How to Ace the NBME Shelf Exams, In-Training Exams and Your Boards.

Ok, now that I have your attention, let me share something with you. I’m going to show you how to maximize what you learn from the “school” we call rotations in medical school and residency so you can be an awesome master clinician. And, yes, it’s going to help you with your exams, so stay with me.

Clinical rotations are a strange blend of learning and work. You learn from the work, but we all forget that the work is not the purpose of these clinical experiences. The purpose of rotations is to be able to “practice” medicine (as a student) and then master the art of your specialty (as a resident.)

There are six basic principles to learn medicine, and then learn your specialty …and on the way ace the exams:

  1. Remember it’s school.
  2. At the beginning of each rotation, decide what topics you need to learn during the rotation and make a list.
  3. Take notes. All the time.
  4. Figure out how you will store your notes so you can find them quickly and organize them for review.
  5. Go through the notes you make every day to review them and then store them in your system.
  6. You can’t learn medicine from a review book (yes, including UWorld)

Somewhere around the beginning of my third year of residency, I was sitting in the “dome” (the chief resident’s “office” above OR 1 in our County Hospital) when Fred, one of my fellow 3rd years, walked in. He sat down and started to look through a stack of 3×5 cards so I asked him what he was doing. We all knew that he had scored the highest in our class on the ABSITE (the surgery in-service exam) and I was about to find out why.

REMEMBER IT’S SCHOOL

Fred figured out from day one that there was no way he was going to be able to study like he did in college and during basic sciences. Instead of hours to sit and read, it had to be flexible “on the job” learning.

This mindset is probably the single more important thing to cultivate. It’s the thing that drives you to constantly ask questions about why things are done the way they are and then go look up the answers.

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AT THE BEGINNING OF EACH ROTATION, DECIDE WHAT TOPICS YOU NEED TO LEARN DURING THE ROTATION AND MAKE A LIST. 

Your list can be pretty simple, or more complex, but it needs to be enough.

First hint – There is a curriculum that has been defined for your rotations. Everything your professors have decided should be taught should absolutely be on your list.   (By the way….If it’s in the curriculum, it has to be part of an objective. If there is an objective, it has to be linked to a test question)

Second hint – There is no way in medical school that “surgery” (or any specialty) can be covered in 8-12 lectures. The same is true for your rotations in residency. You have to do more.

This is one time that an example may be better than a formula. Let’s say I’m a brand new clinical student on my core surgery rotation….

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 Step 1. Find a textbook of Surgery and make a list of the topics from the chapters. A spreadsheet may be best for this, but any kind of list will do. 

For example, our library has Sabiston’s Textbook of Surgery (20th edition, 2017) on line:

 

 Step 2. Breathe deeply. There are 72 chapters and no, you are not going to read all these pages.

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Step 3. Create a schedule to SKIM every chapter during the rotation. Look only at the “big picture” i.e. headings, section titles, diagrams, tables. Your schedule should leave the last week or two free. So, for example, if your rotation is 2 months long, plan to SKIM 12 chapters a week to get them done in 6 weeks.

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 Step 4 – Now we get to the real deal (remember, this is graduate school and/or specialty training).

List the sections on your spreadsheet.

As a student, you won’t read every section – unless they are very general (Acute Abdomen, for example) or if you have a patient with that particular problem. Here’s what it might look like:

 

TAKE NOTES. ALL THE TIME.

After I learned Fred’s system, I always kept a stack of blank 3×5 cards in my pocket. Like him, for the last 3 years of my residency, I made notes ALL the time.  Here’s the kind of notes we are talking about:

  1. Reading textbooks or other curricular readings. Take the time to make the notes and make them well so you never have to go back to the chapter to review it.
  2. On rounds when someone teaches an important point (e.g. the 7 things that keep a fistula from closing)
  3. During Grand Rounds
  4. During conferences
  5. When you look up a paper to read about a patient
  6. And – most important – what you learn from specific patients. Do NOT put the name of the patient or their MRN (HIPPA). But, do put specifics that help you remember the patient (e.g. pt that always wore a red baseball cap and had a tattoo of a dragon)

As you can imagine, once I started this system, I was making 10-20 notes a day. It is remarkable how much you learn in a given day… and how it’s almost instantly gone if you don’t write it down.  In three years I filled up two boxes with cards. These cards were the only thing I reviewed for my Board exams.

