Insights on Residency Training

Justin Davis, MBBS, is a Chief Resident at Barwon Health in Geelong, Australia.

I run a clinic a couple of times a week as part of my nephrology training here at Barwon Health. I love my clinic. In addition to enjoying the longitudinal follow-up of patients and the relationships you build with them (one of the quintessential things that drew me toward physician training, and nephrology in particular), I like that it is rather varied. On any day, I might be dealing with relapsing glomerulonephritis, seeing one of our long-term haemodialysis or transplant recipients, or managing something like recurrent renal calculi. But far and away, the biggest number of patients that we see are those with chronic kidney disease (CKD). CKD is an interesting beast. While you get occasional cases that occur after severe acute kidney injury or are associated with a single kidney or perhaps obstructive uropathy, most CKD cases occur in people who are lumped into the category of “renovascular disease/diabetic nephropathy” — a nebulous miasma of patients who, more often than not, have raging metabolic syndrome or at least a whole bunch of cardiovascular risk factors that presumably have driven their CKD.

And, it was seeing these patients in clinic — these patients with obesity and relentlessly progressive CKD and a multitude of other chronic, incurable issues — that made me reflect on my own metabolic health. And while I don’t want to sound pejorative, it also made me vow to never turn out like them. I don’t want to be the overweight chap with uncontrolled diabetes who is sitting opposite the specialist. But what I want to touch on in this post is exactly that – how easy it can be to fall into that downward metabolic spiral, particularly with a job like ours.

The Cornered Badgers. Quite possibly the greatest basketball team you could be a part of.

Let’s all sit down for story time with Uncle Justin. I love playing basketball. I have loved it since I started in … what? Under 9s? Under 10s? (Somewhere around there). I’m tall, lanky, and completely uncoordinated, which makes me a terrible basketball player, but I still enjoy getting out there and running about (and the team aspect of it). Back in medical school, I was playing on three different teams a week (including one with the other medical students, called Rebound Tenderness, which is simultaneously the dorkiest and best name for a medical school basketball team ever). This was my major form of sport and activity, and it kept me in reasonable fitness for the 15+ years that I played.

Then something happened. That something was the physician’s exam; specifically, the written component of the exam. Suddenly (although “suddenly” is the wrong word, given you have well over a year to prepare and study, but I think it encapsulates just how disruptive that exam is to your life and schedule), I was heading to lectures that were broadcast by the Royal Australian College of Physicians every Thursday evening. (I’m aware I could have watched them later, but I wouldn’t have (a) paid attention or (b) learnt stuff that way. It’s just how I am.) Thursday was my one remaining basketball evening (the others having been whittled down slowly by demands during my intern and residency years). And just like that, I went from being a reasonably active kind of guy to doing no exercise and slaving over a computer. I wrote over a million words for this exam during the course of a year — the number of hours I put into it is kind of staggering. I was studying late, working long hours, and eating poorly. That, naturally, is a recipe for the kind of unhealthy lifestyle and diet that I like to call “the medicine-induced metabolic syndrome.”

A typical night at the RACP lectures, me being the only person there studying, happily watching (and clapping, apparently) alone.

It was just after the written exam when I realised just what the sequelae of study and work with no exercise had done to me. I had just come off my intensive care unit rotation, which I found exceptionally challenging, both because of the unique work involved and the nasty hours. (Physicians are not a critical care–trained specialty in Australia. I can happily work up a patient with raging lupus nephritis, but ask me which vasopressor to use next or how to fiddle with some ventilator settings, and you’ll likely just get a blank look from me.) The paradigm of 7-day, 12-hour shifts, week on– week off, plays absolute havoc with your circadian rhythm, particularly if you’re using energy drinks (like I was) to stay awake during the long nights and then spending off weeks doing nothing but study for an exam.

And so, just like that (although really, it was the consequence of the previous year of little exercise and an unhealthy diet), I had put on 10+ kg (I have no idea how many pounds this translates to, for our American audience. [Consults Google.] Ok, it’s about 22 pounds.) Although I was still a tall and (now, slightly less) lanky guy, most of that extra poundage had sneaked its way directly onto the stomach region — you know, the exact area that poses the highest metabolic risk, and where you don’t want extra adiposity.

It was a surprising wake up call, one that is echoed every time I’m in clinic with patients who have raging metabolic syndrome (and there are a lot of those people). Because I can understand how easy it is to fall into that trap. For me, it is associated with the particularly in the high-stress environment that calls itself medicine and with studying for the once-a-year, high stakes exam that you must pass. Why would I waste an hour running when that hour could be used for study? It’s the pitfall that causes medicine-induced metabolic syndrome – we need to look out for our own health, too.

How could you not want to go for a run around my hometown of Geelong, when it offers up views such as this?

I’m thankful to my fiancée (for this and many other reasons), because she encouraged me to eat better, and I started to run with her, which I’ve found is a fantastic way to stay active and avoid the dangers of the work/study black hole. I’ve figured out that running also is a great way to fit in the video game podcasts I enjoy listening to (and when else would I have time to listen?) I’m much healthier than I was at this time a couple of years ago. I’m currently 15 kg down (33 pounds, for our imperial system friends) from where I was right after the written exam, and that’s a good thing. Because I don’t want to be that guy on the other side of the doctor’s desk with unchecked metabolic syndrome, if I can help it. I just wish I had thought about that while I was studying.

“Do not allow the quest for knowledge to become paralytic. Only through action can you iterate on your belief.”

* The quotes from the unnamed source continue for my own amusement. Although I understand a few people have Googled it to come up with the answer.