Fast Food for Call Nights

It’s 2am on call.  All of a sudden you are starving, not to mention craving comfort food.  The only thing available is MacDonald’s or (on rare occasions) the leftover pizza from the noon conference.  It’s a problem.  Eating that kind of food at 2am will almost certainly result in food coma, not to mention that you really know it’s not healithy or what you would recommend for your patients.

Here’s the answer.

These tacos are a great breakfast on the run, afternoon snack or 2am call food.  It takes ~15 minutes to make 10 of them on the weekend – which is enough to last for several weeks.

Start by chopping up the veggies you want to put in the tacos.  My “go to” is one red bell pepper and a poblano pepper.  Corn and rice work well, too.  You can change the taste by using different cheese and different veggies (brocolli, carrots etc with Monterey Jack, for example).

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Buy the cheese you want already shredded.  Lowfat Mexican is my usual choice, but any cheese is fine.  I’ll often cut up a block of 50% Cabot cheddar cheese which is a great tasting low calorie cheese.

Put 10 whole wheat tortillas on the counter and divide one can of refried beans between them.  Use nonfat if you are watching calories.  Black beans, pinto beans, spicy or not – your choice!

Divide up your veggies and cheese onto the 10 tacos.

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Roll them up and put them in snack size plastic bags.

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Put the little bags in a gallon freezer bag (important to prevent the bad taste of freezer burn) and put them in the freezer.  They last for weeks.

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Two minutes in the microwave directly from the freezer gives you a great breakfast, snack, or middle of the night comfort food!

Duty Hours, Interns and Training Doctors

For most people, talking about a 16-hour workday is outrageous.  For doctors in training, it may not be enough.

Training doctors is not easy.  It’s not just a matter of learning what is in the books or latest articles. Under the supervision of attending physicians, young doctors learn the art of doctoring by staying with and caring for their patients.  Because of the work they do while they are learning, resident salaries are supported through Medicare… mostly.  That’s another issue, but not unrelated to the issue of duty hours.

Twenty years ago, it wasn’t unusual for an intern to arrive at 5 or 5:30 in the morning, work all day, stay up all night on call, and then work the following day until evening rounds were finished.  That meant 36-hour shifts and many weeks with more than 100 hours in the hospital.  It was clear that this wasn’t sustainable, nor was it safe.

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After much debate, in 2003, the initial duty hour regulations were put into effect.  In a nutshell, residents couldn’t work over 80 hours a week (on average) and they weren’t allowed to stay longer than 24 hours.  If they worked all night, they had to go home the next day.  In 2011, the regulations were revised.  The major change was that interns (residents in their first year of training) could only work 16 hours in a row instead of 24.  On the surface, this made sense.  Fewer hours should mean more sleep.  More sleep should mean rested interns and fewer mistakes.

I wasn’t surprised to read the article published by Time magazine entitled “Fewer Hours for Doctors-in-Training Leading To More Mistakes.”  This report, summarizing the on line JAMA Internal Medicine article from this week, noted that “interns working under the new rules are reporting more mistakes, not enough sleep and symptoms of depression.”  In the same issue, authors from Johns Hopkins reported the results of a prospective, randomized crossover trial comparing the new regulations (16 hr work day) to a 24 hours work day with the next day off. They showed no significant difference in the number of hours the interns slept per week between the 16 hour and 24 hour shifts.  However, there was a marked decrease in educational opportunities, a significant increase in the number of handoffs, and less resident satisfaction with the 16 hour work day.  Most importantly, both the interns and the nurses caring for patients felt that the quality of patient care was decreased by the 16 hour duty hour regulation.

Why would there be more mistakes? Patient care is usually transferred in the morning (to the entire team) and in the evening (to the resident covering the patients at night).  That’s roughly every 12 hours.  When a portion of the team is rotating on a 16-hour schedule, it results in more handoffs (usually to fewer team members). Increasing the number of times information is transferred between doctors means increasing the risk of communication errors.

If they are working fewer hours why are they not more rested?  The new regulations almost require a “night float” system to insure that the patients are taken care of.  Working nothing but nights for one week a month followed by 16 hour days is not conducive to being rested.

