Author + information
- Jackson J. Liang, DO∗ ()
- ↵∗Reprint requests and correspondence:
Dr. Jackson J. Liang, Hospital of the University of Pennsylvania, 3400 Spruce Street, 9 Gates Building, Philadelphia, Pennsylvania 19104.
Cardiologists and cardiology fellows routinely recommend lifestyle modifications for patients with chronic cardiovascular conditions, such as coronary heart disease and congestive heart failure. In particular, exercise and eating a healthy diet comprise the backbone of recommendations provided to patients. Ironically, however, providers often do not adhere to their own recommendations.
It is well known and accepted that cardiology is one of the busiest, most demanding fellowships among the internal medicine subspecialties, and the additional 3-plus years of training to be a cardiologist can be stressful. Many have other personal responsibilities related to their families (spouses or children), as well as financial stressors. Exorbitant debts resulting from a decade’s worth of tuition fees may drive already-overworked fellows to take up additional clinical duties in their “free time,” such as moonlighting, to make ends meet.
Given the demanding schedules and rigorous clinical and research responsibilities of cardiovascular fellowship, it is understandable why fellows often find it difficult to eat healthily and make time to exercise. Despite this, it is imperative that trainees develop good lifestyle habits early on during training such that optimal health can be maintained throughout their careers.
The obesity epidemic in America is growing at an exponential pace, and physicians are not immune. The Physician’s Health Study reported that 44% of male physicians age >40 years were overweight or obese, and that body mass index directly correlated with all-cause and cardiovascular mortality (1).
Scheduling difficulties, frequent overnight calls, and moonlighting shifts often make it difficult for cardiology fellows to eat meals at regular times. Skipped meals and late-night eating are extremely commonly seen practices during training. The practice of meal-skipping has been associated with obesity, hypertension, insulin resistance, diabetes, and dyslipidemia (2–6). Cahill et al. (7) recently analyzed more than 25,000 men age >45 years and found that skipping breakfast was associated with a 27% increased risk of coronary heart disease, whereas late-night eating was associated with a 55% increased risk (7).
The nutritional quality of food served at meetings and conferences has been previously commented on and changes have been proposed (8). Cardiology fellows frequently have didactic lectures and conferences that provide breakfast and lunch. On many occasions, those lunches consist of high-calorie (high-fat, high-sugar), high-sodium, low-nutritional value foods which cardiologists ironically routinely recommend that their patients avoid (e.g., pizza, desserts, sugary beverages). Meals provided at morning and noon conferences in many programs generally exhibit a paucity of lean meats, whole grains, fresh fruits, or vegetables. Although availability of these unhealthy foods at conferences may be better than the alternative (skipping breakfast and lunch altogether due to time constraints), physicians must make an extra effort to limit portion sizes and choose healthier options, when available. Bringing healthy meals from home is another alternate option.
During procedural rotations, such as interventional cardiology or electrophysiology, much of the day is spent performing procedures in the laboratories. Due to emergent add-on cases or other clinical responsibilities, fellows often will have inadequate time to eat a full meal between cases. As such, there may be a temptation to snack on unhealthy options in the break rooms between cases. Simple measures, such as bringing in fruits or healthier snacks (e.g., nuts or low-fat yogurt), could be considered to avoid this pitfall.
Due to the work hours during fellowship training, cardiology fellows may find it difficult to set aside time for dedicated exercise outside of work. Only 5 to 10 min of slow running per day has been associated with markedly reduced all-cause and cardiovascular mortality (9). Although cardiology fellows may believe that their routine job requirements are relatively physically demanding, the true physical demands of the job remain unknown. One study of obstetricians demonstrated the actual amount of physical activity associated with work was less than perceived (10). In addition to affecting personal health, the physical activity level of physicians may also correlate with patient counseling practices about exercise (11).
Stanford et al. (12) recently surveyed 1,949 medical students and physicians (residents, fellows, and attending physicians) to determine how many of them met the physical activity recommendations set forth by the U.S. Department of Health and Human Services (HHS) (12). The 2008 guidelines state that to attain substantial health benefits, including lowering risk for premature death, coronary heart disease, stroke, hypertension, diabetes, and depression, adults should participate in at least 150 min/week of moderate-intensity aerobic activity to obtain substantial health benefits and more than 300 min/week to obtain more extensive health benefits (13). They found that fellows were less likely to meet the HHS guidelines (68%) than attending physicians (85%), medical students (84%), or residents (73%) (12). The odds ratios (ORs) for meeting the guideline recommendations were significantly lower for fellows (0.5; 95% confidence interval [CI]: 0.31 to 0.80; p = 0.04) compared with the other groups. Additional predictors for lower activity compliance included female sex (OR for male sex: 1.39, 95% CI: 1.10 to 1.76; p = 0.007) and age 30 to 39 years (OR: 0.69; 95% CI: 0.52 to 0.93; p = 0.001). The number of hours worked per week was inversely associated with physical activity level and was a likely contributor to suboptimal physical activity in residents and fellows.
Personal fitness often is overlooked by fellowship programs, but formal prompting of trainees may improve exercise adherence. Participation in an elective, team-based, incentivized exercise program has been shown to improve physical activity and quality of life, and possibly reduce burnout among trainees (14). If programs do not make the additional effort to promote physical fitness, cardiology fellows need to take it upon themselves to maintain their own health.
In an effort to promote health, many training programs have been proactive in recent years. For example, some steps taken by programs have included offering free or discounted gym memberships, supplying healthier in-hospital meal options, and posting nutritional facts for food offered at conferences and in the cafeteria. Furthermore, some institutions have offered incentives such as discounted medical insurance for employees who report meeting certain health milestones, such as eating a certain number of servings of fruits and vegetables per week, avoiding fast foods, exercising a certain number of days per week, or participating in sponsored walks or 5K runs. Ultimately, the responsibility to maintain fitness and a healthy diet falls on the shoulders of the individual, but encouragement from cofellows and program faculty to exercise and eat healthy goes a long way.
Cardiology fellowship is a rigorous but rewarding experience, which is necessary to adequately prepare trainees to become competent cardiologists. However, it is also a physically and emotionally stressful period with long work hours that make self-care habits difficult to maintain. Despite this, trainees must make the extra effort to practice healthy lifestyle habits, such that the groundwork is set for these habits to be maintained throughout their careers. Increased awareness of this issue by many fellowship programs has prompted efforts to motivate fellows to incorporate healthy diet and regular exercise into their daily routine. Personal exercise and eating habits correlate with how physicians counsel their patients. Regular recommendation of lifestyle modifications to our patients should serve as a routine reminder to ourselves to follow our own recommendations and “practice what we preach.” This will ultimately allow us to become healthier, more effective cardiologists.
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