 

FIGURE OUT HOW YOU WILL STORE YOUR NOTES SO YOU CAN FIND THEM QUICKLY AND ORGANIZE THEM FOR REVIEW

This is why using a notebook isn’t the best way to keep notes on rotations. You’ll take them chronologically and, unless you have an amazing index at the back with all the key words and pages listed, you’ll never be able to find a specific note.

The key is being able to “file” the notes so you can find them.  For the 3×5 system, leave a blank square at the top to put the topic you’ll use to file them.

I used anatomy as the basis for my filing system. So I would use a pencil (so I could change it later if I needed to) to put the topic in the box.  For example

Pancreas, pancreatitis

Appendix, neoplasms, carcinoid

This is very old-fashioned (but very effective) system.. I personally think there are better ways to do this now using scanning, cloud storage, key words and tags.  For some ideas, check out this post.

What doesn’t work well is to try to type notes on your phone.  What REALLY doesn’t work is to make notes and then decide to copy them, type them or somehow redo them later. (It never happens).

 

GO THROUGH THE NOTES YOU MAKE EVERY DAY TO REVIEW THEM AND THEN STORE THEM IN YOUR SYSTEM

The key to learning (as opposed to memorizing for a test) is review. Simply filing the cards means you are reviewing them. Plan to pull them out to look at them (and all the work you accomplished!) every week or two.

More importantly, when you see a patient with pancreatitis 5 months from now on a different rotation, pull the cards you made on this rotation. You’ll find you have 20 or so cards (or card equivalents) on pancreatitis … a review of the Surgery textbook, notes from Grand Rounds, the 3 patients you saw with pancreatitis that taught you about the disease and a few pearls you learned on rounds from your chief resident.

 

YOU CAN’T LEARN MEDICINE FROM A REVIEW BOOK (YES, INCLUDING UWORLD) 

I’m really serious. Not only will you suffer when you are taking care of patients, you won’t do as well on the tests (despite what the upper level students or residents tell you).

Remember the last two weeks of the rotation that you saved?  Now’s the time to pull out the review books.  It’s a wonderful way to review what you have learned from your skimming and patient oriented reading.  It’s also a great way to identify gaps and look up information.

p.s. Take more notes while you are doing this.

p.p.s Review all your notes, including the ones you make from the review books.

p.p.p.s Review them again.

Link to the Wikipedia article about the forgetting curve

We All Need a Compass

I was delighted to be asked to be the AOA visiting professor at the University of Miami Miller School of Medicine this week.  The following is the speech I gave at the induction banquet.  For those who are not in medicine, Alpha Omega Alpha is the “Phi Beta Kappa” of medical school, an honor society that recognizes students who are at the top of their class… but who have also demonstrated service, leadership and professionalism. 

 

What an honor that I have been asked to be here tonight for this celebration!  I am in the company of superstars and great friends, both new and old … what could be better?

I want to start by congratulating the junior AOA, resident and faculty inductees.  For the junior AOA inductees, you are clearly on a strong path to excellence which will serve you well.  Although I’m going to address my remarks to the graduating seniors, please know that I haven’t forgotten you or what it took for you to be here tonight.  For the resident and faculty inductees, you have been singled out for this very particular honor because you are amazing clinicians, educators and role models.  Thank you for what you do.

I thought I’d start with a short description of what it means to be inducted into AOA from the AOA website.

“Election to Alpha Omega Alpha is an honor signifying a lasting commitment to scholarship, leadership, professionalism, and service. A lifelong honor, membership in the society confers recognition for a physician’s dedication to the profession and art of healing.”

Induction into AOA is a major milestone in your career and, based on your predecessors in the organization, it also represents the beginning of a remarkable journey.  It’s a journey that you won’t take alone.  If history is a guide, you represent the future leaders of medicine, which means you’ll be guiding others on this journey as well.

That’s the reason I decided I should talk about how to use a compass.

 

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I suspect that you have all used a compass before but, like me, you probably haven’t given it much thought.  A traditional compass works by aligning a needle to the magnetic pulls of the north and south poles.  Although we really could use either north or south as a reference point, by convention we use north. I’m not going to get into the differences between true north and magnetic north*… suffice it to say that because a compass lets us know where north is, we can calculate the difference between “true north” and where we are heading, which in nautical terms, is called our “absolute bearing”.

So where am I going with this?  Why is it important to have a point of reference, a “true north”, as you start your journey through residency into the practice of medicine?

