Positive medicine - getting stronger, getting fitter

Surf workouts

I'm away to unwind on a surf week to Taghazout, Morocco over New Years, with its killer whales and big breakers (I'll be starting on the nursery waves) and wondering how best to get in shape for it.  Boozy with lots of laughs & games w/nieces is the likely prep I'll do (since it's Christmas just before) but be good to know what I should be doing!  Over all these years of exercising (hillwalking, runs, swims, rides, football, climbs, racquetsports, capoeira, kayaking, surftrips, snowboarding, hockey, and very occasional gym/CrossFit sessions) I've never devoted much time to finding out what constitutes effective training, I've just worked on the basis of volume and a competitive streak.  The answer is unlikely to come up in our medical lectures: sports preparation falls a bit too much on the 'wellbeing' side for our 'heal-the-sick' focused course.

So how generally to optimise strength/fitness?  What do I know already?  I've learned along the way to fuel before & after exercise, and my dad, once ripped back in the 70s, suggested to us as boys that pushing to the limits was good, and on strength building 3 sets of 8 was the way to go then to up the weight when it became too easy.  My triathlon buddies seem to blend interval and slow-paced runs into their endurance training.  My electrophysiologist buddy Marie suggested pushing to failure on the last set.  Let's see what a bit of research has to say about getting stronger and getting fitter...


General principles of strength and fitness building

Accepted advantages of exercise: energy, mood, sporting ability, improved sleep, stress tolerance, attractiveness, libido & sexual prowess (whoop!), alertness, weight management, improved immunity, chronic disease avoidance.  Strength & bulk-wise: some say this confers a perception of authoritativeness, and you might imagine some occasional practical application (lifting fallen trees from crushed cars is a rarity, though...)

Tips on exercise motivation: ideally be doing an activity that you intrinsically love, vary the monotony of training formats, capitalise on supportive friends&family, make a plan, reward yourself, find a role model, develop your background knowledge, set goals, measure your performance against those goals, train socially.  Sounds reasonable enough.

Nutrition - quantity:

The body uses the same energy molecular currency 'ATP' everywhere. This is the end product of breakdown of carbohydrates, proteins, fats.  Adequate protein levels are necessary for tissue repair and muscle building, and fats are important for vitamin absorption and hormone production.

During intense training periods, increased intake is recommended:
1.3-1.8g protein/Kg/day (that'd be 104-144g for me, = 4 tins tuna or 4 chicken breasts or 20 eggs!) (Phillips & Van Loon, 2011)
30-60 kcal/Kg, that'd be 2400-4800kcal for me, of which 30kcal/Kg should be carbs.  (Tarnopolsky, 2008)
Lots of water, even better if this replaces electrolytes too post-exercise, particularly sodium.

Nutrition - timing (I've used weak sources here, but I've found consistent guidance)
3-4 days before endurance event: carb-load with 12g/Kg/day of low-GI foods (e.g. seeds, wholegrains) prior to an event to maximise glycogen stores
3 hours before race: eat a small meal (400kcal) to allow insulin to normalise
In the last 3 hours pre-event: keep drinking about a pint of water an hour
Immediately before exercise: top-up a few mins before with a carb snack with a little protein
During exercise: Isotonic carb drinks/snacks during exercise (i.e. take an energy bar to the beach).  If exercise lasts >2 hours, incorporate some protein into the fuel during the exercise to avoid muscle catabolism.
Recovery: carb (1.5g/Kg in first 30 mins after exercise) w/ protein snack (~40g) post-exercise
There's no evidence that splitting the diet into more than 3 meals a day makes a difference - many researchers have looked into this (Helms et al., 2014)

Getting stronger - and building muscle

Strength and power:
Simply, strength = ability to lift things (force).  Power = ability to lift them fast (force x velocity).
Weight training also offers a choice between strength increase and hypertrophy (muscle size) - it is possible to prioritise the look rather than the functional ability.  Functional goals first seem more my kind of principle...

Frequency of exercise:
Reps: 1-5 strength; 5-8 muscle hypertrophy & strength equally, 8-10 hypertrophy; 12+ endurance  (meathead wisdom, supported by Mangine et al., 2015)
Sets: 2-3 for strength, this is 45% more effective than just 1 set.  (Krieger, 2009)
Rest: 5mins for strength; 30-60secs for hypertrophy (one study suggests 3mins); 20-60secs for endurance (de Salles et al., 2009)
Sessions: 3x per week is optimal for beginners to avoid mental fatigue, leaving at least 48h between the same exercise, and at least 1 full day off a week (therefore maximum 6x training per week)
Vary your training across the week: using one day in the week to focus on each of strength, power and hypertrophy is best - thanks Rob for the intro to Daily Undulating Periodisation (Rhea et al., 2002)

Features of the exercise (more meathead wisdom):

• Compound exercises are most time-efficient (rather than isolating a specific muscle and working it, which means much more time in the gym would be required)
• Free weights use more muscles than resistance machines - you use the stabilisation muscles too
• Injury avoidance - proper form when lifting reduces injury risks, and barbells are best to avoid injuring yourself
• Training to failure (i.e. until you can't do any more reps): this is exhausting, and may affect the rest of a workout leading to less overall work done, aka 'central fatigue'.  That said, the intensity may increase strength gains for the target muscle.  So - use it with consideration!
• Specific exercises: squat and benchpress at least twice per week 
• Endurance training decreases strength training performance - so cut the long runs if you're looking simply to strengthen up

