Category Archives: Exercise

Motivation

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I worry that trainees who read this blog might think I’ve somehow figured all this out and they never will.  Nothing could be farther from the truth!   What I have figured out, though, is that working on wellness is a journey and not a destination.  The same holds true for anything that needs some motivation (studying for the inservice exams, etc).  No one does this perfectly – we all have times we do better on the journey, and times we don’t.  What’s important is not letting the momentum of a crazy schedule drag you away from taking care of yourself.  Getting off track is expected.  Getting back on is the key.  Last week, for example, I really wanted to work out every day (and thought I actually might have time).  I knew ahead of time that setting that goal might mean working out 3 or 4 times.  But the reality is that I only made it to the gym once.  Some of it was setting expectations too high for a predictably busy week.  Some of it was not having a back up plan with some lighter or smaller workout when “Plan A” fell through.  And most of it (which I know you can relate to) was fatigue that made being motivated difficult.

Which got me thinking about motivation in general and what I might be able to learn from last week.  Here’s what I found….

“Viewing motivation as the ability to resist the lure of “bad” foods or overcome the appeal of lying on the couch will only lead to frustration and self-blame. Things go much better when you see motivation as the ability to give yourself the chance to make conscious decisions and take responsibility for these choices. Therefore, the main “enemy” of motivation is the tendency to see yourself as the hapless victim of forces (or urges) over which you have no control.”

http://www.sparkpeople.com/resource/motivation_articles.asp?id=630

“Being healthy isn’t a decision you make once — it’s one you make every day. Recommitting to your goals is necessary to keep yourself on track.”

http://exercise.about.com/od/plateausmotivation/a/motivation_2.htm

You have to find ways to find motivation when it lags like “avoiding the feeling of yuck” (one of my favorites on this list)

http://zenhabits.net/2007/10/31-ways-to-motivate-yourself-to-exercise/

Why You Should Run and How to Get Started

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I hate running.  Whew.. that’s out of the way.  BUT – I have been a runner in the past, I live with a runner, and it’s absolutely clear to me that running is the ideal cardio exercise for medical students and residents.  So, I’m going to try to convince you that you should incorporate running – even in a very small amount – into your daily routine .

Why Running is Perfect for Medical Students and Residents

  • It’s cheap.  Other than an good pair of running shoes (and don’t buy less than good ones), there is no expense.
  • It’s portable.  A bag with your shoes, shirt and shorts can stay in the trunk of your car.
  • It’s social.  Once you identify a friend or two who agree it’s a good idea to run, you can do it together.
  • It’s efficient.  Short runs are still a great workout.  Unlike other workouts which require planning, travel and time to complete, you can walk out the front door and run.
  • It’s empowering.  You can set goals and easily accomplish them.  There are a lot of times during your training that you will feel things are out of your control. Setting a goal (I’m going to run a mile) and then doing it (Yeah!) is empowering.
  • It does more than just get you fit.  There are good data that show that exercise in general (and running in particular) decreases stress, improves depression, helps sleep, etc. etc.

How to get started

Here is a great guide for beginners from the New York Times that I recommend you read. Another qreat source is the most recent online Runner’s World guide on how to start running.  It’s hard to find now, but here are some tips from the Runner’s World May 2010 Special Beginner’s Guide:

  1. Don’t do too much to start with.  Start with walking and add in small amounts of running.  “Every able-bodied person can be a runner,” says Gordon Bakoulis, a running coach based in New York City, :Just start slowly and build up gradually.”
  2. Be consistent.  Your goal is to exercise every day. Cardio is an important part of your exercise, but not all of it.  You can run every day, but you’ll have to find  time to do resistance and flexibility training as well.  Alternatively, you can view resistance days as “recovery” from running i.e. alternate the days. Commit to some kind of exercise everyday.  Plan your week to make sure you get at least 3-4 cardio sessions/week – and then cut yourself some slack if something happens that pushes you off track.  It’s human nature – if you say you are going to run every day, you’ll probably run 4 or 5 times.  But, if you say you’ll run 3 times a week, it will probably end up being only once.
  3. Read, ask questions, learn about this skill.  Every city has a “runner’s store” (which is different from a store than sells running shoes).  Ask the runner’s in your class where they go to buy their shoes.  The store will have shoes, but it will also have very knowledgeable people who will be delighted to help you learn about running.