I know you’ve already been on services where the focus seemed to be more on checking the boxes on the scut list than on caring for the patients… and you had the feeling that there was something missing.

That’s why you need a “true north”.

You’ve also been on committees or in organizations that seemed to worry more about policies and procedures than how to use those policies and procedures for the better good.

That’s why you need a “true north.”

And I know that you have experienced days where you manifested one or more of the three cardinal symptoms of burnout, days when you lost enthusiasm for your work, felt that patients were objects rather than people and/or decided everyone around you could do a better job than you could.

That’s why you need a “true north”.

Unless you know where your “true north” is, you can’t navigate… you can’t make the adjustments that keep you on course.

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The single most important piece of advice I can give you as you start on this journey is to make sure you know where “true north” is for you.  As each of you define your own personal “true north”, you will share things in common.  For example, loving your family and friends, being kind, and trying to make a difference.  But even though there will be common themes, “true north” will be a little different for each of you.  This is not as abstract a concept as you might think. It is not only possible to articulate your goals, what gives you meaning and how you define your own integrity, it’s important to do so. And, yes, I mean write them down, think about them, and revise them when necessary.  When you hit the inevitable days of stormy weather, having a compass that it true is critically important.

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In reading about compasses, I also learned that the traditional compass has to be held level to work.  I learned that “when the compass is held level, the needle turns until, after a few seconds to allow oscillation to die out, it settles into its equilibrium orientation.”

What a great image.  You have to be still to let the compass equilibrate.  You have to be mindful to look at the needle to calculate your absolute bearing.  And then you have to take that information and apply it to correct your course.  And to do so, you have to hold the compass level, which I think is a great metaphor for taking care of yourself – physically, emotionally and spiritually.

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There is not a lot in the day to day life of an intern, resident or practicing physician that teaches us the skill of focusing on that still point, on getting our bearings to make sure we don’t veer off course.

It’s not a trivial problem.  Veering off course can result in doing something we don’t want to do or, more importantly, becoming someone we don’t want to be.  More importantly for those of you just starting on this journey, a small error in navigation at the beginning of a journey results in a very large error when you arrive.  That’s why, as you start this journey, it’s so important to know what “true north” is for you.

As you articulate what your “true north” is, I would also urge you to translate it into something that is easy to remember for those times that you are making a decision in a difficult moment.   For me, my “true north” as a physician has been distilled into three rules that I try to follow and that I teach my trainees.

Rule 1:  Do what’s right for the patient.

Rule 2:  Look cool doing it.

Rule 3:  Don’t hurt anything that has a name.

Let me expand just a little…

Rule 1 means always do what’s right for the patient.  Even if you are tired, even if others disagree, even if you don’t get paid, even if it’s not technically “your” patient – do what’s right.  It also means developing an life-long method to deliberately read and study so you know the right thing to do.  And it means doing all of this with compassion and integrity.

Rule 2, “Look cool doing it”, means practicing your art until you look cool.  If you are surgeon, make sure your movements look like Tai Chi and that you have no wasted motion.  If you are a pathologist, learn all the variations on the themes that cells can create. No matter what your specialty, read about each of your patients, prepare for all cases, procedures and conferences deliberately and diligently. “Look cool doing it” also means don’t lose your cool.  Be professional, which at its core is just another way of saying kindness and integrity matter.

Rule 3, “Don’t hurt anything that has a name”, certainly means don’t cut the ureter if you are doing a colectomy, but it means more than that because…

You have a name.

Your significant other has a name.

Your institution, your friends, your family all have names.

You are about to embark on the amazing and challenging journey of residency… I know you have a sense of trepidation and also a sense of incredible excitement.  Everyone in this room who has been there remembers and, to be honest, is probably a little jealous. What an amazing time to start a career in medicine.

Congratulations on all you have accomplished so far. I wish you smooth sailing and a compass that is true.

 

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*Because I am using “true north” as a metaphor, the scientists will have to forgive me.  There is a difference between “true north”, which is the actual north pole and “magnetic north” which is what a compass shows.  Here’s a great link that explains this further:  Magnetic North vs Geographic (True) North Pole

 

 

 

Top 10 Holiday Gifts for Physicians and Physicians in Training

The holiday season is rapidly approaching.   Here’s my top ten gifts for medical students, residents and physicians…. or any busy friend!

