You Can Exercise Even if You are on Call

Posted on April 7, 2010 by marylbrandt

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

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.
Take a jump rope to the hospital and keep it in the call room
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.
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).
Talk your program into paying for a used bike or treadmill.
Commute to work on your feet or on a bicycle (more on that later…)

Strength training options

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.
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.
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.

Cooking for Yourself in Medical School and Residency

Posted on April 6, 2010 by marylbrandt

Most medical students and residents eat poorly. It’s not really a surprise – the days are packed with work from sun-up to sun-down. There are no planned meals because there can’t be. Food is a quick bite when it is available. It’s feast or famine. On the far end of the scale, the stereotypical diet of a resident is no breakfast (but usually coffee), a doughnut and coffee grabbed on the run once you get to work, some mid-day meal of fast food, and pizza on call. Food, particularly fast food, becomes solace. In the stressful world of residency, this kind of “comfort food” becomes a “reward” for the hard work and tribulations. It’s not rocket science. This kind of diet doesn’t give you the energy you need to function at your peak. It is also a diet that is very likely to lead to weight gain. In your 20s, your body can cope with this suboptimal fuel, but it’s not ideal. However, what “works” in your 20s won’t work as you get older and could even be responsible for a heart attack, diabetes, or other medical problems in your 40s and 50s. On a more philosophical level, you would never advise this kind of diet to one of your patients. None of us want to be hypocrites.

The answer is to cook for yourself. Not everyone likes to cook, and not every one knows how. I’m going to make a case that you should learn. Trust me – if you can learn to take out an appendix, or diagnose a pneumonia, you can learn to cook. I’m going to assume that you are single for the sake of this description. But, if you have a significant other, it’s even more important to cook at home. He or she can participate in helping with the meal preparation, and, by doing this together and for each other, there is added benefit for your relationship. Having dinner at home with a significant other will become an “anchor” to your day that will become very important to you. As hard as it is to work around a busy schedule, if you can eat together, and have a real conversation, you will both benefit greatly.

Cooking is a wonderful therapy for the stress of medical school and residency. If you’ve never learned how to cook, this is a hard time to learn complicated techniques, but it’s not hard to learn simple techniques. There are several advantages of cooking for yourself that outweigh (on most days) the hassle of spending the time. The act of cooking for yourself can be a time of “decompressing” from work. Arranging vegetables, cutting them, smelling the odor of the food appeals to all your senses and is a moment in the day that you can intentionally slow down. It’s very important that the recipes you choose are simple and quickly prepared. No one wants to come home to a 2 hour task in the kitchen after a hard day. Cooking for yourself has other benefits as well. First, it is tangible evidence that you are taking care of yourself. This is not a trivial point. There are days during your training when it seems no one is taking care of you. Having concrete evidence that you are caring for yourself is an antidote to that feeling. Secondly, you will eat better. By cooking from fresh ingredients, you will decrease the amount of pre-packaged and fast food. Even without medical school, you know that this will result in better nutrition. Thirdly, you will eat cheaper. Other than the “free” pizza (ethically debatable, but financially clear), processed food is usually more expensive. And lastly, you can share. It isn’t any more work to make 4 or 6 portions of a dish than it is to make 2, and it usually isn’t that much more expensive, either. If you can convince one of your colleagues that this is a good idea, you can cook for each other on alternate days. Likewise, you can cook larger amounts and, using freezer ready containers, freeze portions for yourself for the future. Doesn’t homemade pasta with a side of fresh vegetables really sound better than the greasy middle of the night food that is available in most hospitals? It’s true that you can’t cook just anything with the kind of schedule you will have in medical school and your residency. But, there are few key rules that will make it possible for you to do this, enjoy it, and eat well.

Rule 1: Don’t cook anything that takes more than 30 minutes to prepare.

Let’s be realistic – you are not going to walk into your home at 8 o’clock at night, hungry, and spend an hour preparing something. But – there are very nutritious dinners that take less than 10 minutes, so getting home late is no excuse.

