Stand Up - Annals of Internal Medicine: Fresh Look Blog


Wednesday, August 1, 2018

Stand Up

5:05 a.m.: Alarm. Get out of bed.
5:30 a.m.: Respond to e-mails, work on lectures, update ongoing projects.
6:30 a.m.: Drink tea, eat granola bar on morning commute.
6:45 a.m.: Arrive at work, respond to electronic health record alerts, secure messages from patients, work e-mails.
8:00 a.m.–noon: See patients. Sit at computer, typing before, during, after all encounters. Stand up to examine patients and to walk them to/from the lobby.
Noon: Walk to meetings (usually 15-20 minutes late because of patient care). If no meeting, microwave leftovers to eat in front of the computer and finish some alerts.
1:00–4:30 p.m.: See patients.
4:30–6:00 p.m.: Respond to electronic health record alerts, secure messages from patients, work e-mails.
6:30 p.m.: Start dinner. Sit down and open Annals of Internal Medicine to an article finding that “Both the total volume of sedentary time and its accrual in prolonged, uninterrupted bouts are associated with all-cause mortality, suggesting that physical activity guidelines should target reducing and interrupting sedentary time to reduce risk for death” (1)

I think to myself, “Doctors are some of the worst patients.” It’s a joke we tell ourselves when we miss our own doctors’ appointments (or fail to schedule them in the first place). We self-diagnose, defer treatment, and generally think we “know what’s better” when evidence routinely suggests we do not.

In response to our daily and professional expectations, many of us also adopt unhealthy lifestyles. As a primary care doctor, I counsel my patients on healthy lifestyle choices while slumped over my keyboard. I explain the importance of posture to improve their chronic low back pain, taking the opportunity to stand up to illustrate the contrast between a “natural” alignment and the malignant one I had been holding for the beginning of our 30-minute visit at my desk. “Do as I say, not as I do,” I joke.

But it’s not funny. Evidence has already shown that activity benefits health. It can improve mobility (2), depression (3), and chronic pain (4). The Annals study I read as I prepared dinner goes even further to suggest that lack of movement is a health risk. It’s a fine line, but the study suggests that simply standing up more often and for longer periods of time might help us live longer.

Some practices have standing desks between patient rooms where physicians can finish charting. Some have convertible desks that can raise up between patient visits so physicians can stand. Some practices are admittedly so busy that physicians run between exam rooms in 15 minutes or less. (Note: This is not a recommended solution.)

Like any important widespread issue, physicians ' sedentary lifestyles probably also requires systematic changes. Most of my sedentary time is mandated by the amount of computer-related work I have to do. The administrative burdens of medicine are well-documented, as are their effects on physician wellness (5). Many physician organizations, including my own (American College of Physicians and Society of General Internal Medicine) have been in Washington, calling for changes to rules and regulations that keep us at our desks when we would prefer to be with our patients (6). Now I add to the list the impact this has on our own physical health, and I’m making my own call for action. No joke, our lives depend on it.

6:45 p.m.: Stand up.

  1. Diaz KM, Howard VJ, Hutto B, Colabianchi N, Vena JE, Safford MM, et al. Patterns of sedentary behavior and mortality in u.s. middle-aged and older adults: a national cohort study. Ann Intern Med. 2017;167:465-475. [PMID: 28892811] doi:10.7326/M17-0212
  2. Gill TM, Guralnik JM, Pahor M, Church T, Fielding RA, King AC, et al; LIFE Study Investigators. Effect of structured physical activity on overall burden and transitions between states of major mobility disability in older persons: secondary analysis of a randomized trial. Ann Intern Med. 2016;165:833-840. [PMID: 27669457] doi:10.7326/M16-0529
  3. Gartlehner G, Gaynes BN, Amick HR, Asher GN, Morgan LC, Coker-Schwimmer E, et al. Comparative benefits and harms of antidepressant, psychological, complementary, and exercise treatments for major depression: an evidence report for a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2016;164:331-41. [PMID: 26857743] doi:10.7326/M15-1813 
  4. Staud R. Tai chi reduced severity of fibromyalgia symptoms at 24 weeks compared with aerobic exercise. Ann Intern Med. 2018;168:JC70. [PMID: 29913495] doi:10.7326/ACPJC-2018-168-12-070
  5. Downing NL, Bates DW, Longhurst CA. Physician burnout in the electronic health record era: are we ignoring the real cause? Ann Intern Med. 2018. [PMID: 29801050] doi:10.7326/M18-0139 
  6. Erickson SM, Rockwern B, Koltov M, McLean RM; Medical Practice and Quality Committee of the American College of Physicians. Putting patients first by reducing administrative tasks in health care: a position paper of the American College of Physicians. Ann Intern Med. 2017;166:659-661. [PMID: 28346948] doi:10.7326/M16-2697


  1. Well said. Let us hope it will done as well.

  2. Thanks a lot for this Dr Candler. I know during that morning and afternoon of patient care you saved someone’s life by adjusting a med, diagnosing and treating a new problem, and that you comforted many and gave important news. Compartmentalization of our intellectual and emotional struggles is a regular part of our professional life, but as stressful as that defense mechanism is it’s trumped by the lack of motion of that life.

    1. Yes, there are some great rewards from the work we do--no matter how long the hours or sedentary the task. That's what keeps me going. Thanks for reading.

  3. I totally agree with you but I am not really I understood the solution you suggested.
    Notes still need to be typed. A scribe could be a major help but very few institutions agree to pay for them. Is there any realistic and available solution?

    1. Thanks for reading! I think part of the solution is to decrease the number of administrative tasks we're asked to perform. Steps toward decreasing documentation requirements and utilizing teams to help triage tasks may help. At this point, I think it will take a combination of these approaches to really impact the time we spend as physicians at our computers.

  4. I appreciate your perspective on physician health and how sedentary we can be. I have found myself naturally standing up to chart and conduct conference calls. Sounds like my body is telling me to stand up!

    1. Standing up for charting and conference calls is a great idea! A colleague asked for a standing desk to do his after-hours work upright. Maybe the next step is making this an opt-out consideration. Thanks for reading!


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