This Week’s Highlights from @drmlb

Twitter has become a wonderful way for me to send out a variety of ideas and links that I think are helpful (and/or interesting).  Here are this week’s highlights!  If you are new to Twitter RT means Retweet (just “forwarding” it as is) and MT means Modified Tweet (“forwarding” it with a comment).

  • “This is definitely a 15 minute video every medical student should see.” The art of the physical exam @drmlb
  • Comments one makes to colleagues: as important as the interview. Professionalism = doing the right thing when no one’s watching. RT @MedPedsDoctor
  • Beginner’s mind in medicine. How to keep what we do exciting! MT@KevinMD
  • One flight of stairs = 16 calories burned. One day on call = ?10 flights ?20 ?30) adds up! @drmlb
  • Epidemiologist with humor?!? This is a great talk about drug development. @drmlb
  • “…small things often adds up to produce a far greater impact than any of us realize.” Surgery through different eyes  @drmlb
  • “..those of us who spend our emotions at work are not the kind to view our work as “just a job.” MT@Kevin MD  @drmlb

Thanksgiving Gratitude

Gratitude is not only the greatest of the virtues but the parent of all others.”  Cicero

Gratitude is a powerful tool.  There is good evidence that being grateful leads to a greater sense of well-being and less stress.   Practicing gratitude on a regular basis can be as simple as “counting your blessings” every morning, or listing things you are grateful for on your scut list, in a journal,or on your smart phone.  Another useful practice is to write letters (to send or not) to your parents, teachers, friends or mentors to thank them.  If you aren’t convinced that practicing gratitude can have a profound effect on your well-being,  take the “2 minute challenge”.  Get a piece of paper and for two minutes write down everything thing you are grateful for.  Don’t lift the pen off the paper and keep writing (non-stop) for the entire two minutes.

Today, as I am spending time with family and friends, making our Thanksgiving feast and counting our blessings, I am reminded that all over the United States, there are physicians, residents, nurses, therapists, and support personnel who are spending this holiday taking care of patients.  Along with the patients and families in their care, I am thankful for their sacrifice and their compassion.  It is a blessing to have the skills and the heart to care for others, and we are grateful for that privilege .

“If the only prayer you say in your whole life is “thank you,” that would suffice.  Meister Eckhart

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Writing an “Exercise Prescription”

According to exercise physiologist Michael Hewitt, PhD, health can be viewed as a four-legged stool.  The four legs are physical activity, optimal nutrition, stress management and sleep.  If any one of them is missing, the stool will wobble.  If two are missing, it will fall.  For practicing physicians and trainees, sleep is often the hardest of the four to manage.  Stress is next – it is part of our job, but can be reduced with with meditation and exercise.  Paying attention to what you eat (especially on call) and cooking your own food will help improve your nutrition.  The fourth “leg” may be the most important (and most neglected) aspect of physician health – physical activity.

It doesn’t matter how healthy (or not) you are  – if you add more physical activity to your week you will improve your health.  We all learn this in medical school – exercise helps prevent and treat a wide variety of chronic diseases like diabetes, hypertension, myocardial ischemia, arthritis… the list goes on and on.  Exercise is medicine! The message is clear, we should be increasing our own physical activity and “prescribing” activity for our patients.

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Dr. Hewitt suggests that it’s not that hard to write an actual prescription for exercise.  First, decide what “dose” is needed – disease prevention, basic health level, enhanced fitness level, or performance level and then – literally – write a prescription that includes each of the 5 components of exercise.

Here is what the prescriptions would look like (below).  You can actually write them on prescription pads for your patients. (Don’t forget to write one for yourself… this is a really good exception to the rule that we shouldn’t write prescriptions for ourselves or our families.)

Disease Prevention

Cardiovascular Exercise: Accumulate 30-60 minutes of physical activity most days

Strength Training: Include weight-bearing activity most days

Flexibility: Maintain range of motion by bending and stretching in daily activities

Body Composition: Men <25% body fat, Women <38% body fat

Balance and Agility:

Basic Health Level

Cardiovascular Exercise: Play or large muscle repetitive activity 20+ minutes 3 times a week

Strength Training: Leg press or squat,chest press, lat pull down or row 1-2 sets 2x/week with enough weight to challenge your muscles

Flexibility: 2-4 limitation-specific stretches after activity, hold 20-30 seconds