Getting fitter and faster

What is fitness? (US Surgeon General, 1996, Ch3 p.72)
(1) Cardiovascular capacity (heart contractility, left ventricle dilation, stroke volume)
(2) Skeletal muscle adaptations (increase in number of mitochondria in muscle, more oxidative enzymes within mitochondria, better capillarisation, faster diffusion of oxygen and fuel into muscle, increase of fatigue-resistant slow-twitch muscle fibres)

(3) Metabolic adaptations (better disposal of metabolic waste, increased use of fat as fuel)

General tips on building fitness
|A| A regular training stimulus is required for adaptation to occur and be maintained

• adaptation: (1) after a power sprint session - 2 days; (2) after a VO2 max oxygen debt, e.g. hills session - 2 weeks; (3) after a long endurance session - 6 weeks.
• detraining: this is significant within 2-4 weeks.  Fitness can be maintained despite a 70% reduction in training frequency/duration, as long as the intensity of that training is maintained, but if not then all functional gains are lost after 2-8 months (US Surgeon General, 1996, Ch3 p.72)

|B| Structure your fitness training around the race calendar - so you peak at specific competitive events.

• generally start with higher volume & low intensity, and adapt to lower volume & high intensity as competition approaches
• 'periodise' into four week blocks, and make a focus out of each of the four-week blocks, e.g. strength, speed, power, technique, endurance or post-race active rest (Bazyler et al., 2015)
• focus on skill acquisition in periods of lower training volume & intensity
• taper off before competition (for 1-4 weeks, depending on how rapidly you detrain)

|C| Vary your fitness training approach.

• vary the intensity of training.  One coach recommends that 10% of your training should be faster than your race pace, i.e. if your 5km run pace is 6m15 miles, do 80% at 8min miles, 10% at 7min miles, 8% at 6min miles and 2% at 5min miles.  This 80:20 split of higher to lower intensity training is accepted wisdom for runners and other endurance athletes (Seiler & Tonnessen, 2009)
• incorporate muscle-work: when strength training is the focus, use the gym.  High-force, low-velocity training at 80% of your 1 repetition maximum for 5 or 6 repetitions on relevant muscle groups yields the best results (even tho' lots of people don't like the gym!) (Bazyler et al., 2015)
• have a calmer week every fourth week or so - helps you recover and stay fresh & keen
• high intensity interval training (HIIT) incorporates short periods (e.g. 30s-5m) of maximal effort followed by a rest, preferably of active recovery.  There's no clear optimal level of the work:rest interval, but 1:2, 1:1, 2:1 are frequently mentioned, confers endurance benefits up to 2x per week (Seiler & Tonnessen, 2009)

For those looking to burn fat: a moderate exercise intensity is best


So what about the surfing?
What's needed:
- strength and endurance: bursts to catch the waves, endurance to paddle all day, balance and power to pop-up on uneven waves

Use a surfing-specific training manual to make the plan:
- Nutrition: pre-load with lots of high GI carbs, carb/protein snacks, energy drink, carb/protein recovery drinks
- Warmup: follow the 7 surfing-specific dynamic routines
- Swim (in the pool): interval training combining high intensity burst swimming (30-60s) with endurance work.
- Strength @ home: HIIT the pull ups, push-ups, lunges, squats
- Gym (1): full body/balance - deadlifts, overhead presses, single-leg squats/medicine ball tosses,
- Gym (2): core - medicine ball / stability ball
- Gym (3): shoulders&back - cable chops, bent rows, cable pulldowns etc.
- Stretching: best done post-exercise


And what next...
So food's in the bag, exercise is in the mind (!), now for tagines, freshly caught fish, and NYE beach party...

Local transport here we come

Review credit - thanks to Rob Armstrong, including his important caveat that although general principles apply, everyone is genetically different, one size does not fit all, so you have to try things out to see what works for you.

Top advice for an aspiring doctor

The seat of the wise ones...

So, I've been gathering useful bits of 'how to be a doctor' advice from wise people around the place since this medical quest of mine began with applications in 2013.  The first from a riverbarge at 3am, the last on a breathless trip up and down to the basement of the big QMC hospital in Nottingham.  Three years' worth of glimmering pearls follow.  My favourite?  Vicky's take on everyone quietly freaking out in the operating theatre on the inside during an emergency, but you'd never know it to look at them! As I walk the halls I like the idea of picturing the faces of these giants shooing me along...

Real people's advice (non medics!)
C (management team @ RCS) – remember, surgeons just love to teach.  They’ve spent their lives acquiring such a large body of knowledge; so they just want someone to tell their story to.  They want someone to listen, ahhhhh :)
LQ (engineer) – well-being guidance from your doctor is important; not just the information about how to avoid being ill.  This means lifestyle advice (exercise, sport, socialise, sleep), as well as some handy practical advice about what makes you vital.  Docs rarely cover this, but they're missing a trick!

SL (clinical psychologist) – beware the prospect of being a doctor turning into an endeavour in which you are simply a well trained algorithm reproducer – in which there isn’t creativity, but simply the ability to remember a series of instructions to follow.  There needs to be so much more than this.

PJ (diabetes nurse) – it’s personally safer to see being a doctor as being an advisor, you need to structure and provide the best advice possible.  The responsibility for enacting that advice lies with your patient, and you can’t allow yourself to be measured on whether they decide to follow it, else you may well end up frustrated and disappointed.

RB (midwifery lecturer) - we’re all judgemental.  We can’t help it – we do it every time someone comes into the room.  It’s important to notice it, accept it, be informed by it, but not let it affect the quality of care you offer or show on your face. 