How to fit it in and how to stay motivated

  • I know you don’t want to hear this, but early morning is the best time to run.  It’s an energizing way to start the day, you “get it out of the way”, and you don’t have to fight the siren song of the couch at the end of a long day.  If you do choose to run at the end of the day, change into your clothes before you leave school or the hospital and run before you get home.  If you have willpower of iron you might be able to lace up the shoes and run before you go to sleep … if it works for you, great!  (but it won’t for most people) .
  • Think about signing up for a fund raising group.  Running for kids with cancer makes you feel pretty silly about whining….
  • Register for a 5K race – having a goal to finish  (and getting your first time) will be motivating
  • “Gratitude is contagious.”  Kristen Armstrong suggests that instead of feeling like you “have” to run that you think about what a gift it is that you “get” to run.  “If you view your run as an opportunity, your attitude will get an adjustment”.

My Back Hurts…

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Back pain is very common during medical training.   All doctors spend time leaning over beds …. some of us (e.g. surgeons) more than others.  Back pain for most physicians is about core fatigue.  When you lean over for any length of time you are supported by your core muscles.  When the core muscles begin to fatigue, you transfer the job of holding the position to your joints (spine, hips, knees) and the muscles of your back.  So – the most important way to prevent or get rid of back pain is core training.   Crunches alone won’t do it – they just work the muscles in one direction.  What causes our pain is twisting with bending over.  You need a set of exercises that strengthen your core in more than one direction.  A great way to strengthen your core (if you have time for the classes) is doing yoga, pilates, or tai chi.  But (assuming you don’t really have time for classes), commit to 5 minutes a day of core exercises and I bet you’ll see a difference.  Needless to say, we’re talking about “ordinary” back pain here.  If you have symptoms of radicular pain, weakness or paresthesias go see a doctor!!!

Here’s some urls with good illustrations of functional (i.e. all directions) core exercises

http://www.mayoclinic.com/health/core-strength/SM00047

http://sportsmedicine.about.com/od/bestabexercises/a/all_abs.htm

One other really important thing – make sure you use a good technique if you have to lift a patient (or any other heavy object) i.e. face the object (no twisting) and use your legs, not your back.   http://www.webmd.com/back-pain/lifting-properly-to-prevent-back-injury

For surgeons, you can do a few things in the operating room that will help.  This list is from an article I published last December (Am J Surg. 2009 Dec;198(6):742-7. PMID: 19969123)

All surgery

  • Set the table height at the level of the umbilicus of the tallest assistant/surgeon and use standing stools for all other personnel

Open surgery

  • For long cases that require torsion of the back (pelvic surgery, head and neck surgery), change positions often; raise or lower the bed slightly; switch sides; and stretch periodically

Laparoscopic surgery

  • Place the monitors so they are directly in front of the operating surgeon/assistant, the goal is to avoid any twisting of the neck for the surgeon or assistants
  • Place the monitors in laparoscopic surgery slightly below eye level (15° is best) to have a slight head-down gaze
  • Use enough standing stools to provide a large enough platform for foot pedals (2 deep, 2 wide if necessary)
  • Once the trocars are in place, lower the table (or add standing stools) so the operating surgeon has relaxed shoulders
  • Avoid positioning foot pedals so the surgeon has to stand on one foot; even better, switch to the most ergonomic possible hand control

Fun Ways to Exercise

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This list is taken from a site I came across a while ago. http://zenhabits.net/2009/12/48-fun-exercises/    The work we do as medical students, residents  or practicing docs is hard.  Adding more “work” is not the answer. Put another way, sometimes “going to work out” becomes one more thing on the day’s scut list.  A far better approach is to look for fun ways to add activity to the day.  Go outside and play!

  • Aerobics
  • Ballet
  • Baseball
  • Basketball
  • Biking
  • Boating
  • Bowling
  • Boxing
  • Canoeing
  • Dance Revolution
  • Dancing
  • Double Dutch
  • Field Hockey
  • Football
  • Frisbee
  • Golf
  • Gymnastics
  • Hiking
  • Hockey
  • Hopscotch
  • Horseback Riding
  • Hula hooping
  • Ice Skating
  • Jogging
  • Juggling
  • Jump rope
  • Laser tag
  • Paintball
  • Ping-Pong
  • Playing catch
  • Rock Climbing
  • Roller Blading
  • Roller Skating
  • Running
  • Skateboarding
  • Skiing
  • Soccer
  • Softball
  • Swimming
  • Tae Kwon Do
  • Tennis
  • Trampoline
  • Treadmill
  • Unicycling
  • Volleyball
  • Walking
  • Weightlifting
  • Wii sports games

    • Top Gifts for Medical School Graduates

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    This may be open for (a lot of) discussion… but here’s my list.  Feel free to send it to parents, significant others, etc.  If anyone has any other ideas, let me know – I’ll keep adding to the list!