Body Composition: Men <25% body fat, Women <38% body fat

Balance and Agility: “Act like a child” – balance line, “step on a crack”, brush teeth standing on one foot

Enhanced Fitness Level

Cardiovascular Exercise: Play or aerobic activity 40-60+minutes 4-6 times per week

Strength Training:  Balanced whole-body machine or free weight program, 2-3 sets, 3x/week to “functional failure”

Flexibility: 6-10+ whole-body stretches after activity, 1-2 reps

Body Composition: Men: 12-20% body fat, Women 20-30% body fat

Balance and Agility: Recreational sports:  tennis, bicycle, tai chi, dancing, stability ball training

Performance Level

Cardiovascular Exercise: Add interval training and/or competition

Strength Training: Add muscle endurance or power training, add pilates work, add ascending or descending pyramids

Felixibility: Add yoga, pilates, facilitated stretching with a partner

Body Composition: Men 8-15% body fat, Women 17-25% body fat

Balance and Agility: High level sports: ski, skate, surf, yoga, martial arts

Other resources:

How to Write an Exercise Prescription – Uniformed Services University of Health Sciences

Measuring body fat (caliper and tape measure calculators)

Physician Suicide

What a hard topic to write about.

Like most physicians, I knew a colleague who committed suicide.  Also, like most physicians, I didn’t see any warning signals.  I recently came across a review article on the subject of physician suicide on emedicine that made me decide to post some information.

Every year in the United States, we lose the equivalent of at least an entire medical school class to physician suicide.  It happens during medical school, residency and once doctors are in practice.  It’s nearly always related to depression – a clinical problem we all learn about, but have trouble recognizing in ourselves or our colleagues.

Depression is a disease, not a personal failing.  It affects 12-18% of practicing physicians and – it’s treatable. It’s often associated with alcohol or substance abuse, which are also treatable.  The good news is that depression, substance abuse and alcoholism are more successfully treated in physicians (and trainees) than the general public – probably because of the personality traits that lead us to become physicians in the first place.

All medical schools have confidential and free support for students and residents.  If you are worried about the effect on your career – don’t.  Seeking treatment is a sign of strength, not weakness.  If you are struggling, please know that there is help and you are not alone.

Here are some important resources (you don’t have to be suicidal to ask any of these sites for information or help)

National Suicide Prevention Hotline 1-800-273-TALK (8255). an outreach program from  The American Foundation for Suicide Prevention

The Perils of Perfectionism

Last week I attended a wonderful lecture in Baylor’s Medicine and the Art of Compassion lecture series entitled  “The Perils of Perfectionism”.  It was presented by Dr. Glen Gabbard, who is a psychiatrist and author with great expertise in physician wellness.   I can’t do justice to the entire lecture, but there were a few key points that I wanted to share:

Compulsion is one of our our greatest assets as physicians, but it can become one of our greatest liabilities.

One of the key personality traits that physicians need to have (and/or develop) is to be compulsive.  In fact, many of us choose medicine because it’s a good fit for our basically compulsive personalities.  Unfortunately, as Dr. Gabbard pointed out, unbridled compulsiveness can lead to “excessive devotion to work and productivity to the exclusion of leisure activities and friendships.”   How do you tell if a good thing (caring about patients, being compulsive) has become an unhealthy behavior?   Here’s some warning signs that he pointed out in his lecture:

  • A reluctance to delegate tasks or work with others unless they submit to exactly the way you want it done
  • Rigidity and stubborness
  • Perfectionism that interferes with completion of the task (checking the reflexes 10 times on rounds instead of once or twice)
  • Self-doubt
  • Guilt
  • An exaggerated sense of responsibility
  • Failure to take vacation
  • Cynicism
  • Chronic fatigue
  • Emotional outbursts
  • Headaches
  • Increased alcohol consumption
  • Marital “deadness” or discord

It’s dangerous to look at the issue of physician stress with an “us-them” mentality

It’s easy to think that discussions of physician stress and impairment apply only to “other doctors” (or “other” medical students).  Unfortunately, the stress that comes with out of control perfectionism can lead to suffering for any physician.  In extreme cases, it can lead to physician impairment, destruction of relationships, burnout and physical illness.  As Dr. Gabbard pointed out in his lecture “impairment is the endpoint on a continuum.”  Every physician, when exposed to the right combination of stressors, can become impaired.  The key is to realize that all physicians are susceptible, that it’s important to watch for warning signs, and that’s it’s even more important to seek help when its needed.

