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!