Rule 2: Plan ahead.

The first step in preparing dinner for most busy people is to open the refrigerator door and ask “What can I eat tonight?: If you are anything like I was in residency, the refrigerator had some cheese, some vegetables (often way past their prime), and maybe some leftovers. Not very appetizing. There is an easy way to prevent this from happening. On whatever day you have off and have time to shop, spend 30 minutes making a menu. Start by making a table for the week with what is happening.

	Breakfast	Lunch	Snack	Dinner	Comments
Sun
Mon					On call – take Tues meals, too
Tues
Wed				Out	Out with friends after rounds
Thur
Fri					On call
Sat

Once you have an outline of your week, fill in the blanks with the meals. Now, most of us can handle “hamburgers” or “Raisin Bran” as a menu item… but it’s more fun, and healthier to branch out a bit. So, if you are not used to looking for new things to cook, how do you find recipes? Cookbooks can be fun, particularly if you are looking for a particular ethnic food or a style (e.g. low-fat) of cooking. If you like cookbooks, and bookstores, find the used book store nearest you and go to town! There are also web sites for recipes. Many of them also have “cooking lessons” on line. Most cooking shows have a web based recipe site as well. So, say you start by searching the web and find this recipe. (for this particular recipe, I’m assuming you have no concerns about calories) It looks easy, and like it would taste good. So you print it out.

NEW ORLEANS PASTA

ESSENCE OF EMERIL (FOODTV) SHOW #EE123 – http://www.recipesource.com/main-dishes/pasta/11/rec1100.html

1 tablespoon olive oil

16 ounces chicken breast half, cut into strips (about 1/2 cup)

1/4 cup chopped chorizo sausage

2 tablespoons chopped green onions, plus extra for garnish

1/2 tablespoon chopped garlic

Tabasco and Worcestershire sauce

3/4 cup heavy cream

1/4 cup grated Parmesan cheese

1/4 pound shrimp, peeled and deveined

1/2 pound penne pasta, cooked al dente and tossed in oil to coat

Creole spice, salt and pepper

In a large saute pan heat oil, add chicken and sausage and cook 5 minutes, stirring often. Add green onions, garlic, 2 dashes each Tabasco and Worcestershire sauce or to taste, and cook for 1 minute. Add cream, cheese, shrimp and pasta. Cook, tossing, to heat through. Adjust seasoning to taste with Creole spice, salt and pepper. Serve garnished with green onions.

Yield: 2 servings

Now what? First, cut and paste the ingredient list to a shopping list. If you are compulsive, you can organize it into meat, dairy, produce, etc (it makes shopping easier, but it’s not essential). You’ll need to add a vegetable or salad to balance this out nutritionally. (I picked broccoli as an example) If you can afford the calories, add a desert. (Ice cream in this case) Then decide what night in your schedule this will work best. This recipe will take about 12 minutes total so it would be great for a night you are getting home late. You can either share the other portion with your significant other or you can take it with you the next day as lunch. You can double the recipe and have it more than one night. For example:

	Breakfast	Lunch	Snack	Dinner	Comments
Sun
Mon					On call – take Tues meals, too
Tues
Wed				Out	Out with friends after roundsThaw shrimp for tomorrow
Thur				NEW ORLEANS PASTA (CHICKEN, CHORIZO)Steamed broccoliIce Cream	Freeze one portion for later
Fri				NEW ORLEANS PASTA (CHICKEN, CHORIZO)Steamed broccoli	On call
Sat		NEW NEW ORLEANS PASTA (CHICKEN, CHORIZO)Steamed broccoli

Shopping list:

2 lbs chicken breast (16 oz x 2)

1/2 cup chopped chorizo sausage

1/2 pound shrimp, peeled and deveined

heavy cream (need 1 1/5 cup)

Parmesan cheese (need 1/2 cup grated)

Olive oil

Creole spice

green onions

garlic

broccoli (4 portions to steam)

One pound penne pasta

Ice cream

Rule 3: Cook (or prep) today today to eat tomorrow

As soon as you get home from the grocery store:

Freeze any meat that is for later in the week (and make a note to yourself to put in into the refrigerator to thaw a day or two before you are going to use it.)
Wash the vegetables, dry them and put them away
Wash lettuce for salads and dry completely (a spin dryer is the best). Store in a zip lock plastic bag with a paper towel in the bag (which absorbs any residual water). Make sure you squeeze out all the air you can before closing the bag.