“The desire to excel must be differentiated from the desire to be perfect.”

I thought this was a wonderful rule for physicians to remember.  We all want to do our best, and we all want our patients to do well.  We want to excel, but we can’t ever be perfect.  Physicians don’t have control over many outcomes – some patients will develop complications or die despite our best efforts.  And… we are human.  Mistakes will be made.  The goal is to minimize them, learn from them, and forgive yourself.

“A physician that treats himself has a fool for a patient” (William Osler)

Every physician should have a personal physician.  As much as possible, the relationship should be as “normal” as possible i.e. even though you are a doctor, you should be treated just like any other patient.  That’s not as easy as it sounds, but it’s the right approach for both you (as a patient) and the physician treating you.   Why go to the trouble of finding a personal physician?  If you become ill, it’s nice to have an established relationship with the person who will be treating you.  It’s also nice to have someone you can talk to if you are feeling burnt out.  Depression, stress, and impairment can all be treated.  It’s really no different than going to the orthopedic surgeon if you break your arm.  If you need help, talk to your primary care physician or a mental health expert.

Some of our greatest lessons come from dying patients.

Anyone who has had the blessing of caring for a dying patient has learned from them that there are only two important things in life: to live wisely and to love well.  Our family and our friends are our greatest treasures.   Learn to spend time taking care of yourself  and nurturing these important relationships.  It’s easy to fall into the trap of putting off this important work… but don’t.    “The fool with all his other thoughts has this also:  he is always getting ready to live.”  (Epicurus)

Wellness for Emergency Room Residents

I came across this lecture by Lily C. Conrad, MD PhD FACEP on Wellness for Emergency Room Residents and thought I’d share it.  It’s a good review and makes some interesting points.  She raises issues applicable to all residents as well as more specific issues for residents in Emergency Medicine.

The concept of renewal is critical:

  • A single-minded devotion to career is impoverishing
  • By neglecting restorative activities physicians tend to lose their emotional resilience
  • We need to establish time for rest, revitalization, exploration and emotional and well as intellectual growth

Link to the lecture – Wellness for Emergency Room Residents

Attitude, Composure, and Peak Performance

Anger is the only emotion you can’t show if you are a professional.  You can be angry, you just can’t show it.  Last week I lost my temper at work.  It’s rare for me to lose my temper, but when it happens it’s a good time for reflection on what happened.

Tennis is unique as a sport for a lot of reasons.  It’s an individual sport (which immediately puts it in a different class than team sports).  It’s also not a race, so that makes it different from cycling, running, swimming,etc.  It requires a lot of strength and cardiovascular fitness, like gymastics, and a lot of strategy, like golf… but it’s different than those two sports as well.  To be a successful tennis player you have to be fit, strong and smart.  But like other athletes, these are necessary but not sufficient – there is still one more critical skill that has to be mastered – the ability to control your emotions.

Athletes at their peak have mastered the sport, but they also have learned how to manage adremalin and control emotions. “Peak performance” is a term usually applied to athletes, but the concept applies to physicans as well.  How do we “train” to be able to work at our “peak”?  As someone who teaches surgeons, it’s one of the biggest challenges I face.  We can teach young surgeons how to operate, we can teach them when to operate… but we can’t convince them that they can do it on their own.  The ability to stand with confidence at the baseline in the French Open or at the OR table to start a big case has to come from within and is the result of practicing the task and managing the stress.

Sam Stosur is one of my current favorite tennis pros to watch.  Her game is magnificent but its how she has struggled with and learned to manage the stress of competition that I really find fascinating.  During a recent match she had two words written on her wristband – “Attitude” and “Composure”.  It served as a reminder to her to take a deep breath and focus on the task at hand.  Physicians are no different – we need to find ways to remind us to adjust our attitude and maintain our composure.

Next time I’m tempted to get upset at work, I think I’ll remember Sam Stosur’s wristband…

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iPhone apps for Docs

1.  Epocrates – this is probably on the phone of every medical student, resident and practicing doc in the United States.  It’s a great database of information that’s easy to navigate.

2.  Medscape – similar to Epocrates, but not as commonly used (at least where I practice).  It sounds really good, though.

3.  MedCalc.  The name says it all – easy calculation of medical formulas.  This is another app that is on the iPhone of every doctor I know.