Why are interns depressed? Remember, decreasing intern work hours didn’t change how much work there was to do in a day – and most hospitals didn’t respond by hiring more people to help.  Interns worry that they are “dumping” on their colleagues because they are being required to leave earlier than the other residents.  Less obviously, they are learning to be professionals but are being treated like they can’t “take” the hours of the residents one year above them. The message is subtle but real.  There’s also a perception that the quality of patient care is decreased by the new system – which is reason enough for a young doctor to feel bad.

Education is clearly impacted.  These studies document what we have all observed on the wards.  Interns working 16 instead of 24 hours admit and follow fewer patients.  In the surgical specialties, they participate in fewer cases.  They also attend fewer teaching conferences.

The solution to this complex problem isn’t going to be easy.  It’s an ongoing struggle to balance service vs. education, fatigue vs. experience and, maybe most importantly, how we pay for the incredibly important mission of training doctors.

I’m working hard to be part of the solution – along with everyone else in medical education.  We owe it to the future physicians we will train and the patients they will take care of.

Starting Internship (I know what you are worried about)

I sat at the table this week with our new interns and the outgoing chief residents. Listening to our new interns as they asked questions, I realized everyone starting their internship has the same fears, whether or not they express them:  Will I kill or hurt someone?  Will I look stupid?  What if they find out I’m not as smart as everyone else?  Will I get divorced/separated/alienated from my friends?  Will I gain weight?  How am I going to find time to take care of myself?

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What you are feeling is normal. Every doctor who ever started an internship felt exactly the same way.  The best way to manage your (healthy) fear is to have a strategy.   I’ve written in the past about how to succeed as an intern.  But if I were going to condense that advice into three easy rules (for every day except your day off)  it would be these:

1.    Read at least one section from a textbook in your field every day

2.    Learn something (in detail) from at least one patient every day

3.    Do something to take care of yourself every day

Read at least one section from a textbook in your field every day.

Your goal for the year should be to read a major textbook in your field cover to cover.  You don’t have to buy the physical book.  It’s fine if it’s on line or downloaded onto your iPad.

Once you have the book, make a list or spreadsheet of all the sections in all the chapters.  For most textbooks, it’s probably going to be a list somewhere between 150 and 200 topics.  When you look at the 48-50 weeks you will be working this year, it works out to basically a topic a day (with some days for review).

The real goal is not just to read these topics, but to really learn them.  So, when you read, don’t just skim.  Read to learn.  That means taking notes – and reviewing them.

Put a chart on the wall with the list and give yourself a gold star when you finish a topic if you have to, but find a way to make sure you cover all the topics (at a steady pace) during the year.

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Learn something (in detail) from at least one patient every day.

It’s really easy, as an intern, to get caught up in the work and forget that you are fundamentally here to learn – not to provide service.  Make it a daily habit to learn in detail about one patient in your care.  It will overlap nicely with your goal to read a complete textbook.  When you admit a patient with pneumonia, read the section (and make notes) on pneumonia and then check it off your list.

One other important point (that none of us like to hear) – You will make mistakes. Be humble, be honest, and learn from your mistakes. The mistakes you make (and maybe more importantly your “near misses”) are absolutely your most valuable teacher.  When you do make a mistake, use it as the topic you will review for the day. You are going to be really upset but be easy on yourself.  Being upset is the mark of someone who cares, but don’t let it escalate beyond a healthy response. Talk to your mentors and senior residents.  They’ve been there.

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Do at least one thing to take care of yourself every day.

This may sound trivial, but it’s not. If you can, try to eat well, get some exercise and be social every day.  At a minimum, though, pick one specific thing you are going to do for yourself and then do it.

Eat well

Get Some Exercise

Be social

Beepers and Pagers and Phones… Oh, my!

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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Eat Healthy Fats (July’s Healthy Habit)

One of my New Year’s resolutions this year was to come up with monthly “resolutions” for myself and for anyone who follows this blog.  Cooking Light magazine (which is one of my favorite sources of recipes and ideas for healthy living) had the same idea, so I am shamelessly borrowing their healthy habits!

It’s a lot easier to commit to 30 days of a new habit than a full year.  So this month’s goal is to eat more healthy fats.