  1. Mark Bittman’s new book How To Cook Everything Fast.

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This is an amazing cookbook and it is perfect for busy people. The recipes are interesting, delicious and healthy. The instructions are easy for a novice without being simplistic and the layout of the book in innovative and makes it really easy to use.

 

  1. An electric pressure cooker.

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Slow cookers are often suggested for medical students and residents but I don’t think they are as good as a pressure cooker.   You have to be there when slow cookers are (slowly) cooking, which is usually your rare day off. Also, it’s hard to cook vegetables in a slow cooker. Pressure cookers on the other hand cook broccoli in 2 minutes (perfectly!).  I’ve been told that the electric pressure cookers take a little longer to come up to pressure, but it seems a small downside for a device that also lets you slow cook, steam, sauté, and cook rice.

 

  1. Coffee or Tea

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There are several options to consider if they are a serious coffee or tea drinker. A Starbucks or Teavana gift card in a cute “medical” coffee mug? A Starbucks Verismo coffee brewer? Nespresso? Keurig?

 

  1. A FitBit

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Anyone in medicine loves gadgets and loves data. The fitbit has become a socially acceptable piece of “jewelry” in the hospital and it unquestionably changes behavior to increase activity. Having washed three of the “clip on” Fitbits with my scrubs, I would recommend one of the wristband Fitbits!

 

  1. A maid or housecleaning service

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Doing housework has to be on everyone’s lowest list of fun things to do on your day off, but it’s especially true for people who are studying extensively or taking call in the hospital. My parents helped finance someone to come occasionally to help clean my apartment when I was an intern. It was without a doubt the best present I’ve ever received.

 

  1. Anything that helps make it easy to get more exercise

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Another great gift is anything that will promote more exercise… a bicycle to commute to school or work? Yoga classes? Spin classes? A gift certificate for new running shoes? Resistance bands for the call room? A membership to a YMCA or a gym close to where they live? Certificates for post workout massages?

 

  1. “Date night” packages

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Whether they are single or have a significant other, being able to socialize is an important part of stress reduction for busy people.   Create combinations of gift cards to movie theaters and restaurants to support “date nights”. If they love art, music, or sports think of season tickets (or ticket packages) to museums, music venues or professional sport teams.

 

  1. An “over the top” alarm clock

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It’s not easy getting up at “dark thirty” to make it to rounds, but being on time is important.   The snooze button is not a good idea… but it’s so easy to hit. This alarm clock is my personal favorite to make sure you get out of bed. After a few hits of the snooze button, it rolls off the table and around the room until you turn it off!

 

  1. Great books by, for and about doctors.  

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If they are a serious reader, think about a Kindle (or other eReader). The Kindle paperwhite is small, lightweight, back lit and has a great battery life – which makes it great for the occasional times on call that you can find 30 minutes to escape into a good book. You can also read it outside in bright sunlight (unlike tablets like the iPad) On my list of great reads for doctors (in no particular order)…

Cutting for Stone by Abrahan Verghese

How Doctors Think by Jerome Groopman

House of God by Samuel Shem

The Immortal Life of Henrietta Lacks by Rebecca Skloot

The Emperor of All Maladies: A Biography of Cancer by Siddhartha Mukheries

Being Mortal: Medicine and What Matters in the End by Atul Guwande

William Osler: A Life in Medicine by Michael Bliss

The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures by Anne Fadiman

 

  1. The always appropriate gift of money

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If you are going to give gift certificates or money,  “package” it with some humor (in a pill bottle with a “prescription”) or a context (this is to help you buy good food for times you are too busy).

Please let me know (comment or email) anything else to add to this list!  Happy Holidays to all!

 

 

Fast and Easy Recipes – Protein Bars

The senior class ends their formal education at Baylor with a capstone course called “APEX”. In addition to reviewing critical medical information, communication skills and other important aspects of becoming an intern, there are also wonderful lectures from faculty on “how to be an intern”.

One of the APEX speakers this year was Dr. Sally Raty, who stressed how important it was to take time to care for yourself.. but that you had to look for efficient ways to do it! She promised to share recipes that are easy and take very little time to cook. I’ll share the rest of the recipes on future posts… but here is the first one (which she adapted from this recipe).

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These bars have a ton of ingredients, but they are easy to find, and this bar is way better for you than those processed, chemical blobs you’re spending $2+ on. I keep all of the dry ingredients for these bars in a basket in my pantry. I just pull the basket out and make the bars. The crumbs are amazing on vanilla ice cream….not that I would ever do that, but I’ve heard it is good.