Take advantage of days off to cook things that may take a little more time or effort. While you are watch the football game on Sunday, you can cook chili in a crock pot for Wednesday. If you know that your vegetable stir fry on Tuesday is going to be after a long day, go ahead and chop all the vegetables and meat a day or two before when you have the time and have them stored in the refrigerator. When Tuesday rolls around (and you are exhausted from work), you’ll have all the ingredients chopped and ready to throw in the pan.

Preventing Weight Gain in Residency

Posted on April 5, 2010 by marylbrandt

This is the time of year when 4^th year medical students are winding down and preparing for the “big move” into internship. Our 4^th 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]

Post Call Recovery

Posted on April 4, 2010 by marylbrandt

I’m on call this weekend. As we started rounds this morning, the conversation turned to one of our superstar residents who (uncharacteristically) was late to rounds. He was up all night and overslept after falling asleep in the wee hours of the morning. What struck me was what he told us… “I knew something was wrong when I woke up feeling good.” Being on call, and being up all night is part of medical training (and practice). And it’s not just an occasional event – we often have to do it every three or four days. It’s essentially iatrogenic jet-lag and it takes some time to learn how to manage this kind of fatigue.

Photo credit

Being tired after call takes two major forms: with sleep and without sleep. Depending on the type of call, the recovery is different. If you have been inundated with work, but were able to sleep, you will be physically (somewhat) and emotionally (a lot) tired. The treatment for this is play. You need to spend some time doing something that is not related to work, preferably in the company of friends. You need time to process what you have just seen and done, but, more importantly, you need to feel like you are still connected to the world outside of work. Physical activity is essential. Even if you get home late, do something to stretch and use your body. Even a 15 minute walk outside followed by 5 minutes of stretching will do the trick. If you live with a significant other, make sure you have dinner together and really talk. Put on some nice music. Call a friend. Go out to eat. Whatever you do, don’t “numb out” by drinking a beer in front of the TV set.

Being tired without sleep is a physiologically abnormal state for human beings. No matter how much the culture says you should be “tough enough” to go without sleep, it’s crazy. We are designed to sleep 7-9 hours every night and, when we don’t, we don’t function as well. There is an amazing amount of literature on the effect of sleep deprivation on performance, competence and health. Suffice it to say that we all realize we don’t want the pilot of our plane to have been up for 24 hours prior to our flight. It’s no different for a doctors.

There is literature on this problem, but these are studies that doctors don’t often review. A sleepless call night is basically a shift in your body clock i.e. jet-lag. The big difference is that the light cues are the same after call (unlike when you fly to Europe). So what have business executives and airline pilots learned about dealing with this kind of time shift?

Stay hydrated. It may sound silly, but paying attention to drinking enough water will make a big difference. How much is enough? Enough to keep your urine clear. It is amazing how, during a busy day, you can forget to drink water. Start looking for the drinking fountains and stop for a drink when you see them. Carry a water bottle in your on-call bag and pull it out when you are doing sign outs, or taking a break. Having a bag of cut up lemons helps, too. A tall glass of ice water with fresh lemon in it is a fabulous treat in the middle of a busy night. Mild dehydration will increase your level of fatigue. Watch out for soft drinks and tea – the caffeine may give you a little kick (and there is nothing wrong with that from time to time) but, if you drink a lot of caffeine, it will really mess up your sleep cycle when you do get to sleep. Also, tea and coffee act as a diuretic, so your net hydration may be negative. Water is by far the best choice.