4. Eponyms.  Medical students struggle with learning the eponyms associated with diseases, anatomy, etc.  This is a mini dictionary of 1700 eponyms.

4.  Medical Spanish.  This really lets you do the basics (until the interpreter gets there)

5. iMurmur.  You have to use the earbuds, but this is really good app to learn (and review) heart sounds.

6. Evernote. You have to play with this to fully grasp how powerful it is.  In a nutshell, you store “notes” on a server for free.  (Premium, which is $45/year lets you add attachments and increases your storage and is well worth the money).  Notes can be web pages, text from the internet, documents, photos, or voice recording.  Most importantly, you can search all your notes (and it has text recognition for photos, too).  In effect, it’s like having a “google” of your own notes.  Download the desktop app as well as the iphone app if you choose to use this – it makes it even more flexible by letting you create folders.

7. Remember The Milk.  This is the “to do list” app that I use.  It’s gotten really good reviews, but I’m sure there are other task lists that are good out there to.  This has it’s own email address for you, so you can forward emails to your RTM account which then become “tasks” on your list.  You can create categories, set reminders, etc – all in all it’s a great app.

8.  Pandora radio.  Check this out on the web first and then download the iphone app.  This started as a PhD dissertation on the “music genome” – trying to find out what make certain music similar to other music (and why that could be used to define what you like).  The end result is personalized music – for free.  It’s nice to have on your phone to listen to when doing paperwork or waiting on call.

9.  Peggle.  Ok, you may think this one is silly (and it is a little).  I’m not at all a video or computer game person, but I read about this game in an article on stress reduction.  It’s addicting, fun and most people who play it would agree with pilot studies that show it reduces stress.

If you have an app that you think should be added to the list, please comment!

Managing Money as a Medical Student and Resident

Financial issues are a source of intense stress for most students and residents.  It costs a lot to become a doctor and is costing more each year.   The goal is to finish your training without being handicapped by financial issues.    Doctors (including me) are not experts in financial issues (even if they think they are).   There are financial counselors at every medical school, or they will at least be able to refer you to someone.  It’s a really good idea to learn about this early.  Make an appointment and go talk to them about they best way for you to approach your own financial challenges.   There are some basic principles that will help get you started:

  • Limit your debt.  Pay off credit cards every month.  There is really no exception to this rule.  The interest on credit card debt is obscene.  You have to avoid it at all costs.  You have to make a conscious effort to live within your means.  It may be you have to have a car, apartment or clothes that aren’t what you would consider ideal.  But, in the long run, not running up the debt is far more important.  Make a budget, keep track and monitor your spending.    This is a really good resource from the AAMC to help you understand how to manage your money in medical school, including how to budget:


  • Your credit report is important.  Let me repeat that… Your credit report is important.  It doesn’t take much to have the score slide (a few late payments, missing a payment) and it will follow you a long time!  It takes about 7 years of perfect credit to get the score up to a level where you can buy a car or a house.   It is really easy to not pay attention to this during your training… and then pay the consequences after you finish.


  • Before you worry about investing, you should worry about protecting what you have (even if it’s not very much).   You should automatically have life insurance and disability insurance from your institution, but you need to check.  Unfortunately, if you are a resident, the “MD” behind your name makes you more vulnerable than the general public – and lawsuits can be against future earnings, not just current salary.  Many attorneys recommend that you spend the relatively small amount it costs to obtain an “umbrella” personal liability policy to help prevent a large lawsuit from someone if you are involved in an automobile accident or someone trips on your front porch.  When you are in training, these kinds of insurance policies seem like a waste of money.  But – they aren’t that expensive when you consider that all your money can be wiped out with a single disabling injury or personal lawsuit.  When you go to meet with the financial experts, this would be a good question to ask.


  • Once your insurance is covered, and you start having a salary (i.e. when you start your residency) invest a little on a regular basis through payroll deduction.  Having the money taken out before you see the check is key.  This is a habit that you want to start early.  This can be for a retirement account (pretax money) or another kind of investment account.  Again, talk to the financial counselors to learn about these options and decide which is best for you.  The pretax dollars are important….  If, for example you earn $1000, you will be taxed roughly 30% on that money i.e. $300, leaving you $700.  If you invest $100 dollars into your retirement fund, you will only be taxed on $900.  That means you will pay the government $270 instead of $300.  You will now have $630 to spend, instead of $700.  But – the $100 will compound incredibly.   Try it out..