Med Students

AL - remember when you’re choosing specialty, it’s not a case of whether you could do it (be aware that you’re fully capable of doing any specialty!), it’s a matter of determining which is the right choice for your life ahead.  Beastingly tough specialties don't necessarily make for a happy life!

JG - the type of hospital you end up working in matters – if you can be in a small district hospital, you can see and be responsible for a great variety of work – for some this can make all the difference, between a stimulating and interesting job, and a mundane one

Consultants 

LM (GP) – when you’re shadowing in UK or overseas, focus on maximising the amount you can contribute to the environment you’re shadowing in.  Don’t rock the boat either.  This will endear you to your seniors.

Unnamed (general surgeon) – keep patients’ thank you letters – they’ll help you smell the roses in the bad times, and you can count on it, there will be bad times. 

WD (obstetrics&gynae - cancer specialist) – sometimes the pregnant pause is all that’s needed to draw a patient out.  And if they’re particularly unhappy or complaining about something, keep asking them what they want you to do – if you put them in the driving seat, they’ll find it hard to complain.

JL (colorectal surgeon) – it’s the clinical skills that will stand you in good stead when you're actually practising, not the academic science.  Focus on the clinical areas and you’ll be well set.  Oh, and tick the boxes.  People jump through the surgical training hoops if they tick the right boxes...

DB (cardiologist) – some medical specialties are distinguished by certainty (e.g. specialist cardiology, hand surgery) vs uncertainty (e.g. infectious disease, GP).   And specialist wards are usually a better and happier environment than generalist wards – the ability to actually solve the problems faced avoids despondency!

DB (cardiologist, again) – GPs function best when they have a speciality interest to keep them motivated, if you're considering it, find that interest and hone in on it!

SS (paed surgeon) – it’s all about miles on the clock – it’s not how long you’ve been a surgeon, it’s how many cases you’ve seen and done.  That’s what makes you good.  Conducting surgery after surgery on the job can be the best way to build those skills (he talked of a hospital in the Kashmir).

KG (GI - functional GI specialist) – don’t judge patients’ poor lifestyle decisions by your own yardstick.  They aren’t necessarily in the habit of thinking for the long term, many of them have always lived from week to week, and what sounds like a reasoned solutions to you may therefore not be absorbed by them.  Give them a short-term reason to follow your advice.

Unnamed (online) – what makes a good F1 isn’t being a genius, but it’s someone who’s honest, reliable and trustworthy.  Be that guy.

Juniors

VW (ST5 obstetrics&gynae trainee) – don’t be fooled by the level of calmness on everyone’s face in the obstetric operating theatre.  If there’s a major haemorrhage, the anaesthetist will be freaking out, the surgeon will be freaking out, they’re just good at suppressing it.

FA (ST5 urology trainee) – don’t focus too much on the technical details of the procedures you’d end up doing in a surgical specialty.  All of these will become commonplace to you after a time.  Work-life balance and the future trajectory of your career are more important.

GB (ST paediatric trainee) – patients lie.  Teenage girls lie in particular.  If she claims she's had her body ravaged by disease / mauled by a tiger, don't trust it.  Equally, if he says he's fine, he's probably dying.  Ask a family member and trust the examination findings. 

GB (ST paediatric trainee, again) – don’t allow the trend of over-modesty and deskilling to seep into the profession of being a doctor ("oh, you nurses know so much more, you HCAs, you're all get the patients so much better than we do").  They're good, but they're not doctors.  Be confident about what docs can do.

RW (SHO genito-urinary medicine trainee) – know your emergencies section from the OHCM – that’ll cover you for F1.

E (MSF Amsterdam and GP trainee) – when you’re in GP, the biggest question on your mind should be: is this urgent?  Or can this wait.  If it can wait, breathe out, you can get them to come back…
RA (plastics trainee and journal founder) – contracts and cash are going to be a constraint all the way through your medical career.  Generate a secondary source of income to limit the impact of this.
HE (ST? geriatrics clinical-academic trainee) – don’t be afraid to step off the training pathway, it can really help you to figure out what’s right for you at each stage.  From all angles you'll get pressure to stay on it, but you’ll need to hold your nerve in the confidence that you’ll get a training number at the end of it.
AC (ST4 ortho -> HEMS trainee) and here's the most comical of the lot.  How to accept that you'll find arrogance in those surgeons who have to make massive life-changing decisions?  Remember, dear student, "The bigger the balls, the bigger the cock".  Priceless.

Nice eh?  That's it for now - Christmas is coming and these presents aren't gonna choose themselves...

Not much chance of one of these!

Extraordinary experiences in medicine

Nottingham Medical school, QMC

Medical school is an extraordinary place to be.  Some lifestyle things get left by the wayside on a tight schedule in the Midlands, but the existence offers some most unusual experiences.  They've engaged us with some of the UK's extraordinary events on my doorstep, reminding me of Sheffield days.  A few of the memorable medical experiences so far below...

We're skilling up - and hence to learn we have to 'do':

• Attending to a crashed motorcyclist and leading the first aid until the doctor and helicopter arrived
• Delivering a baby as a midwife stood by
• Performing CPR with a paramedic on a dying man's chest at his home
• Visiting and assessing a patient having a heart attack in his house
• Suturing the skin of an anaesthetised patient (after having taken consent!), and removing non-absorbable suture 5 days later (tougher than you might think!)
• Physically tapping-in a regionally anaesthetised but awake patient's wrist prosthesis
• Performing a surgical evacuation of retained products of conception (under close surgical observation, mind, with consent!)
• Cradling human prosections of brain, liver, heart, lung in my hands (that's in the anatomy suite) 
• Assessing a still-warm placenta in my hands
• Training in laparoscopic (keyhole) surgery on a simulator
• Assisting in surgery as the camera operator
• Teaching practical skills in formal classes for the first time in all my days - cardiac dissection and suturing ; and a large handful of theory workshops & lectures, the like of which I've not taught for years.
• Explaining to a fella and his family what it means that he just had a heart attack
• Visiting a tuberculous patient on the infectious disease wards while wearing a facemask, reminiscent of a plague-doctor's beak
• Cannulating, bloodtaking and injecting - needling becomes surprisingly consistent once you get your eye in.