Don’t skip meals. Most importantly, don’t skip breakfast. Most students and residents have to get up really early to get to work. And, most people just don’t feel like eating a big breakfast at 5:30 in the morning. Eat something before you leave the house (a cereal bar or piece of fruit, for example) and then take something more substantial for later in the morning. Even if it’s only an energy bar in the pocket of your white coat – take something and then eat it!

Don’t go too long without food during a long shift. You need to eat something every 3-4 hours if you are working hard. You should carry at least one snack in your coat pocket such as a small bag of nuts, an energy bar, some raisins, or some dried fruit.

Probably the worst mistake people make in recovering from call is what they do once they leave the hospital. You can really help your recovery, enjoy your time off more, and return to work ready if you realize one fact: You have shifted your biologic clock by staying awake all night. If you go home the next morning (or afternoon) and sleep for 8-10 hours, you will have shifted it even more. So how do you best recover?

No matter how tired you are, your first stop should be the gym, a park, or someplace you can work out. This does not have to be (and shouldn’t be) a hard workout. This should be a “work out the stress” workout. Don’t push yourself hard, but work up a little sweat. Even if it’s just 20 minutes of walking in a park, you will feel better.

Treat yourself well. Take a nice long shower when you get home. Make yourself a nice meal, but not junk food. Eating a lot of protein and fat will put you in a fatigue tail-spin.

Take a nap, but make yourself get up so you can sleep that night. 3-4 hours is usually about right. Make arrangements to have dinner with friends, if you live alone. If you have a significant other, make plans to do something together in the evening. If you want to have a glass of wine, or one beer, do so – but don’t have more than that. It will mess up your sleep and it’s not worth it.

Don’t drink caffeine after the morning. Even though you will be sluggish in the afternoon, don’t sabotage your night time sleep with caffeine.

Go to sleep early. In addition to being sleep deprived, you will also feel socially deprived. It’s natural to want to go out with friends when you feel this way. However, they are not as sleep deprived as you are, and they don’t have to do this again in a few days. If you’ve had a hard call, with very little sleep, you should plan to get 10-12 hours of sleep the next night. You have to get at least 8 hours. In other words, if you have to be up at 6, you should be in bed no later than 10 pm, but, as crazy as it sounds, if you can get to sleep at 8, it will be better.

Energy for Call

Posted on April 3, 2010 by marylbrandt

Food is fuel. It’s also solice if you are stressed, and face it – it’s fun to eat. Other professions that deal with stress and physical labor have learned the lesson about not paying attention to nutrition. The culture of medicine demands a “selflessness” that borders on the absurd. It is often a badge of honor that you can go all day without eating. But, when you consider the consequences of such behavior, it is really crazy. There is no benefit to the patients, and clear harm to the doctor.

Eat often and eat well

When you are physically and intellectually busy (an average day on call in the hospital) you need to plan to eat every 3-4 hours. In general, you will have one “meal” (i.e lunch) in the middle of the day and two snacks. It’s not always going to possible to stop for lunch at lunchtime, but you should be able to find 10 minutes at some point in between 11 and 4 to eat a meal. Different rotations have different demands, and you can certainly take this into account when planning your meals. A peanut butter and jelly sandwich on whole wheat requires no preparation, and no refrigeration (it can even go in the pocket of your white coat). Alternatively, buy a loaf of whole wheat bread every week, and put the bread, a jar of peanut butter and a jar of jelly in your locker. It takes 2 minutes to make a sandwich to put into your pocket on the way to a conference or a brief break. Bring leftovers from the previous night’s dinner to reheat and have for lunch. You need to plan to include fruits and vegetables as part of every meal and your snacks. Buy a bag of apples once a week and put them in your locker.. and then make sure you eat the entire bag every week. The snacks don’t need to be elaborate, but you do need to watch the clock and eat them – even if you are not hungry!

Examples of easy snacks for the hospital