day time shift without waking up patients?  Would it really change things if stable patients (particularly if they are on monitors!) were allowed to sleep through the night?  Would it change therapy if the daily weights were at 10 in the morning instead of 4 in the morning?

There’s no question it’s nice to have data for morning rounds – but is it really essential?  How much of this is a holdover from the paper chart era? In the era of the electronic medical record, access to data- at any time of the day or night – is easier than it used to be.  Granted, morning report or rounds would be different, but I think it’s something we could figure out.

There is financial (and other) pressure to get patients out of the hospital.  But have we looked at ways to manage this that don’t involve waking up patients?  For example, there are hospitals that count the “day” in the hospital by the patient census at midnight.  As long as you are out of the bed at midnight you don’t get charged for the day.

Sleep is important for recovery from illness or injury.

There are numerous studies that suggest that the immune system in particular is affected by disruption of sleep.  The data are not conclusive, but many physicians, nurses and scientists have published work suggesting that protecting sleep for ill or injured patients might be important:

• “When tissues have been damaged, the rate of healing is greater during sleep.”

• “Hospitalization may severely disrupt sleep, which can worsen pain, cardiorespiratory status, and the psychiatric health of acutely ill patients”

• “Immune system dysfunction, impaired wound healing, and changes in behavior are all observed in patients who are sleep deprived.”

• “Disrupted sleep is associated with immune system dysfunction, impaired resistance to infection, as well as alterations in nitrogen balance and wound healing.”

• “Sleep deprivation has been shown to be associated with an increase in inflammation that is also involved in the development of neointimal hyperplasia (or restenosis).”

• “Indirect epidemiological and experimental evidence suggest that the severity of injury during stroke is influenced by prior sleep history.”

• “Both acute and chronic intermittent sleep deprivation exacerbate colonic inflammation.”

Sometimes it’s not about the patient.

In babies with necrotizing enterocolitis, we order abdominal x-rays every 8 hours for at least a day or two (to look for air in the abdomen.).  If the x-ray shows “free air” (like the one below), it means they need emergency surgery to deal with the perforated bowel.

The standard schedule in our hospital for q8 (every 8 hours) x-rays is 6am, 2pm and 10pm.  Here’s the problem with that schedule as far as hospital efficiency goes:

• The 6am xray, if it shows a problem, will result in action around 7.  If the baby needs surgery, the operating room is already set up for the 7:30 cases.  Because the OR schedules is usually very full at the beginning of the day, we often then have to “bump” (postpone) a patient to do this emergency case.
• The 2pm x-ray will result in the surgery being posted around 3,  a complicated time in the OR since day time nursing staff is leaving and the remaining cases are being juggled.
• The 10pm xray will start the process rolling at 11 or so – putting the surgeon in the OR in the middle of the night.

Since the timing of the x-ray has a big effect on the timing of the surgery, it becomes a variable that really affects what happens. Here’s what happens if you change the schedule to 3am, 10am, and 8pm

• The 3am xray, if it shows a problem, will result in action around 4. Surgeons are the early-birds of the hospital. Since they will be waking up early anyway, the case can easily be started at 5 or 6, which helps with the OR schedule and keeps the surgeon from being up all night.
• The 10am x-ray will result in the surgery being posted around 11 – this is a time when “holes” in the OR schedule are easier to find, and getting the baby into the operating room will be easier.
• The 8pm xray will start the process rolling at 9 or so – which means the surgeon is more likely to get some sleep.

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What’s the bottom line?  We don’t think about some of the unintended consequences of our orders.  Sleep is important – for both patients and the people taking care of them. It’s worth thinking about.

HAPPY NEW YEAR TO EVERYONE!

Advice for interns

Why I hardly ever drink diet drinks

How to choose your specialty

What to do on your day off

Studying basic sciences – strategies for success

Studying clinical medicine

Getting (and staying) motivated to exercise

How to succeed on clinical rotations

Gifts for medical students and residents

Why I’m spending more time on Twitter

How not to have sore feet after a day in the hospital