It's not just doing, it's observing life and death too - watching experts in action

• A major obstetric caesarean haemorrhage with a terminally ill-unless-supported baby with a very slow heartbeat, all in a completely calm room, mother and baby's problems resolved so calmly by the surgical team that the husband (present in the theatre) was unaware!
• Re-break of a man's malunioned tibial fracture by an orthopaedic surgeon using his bare arms, and then fixing it with a 14" titanium nail!
• A one-sided breast surgery (mastectomy) performed using a large oval incision to remove a huge cancer that the patient had left unchecked for years 
• Breaking bad news - of serious inoperable abdominal cancer to an elderly woman, but focused on what could be done.
• Rapid decline from chatty to death of a young alcoholic (30s) - seeing a valiant but unsuccessful team effort over two days, after variceal-rupture induced oesophageal bleeding
• Watching a postmortem take place, respectfully but unflinchingly by the mortuary team
• Watching an embalming being performed on a tour of a funeral home (a respectful team, a calming outcome for the family, but a process takes a bit of getting used to)
• Breaking bad news to a family - of meningitis in their daughter - seeing how this tragic situation can be approached sensitively
• AND - seeing a (clearly delighted) male college pupil learn that girls can take contraceptives in a 'pick up your condoms' drop-in session
• seeing a baby quietly have its tongue-tie (frenulum) cut in clinic
• seeing a comical mountainbiker who was trying to impress his son on BMX have his broken ankle (trimalleolar) tractioned and twisted back into place in A&E.  Yeowwwch!
• seeing a guy who'd just had a heart attack being rushed into the cardiac catheter lab to have his coronary arteries stented (i.e. opened back up)

Meeting compelling characters in this people profession makes it all worthwhile

• A PT instructor (who was an ex- army gymnastics display team member) who told his compelling story of career, sustaining a neck fracture, becoming paraplegic, and coming to terms with it through an exercise device, a mighty modified Mercedes van, an army pension and getting used to scanning new venues for toilet opportunities
• Special needs kids (a busload of them - nice bunch) who we took to a family festival, though after a dramatic rendition of 'The boy who cried Wolf', mine did spend the day making sheep sounds.
• Recovering alcoholics - in a group session where they shared their childhood-to-present life stories
• Extraordinary fellow medical students on their journeys, including the young, the fiercely bright, the wealthy and sporty enjoying the experience; the something-to-prove career-hungry surgeons; the settled, balanced characters approaching the creative opportunities to serve well in the GP niche; the industrious mature students hunting and carving out meaning in a speciality, the rangy or gawky among us finding something to excel at.
• Dedicated GPs and hospital staff, whose general desire to invest in others emerges in the effort they expend to teach and mentor each of us, and help us swell their ranks.

And in my pipeline - I'm still waiting for the day I nail my first medical consultation

• It'll be the day where I gather the right history, I examine the patient right, come up with the right differential diagnoses, and recommend the right investigations and empirical treatment.  Am closing in...I can sense a gastric reflux patient coming my way...here's hoping it'll come in time for Christmas!

'tis a privilege, this.

Levity

Positive medicine - sauna, steam rooms and cold dips

Sweatfest

My best sauna and steam experiences have been up in Gazelle resort in western Turkey (near Lake Abant), seven different saunas from hot and hotter to salt, farmyard-acoustic (!) to the Turkish hammam.  I also used to exchange with a German lad as a boy whose family would have a weekly outing to one.  So what's the medical effect of these saunas?

Sauna and steam room
What is a sauna, what'a a steam room?
Finnish sauna: dry heat, 15-30% humidity, 80-90 centigrade.  2-3 heat-cool cycles each of 15 mins+.  The Finnish are the cultural custodians of the sauna - having one in almost every home  LINK (1997)
Turkish bath / steam room: 100% humidity at 41 centigrade.  Limited research available on these.

Cardiovascular effects of sauna: 

• Equivalent stress to the system as a brisk walk LINK (1997), p. 656 
• Saunas significantly reduce the risk of cardiovascular disease and all-cause mortality LINK (2015)
• Orthostatic hypotension possible in those on antihypertensive medication, generally acceptable in cardiovascular diseased patients unless their hypertension is poorly controlled. LINK (1997), p. 657 

Respiratory effects of sauna:

• Absenteeism reduction: in children taking a once weekly sauna in two studies, and replicated in a study with an adult group after 3 months, absenteeism caused by URTI was reduced by 50% LINK (1997).  However, one study did not replicate this LINK (1994)
• Chronic/recurrent sinus symptoms: no effect of steam inhalation LINK (2016)
• Bacteria: few micro-organisms are viable above 80 degrees so sauna air is relatively sterile and risk of inhalation of active microbes is small LINK (1997), p. 656 
• Heat: in sauna, water and heat transfer to the lung tissue remains small, and hence negligible risk of thermal-induced lung damage.  LINK (1997), p. 656 

Effects of sauna on skin: LINK (2008)

• Improved epidermal blood perfusion  (by 20-40x) during LINK (1997), p. 656 and with a preserved effect after regular saunas LINK (2008) 
• Improved water-holding capacity of skin (i.e. less dry skin) and recovery of skin pH, both of which are associated with stability of the epidermal barrier and prevention of skin disease LINK (2008)  
• Unclear effects on skin turgor

Cold water immersion 
The icy plunge pool after that delightfully relaxing hot room...