    1.  A weekly maid service for period of time (a year if you can)

    2.  A gym membership for a period of time (a year if you can).  Probably better to make this a certificate of some kind for “after you get settled” – if they are moving to another city for their internship, they will want to join the gym that their friends use.

    2.  A new (top of the line) smart phone

    3.  A Kindle or other electronic reader (plus a gift certificate for non-medical books, if you can)

    4.  “Homemade” meals certificates (if you don’t live somewhere close and can’t do this yourself, find a “ready prepared” food service.   I googled for “premade healthy meals” in Houston, for example,  and found at least 8 different businesses that do this. )

    5.  Gift certificates to Whole Foods market or other healthy grocery stores.

    6.  A new laptop with video (if they don’t have one that lets them use Skype or other video services)

    7.  A week of vacation before they start their internship.

    8.  A nice pen will be appreciated… and might be used… if it’s not immediately lost when you are on call…

    9.  If you are thinking about a watch (which is nice) remember where it is going to live and that it will be taken on and off all day.  It should have practical things like an alarm and a stopwatch/second hand.  It’s fine to get a fancy watch, but it will be worn on vacation or trips home (and not in the hospital).

    10.  A letter with all the things you think are wonderful about them, why you are proud of them and why you think they are going to be a fabulous doctor.

    11.  A wok.  It turns out that cheaper (carbon steel) is better than expensive when it comes to woks.  Do a little research on the subject, but I recommend the classic, round bottom cheap wok.

    12.  Kitchen supplies to cook for themselves.  There are several options in this category:  a good set of knives, a set of pots and pans, baking supplies, or a gift certificate to a cooking store.

    13.  A gift certificate to Penzey’s spices (www.penzeys.com) if they are already a cook (or you think it will encourage them to cook)

    What NOT to buy —-

    1.  Any medical equipment (unless you are a practicing physician yourself and it’s specific to the graduate’s chosen specialty).

    2.  A black bag.  This is a little debatable because these are very sentimental… but no one I know has ever used their black bag.

    3.  Anything for an office (won’t happen until after residency, so save this for when they finish their residency)

    Book Recomendation: Iron Doc by Mamta Gautam, MD

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    I became aware of this book last week through one of the anesthesia residents at work (whose chairman made this book required reading for all residents in his department).  Dr. Gautam is a psychiatrist who has specialized in caring for physicians and is an expert in physician wellness.  She uses training for an Ironman triathalon as an analogy.  Physicians have to “train” for different roles (personal and professional) if we want to prevent burnout.  She proposes a training program that helps keep balance in the complicated life of a doctor. The book primarily addresses physicians already in practice, but the information is very applicable to trainees, as well.

    Here’s her website if you are interested:  http://www.drgautam.com/gautam/books.htm

    You Can Exercise Even if You are on Call

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    One of the great fallacies about working out is that you need to “go somewhere” to work out.  This idea that working out is separate from the rest of your life is the main reason people don’t work out.  Be creative – there are lots of ways to work out that don’t require much and can be done in the hospital.  There are days on call and then there are days on call (everyone who has done it knows what I am talking about).  On the days that have a little “breathing room” here are some ways to work out while you are at work.

    Cardio options

    1. Take the stairs instead of the elevator.  There are good data that 3 sessions of 10 minutes of cardio has the same result as a 30 minute cardio session.  Those 2-3 minute “sessions” of going from floor to floor will add up to 20-30 minutes easily by the end of the day.  Or, if you want to push it a bit, add a few flights (or minutes) here and there.  You can always find 10 minutes (or 20, if the day permits) and really climb the stairs.
    2. Take a jump rope to the hospital and keep it in the call room
    3. Find out if there is a stress test lab or PT area in the hospital that has stationary bikes or treadmills that you can use.
    4. Go for a walk.  If it’s safe, and your beeper and cell phone permit, walk outside the hospital.  If not, do “power rounds” on the floors for exercise (do the circuit of each floor, climb the stairs to the next floor and continue).
    5. Talk your program into paying for a used bike or treadmill.
    6. Commute to work on your feet or on a bicycle (more on that later…)

    Strength training options

    1. Buy a set of stretch bands or inflatable (with water) dumbbells and throw them into your on-call bag.  You can get a good strength training workout with these.
    2. Cheap dumbbells are easy to find.  For $20-30, you can put a pair or two  in the call room or resident lounge.  See if there are other residents that want to go in with you to buy a complete set.  Of course, you will have to find a way to lock them up if, like most hospitals, things have a habit of walking away.
    3. Old fashion calesthenics (push-ups, squats, etc) will provide a good strength workout , too. You might consider one of the many popular DVD based programs that are making the rounds (no pun intended) at the moment.

