• Exercise and the Pursuit of Balance

    Author: Daniel K. Resnick, MD

    Neurosurgery is a physically and emotionally demanding career all by itself. Our patients are often very sick and in great pain. Our best therapies may be effective most of the time, but all are associated with the occasional occurrence of devastating complications. Operations can be lengthy, and even with optimal ergonomics, can result in discomfort and fatigue. Sleep is frequently disrupted and a balanced diet is often subjugated to convenience or inattention. When one adds in the psychosocial stressors of workplace dissatisfaction due to increasing administrative hassles and the disruption of family life, it would seem that only a lunatic would pursue such a career.

    About thirty years ago, Joe Maroon, in his CNS presidential address reintroduced and expanded upon Osler's concept of Aequanimitas. During his presentation, he reminded us of the importance of making time for physical and spiritual growth to improve our ability to become better surgeons and better people. We revisited this theme in 2014, when Joe and I both spoke about the importance of achieving a balance in life to avoid early career burnout, and to optimize our ability to take care of the people we truly care about-our family, friends, and patients.

    While the benefits of achieving balance sound great, is there any real evidence to support what Joe and I believe? As a natural cynic, I am forced to acknowledge that a lot of the "mindfulness" training I am subjected to seems like well-intentioned pablum. I have exercised most of my life (largely as a weight control exercise) and personally believe that it makes a huge difference in my ability to be a productive academic surgeon and to remain (mostly) sane. This belief is not exactly high-quality scientific evidence. Therefore, I'd like to spend a few paragraphs examining what evidence exists to support the hypothesis that regular exercise can actually make a difference in a physician's career.

    The short answer is that there is no short answer. In a systematic review of health care worker well-being, Brand and colleagues1 identified 11 studies that described whole-system approaches to improving healthcare worker well-being. Of the 11 studies, three were RCT's and the remainder "before/after" studies, in which workers were surveyed about various aspects of their well-being before and after some sort of intervention. The studies were all graded as providing relatively low-quality evidence due to methodological concerns (study design flaws, high loss to follow up, low participation rates, non-validated outcomes measures, etc.). All of the reviewed studies reported some sort of improvement in a particular measure, but the measures used and interventions used varied between studies. Therefore, drawing a meaningful conclusion is difficult. Furthermore, the interventions were not necessarily inclusive of, or limited to, exercise programs.

    When looking at individual studies, several themes emerge. First of all, getting employees to buy into meaningful exercise-based programs is difficult. While exercise-based interventions do provide benefit for those who participate, many workers choose not to participate. For example, Atlantis et al2 performed a randomized trial looking at the effects of nutritional counseling and exercise intervention with casino workers. Only 6.4 percent of the workers expressed interest in the program and of those participating, only 60 percent completed the program. Of the study participants, those in the exercise group did improve their waist circumference and aerobic fitness compared to controls, however substantial barriers to participation exist in this worker population.2 In a small, randomized study in Scandinavian, de Vreis and colleagues found that a six-week exercise intervention significantly reduced self-reported work-related fatigue.3 Several other studies have found that workplace interventions to promote exercise and nutritional awareness can result in health improvements, lower absenteeism, and higher workplace satisfaction among hospital workers who participate in the programs.4,5

    Daniel Resnick, MD, with composer Philip Glass, and Arun Amar, MD, at the 2014 CNS Annual Meeting.

    Further evidence for the role of exercise as a means to improve workplace satisfaction and performance comes from employee surveys querying non-prescribed health behaviors. In a study of school workers, LeCheminant found that those who reported a greater degree of recreational physical activity, more fruit and vegetable consumption, and restful sleep reported higher job satisfaction, lower absenteeism, and better work performance.6

    Further examples of the benefit of regular exercise exist much closer to home. Joe Maroon is the poster child for exercise as a means to prolong neurosurgical productivity, competing in the Iron Man championship on multiple occasions and still going strong thirty years after his presidential address. Multiple other prominent examples exist of physically active neurosurgeons maintaining peak intellectual performance well beyond traditional retirement age-think of Volker K. H. Sonntag and Robert Spetzler at Barrow Neurological Institute, Albert Rhoton with his legendary push-ups, and Edward Benzel with his cross country runs (amongst many others). Other Iron Men among us include Elad Levy and Richard Byrne- both energetic chairs of excellent programs. Personally, exercise is a healthful and intellectually productive escape. I apparently do my best thinking when borderline hypoxic. Problems that stumped me in the afternoon all of a sudden become less complex during a run or ride. I remember things better and feel better after exercise. I am a nicer person when I get a good run in. I also feel less guilty about enjoying a good meal in the evening!

    Regular exercise requires a commitment of time and effort. Such a commitment can be difficult to make, given the uncertainty of our schedules and the other demands on our time. Carving the time out to exercise is in some ways selfish-should we not be using that time to spend with our families, or write that paper sitting on the desk, or see another add-on patient? I have decided that it is OK to be a little bit selfish and take the time to sweat. I am smarter, nicer, and more efficient after exercise. To summarize: no pain, no gain. It is worth the pain as the gain is substantial.



    1. Brand SL, Thompson Coon J, Fleming LE, Carroll L, Bethel A, Wyatt K. Whole-system approaches to improving the health and wellbeing of healthcare workers: a systematic review. PLoS ONE. 2017:12(12):e0188418. https://doi.org/10.1371/journal.pone.0188418 
    2. Atlantis E1, Chow CM, Kirby A, Fiatarone Singh MA. Worksite intervention effects on physical health: a randomized controlled trial. Health Promot Int. 2006 Sep;21(3):191-200. Epub 2006 Apr 4.
    3. de Vries JD1, van Hooff ML, Guerts SA, Kompier MA. Exercise to reduce work-related fatigue among employees: a randomized controlled trial. Scand J Work Environ Health. 2017 Jul 1;43(4):337-349. doi: 10.5271/sjweh.3634. Epub 2017 Mar 21. 
    4. Hess I1, Borg J, Rissel C. Workplace nutrition and physical activity promotion at Liverpool Hospital. Health Promot J Austr. 2011 Apr;22(1):44-50.  
    5. Blake H1, Zhou D, Batt ME. Five-year workplace wellness intervention in the NHS. Perspect Public Health. 2013 Sep;133(5):262-71. doi: 10.1177/1757913913489611. Epub 2013 Jun 14.  
    6. LeCheminant JD1, Merrill RM2, Masterson T3. Health behaviors and work-related outcomes among school employees. Am J Health Behav. 2015 May;39(3):345-51. doi: 10.5993/AJHB.39.3.7.

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