3 cups raw oats
(nothing fancy. Quaker 3 minute (not instant) oats are fine)

1/2 cup whole sesame seeds, or shelled sunflower seeds

1/2 cup shredded coconut (unsweetened is best, but sweetened is easier to find)

1 teaspoon ground cinnamon

1 teaspoon salt

1/4 cup brown sugar

1 cup vanilla Greek yogurt

1/4 cup + 2 tablespoons pure maple syrup or honey

1 cup peanut or almond butter

1 teaspoon vanilla extract

1/4 cup coconut oil, liquefied if solid (or just use canola oil)

1/2 cup chopped chocolate chips (> or = 70% cacao is best)

1/2 cup chopped nuts (almonds, walnuts or pecans)

1/2 cup chopped dates, raisins, figs or other dried fruit–optional (I don’t typically add these)

1 cup vanilla or chocolate whey protein powder– Garden of Life Raw Protein is a good one and is available at Whole Foods Market

2 eggs

½ cup egg whites (or add a 3rd egg)

Heat oven to 350F. Spray an 11 X 7 inch glass baking dish with nonstick stuff. Throw everything in a big bowl. Mix well with your hands. Place in the baking dish, press into the pan to eliminate bubbles and try to get it level. Cook for about 20-25 minutes. Let cool completely to room temp. Refrigerate for a few hours before cutting into bars. Cut into about 48 bars. Refrigerate the cut bars.

 

This Year’s @drmlb’s Top 10 Gifts for Medical Students, Residents and Busy Docs.

This time of year, family and friends of docs and/or docs in training are looking for the last minute holiday gifts (if you are trying to have them shipped) or planning the trip to the store(s) for gifts.

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The one thing any busy person doesn’t have enough of is time.  If you think about it in that context, you can find presents to support interests, fitness, studying (or just having fun) in a thoughtful way.

1. Someone to help clean their home.  It is the most amazing present to come one once a week (or even once a month) to a house that has been cleaned by someone else.  If there are family members who are willing (and it’s appropriate) you can put together a gift of cleaning supplies with a certificate for monthly housecleaning.  If not, word of mouth to find the best person is usually the best way, and will often help you find someone who also does laundry and ironing.  (a true gift!).   There are professional services in every city as well that can be found with an easy internet search.
2. Something to help integrate fitness into their every day activities.  If they don’t have a good bike to commute to school or the hospital (and this is something they would like) this is a great present.  Don’t forget the helmet, reflective vest and very bright lights as part of the package!
3. A fast computer.  If they have the same computer they had in college and you are able to do this for them, the time they will save in uploads will be very appreciated!
4. A smart phone or mini iPad (especially the new iPad air).  Like the computer, if the phone they have is more than 3-4 years old, the upgrade will be much appreciated.  The mini iPad (instead of the regular size) fits in a white coat pocket, which is why it’s ideal for anyone who wears a white coat.  If they have an iPad, think about some of the more expensive medical apps. (or a certificate for the App store
5. Kitchen appliances to save time (and promote healthy eating).  My favorites on this list would include a rice maker (which can also be used to steam meat and vegetables), a pressure cooker a slow cooker or the Krups multi-cooker.  A blender is always a good gift (to make smoothies and soups).  If you are feeling particularly generous, a VitaMix instead of a blender is much more versatile (and makes much better smoothies!).
6. Prepared meals. If you have family who love to cook, you can make a “certificate” for homemade food in freezable portions.  If you can afford it, there are personal chefs who do the same thing.  You can also give them a gift certificate for a grocery store like Whole Foods that has healthy prepared food or companies that deliver healthy meals (In Houston, it’s companies like MyFitFoods – but this varies from city to city).
7. Fitness equipment for home.  For medical students who are spending a lot of time studying think about a FitDesk, FitBike or a treadmill desk.  The standard stationary bikes, treadmills, etc are another option, but they are expensive and you have to really know that they are preferred over going to the gym (see #8).  A less expensive but very effective gift would be a “fitness care package” with resistance bands, FitDeck cards, a gift certificate for running shoes, and other small less expensive gifts.