    Flexibility training

    Stretching can be done anywhere, anytime.  Like weight training, there are some good tips that can be taught by a pro.  Make sure if you hire a personal trainer that you ask them to give you some tips about stretching, too.  There are also excellent books on stretching.  You might think about web based or DVD yoga sessions as another alternative.

    The key concept here is that working out during call is doable – and will often help with fatigue, stress and the feeling of being overworked.  These “workouts” don’t have to be long – even 10 minutes will help.

    Preventing Weight Gain in Residency

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    This is the time of year when 4th year medical students are winding down and preparing for the “big move” into internship.  Our 4th year students take a special 3 week course to get them ready – a wonderful mix of small groups on professionalism, ACLS training, first night on call beeper emergencies…etc, etc.  It ends with a small group of senior faculty who talk about making the transition to residency.  I wish we’d recorded the talks – they were all really wonderful.  In addition to giving wonderful professional advice,  all of the faculty included advice on taking care of yourself.  It struck me that one of the specific issues that each of them mentioned (well, four out of five) was how much weight they had gained in their internship and residency.

    Losing weight is not easy for those that struggle with this issue – but preventing weight gain is not as hard – and should be a goal for every intern and resident!   It’s not hard – you need to increase your activity (a little) and watch out for stupid food choices.   Here’s the “rules” I wish someone had given me before I started my residency (if you have rules you would add, please send a comment!)

    1.  No junk food (doughnuts, pizza, hamburgers, etc)

    2.  Take healthy food with you to work – especially for call nights.  Keep emergency healthy food in your locker i.e. high quality energy bars, dried fruit/nuts (in appropriate small portions).

    3.  Make sure you get an hour of real exercise on days when you are not in the hospital

    4.  Take the stairs instead of the elevators.

    JAMA. 2010 Mar 24;303(12):1173-9.

    Physical activity and weight gain prevention.

    Lee IM, Djoussé L, Sesso HD, Wang L, Buring JE.

    Division of Preventive Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02215, USA. ilee@rics.bwh.harvard.edu

    CONTEXT: The amount of physical activity needed to prevent long-term weight gain is unclear. In 2008, federal guidelines recommended at least 150 minutes per week (7.5 metabolic equivalent [MET] hours per week) of moderate-intensity activity for “substantial health benefits.”

    OBJECTIVE: To examine the association of different amounts of physical activity with long-term weight changes among women consuming a usual diet.

    DESIGN, SETTING, AND PARTICIPANTS: A prospective cohort study involving 34,079 healthy US women (mean age, 54.2 years) from 1992-2007. At baseline and months 36, 72, 96, 120, 144, and 156, women reported their physical activity and body weight. Women were classified as expending less than 7.5, 7.5 to less than 21, and 21 or more MET hours per week of activity at each time. Repeated-measures regression prospectively examined physical activity and weight change over intervals averaging 3 years.

    MAIN OUTCOME MEASURE: Change in weight.

    RESULTS: Women gained a mean of 2.6 kg throughout the study. A multivariate analysis comparing women expending 21 or more MET hours per week with those expending from 7.5 to less than 21 MET hours per week showed that the latter group gained a mean (SD) 0.11 kg (0.04 kg; P = .003) over a mean interval of 3 years, and those expending less than 7.5 MET hours per week gained 0.12 kg (0.04; P = .002). There was a significant interaction with body mass index (BMI), such that there was an inverse dose-response relation between activity levels and weight gain among women with a BMI of less than 25 (P for trend < .001) but no relation among women with a BMI from 25 to 29.9 (P for trend = .56) or with a BMI of 30.0 or higher (P for trend = .50). A total of 4540 women (13.3%) with a BMI lower than 25 at study start successfully maintained their weight by gaining less than 2.3 kg throughout. Their mean activity level over the study was 21.5 MET hours per week (approximately 60 minutes a day of moderate-intensity activity).