The “myth” of fats has become so pervasive in our society that even physicians (and physicians in training) succumb to the idea that fats are somehow “bad”.  The type of fats we consume as a society have changed in the last few decades, a change that may have played a part in our current obesity epidemic (and associated diseases).  If you are interested in reading more about this, I would suggest starting with Michael Pollan’s In Defense of Food, David Kessler’s The End of Overeating:Taking Control of the Insatiable American Appetite, and Laura Sim’s The Politics of Fat: Food and Nutrition in America.

What kind of fats are in the food we eat?

There are three important dietary fats :  saturated fats, unsaturated fats, and transfats.

Fat-ChartLink to source for this chart

  • Saturated fats are generally solid at room temperature.  All animal fats are primarily saturated (meat, lard, butter, cream, fish oil).  The majority of plant based oils are primarily unsaturated, but there are a few exceptions.  Examples of vegetable oils that have a high percentage of saturated fat include palm oil and coconut oil.

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What fats should I eat?

Here is a great summary from mayoclinic.com– the “bottom line” of how to adjust your fat intake for an optimal healthy diet

  • Limit total fat to 20 to 35 percent of your daily calories. Fat has 9 calories a gram. Based on a 2,000-calorie-a-day diet, this amounts to about 400 to 700 calories a day, or about 44 to 78 grams of total fat.
  • Emphasize unsaturated fats from healthier sources, such as lean poultry, fish and healthy oils, such as olive, canola and nut oils.
  • Limit less healthy full-fat dairy products, desserts, pizza, burgers and sausage, and other fatty meats.

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Fat content in “I forgot to bring my own food” on-call food….   Which is why it’s so important to plan your food on call.

  • McDonald’s Quarter Pounder with cheese:  26 grams of fat (12 saturated, 2 transfat)
  • McDonald’s Big Mac: 29 grams of fat (10 saturated, 2 transfat)
  • McDonald’s large fries: 30 grams of fat (6 saturated, 8 transfat)
  • Domino’s Pizza (2 slices Pepperoni): 26 grams of fat (11 sat, 0 transfat)
  • Chipotle Chicken burrito (all the way): 53 grams of fat (20 sat, 0 transfat)


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Recipes with healthy fats (that meet the “pizza rule”)

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Heirloom tomato avocado stack

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Marinated salmon with mango kiwi relish

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Vegetarian West African Soup

More information on dietary fat:

Dietary fats: Know which types to choose from mayoclinic.com

Fats and cholesterol from the Harvard School of Public Health

Fat – From the NY Times Health Guide

Advice for New Interns

This is the week that the roughly 16,000 new doctors in the United States will start their residency training.  Even though it doesn’t feel like it, you are ready!  The first year of medical school gave you the “vocabulary” you needed for this new language.  The second year gave you the “grammar.”  Your rotations in the clinics taught you the “language”.  Now you get to actually use it every day!

This year will be one of the most profound transitions you will ever make…. and it will also be a year of intense and fabulous memories.  Take some time to write down the stories, or take some photos (but not of patients unless you have their permission!).  These notes and images will be precious memories in the future.

In talking to other physicians and thinking about my own experiences, here are a few words of advice for you as you start your internship this week:

Learn from every patient.

As an intern, you will need to know a lot of detailed information on your patients.  You’ll need to use a system to keep track of all this information so that when you are asked, you know the last potassium level, which antibiotics were ordered and what the ID consultant said.  If you have a system you developed as a 4th year medical student, great!  If not, start with 3×5 cards. Keep one card per patient, clipped together or held together with a metal ring.   There are electronic systems available like iScut and My scut list.  I haven’t found one that I think is adequate -  but I’d love to hear from anyone who has found good software that works!  Also (very important) – if you are going to have any patient information stored electronically, please make sure it is HIPAA compliant.

That covers the information, but not the learning.  Learning is something that should be actively integrated into your day, not something you do at night when you are falling asleep.   Work on a system that lets you record what you are learning during your daily tasks in a way you can review later.  3×5 cards are a simple, cheap and very effective system for studying medicine, which I’ve described in a previous post. Make a separate card (or use the back of your rounding card) to list something (anything) you learned from every patient you see.

Don’t confuse gathering information with studying information.  Taking notes is a critical part of learning. Don’t just make files of chapters and articles… summarize them to review later by taking notes.

Be the doctor for your patients.

