I strongly believe that exercise is medicine. Exercise has been proven to improve cognitive functioning, reduce burnout rates, and support sound mental well-being. However, developing an exercise regimen can be difficult, especially in a demanding academic program such as medicine where time is limited, or after a long shift in the emergency department (ED). Some common barriers to exercise reported in published studies include lack of time and laziness. Though laziness was the term used in these research studies, I prefer fatigue or burnout. Many classmates and colleagues I know, that do not work out, work themselves to the bone, therefore limiting the excess energy available for working out. While I have yet to experience the fatigue of a long ED shift, I have experienced long workdays, and for me, no matter how tired I am, a quick work out can always help me get back into the zone, feel more productive or improve my mood.
In university students, physical activity has been linked with decreased rates of burn-out, decreased perceived stress, and higher academic performance. As mentioned in my previous post, burnout is not good for physician performance. Burnout can increase the risk of medical errors, and more importantly, reduce the patient-physician experience. Imagine attending an event with a group of friends or colleagues. Would you be drawn to those who are happy, energetic, and lively; or would you rather spend your time with someone who seems so tired and disengaged, someone who keeps asking you to repeat yourself or do not respond to your social cues in an appropriate manner. I would prefer the former, though I have experienced the latter, and do not want to become victim to compassion fatigue because I could not support my own health and wellness. Compassion fatigue, a term I recently learned, is an inability to empathize or show compassion to others due to physical or mental burn out.
Overall, I believe that exercise is important to support one’s health and avoid compassion fatigue or other signs of burnout. However, when it comes to incorporating exercise into your daily routine, there is no one size fits all. The goal of this article is to share three of my favorite styles of exercise, that can be short and effective if done at a proper intensity. At the end of the article, I will have a list of YouTube Channels that provide free workouts, that I am using during COVID-19 as I wait for the gyms to safely open. All these channels have some videos on Tabata, HIIT, and AMRAP training (described below). These can be shared with patients as well, if appropriate, knowing that at times, exercise can be one of the best forms of medicine out there.
Tabata – Named after the Man, the Myth, the Legend
Tabata training is named after the creator, Dr. Izumi Tabata, and his lab, located in Tokyo. Tabata is a specific form of high-intensity interval training. Each exercise (i.e. push-up) is performed for 4 minutes. Within each 4-minute block, the exercise will be performed for 20s with a 10s rest. Overall, the exercise will be performed 8 times in the 4-minute window frame. The workout can be tailored with as many exercises as one wishes. An example of a 16-minute full-body workout can look like the following:
- 4 minutes push-ups (20s on – 10s off x8)
- 4 minutes of body-weight squats (20s on – 10s off x8)
- 4 minutes of sit-ups (20s on – 10s off x8)
- 4 minutes of burpees (20s on – 10s off x8)
Don’t forget that exercises always have modifications. For example, if a lunge or squat hurts your knees or your legs are beat after standing in the ED for a long shift, then a wall sit can always be a substitute.
HIIT – High-Intensity Interval Training
HIIT often gets mixed up with Tabata training. While they are very similar, HIIT is not as specific as the Tabata framework. HIIT training is similar in which you perform an exercise at a high intensity for a given amount of time followed by a rest period. The rest is important to prevent injury and give your body time to recover from the previous spurt of exercise. There are two ways this can be incorporated:
- One exercise at a time (rest in between every single exercise)
For this style of HIIT, you perform one exercise, the work period, and then rest, the rest period. I remember when I used to run or bike, I would start with a 1:2 ratio of work to rest (30 second sprint, 1 minute rest), and slowly work to a 1:1 ratio (30 second sprint, 30 second rest). The example I gave was a form of cardio, but the principles can apply to weights. For example, bicep curl for 2 minutes and rest for 2 minutes. Squat for 30s, rest for 30s.
- A series of exercises with rest after the series
In this second form of HIIT, you perform a series of exercises, as shown in the example below, and only rest after completing the entire series. The duration of the exercise time for each exercise is variable, but the entire series is usually the same.
AMRAP – As Many Reps as Possible
In AMRAP exercises, you pick one or two exercises and alternate between the two, until the timer tells you it’s time to rest. For example, say you choose squats and lunges (12 reps each) for the exercises, and you pick a 4-minute work period, then you would alternate between 12 squats and 12 lunges until the 4 minutes had passed. You then rest and can repeat with the same two exercises, or two new exercises for as many rounds as you wish. I love this style because you feel like you got an awesome workout in such a short period of time! It was the closest thing I could get to a runner’s high when I couldn’t run, and I could usually do a shorter workout, and feel satisfied. For the timer, I like the website linked below, which allows you to play with the number of intervals and the work/rest periods. The best part is it’s free and provides audio alerts to let you know when the work or rest period is complete. https://fitlb.com/tabata-timer
Here is an example of a workout I put together this summer. After working out, I always found myself to be more productive during the day.