• Reduces dehydration from sweat after sauna (due to more rapid cooling) and transiently induces skin oedema, thereby smoothing those wrinkles temporarily!  LINK (1997), p.655
• Cold exposure activates deposits of brown fat - which are metabolically active.  Frequent exposure to cold increases the activity of these which encourages weight loss LINK (2012) ; LINK (2014)
• Cochrane reviews have found no consistent evidence that cold dips reduce muscle soreness LINK (2015)
• It's certainly invigorating, whether after a sauna or in a wetsuit on a cold day.  Gets easier the longer you stay in.  Mechanism likely is through plasma noradrenaline, adrenaline, cortisol and endorphins LINK (1997), p. 655

Summary
Saunas seem to be much the equivalent of exercise - positive respiratory and cardiovascular effects, and a healthy glow.  Just sociably and in the calm!  As for the cold dips, well, that's just more hardcore, isn't it?!

Brass monkeys

Caesarean section suturing skills

Caesarean section

Surgery.  It's a serious business with high stakes, taking place in a brightly lit operating theatre buzzing with the competence of the practitioners.  I'm writing at the end of my 8-week obstetrics and gynaecology attachment, and having worked through the basics of the knowledge in the books, lectures and clinics, I've now assisted the surgeons in the theatre - holding instruments, and for the first time, under the watchful eye of a surgeon (and with permission of the patient), stitching closed one of the tiny incisions.  Skills have come together from one of our teaching groups, SCRUBS where students teach each other suturing classes, and also from various bits of training from the experienced consultants.

The basics of any surgery are pretty formulaic (allowing you to automate the simple bits so you can deal with the unexpected).  So there are plenty of steps to learn.

Trying to describe the atmosphere to someone who's not been in an operating theatre is a challenge.  One way is to liken it to other activities from regular life:
- in some ways the operating theatre is like a formal meeting or dining occasion (there's a dress code, formal arrangements for who is placed where, you must not start until everyone is ready, there's etiquette about who talks to whom, no elbows/leaning on the table, and depending on status you may need to ask permission to get down from the table).
- in some ways the theatre is protocol driven like following a recipe (you have a set of instructions that need a bit of interpretation, there's cutting, there's searing with a diathermy probe, and there's plenty of cleaning up to do afterwards)
- and it's also a little like a home improvement project (if it ain't broke don't fix it, you get best results if you drill pilot holes before you screw in, nails need to be hammered in, the experienced practitioner lines things up by eye, and you have to know not to meddle too much - leave when it's good enough).

Steps of learning for any surgery

• Learn the anatomy of the body region
• Learn the steps in the procedure
• Learn the names of the instruments and sutures
• Train your muscles to learn the knots

Suturing and muscle memory needed for C-section skin 

• Hand-tying the basic surgeon's knot
• The running subcuticular suture
• The Aberdeen knot
• A summary video of the skin closure used by the docs I've seen at King's Mill 

My experience has been such that the team here are quite particular about skin suturing in caesarean section, and this placement I've not had a chance to deploy those skills learned on the skin pads.  Next surgical placements will be in the new year - ENT followed by orthopaedics - we'll see what the prospects are there. 

Positive medicine - stretching and warming up

Post-run stretching at Hackney Marshes parkrun

I've run 5-15km a week for the last 25 years (somewhere approaching 7000km) and continue to do so on the medical course.  It's a part of life now - I neither love it (apart from those times when I'm super fit) nor loathe it (aside from the repetitiousness!).  Up and down Donegal mountains on the Glover Highlander, searching new streets when growing into Maidstone or settling into Bavaria, Lancashire, Sheffield, Battersea and Derby; sweating buckets against all advice in Ghana in the midday sun (ouch!), and joining running clubs in Kent, Clapham, Nairobi, Derby and Mansfield, it's been consistent at least.  I've heard a load of received wisdom about stretching over the years, precious little of which I ever imagine has been researched by the people who have told me.  And as a medic, perhaps I should now be a little better informed...

The research consensus on stretching and warming up seems to be (1) DO warm up before exercise but (2) DO NOT stretch before exercise, but instead stretch (particularly the hips) at other times.  And - stretches, like so many things, are activity specific.  May be a surprise - so below details how stretches increase range of movement, performance, and affect injuries.  Here's the evidence...

Stretching

What is the physiological effect of stretching (i.e. what's happening in your muscles)?