8. A membership in a local gym. You can also consider a certificate for group classes in spinning, yoga, or whatever they enjoy.
9. Time with family and friends.  Think about a “certificate” for time together – maybe with restaurant gift cards or movie gift cards attached.  A “certificate” for a monthly home cooked meal?  If you aren’t in the same town, think about how to make it easy for them to spend time with their friends.  If you know their favorite restaurant or hangout, see if you can get a gift certificate.  If not, go for tickets to the local theater, one of the movie chains (find out which one is closest to where they live), or their favorite restaurant chain. If they have children, babysitting is a wonderful gift.
10. Whatever you can think of that makes gives them more time and/or will support them during times of stressful and busy work!

 

 HAPPY HOLIDAYS TO ALL!!!PEACE_ON_EARTH

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Last year’s suggestions on wellnessrounds.org

Eating on the Run

“Downside, I skipped lunch and it is still in the work fridge. Upside, I don’t have to pack a lunch tomorrow!” – tweet from a new intern on her first day of work

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July 1st has arrived and a new group of interns are learning that’s it’s hard to eat well when you are crazy busy taking care of patients. Doctors really do know about nutrition, and we know we should set a good example. So why do we eat so poorly at work?  I can’t do better than the list of reasons from this post:

1.  The ”I don’t know when I’ll get to eat again” Phenomenon

2.  The “Graham Crackers and Peanut Butter” Phenomenon

3.  The “It’s free, therefore I must eat it” Phenomenon.

4.  The “I’m so tired I have to eat something to stay awake” Phenomenon

5.  The “I’m on call so I deserve a giant cookie” Phenomenon

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Why it’s important to make conscious choices about what you eat at work 

1. You actually hurt your patients if you don’t eat well. 

Physicians that don’t eat at work have slower simple and complex reaction times. You don’t think as clearly or respond as quickly. Start thinking about your own nutrition as a part of good patient care.

 2. If you are like most people, not eating at work will result in gaining weight.  

Even if you don’t gain weight, you will likely have a detrimental change in your body composition. (i.e. you’ll get flabby)

3. Not eating at work will result in losing weight for some people. 

For some people stress leads to appetite loss.  These are the residents that aren’t hungry even though they are not eating enough. The message here is that your weight during residency is a decent barometer of your stress level and how well you are coping.  If you are losing or gaining, notice it early and adjust how you are eating, working out and coping with the stress of your job.

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There’s no question that the best option is to plan, prepare and bring your own food to work.  Even though it takes time to do this, you’ll save time in the hospital by knowing what you have and where it is.  (A good point made in the article “Strategies Resident-Physicians Use to Manage Sleep Loss and Fatigue” which you can download from http://med-ed-online.net/index.php/meo/article/download/4376/4558). Food choices in the hospital are limited, often poor,  and not always available. Make time on the weekends to plan for the upcoming week and shop for good food.  If you can, choose one healthy recipe to cook on your day off and make enough that you have plenty of meals in the refrigerator for when you get home.

General principles 

  • Eat at least every 6 hours.  It’s probably better if you eat smaller amounts every 3-4 hours.  Eat even if you are “not hungry” if it’s been 4-6 hours since your last meal.
  • Make sure you are getting plenty of protein.  Eating simple carbohydrates makes you less alert and creates bigger swings of insulin levels.
  • Don’t drink your calories.  (But do drink enough water)
  • The processed comfort foods that appear like magic in hospitals (doughnuts, pizza, etc) seem delicious when you eat them, but are terrible for you.
  • Plan, plan, plan.  It’s worth it.
  • Eat fruits and/or vegetables with every meal.
  • Bring good food from home.  If you don’t cook, buy good food to bring.
  • Make sure you have “pocket food” in your pocket at all times.  (Food that fits in your pocket and doesn’t need refrigeration.) You may not be able to stop for a real meal, but you’ll be able to eat something.

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Examples of  “pocket foods”

  • Kind bars.  Many meal replacement bars might as well be candy bars when you look at the ingredients.  Clif, Larabar, and Odwalla are all good choices.  Kind bars have no added sugar, a fair amount of protein and are made of only real food.
  • Peanut butter and jelly sandwich.  (Whole wheat bread, fruit spread, peanut butter without transfats)
  • Cabot 50% cheese or string cheese (higher protein, lower fat than most cheese)
  • Edamame (shelled is easier)
  • Homemade Trail mix – mix different nuts and dried fruits together and put in snack bags
  • Baked or steamed sweet potatoes with a little salt
  • Fruit

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.

residents-sleeping

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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.