The Physical Toll of Doctoring

Lately my body has been sending me messages. These arrive in units equivalent to somatic emails or text messages: isolated aches in the sacroiliac joint, shooting plantar fascia pains, tension-type headaches. Furthermore, I've been noticing a distressing increase in facial blotchiness after a long night on call. The first bloom of youth, which masks the mundane ugliness of fatigue, is fast disappearing, leaving behind baggy eyes and big pores.

I suppose I practice a particularly awkward style of medicine when it comes to my physical well-being. I don't require women to labor and deliver in dorsal lithotomy position (the infamous "on yer back" position), which means my own position has to be a great deal more creative and acrobatic when I am in attendance. I have caught babies kneeling on cold linoleum floors, squatting in front of the woman in labor, and seated side-saddle at the foot of a bed. On the medical-surgical unit, I'll make rounds standing up, old-school style--a habit pursued more out of necessity than desire, due to the smallness of the patient rooms and general insufficiency of extra guest chairs. If a patient has been mobilized to a chair--a good thing!--and I need to examine her foot ulcer, I will crouch down on the floor to remove the dressing. Our vintage hospital building doesn't help matters much--the floors are concrete-based and have no give at all.

Long ago, I converted to the Cult of Comfy Shoes and elastic-waisted pants. Cuteness no longer enters into the equation when I get dressed in the morning. More recently, I got desperate when the plantar fascia pain became a daily affair. One of my surgeon colleagues suffers greatly from pain in his feet, after two or more decades of operating 7 days a week, and he turned me on to Z-Coil shoes:

The decision to buy these shoes was the last nail in the coffin of my fashion sense. These are ugly shoes. These are quite the ugliest shoes ever made. Not only are they not sexy, they are the Anti-Sexy. Slipping my feet into these shoes, I know I have given up my strutting rights for good.

But do they feel good! The bouncy coil absorbs some of the impact of each heel strike, and if you stand on hard floors for 12 hours at a time, those heel strikes add up. After a long day in the Z-coils, I do not feel like walking on my hands, like I used to do, and my right sacroiliac joint doesn't feel like it's been locked into an Iron Maiden all day.

I also look taller in these shoes. This is such a good thing.

There is a serious side to this issue. Over the last few years I have come to realize that the physical toll of doctoring will eventually limit my participation in clinical medicine. I just can't believe I'll be able to do long stretches of hospitalist shifts in ten years, and I'm almost certain I won't want to be catching babies if it means the general stiffening up of my cervical spine the day after a particularly grueling second stage. I suspect that being up all night and awake all day in the classic 36-hour call scenario--which I have faced more often since leaving residency--is going to lose its glamour.

I'm not the only health care profession confronting the physical toll of their job. One of our hospitalists resigned from our group because the long hours were sapping his energy. He had a lumbar laminectomy years ago and is very protective of his physical endurance. I don't blame him. On the blogs, I see that Reynolds of Random Acts of Reality is contemplating career change due to the physical challenges of transferring patients on an off gurneys, up and down stairs. I know of another medical blogger who has obtained another professional degree in preparation for a career shift, providing cognitive rather than bedside services in the health care system.

I wish we all talked about this issue more. There is a cowboy-tough mentality within medicine. I've heard of doctors who claimed physical limitations as a reason to restrict call responsibilities called wimps: "What, she can't take call because of ARTHRITIS???" Indeed, I've been guilty of these attitudes myself, but now I realize we must acknowledge the physical challenge of clinical medicine. This will inevitably influence the arc of a physician's career.

Please comment on your own experience of the physical toll of medicine.

Comments

[Yehudit]

Ah yes, the "moving and handling" argument for 'traditional' birthing on the bed. Glad to see you are not letting it interfere with the kinds of birth positions you support.

I think pilates, yoga, alexander technique or anything that supports core stability and gives good postural awareness is good. If you are uncomfortable then you need to move and get comfortable, just as the mother does. Kneelers are good - even knee pads. A rolled-up towel under your ankles is good if you are kneeling for any length of time. Pay attention to your own comfort - it's so important.

I do appreciate how hard birth in 'alternative' positions can seem - but....at the same time there is huge hypocrisy about this subject. I know midwives who will not "do" waterbirths because of their backs and yet are happy to attend a woman with a dense epidual and whose "hands-on" style of midwifery means a lot of physical exertion is needed, especially if the woman can't move herself. If a midwife said she couldn't look after a woman with an epidural or high BMI because of moving and handling risk, she wouldn't be able to work on labour ward, but refusing to facilitate upright positions is somehow more acceptable...

The other thing is that back problems are as much about how we (I'm talking midwives here) do the small things, and especially repetitive tasks: the slight bend to take repeated blood pressures is a killer in the long term.

We have just acquired beds that are electronic and go into all kinds of fancy positions (no doubt they have been in US hospitals for years already). They are great for reducing moving and handling risks from helping women with an epidural change positions in bed, but they weigh a ton and if you have to get a woman to theatre you feel that weight when you move the bed. They are also wider, and sliding a woman from the fancy new delivery beds onto the theatre table is no joke from a moving and handling perspective. So I'd say, anything that reduces the need to move the bed to theatre is good from a moving and handling perspective!

[Dragonfly]

The cult of the comfy shoes. I am such a devotee....

[Peggikaye]

Those shoes have been recommended to me. However .. I look at them and to me it looks like a great contraption to get my heel caught in something and find myself sprawled face down and broken legged!

[tbtam]

When I started having numbness in my fingers and arms, my physical therapist insisted that she come in to my office hours with me. She corrected ergonomic mistakes I was making. She taught me that I need to raise the table when doing breast and abdominal exams, and the same with the pelvic exam. She insisted I get a headset for the phone and lower the keyboard tray. All the time we are now spending on the computer can't be helping.

