Performance Enhancement Regimen? No Dope.

Moving about your office seeing patients, rounding or operating isn't that physically demanding, is it? How many muscle groups are at work writing, walking, reading, typing, listening, talking, fretting, transcribing and thinking? I don't recall my heart rate ever getting above 100 bpm in my surgical cases except for brief flutters during particularly tricky cases. I don't seem to be panting or have sweat cascading down my neck in clinic discussing eye pathology with a patient. In the office, I am not tachypneic, or tachycardic; the only thing tacky is my chipped, chart-strewn desk.

While I am certainly no Olympian, I have had my share of taxing athletic endeavors. I have bicycled as an amateur along some of the famous mountainous stages of the Tour de France twice, wobbled up five passes and 16,000 feet in the infamous California Death ride, and endured many a 100-mile bike century. In Iowa, I spent a week perspiring and riding through surprisingly hilly countryside where 100 degree heat conspired with 100 percent humidity. Since evaporation seemed impossible, I thought riding faster would blow the sweat off and undoubtedly my intellect has suffered since. Many doctors have far more exotic, demanding, risky and physiologically challenging pursuits, so I am certainly unexceptional and my physical accomplishments pale in comparison to theirs. The point is, many of us are no couch potatoes. So why do we feel so fatigued after a day of work? What can we do about it?

Well, it seems logical that if the practice of medicine is like any other endeavor, training, proper equipment, and motivation might be optimized to enhance the VO2 max to get one physically and mentally through the day with energy to spare. I don't know much about kinesiology, physiology or psychology anymore, but I do know a cataract when I see one, and also know something about the training and tactics bike racers use to improve their performance. Let's see how professional cyclists' fortitude is derived and maybe I can emulate it without involving EPO, anabolic steroids or suspicious urine tests.

Is it Training?
Could training be the difference? A bike racer, particularly a pro, has undergone years of preparation and qualifying. Virtually all successful champions in the Tour de France are seasoned throughout their young adulthood before reaching the top pro circuit at age 30.

Sound familiar? We as physicians have spent the better part of our youth studying to enter a top university, and then tempering our mental muscles even harder to escalate to medical school. After that, we enter our residency and internship like the apprenticeship of the younger professional bike racers. The job of these younger bike racers - or "domestiques" - is to support the leader of the team by fetching water bottles, getting food and doing the hard work of chasing down a breakaway so the leader of the team has it easier.

That appears similar to internship and residency. We fetch the labs, do the grunt work on rounds and instead of being called domestiques, we are called junior house staff, all to support the attending. Instead of long hours in the bike saddle, we spend long days in the ER, wards or operating rooms and chug black coffee like the bike racers quaff their Gatorade.

Like the junior bike racers we pay our dues and move into the big leagues by entering medical practice after years of grueling internship, residency and fellowship.

We have been steeled by the crucible of training - and proven we have what it takes to take on the race of medicine. So if our training is similar in concept to the professional biker, why do we sometimes feel so exhausted after a day of work? Could it be our equipment?

The bike racer has a 3-pound carbon fiber bike with 14 speeds, yet I have a phone system with 15 lines and a cell phone weighing 3 ounces. Besides, I usually drive to work and my white coat, tie and Docker pants are far more comfortable than the lycra-clad, sweat-wicking tights worn by a racer (although my wife might say that the odor of each is indistinguishable at the end of a day). The bike racer has his tools and supporting "domestiques," and I have mine. But he uses his equipment to ride on average 50 miles a day, while that may just be the number of patients I see.

Energy Management?
The professional bike racer's stamina involves training and proper equipment akin to the skills and support that we physicians also share. So could the difference be in energy management?

Why do 100 riders breeze down a road at 35 miles an hour with only inches between one another when they know touching their wheels together will cause a catastrophic and painful collision? Drafting in pace lines, groups or, in bike-speak, a "peloton" is all about energy management. Riding with the help of fellow cyclists will reduce the amount of effort by 30 to 40 percent by simple aerodynamics.

All in the peloton are supposed to contribute to the effort since the groups' pull helps every individual rider. Those riding in the back of the slipstream draft without sharing the labor are seen as "leeches" and face ostracism; they are remembered when they might need the help of the group. Not.

Our medical practices are helped by a similar phenomenon. Organized medicine is like the peloton, blunting the winds of medical liability, easing the drag of reimbursement inequity, and buffering us from the gusts of legislation that hamper our goals of proper patient care. The exception is that those doctors who don't participate in organized medicine, unlike racers in the peloton, are not ostracized or banished. The slackers get a free ride from the efforts of those doctors who do participate.

On two occasions, I rode my bike in the Tour de France, pedaling along the same roads a few hours before the real bike racers swoosh through the streets or clamber up the mountain passes. One year was in the Alps and the other the Pyrenees. I was sufficiently trained and equipped, and followed the proper biking etiquette by participating in the fast pace lines that preceded the long, arduous, and mercilessly hot ascent into the mountains. Those were the years when a heat wave flambéed France and thousands of elderly perished in their solitary unairconditioned apartments; at times, I was certain my name would be part of the grim census.

Thus, it should have been a physical and mental ordeal - certainly much harder than a day in the office. Why wasn't it?

The Fervent Fans
Along the route of the Tour de France are thousands of fervent fans from all points of the globe, making it the longest continuous tailgate party in the world. Many arrive days in advance and line the roads for miles, a hodgepodge of encampments trailers, sleeping bags and beer kegs. Flags of all the nations fly, but fists don't.

When the real bike racers approach, the tranquil community erupts with excitement; the fans hoot, scream, honk, spray water, wave their nations' flags and show appreciation for the racers as they chug and strain to the summits of the Alpine and Pyrenean passes.

When I came gasping up the mountain, I expected little attention, perhaps even derision. To my astonishment I got a similar reception, including doubling my French vocabulary by hearing "allez" so many times. Perhaps the fans were getting warmed up for the real racers to follow or, more likely, they felt sympathy for the visage of a thin, pale, sweating and wheezing ophthalmologist grinding up the grades. What should have been grueling was blissful; what should have been painful was pleasurable and what could have been a sacrifice was really an honor. I had fans!

And now it dawns upon me, perhaps belatedly due to my hyperthermic brain damage, that the difference between pain, fatigue and joy and energy was a function of learning to recognize that praise and cheer are out there and, like endorphins, are powerful assuagers of fatigue and stimulants to the soul.

Yes, our medical practices can be challenging, but we are up to it; we have been properly prepared by years of training like the racers. We have the equipment of modern medicine to rival the space age composite equipment of bike racers, and we have the organized medicine "peloton" assisting our advances.

But to provide the crucial energy to combat our exhaustion and ennui, we must open our emotional receptors to the daily thanks that we normally shrug off, accept the cheers, cookies, joy and pathos generated by our care of our patients. The bike racers may have their cheering fans, but we have ours, too! They are the grateful patients we help heal and care for and whose appreciation and respect we must accept as a powerful antidote to fatigue. It is a powerful performance-enhancing substance we should add to our daily regimen. And it doesn't show up on urine tests!

rajones@sbcglobal.net