Acutely:

1. Analgesia - increasing your tolerance of stretch, allowing you to tolerate a greater range of movement (ROM) than you had previously  LINK (2012) ; LINK (2006), p.5
2. Stress relaxation of muscle - reducing the passive tension in a muscle.  This tends to last < 1 hour LINK (2006), p.6
3. Elastic extension - as muscle sections (sarcomeres) slide over one another (and to a lesser extent, tendons and other connective tissues stretch) - muscle is the least stiff section so extends the most LINK (2009).  
4. Plastic deformation - short sarcomeres may be torn; connective tissue at the musculo-tendinous junction may be torn, abnormal crosslinks may be torn.  At the end of the muscle's ROM, tendinous collagen may also be torn.  May occur, can be pathological, therefore stop when it hurts. LINK (2005), p.51, 65

Chronically (adaptively):

1. Stretching stimulates protein synthesis in muscle - more sarcomeres are synthesised and added to the end of the myofibril LINK (2005), p.53
2. Ruptured collagen fibres are repaired by synthesis of further collagen which reunites the fibres, adding 'links into the chain' LINK (2005), p.55 

Effect of stretching on Range of Movement (ROM) LINK (2012) ;  LINK (2014) ;

• Static stretching increases ROM maximally if load is applied between 10 and 30 seconds LINK (2012)
• 2-4 repetitions give maximal stretch (subsequent repetitions do not increase range) LINK (2012)
• ROM increase is greatest if the muscle is contracted prior to stretch
• Foam rolling appears to have a far greater influence on ROM than stretching LINK (2014), slide 28
• Acutely, the ROM increase lasts less than an hour, whether the subject is exercising or not LINK (2009)

Effect of stretching on injuries

• Stretching does not reduce the occurrence of injury LINK (2012) ;  LINK (2014), slide 8
• Static and dynamic stretching have equivalent effects; active dynamic stretching is fine (full range), ballistic stretching (full range, bouncing intensely at the ends) increases risk of damage.
• Stability-mobility paradox: highest injury rates are in people at the top and bottom 20% of the flexibility distribution curve. LINK (2014), slide 19

Effect of stretching on power

• Pre-performance static stretching reduces power by 4-30%, LINK (2006), p.8 (this was at a duration of 120 secs+ per muscle group), lower stretching of 30s+ shows little compromise- therefore stretching before exercise is not a good idea for performance.  LINK (2009)
• Post-performance (or inter-performance) appears to elicit long term performance benefits LINK (2009)
• However, increased flexibility in general does not increase running economy, so these benefits of stretching may be activity-specific LINK (2014), slide 19

Optimal level of stretch

• Greater flexibility in the hips is adaptive for running (faster runners have this) LINK (2014)
• Less flexibility than standard in the lower leg joints (i.e. knees and ankles) is adaptive for running LINK (2014)
• However, years at sitting at desks and wearing shoes may exaggerate our inflexibility, and hence it's a probably a good idea to stretch out when you're running, particularly as you age. 

Warm-up

What is the physiological effect of a warm-up?

• temperature effects on the muscles, e.g. increased nerve conduction rate, increased anaerobic energy provision LINK (2003)
• neuromuscular effects, e.g. increased intramuscular Ca2+ LINK (2014)
• psychological effects, e.g. increased exercise enjoyment and motivation LINK (2014)

Performance effects of warm-up

• Stiffness is reduced by warmup LINK (2014), slide 21
• Reduces injuries: the maximum force of energy absorbed before failure is increased if muscle groups are warmed up before training LINK (2014)

Summary guidance on warm-ups and stretching

1. You should warm-up with low intensity exercise before high-intensity exercise
2. You should stretch muscle groups for 2-4 x 10-30s after or between exercise sessions - this helps with muscle synthesis and is likely to yield performance benefits
3. You should not seek super-flexibility; a moderate range of flexibility is optimal for most activities.  For peak performance running (if that's your only sport), flexible hips and slightly stiffer-than-average ankles is probably the best combination

Runner's World offers us an (incompletely evidenced!) guide to stretches

Medical careers - first specialist interest selection

Medical speciality decision: amusement

For the first time in the medical course we're being asked to prioritise from our areas of speciality interest (choosing 4 from 100 or so) to direct 20 days we'll spend during Year 3 of our 4-year graduate medical course.  Eeek!

Overeager?  Well, by most measures it's pretty minor this early on - what's 20 days in a 1500 day course, after all.  But there's something in it.  It's a guarantee that one day some Morpheus-like character will present the proverbial blue pill and a red pill for the speciality choice, and it'll be well to know which one to take.  Else it'll be a rerun of schooldays' UCAS with a zillion courses and little to pick between them, or the extraordinary array of projects to pick from on consulting jobsites...

So - last summer I was gathering tips from my cardiology mentor (Diane) on where next to network and get experience in medicine, and she rightly tasked me to draw out a picture of how the future might look (and where I might be for it).  Undoubtedly, one of the benefits of the medical career is the predictability of career pathways, still a tough task.

View pinged to Diane @ close of 2015

Specialities under consideration
So there are lots of options & here are three which have some appeal...

Orthopaedics (e.g. broken bones, joints, muscles, tendons): a long but practical route, takes about 15 years from med school start till consultant, which is when you're fully trained.  This 15 years would be varied - working on all different parts of the body; then the second half of the career would be potentially 15 years as a specialist hand surgeon (finer detail, get to sit down, better hours!).  It has interesting patients of all ages, you see rapid and dramatic change in the patients, hand patients are awake during the procedures, there's the important psychological angle around pain & physio adherence, and it's internationally relevant - the development agencies seek orthopaedics and there's a big demand for surgical training in the developing world.  Plus I had a great time observing this in Nairobi.  What's not to like? LINK

Infectious disease (e.g. hepatitis / meningitis / HIV / MRSA / TB): there's all the fascination of problem-solving which the medical dramas make a play on, as well as the integration of animal and human disease vectors.  And the great thing is - most diseases are controllable, so the patients tend to get better.  Naturally lots of docs deal with infections, but specialists have extra interest in hepatitis / meningitis / HIV / MRSA / unexplained fever / TB / malaria as well as the less common neglected tropical diseases.  The contagious nature also gives a significant public health component which appeals.  However, bit of a less clear career structure.  Haven't shadowed here yet. LINK LINK

Cardiology (e.g. heart murmurs, heart attacks, blocked arteries): combines some of the interesting breadth of medicine with surgery (e.g. pacemaker fitting, stenting, angiography); and I've met a couple of lovely people that work in it, my bro included.  Only trouble is, it's pretty western-world bound: it's relatively expensive to deliver and patients in poorer parts of the world tend to die before they get old enough for the complex coronary interventions.  Plenty of money available for research tho.  Plus I had a great time observing at Arrowe Park.