I now make sure teach our residents the right way to stand and sit while doing exams so they don't end up with the same neck problems I have.

[dr. bean]

Yes, that 36 hour call definitely loses it's glamor. After about 30 hours one starts to look like one's reflection in the airplane lav mirror after an all night flight to Buenos Aires. Catching babies is without a doubt the main root of *my* plantar fasciitis, for the reasons you mentioned. I too question how long I'll be able--no, willing to keep doing it. I deliberately changed that last because I am undergoing a paradigm shift. I am starting to think that pacing oneself can be okay, even if not forced to by present or imminent breakdown. It is hard, because the needs always outstrip the supply. And of course one feels the cultural need to be "tough." (?Quien es mas macho?)

My uncle was a cardiac surgeon, hardworking (of course!), well respected in his time and place, who suddenly dropped dead in his mid-forties. As I start to push 40 myself, I often wonder whether he had warning signs (angina?) or did he feel healthy as a horse (ha!not likely)?

[Theresa]

DoctorJen,

Re: supporting leg flexion, I have stopped this practice after developing chronic left shoulder impingement during residency. My symptoms are much better but for a while it was really uncomfortable. That's why I like squatting positions and/or squat bars.

Catching babies, if we're practicing laid-back, midwifery-inspired obstetrics, can be very hard on the body. I envy home birth midwives who organize partnerships and provide support for each other as well as for their clients. Its a great challenge in the hospital when you're catching a lot of babies. I had two memorable call nights my third year of residency, in which my team delivered 11 babies in 11 hours. I caught 5-6 of those myself, and helped the intern manage the rest of them, and I was *limping* by 4am. Maybe this accelerated my physical decline.

[doctorjen]

Funny to find this after just coming home from attending 2 births today. One was a very unexpected quick second stage and baby caught while sitting on the edge of the bed - but my hand is aching from the resulting postpartum hemorrhage requiring bimanual uterine massage. Then later this evening, a very long 2nd stage with a fluffier mama and now my arms and back are tired from holding legs, supporting her in a squat, and then finally kneeling on the hard floor as she squatted to push her baby out. Not to mention that I've caught 3 babies in 2 days - and was up all night Monday night and much of last night. I feel like I've been run over by a truck.
Thank goodness I don't suffer from plantar fascitis on top of it!
I'm enjoying your blog - a friend pointed me in your direction as a fellow rural family doc.

[Jessica Bond]

My son's 3rd grade teacher wears Z-coil shoes. I believe that he even told me that she sold them as a side business.

Sounds like it works for teachers who stand all day teaching class.

I don't see how doctors stand on their feet all day. After a morning of observing cases in the OR (with my running shoes), I can't wait to find a chair. Hospital administrators have no idea what doctors go through physically. Maybe if they did, they wouldn't be so upset when discussions about ER call involve the physical demands of the job.

Respectfully,
Jessica Bond

[Heather]

As a Massage Therapist I would love to see more doctors in my office for the many reasons that you mention above. However, the most basic reason is for your body and mind health. Please find a good one in your area. I am in Boston.

[Fizzy]

Things got really physically difficult for me when I was in the last month of my pregnancy (obviously). I was expected to do the same things I always did, which required huge amounts of standing on rounds, walking to see patients at the other side of the hospital, bending to examine legs, etc. Yet I just physically was unable to do some of those things... or I could have really pushed myself and ended up with 10/10 back pain at the end of the day. I still wanted to work until I gave birth and it was horribly frustrating to be put in a position where the only job I was allowed to do was something I couldn't do. (Eventually, some trades were made so I could limit my physical activity and I did manage to work till the last day.)

[MWAS]

I think at some point my career in pediatrics will have to change course. On certain days, I can go home with very little hearing in some ranges because I've examined and endured screaming infant after screaming child. Other pediatricians have also noted their hearing deficits - some cope with hearing aids.

I was awake this week on call for about 36 hours - can definitely feel the effects 2 days later. It gets harder and harder to fall back to sleep after the pager goes off and I answer the call.

I, too, am becoming more protective of "my" time - maybe it's because I was in solo practice for 2 years and all boundaries between home life and work life became a water color blur. I would like to hear more about how others cope with - dare I say it? - ageing in medicine? Not sure I can be a cowboy forever.

[Caroline]

Yeah, those are ugly, but probably totally worth it. My feet kill me after 12 hrs, even in Danskos, so I'm seriously contemplating buying a really expensive pair of Chung Shi shoes. Since I'm new to the profession, I can still prevent the physical tolls if I just invest now. Plus, I have bad, bad, bad knees (all told, probably worth $50,000 after procedures) so that makes expensive shoes seem worth it. :)

[Xavier Emmanuelle]

Wow. Those are some hardcore shoes!

Re: physical toll of medicine - when I did a 6 month veterinary medicine placement we often got down on the floor with the patients. Dogs would get antsy and nervous if you put them up on a table, so we'd just pull out a mat and do the IVs/blood draws/physical exams/that sorta thing down at their level. Aka lots of time spent crouching on the floor. While this didn't bother me too much as I was quite young, I know it gets harder as the vets get older. There you go, at least you're not doing veterinary medicine :)

Good post!

[Mark's Tails]

I've added "orthotics" to my shoes because of intermittent foot pain. It was a lot worse before radiology went electronic and I had to walk back and forth between seeing patients and radiology. I hope I never have to resort to those Z coil shoes. Though I must say the link you provided to them is somewhat humorous.