This may sound obvious, but in the everyday world of the hospital, it is really easy as an intern to get lost in the details of patient care… and forget about caring for the patient.  Stop every once in a while and remember that you really are their doctor.  Take a few deep breaths and put yourself in their shoes for a minute to ask something about their family, hold their hand, or just sit with them for a minute.

It’s very easy to get swept away by the velocity of the work most interns experience and lose the “big picture”.  When you are confronted with something you haven’t seen before, push yourself to make a plan before you call your upper level resident or the attending.  What if you were really the only doctor around?  What would you do?  Spend 2 minutes on UpToDate if you have to, but don’t just be a clerical worker – be their doctor.

Part of being a good doctor to your patients is to recognize your own limitations.  You should never feel bad about calling someone with more experience, no matter how “dumb” you think the question is.  It’s the right thing to do for the patient.

Be deliberate about learning your field.

From day one, commit to an organized plan of study to cover everything you need to learn in your field.  Your goal should be to learn (not just read) everything in the primary textbook for your field.

Make a plan to read (and then study to learn) a textbook every year.  Make notes that are easy to review, so you don’t have to go back to the textbook to review the material.    Whatever system you use, make it easy to integrate the notes you are making in the hospital (i.e. the 3×5 card on each patient) with your organized study system.  Adding articles into the mix is fine – but only after you have mastered the basics.  Don’t let reading the latest finding take the place of really learning the material in the textbook.

Be kind and be part of the team.

Hard work is made easier when it’s done with your friends.  You will all be tired, you will all be stressed, but be kind to each other.  Staying 5 minutes more to help out a fellow intern is an investment that will help both of you.  Look for ways to apply the golden rule of internship:  “Help others the way you would liked to be helped”.

Make your bed.

Do this simple act every morning to remind yourself to take care of yourself.  Find time to consciously take care of your emotional, physical and spiritual health. Take good food to the hospital for your nights on call.   Find ways to get stress reducing exercise into your weekly schedule, or at least find ways to increase your activity while you are at work. Watch your weight – if you are losing or gaining, it’s a sign that you need to focus on your own wellbeing by improving your nutrition and working on your fitness.   Nurture your relationships – make your family and friends a priority.  Take care of your spiritual needs in whatever way is best for you, but don’t ignore this important aspect of self-care.

Smile!

You have the enormous privilege of caring for other people and learning the art of medicine.   Take a little time every day to notice the moments of joy in this work and, if you can, write them down to look at on the days you are tired.

Congratulations to you for all you’ve accomplished thus far!  Enjoy this incredible journey!

Cold Summer Treats

It’s summer and it’s hot.  I’m on call this weekend.  That combination made me think about cold comfort food I could take to work.

Chocolate (in any form) is always the answer… but I decided maybe I could find something a little more healthy (and a little less caloric) that could serve as the “treat” we all crave when we are working hard on call.  I’m thinking the team will like a little Salpicon mid afternoon tomorrow…

Salpicon – a sparkling fruit drink from Columbia

This soup looks delicious, but with the heavy cream probably isn’t in the “low calorie” list.  You can substitute milk or yogurt to cut calories (without too much sacrifice of taste).  But, then again, as an on-call treat this still beats McDonald’s!  This is just one example of cold soups – which are great for summer on-call days.

Cold avocado soup

Smoothies are great comfort food – but logistically not easy when you are on call.  If you love smoothies, you might want to invest in an inexpensive single-serve blender.  Take the fruit in a baggie, put some yogurt and ice cubes in… instant smoothie.  Alternatively, you can blend your smoothie at home and put it in a container in the refrigerator that you can shake up before drinking.

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Banana mango smoothie

Fast Easy Recipes: Skinnytaste.com

In keeping with this month’s goal of cooking more at home, I thought I’d share a website with you. Skinnytaste.com has great low fat, low calorie recipes that are easy to cook (and family tested).  Even if you are not worried about your weight, these recipes are great for being on call – lots of energy and lots of food without too much fat (which will make you sleepy).

Recipe for cheesy zucchini enchiladas

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Recipe for Shephard’s Pie (LIghtened up)

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Recipe for Southwestern Black Bean Salad

February’s Healthy Habit: Get Moving!

One of my New Year’s resolutions was to come up with monthly “resolutions” for myself and for anyone who follows this blog.  Cooking Light magazine (which is one of my favorite sources of recipes and ideas for healthy living) had the same idea, so I am shamelessly borrowing their healthy habits!