Of course, medicine's not all about the theatre or time with the patients.  You have to take on extra responsibility to boost your department, and I think a bit of teaching (I've always enjoyed training/lecturing) and/or management (FMLM is one related  organisation) may suit - whether research is interesting in the domain is probably a bit speciality-dependent.   Time's likely to be pressed, but I also like the idea of engaging with a more broad-reaching institution too.  That could be an international organisation with a speciality focus (e.g. an NGO like WOCUK, GNNTD or WHF), or something more cross-speciality (e.g. the APPG, King's Centre for Global Health: Surgery).  Let's not think too far ahead...

Stereotypes of the specialities (haven't held true yet in my experience)
Aside from the minutiae of which body parts you'll be working on, some say the most important consideration is whether you like the people and the team cultures in the departments you work in, as these specialities can have prevailing cultures. I'll have to see about that as I start rotating through the departments.

Orthopaedic surgeon (general stereotype: of a meaty thuggish sportsnut, well that's certainly not me)
Hand surgeon - a subspeciality of orthopaedics once you're trained (stereotype: a little softer hands, a little calmer)
Infectious disease physician (stereotype: intellectual traveller types - includes lab work tho)
Cardiology (stereotype: smartest of the lot.)

Competition in the specialities (applicants per place) after FY1 and FY2, i.e. 4 years from now for me:
Orthopaedics: 2.5:1 for core surgical training Y1-2; then 5:1 for orthopaedic specialist training Y3-7.  LINK   Alternatively 10:1 for run-through training from ST1-7
Infectious disease: 2:1 for core medical training Y1-2; then 2:1 specialist training Y3-6 + PhD LINK
Cardiology: 2:1 for core medical training Y1-2; then 6.5:1 for specialist cardiology training Y3-7 + PhD LINK

Quotes
> "Every surgeon must have a little internist in them and vice versa if they are going to be master in their field"
> "A wrong decision is generally less disastrous than indecision"
> "Half of graduate medical students become GPs"

Upshot
I've gone for orthopaedics for this specialist placement (I'll give it a go with the meatheads and hopefully practice some of the suturing we've been learning), with a backup choice in hand surgery (which is a part of orthopaedics anyway) as a close second.  With luck it'll be good exposure for ruling in / ruling out.

I'll have to book in those days in infectious disease when I have a gap.  And try for now to ignore the stats which suggest I'll eventually end up as a GP anyway...

Orthopaedics: neck, shoulder, hand, hip, knee, ankle

Infectious disease: pathogens

Cardiology: arterial stent (widens artery at blockage)

Medical context - piano playing injuries

Ageing hands at the piano

I do like to tinkle out a few tunes on the piano, and latest excitement has been with duets.  For this you can buy specialist 2-person sheet music (exploring classical tunes is all the more fun with a beautiful woman to play with).  Alternatively - tough songs are easier with four hands (here's a jazzy one I'm trying).  The charm of a duet is you get good company, and you only have to do half the work!  So, to keep the interest going, I headed to a Joplin ragtime recital out in Nottingham featuring a little Atwell (great) and a Bowie tribute.  Now, chatting with the pianist post-gig, it turned out he was a little anxious about his hand problems, with a wonky thumb and some pain - understandably so.  And the question of medical advice came up.  But, much as we've covered hands in lectures, I had no specific medical context to help out!  So here's an attempt at targeted activity research...
Context of piano playing injuries:
The more you play (and the higher level you play at) the more likely you are to become injured. LINK (2010) - p.61.  Prevalence of ongoing injuries in professional musicians seems to be greater than 50%.

Piano players' common occupational ailments LINK (2010) - p.62
1) Tendinitis - inflammation of tendons
2) Overuse syndrome / RSI (not necessarily an accepted diagnosis) - degeneration of tendons/ligaments/nerves as rate of injury > rate of healing;  LINK
3) Carpal tunnel syndrome - median nerve trapping in the carpal tunnel of the wrist
4) Radial nerve compression syndrome - particularly entrapment of radial nerve at elbow
5) + Osteoarthritis - degenerative changes to hand/wrist joints due to overuse LINK (1984)

Abducted (splayed out) fourth and fifth fingers most likely to be damaged LINK (1989) - p.108
Extended wrist play causes damage, as do fortissimo and octave play LINK (1998) - p.11

Treatments
NB: these are remarkably similar to one another
1) Tendinitis: avoid rapid increase in tendon use; splinting and rest; painkillers; steroid injections.
2) Overuse syndrome: rest and anti-inflammatories; + potential use of ?quack massage therapy (ART) which describes a rather simplistic pathophysiology LINK
3) Carpal tunnel syndrome: splinting and rest; steroids; carpal tunnel release surgery LINK
4) Radial nerve compression: splinting and rest; steroids; surgical release of nerve along its course LINK
5) Osteoarthritis: rest, pain-based treatment and potentially joint replacement LINK

Additional advice

> Most piano-playing hand disorders are due to the mechanical process of learning and playing; non-expert doctors are ill-equipped to be able to offer helpful advice about how to resolve these problems; experienced piano teachers are more likely to be able to do so based on their own experience LINK