Note: Reverse lunges reduce strain on knee compared to forward. Also, all channels have low impact workout options.
AMRAP #1 (2-minutes each round + 1-minute rest in between; Repeat series #1-8 workout twice)
- Air squats
- Reverse lunge left leg
- Reverse lunge right leg
- Calf Raises
- Glute bridge
How to increase the intensity of an exercise:
- Increase the number of reps
- Increase the speed of an exercise (make sure form is intact)
- Add resistance (weights, bands)
- Decrease the rest duration
- Perform moves that focus on more than one muscle group
I hope you learned a bit more about the three styles of exercise described above. They can be done with or without equipment and can be structured based on your goals. I know I would use a quick ten-minute bout of exercise in between a long spurt of studying whenever I would notice my mental fogginess causing careless errors or diminish my quality of work.
While I encourage exercise as medicine, I also support a healthy mindset; do not hate yourself if you miss a workout, do not hate yourself if a workout is too hard, do not hate yourself if you need to rest. We are all human. Importantly, we are using our time and energy every week in school to study or in the ED to make sure that we can rapidly diagnose, treat and decide what the next steps in a patient care plan are. This takes energy, and so we need to make sure we use exercise to increase our wellbeing, not inch closer to burn out. My mentor, who is an ED physician in Toronto Western, always told me that the moment you don’t have the time or energy to exercise and socialize with loved ones is the moment you are starting to enter burnout territory.
Finally, inspired by a classmate, I would like my next article to focus on the impact of shiftwork on sleep hygiene and health, in addition to tactics to overcome the detrimental effects of shiftwork on sleep. Send me a message if you want different wellness topics to be discussed. I am always open to feedback. I look forward to learning alongside the iEM community. Happy exercising!
References and Further Reading
- Al-Drees A, Abdulghani H, Irshad M, et al. Physical activity and academic achievement among the medical students: A cross-sectional study. Med Teach. 2016;38 Suppl 1:S66-S72. doi:10.3109/0142159X.2016.1142516
- Alexandrova-Karamanova, A., Todorova, I., Montgomery, A., Panagopoulou, E., Costa, P., Baban, A., Davas, A., Milosevic, M., & Mijakoski, D. (2016). Burnout and health behaviors in health professionals from seven European countries. International archives of occupational and environmental health, 89(7), 1059–1075. https://doi-org.cmich.idm.oclc.org/10.1007/s00420-016-1143-5
- Costa, E. C., Hay, J. L., Kehler, D. S., Boreskie, K. F., Arora, R. C., Umpierre, D., Szwajcer, A., & Duhamel, T. A. (2018). Effects of High-Intensity Interval Training Versus Moderate-Intensity Continuous Training On Blood Pressure in Adults with Pre- to Established Hypertension: A Systematic Review and Meta-Analysis of Randomized Trials. Sports medicine (Auckland, N.Z.), 48(9), 2127–2142. https://doi-org.cmich.idm.oclc.org/10.1007/s40279-018-0944-y
- Cuthill, J. A., & Shaw, M. (2019). Questionnaire survey assessing the leisure-time physical activity of hospital doctors and awareness of UK physical activity recommendations. BMJ open sport & exercise medicine, 5(1), e000534. https://doi.org/10.1136/bmjsem-2019-000534
- Pereira, E. S., Krause Neto, W., Calefi, A. S., Georgetti, M., Guerreiro, L., Zocoler, C., & Gama, E. F. (2018). Significant Acute Response of Brain-Derived Neurotrophic Factor Following a Session of Extreme Conditioning Program Is Correlated With Volume of Specific Exercise Training in Trained Men. Frontiers in physiology, 9, 823. https://doi-org.cmich.idm.oclc.org/10.3389/fphys.2018.00823
- Rao, C. R., Darshan, B., Das, N., Rajan, V., Bhogun, M., & Gupta, A. (2012). Practice of Physical Activity among Future Doctors: A Cross Sectional Analysis. International journal of preventive medicine, 3(5), 365–369.
- Vankim, N. A., & Nelson, T. F. (2013). Vigorous physical activity, mental health, perceived stress, and socializing among college students. American journal of health promotion : AJHP, 28(1), 7–15. https://doi-org.cmich.idm.oclc.org/10.4278/ajhp.111101-QUAN-395
- Wewege, M., van den Berg, R., Ward, R. E., & Keech, A. (2017). The effects of high-intensity interval training vs. moderate-intensity continuous training on body composition in overweight and obese adults: a systematic review and meta-analysis. Obesity reviews : an official journal of the International Association for the Study of Obesity, 18(6), 635–646. https://doi-org.cmich.idm.oclc.org/10.1111/obr.12532
- Wolf MR, Rosenstock JB. Inadequate Sleep and Exercise Associated with Burnout and Depression Among Medical Students. Acad Psychiatry. 2017;41(2):174-179. doi:10.1007/s40596-016-0526-y