Cooking Light’s 12 Healthy Habits

It’s a lot easier to commit to 30 days of a new habit than a full year.  So this month’s goal is to maintain or improve fitness by increasing activity.

It may seem daunting to stay in shape or even improve your fitness level when you are swamped with studying or work in the hospital.  It’s not easy, but it is absolutely doable.  The best way to start is to pick one or two of the following ideas and make them a resolution for this month.  Pick goals that are “SMART” (Specific, Measurable, Attainable, Realistic and Timely) and then just do it! Consistency is the most important part of setting this goal – so pick something that you know you can do on a regular basis.

Some ideas to consider:

  • Take the stairs at work instead of the elevator
  • Commute to school or the hospital on your feet or on a bicycle
  • Park as far away from school or work as is reasonable and walk the rest of the way
  • Plan ahead for 10 minutes of exercise while you are on call and take what you need
  • Wear a pedometer and get 10,000 steps/day
  • Do push-ups every morning before you go to work
  • Find a cardio exercise that isn’t boring for you and do it 30 minutes 3x/week
  • Run.  It’s easy, it’s cheap and it’s the most effective exercise for busy people!
  • Hire a trainer for one workout a week (or ask for this as a present)
  • Play golf, tennis, racquetball – any game that gets you moving!
  • Find a spin class or other organized exercise class to attend once a week
  • Organize a basketball or ultimate Frisbee game with your friends once a week
  • Shoot for a total minute goal/week of exercise (start with 100?) and keep track
  • Whatever you decide to do, PLAN – make it an appointment on your calendar, put it on your daily scut list, get your clothes out the night before – do whatever it takes to make it happen!

Easy Ways to Increase Activity at Work

The Institute of Medicine recommends 60 minutes of vigorous exercise everyday to maintain optimal health. The scientific evidence is clear – we would all be healthier if we did real exercise for an hour a day.  But – as Dr. Richard Forgos says in his commentary on the subject  - “An hour a day? You’ve got to be kidding!”  I agree – It’s next to impossible for most physicians, students and residents to find an hour to exercise every day.  (Which is really more like 1 ½ or 2 hours if you plan to go somewhere like a gym).

That being said, any amount of exercise you can add to what you are (or aren’t) doing now will improve your health, help you control your weight, and improve your mood.  When you can, try to schedule a real workout.  When you can’t, focus on easy ways to add small amounts of activity into your normal day:

Take the stairs.  For one week, make yourself take the stairs every time you change floors.  You’ll see an improvement in your huffing and puffing by the end of the week, and you’ll be convinced that this is real exercise!  When I was a resident, one of our legendary attendings climbed a new mountain every summer during his vacation.  The only training he ever did was to take the stairs in the hospital.  (He looked great after 10 flights of stairs… the interns were suffering.)  At a minimum make a 2 or 3 floor rule i.e. take the stairs if you are going up 2 or 3 floors.  You should always take the stairs if you are going down!

Commute on your feet. If you live close enough (and it’s safe), walk or bike to work.  If you have to drive, park farther away than you usually do so you have to walk a little farther.

Wear a pedometer. Find out how many steps is an “average” day for you and set a new goal.  Shoot for a minimum of 10,000 steps a day.

Don’t stroll on rounds.  A lot of people who give advice about increasing activity talk about “walk meetings”.  We have walk meetings all the time!  (We call them rounds.)  If you are in charge of rounds, set the standard by walking quickly between areas and taking the stairs.

Drink a lot of water and then use restrooms on a different floor. No one drinks enough water at work, so this helps meet that need.  The obvious consequence of drinking enough water can lead to more walking!

Stand when you are talking on the telephone or writing in a chart. This sounds trivial, but it actually adds a lot to overall activity.  If you are somewhere you won’t be embarrassed, add some squats or lunges while you are talking.

Have active post-call “team meetings”. Instead of meeting for a “beverage” at a restaurant (or other establishment), go play Frisbee in the park (beverages allowed).  (Picture from http://en.wikipedia.org/wiki/Flying_disc)

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10 simple ways to increase your physical activity – obesitypanacea.com

Increasing daily activity – American Heart Association

Exercise at work – about.com