> Resting within and between practice sessions enables removal of metabolic waste products and replenishment of phosphocreatine, ATP, acid/base balance, resting membrane potentials ?weak LINK
> Resting during practising also enhances procedural memory retention LINK
> If you're overstretching with your small hands, you can either pick tunes with smaller spans, or there are people out there who'd like to sell you a smaller-size ergonomic piano, sounds sensible enough, if a little inconvenient to transport to performances! LINK

Tendinitis in the hand LINK

Carpal Tunnel Release

Joint changes in osteoarthritis of the hands LINK

'Play Me I'm Yours' street piano duet - Toronto

Health behaviours influence life expectancy much more than quality of medical care

Dahlgreen Whitehead Model of Health (1991)

Our medical course is satisfyingly broad beyond the physical science - they even have us considering the sex lives of the elderly (all part of a healthy lifestyle, but lots of chlamydia & lack of partners tends to hold many of them back though, apparently).  All the talk of public health rang a bell in my head from psychology days about the importance of health-promotion and the limits of medical care to help.  So I wondered, well, since part of the reason we're in this is to have an impact, just what impact does medical care have on health, relatively speaking?

One meta-analysis [LINK] indicates that health-related behaviour accounts for 40% of early deaths in the US, genetics 20%, stressful social circumstances (e.g. income inequality, discrimination, lack of social relationships 20% (LINK1 LINK2 - together approx equivalent to tobacco smoking)), physical environment 10%, while early death is influenced only to a limited extent by the quality of medical care (10% of deaths).  The challenging message for us trainee doctors is 'public health is much more important than your hospital interventions'.  So - I briefly reviewed the research to see if these stats hold up.  They seem to!  

1) Research papers about common diseases, their causes, and historic changes in life expectancy 

(give qualitative support to the statistic)

The diseases which cause the greatest number of deaths - UK

Ischaemic heart disease (12%), Dementia & Alzheimers (~10%), Stroke (~6%), Lung cancer (~6%), Chronic lower respiratory infections (~5%) (together account for 41% of deaths)

http://www.ons.gov.uk/ons/rel/vsob1/mortality-statistics--deaths-registered-in-england-and-wales--series-dr-/2014/sty-what-do-we-die-from.html

The risk factors which cause the greatest number of early deaths - Europe

Tobacco smoking - 15% of all deaths; Other cardiovascular risk factors: hypertension, obesity, low physical activity/obesity, high blood glucose, high cholesterol, low fruit & veg intake - 25% of all deaths (together smoking and cardiovascular risk therefore account for 40% of deaths)

http://www.who.int/healthinfo/global_burden_disease/GlobalHealthRisks_report_full.pdf

The diseases which cause the greatest number of years lived with disability (DALYs) - UK

Cancer (14%), Ischaemic heart disease (10%), Depression (8%), Stroke, (6%), Road Traffic accidents (4%), Direct effects of alcohol use (4%) - together account for 46% of years lived with disability

http://apps.who.int/quantifying_ehimpacts/methods/en/smith.pdf

Contributing non-medical factors to disease/death pre-20th century (life expectancy has increased by 25 years across the 20th century):

- people weren't aware that tobacco smoking was bad for your health

- people weren't aware that a balanced diet was required for health

- people weren't aware that exercise was good for your health (idleness)

- widespread slum housing (squalor)

- deaths at work

    

Contributing medical factors pre-20th century:

- infant and maternal mortality perinatally (which can now be resolved by obstetric care and vaccination)

- hypertension (which can now be modified by exercise, smoking cessation and diet, as well as being assessed and controlled medically)

- infection (which can now be controlled by antibiotics)

http://www.cdc.gov/about/history/tengpha.htm

2) Back-of-envelope calculations on Quality of Life and behaviour:

(give quantitative support to the statistic)

NHS - £110bn budget, NICE guidelines indicate acceptable spends vary between £0-30k per QALY (Quality-adjusted-life-year), therefore 11m QALYs saved per year if £10k per QALY is assumed.

https://www.nice.org.uk/advice/lgb10/chapter/judging-the-cost-effectiveness-of-public-health-activities

AND

Sedentary lifestyle, i.e. lack of exercise: 7 QALYs lost per sedentary patient -> 60% prevalence -> 252m QALYs

Smoking: 10.5 QALYs lost per heavy smoker -> 20% prevalence -> 120m QALYs

Obesity: 5 QALYs lost per obese patient -> 25% prevalence -> 75m QALYs

High alcohol consumption: 4 QALYs lost per heavy drinker -> 15% prevalence -> 34m QALYs

Total on these factors - 470m QALYs (may be some double counting, but this is 40x the amount of QALYs seemingly accounted for by NHS interventions)

Prevalence stats 1) http://www.hscic.gov.uk/catalogue/PUB05131/obes-phys-acti-diet-eng-2012-rep.pdf

Prevalence stats 2) http://www.hscic.gov.uk/catalogue/PUB17712/alc-eng-2015-rep.pdf

QALYs cost (from a Scandinavian study) http://www.ncbi.nlm.nih.gov/pubmed/17852988

3) Conclusion:

Based on these data, health behaviours in the UK have a far greater impact on life expectancy and quality of life than does the quality of medical care.  Challenging!  A good incentive to encourage our patients to get active, stop smoking, and lose weight.

Causes of death in the UK (2014) - ONS

Risk factors for death with high income Europe highlighted - WHO (2009):
Smoking - 15% of the 3.8m total deaths
The other cardiovascular factors are combined elsewhere in the research paper to give the 25% figure