Use of a Physical Education and Nutrition Program to Improve Outcomes

Introduction

Placing the needs of the patient above one's own needs has long been the call of duty badge worn by the physician. Indeed, emergent patient care needs trump immediate personal needs such as sleep, fatigue, hunger, and family commitments. However, personal health and well-being are paramount to leading long and productive careers. Balancing the demands of a busy medical career with personal wellness is a daunting but necessary skill to acquire, yet there is little education of these principles available to physicians in training. For the most part, organized exercise, diet, and personal fitness programs are entirely lacking in modern graduate medical education. The Accreditation Council for Graduate Medical Education (ACGME) requires the mastery of 7 core competencies among physicians in training. The goal of modern graduate medical education should be to instill its trainees not only with medical knowledge and procedural competency that allows individuals to function as independent physicians, but also the importance of lifelong learning, interpersonal skills, and personal well-being that will ensure career success, longevity, and satisfaction.

Deterioration of Personal Health During Residency Training

Medical students are, in general, active individuals and exercise more frequently than the general population. In fact, most exercise routinely with moderate-intensity activity of at least 2.5–4 h per week. Most studies evaluating the exercise habits of resident physicians have demonstrated a significant reduction in exercise during graduate medical education compared to medical school.

In addition, dietary habits may deteriorate during the long hours of residency training. In association with changes in sleep patterns, this may predispose resident physicians to weight gain. A Brazilian study of resident physicians showed that many were overweight or obese and many self-reported weight gain during residency, particularly males. However, both male and female residents reported poor diets with high intake of sweets and saturated fats with low intake of vegetables and fruits.

Sleep deprivation and poor sleep quality from long work hours, rotating shifts, and interrupted sleep are commonplace. With changes in resident duty hour regulations to help limit fatigue and reduce medical errors, there has been an unclear effect on resident sleep quality. In the context of long hours and alternating shift and sleep cycles, the lack of exercise and poor dietary choices may have negative short- and long-term consequences on physician physical and mental health.

Burnout and Resident Attrition

The percentage of resident physicians reporting burnout during training is unacceptably high. Burnout, a term used to describe feelings of emotional exhaustion, low self-accomplishment, and depersonalization associated with the work environment, is gaining ground as an important marker for resident well-being. Unfortunately, burnout is reported in the majority of resident physicians on surveys, regardless of the specialty. Anywhere from 47% to 70% of residents report burnout during training. Residents who report burnout and personal distress are probably more likely to make medical errors and report suboptimal care for their patients. Residents with burnout may be more likely to display unprofessional behaviors. In addition, burnout and personal distress is associated with resident attrition (quitting or changing residency programs or specialties).

Attrition among surgical residents is not uncommon. In the specialty of general surgery, it has been suggested that about 1 in 5 residents fail to complete residency training. One study of attrition rates across clinical specialties demonstrated rates ~ 2%–7%. In neurosurgeons, attrition rates ~ 15%. In one survey of general surgery residents, nearly 60% of residents strongly considered leaving their program. Sleep deprivation was the most cited reason for considering leaving, while support from other residents was one of the most common reasons for deciding to stay. These studies suggest that programs that help to improve team building support structures and mitigate poor quality sleep may potentially reduce resident distress and attrition.

Exercise Effects on Sleep, Distress, and Fatigue

There is no question that exercise is important for physical health. Exercise is an effective means of losing weight, maintaining a healthy body weight, and preventing disease. In fact, lack of exercise has clearly been linked to the development of chronic diseases. The beneficial effects of exercise on health-related quality of life are well documented.

Exercise is an effective therapy for depression in young adults. Exercise interventions may be beneficial in reducing the symptoms of depression. Patients who engage in regular exercise often report improved sleep quality, higher sleep efficiency, and shorter sleep latencies. Further, exercise is beneficial in reducing the symptoms of fatigue in certain patient populations, such as those with cancer-related fatigue. In addition, physical activity may improve self-esteem and feelings of self-worth in young adults. These studies suggest that subjects engaging in routine physical activity may benefit from improved self-esteem, decreased depressive symptoms, reduced fatigue, and better quality sleep.

Finally, evidence supports the benefit of interventions designed specifically for increasing physical activity and healthy behaviors. Systematic reviews of interventions that promote physical activity have a positive effect on self-reported activity and may result in persistent improvements in physical and mental quality of life in healthy individuals. Similar to exercise, dietary interventions may also improve quality of life.

Benefits of a Balanced Lifestyle in Physicians and Trainees

While there are limited published data on the health and well-being benefits of physical activity on physicians, there are some data supporting a positive effect of exercise. Physicians with healthy behaviors are more likely to be satisfied with their occupation. A study has suggested that restful sleep and exercise have a positive effect on personal well-being in residents. Further, physicians who are engaged in regular exercise are more likely to counsel their patients regarding the benefits of physical fitness.

Historically, a “resident” physician lived in the hospital and was entirely devoted to caring for their patients; thus, personal health was abandoned in the pursuit of a medical education. We now teach residents in the context of enforced duty hour restrictions. However, it is commonplace for physicians (residents and faculty) to be “too busy” to frequent the doctor for routine visits such as health screenings that they themselves would outline for their own patients. Chronic diseases with courses that can be either modified or entirely prevented can thus go unnoticed for many years, causing irreparable damage; for example, undiagnosed hypertension or hypercholesterolemia leading to cardiovascular disease or stroke. In addition, there are increasing data suggesting that psychological distress and burnout are common among physicians and other health care providers. An alarming majority of residents report burnout during training, but these issues do not end with completion of residency. Nearly 50% of US physicians report symptoms of burnout. With an expanding understanding of the health consequences of medicine on the provider, there has been an increasing focus on improving physician well-being.