    CONCLUSIONS: Among women consuming a usual diet, physical activity was associated with less weight gain only among women whose BMI was lower than 25. Women successful in maintaining normal weight and gaining fewer than 2.3 kg over 13 years averaged approximately 60 minutes a day of moderate-intensity activity throughout the study.

    PMID: 20332403 [PubMed – indexed for MEDLINE]

    Exercise for Medical Students and Residents

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    There is no question that there are many people who have integrated exercise into their daily routine so successfully that they don’t even think about it.  It becomes part of their day, just like brushing their teeth, or putting on their pants in the morning.  But even though it seems like the majority of people around you are in this category, it’s just not true.  There are the real exceptions – like the guy who gets up at 4 every morning (even if he went to sleep at 2) to run.  If you have never been an “athlete” you may feel really intimidated by these people.  .

    The benefits of exercise during your training can’t be overestimated.

    • It’s the right thing to do.  Physicians do physical as well as intellectual work.  You are taking care of people’s families.  It doesn’t surprise you that policemen, firemen, astronauts and soldiers have physical fitness as a requirement.  It’s no different for us. .
    • You will have a life after training.  In your 20s and 30s, you may be able to get away with not being active, but those years of inactivity will be paid for later.
    • You will feel better physically.  You will have more energy.
    • You will feel better emotionally.  There is a direct effect of working out (stress reduction), but there is also the psychological benefit of taking care of yourself.

    Consistency, not intensity is the key

    One of the biggest mistakes you can make is to view working out as something that you do as an activity “outside” of your day.  A 45 minute work out, plus the time to get to the gym, plus showering and changing can easily take an hour and a half.  For many residents, that kind of time commitment is a luxury they can’t afford.  So, we have great intentions to get to the gym 3 times a week… and next thing you know, a month has gone by with no trips to the gym at all.  One of the ways to improve consistency is to have a list of a variety of things to choose from.  Although it’s expensive in most cities, a gym membership will help.  See if it can’t be part of your holiday “wish list” for your family.  The other thing that should be on that list, by the way, is a maid once a week to do your laundry and clean your house.  Unless, of course, you want to use housecleaning as one of your calorie burning activities!

    It’s a skill, and there are teachers

    Most people know about cardiovascular training and have probably run, swam, or biked at some point in their life.  The nice thing about running, swimming and biking is that everyone can do them, often at any time of the day, and it doesn’t take a lot of money, or a gym membership to do.  But there are other options for cardiovascular fitness that you can explore – spinning classes, martial arts training, aerobics classes – when these are offered at gyms, there will always be a teacher to help you learn.

    Even though the emphasis is often on cardiovascular training alone, fitness is a composite of cardiovascular, strength and flexibility training.  If you’ve never participated in team sports, and haven’t had a reason to be in a gym, there is a good chance you don’t know the basics about weight training.  You are not alone, and it’s normal to feel a bit intimidated.  You can find a fellow resident to show you, but, often they haven’t learned proper form, either.  It’s better to have a pro show you.  If you join a gym, there are several options.  Many gyms have circuit classes using free weights – which is a great combination of cardiovascular and strength training.  There are also personal trainers.  Although you probably won’t want to spend the money for a trainer on a regular basis, you can hire one for 2 or 3 sessions to teach you about each of the machines, and help you plan a workout routine or two.

    Unfortunately, morning is usually the best time to work out

    There are a few people who, no matter how tired they are can get to the gym, or go for a run after work.  If your day started at 5 or 6 and is ending after 5 or 6 (or 7 or 8 or…), most people are just too tired and the call of the couch is too strong to go workout.   In general, the most consistent exercisers usually get it done first thing in the morning.  For most medical students morning will usually work.  As you enter your residency, you are going to have to be more flexible.

    Different days = different workouts

    Call days are tough… and, for exercise, the day after call is the toughest of all.  The key here is consistency.  On the post-call day, don’t plan for long workout at the gym, but do plan for a 20 minute brisk walk when you get home.  If there is a way to have someone cover you for 30 minutes before morning rounds, go for an early morning run outside, or climb the stairs in the hospital for 20 minutes.  Don’t forget to plan in a day or two of rest, every week.  It’s tempting to use the post-call day for your recovery and that may be the best thing some weeks.  However, recovery from call is easier if it includes some working out.