By Mary Claire Manske, MD

As a pediatric hand surgeon, I am reminded with nearly every clinic encounter that summertime is now upon us. Aside from the increasing temperatures outside (and the fact that the sun is out both when I arrive at and leave the hospital!), summer announces its arrival in a variety of ways.  There is the expected up-tick in the incidence of pediatric fractures, the discussion between parents and children regarding the pros and cons for undergoing surgery for elective conditions during the summer versus during the school year, and of course, the inevitable question or “can I swim in my cast?”  Invariably, when I ask patients about their summer plans, kids tell me something about being outside—going to the pool or beach, camping trips with family and friends, and joining outdoor sports teams.

Although those in clinical practice do not have the same luxury of a nearly three-month hiatus from our routine, I try to take a cue from my patients and incorporate outdoor time into my summer routine. As a relative newcomer to northern California, there are abundant opportunities to do so. Whether taking a walk with my dogs in nearby McKinley park in Sacramento, kayaking on the Russian River, or hiking in the Sierra Nevadas, I have found that few activities are as restorative as time spent in nature, from which I return less stressed, more clearheaded, and mentally rejuvenated to face the challenges of a career as a surgeon.

The physical and mental health benefits of outdoor activity are well documented.

Contact with nature has been shown to have positive effects on blood pressure, heart rate, muscle tension, sleep patterns, recovery from illness, and mortality.[1,2] The mental health benefits are just as profound, as both objective findings of decreased cortisol levels and subjective reports of decreased stress and anxiety are associated with exposure to green space. There are certainly confounding factors; time spent is outdoors is often associated with physical activity and socializing, both of which are have known physical and mental health benefits.[3-7] Moreover, time spent outdoors is associated with vitamin D production and reduction in air pollution exposure, as vegetation is known to reduce air pollution levels.  But there likely inherent health benefits of green space; studies have suggested that “green exercise,” i.e. exercise occurring in the outdoors, has greater positive mental health benefits than exercise occurring indoors.

The good news is that to achieve the mental health benefits of nature, you don’t have to dedicate your whole weekend or even a whole day to outdoor activities.  While there is thought to be a dose effect of green exercise, the greatest effect on self-esteem are achieved in the first five minutes of outdoor exposure.[8]

The studies referenced above are just a few supporting the concept that time spent outdoors affords both health and societal benefits. It is certainly effective for me.  I urge you to reflect for a few moments on what strategies are beneficial for you in decreasing stress.  In the wake of increased appreciation of physician burnout,[9] I think it is incumbent upon each of us to identify modifiable ways we can mitigate our stresses, in part so we can take better care of our patients by taking better care of ourselves.  While physician burnout is a certainly a complex and multi-factorial phenomenon for which there is not a single solution that works for everyone, I think it begins with self-reflection. This mindfulness and self-reflection is a necessary, but not sufficient, component.  But it is a start.

I wrote these reflections while taking a break from my preparation for the ABOS II oral exam.  Before I return to that, though, I’m going to take the dogs outside for a quick walk.

 

References:

[1] Roe JJ, Thompson CW, Aspinall PA, et al. Green Space and Stress: Evidence from Cortisol Measures in Deprived Urban Communities. International Journal of Environmental Research and Public Health. 2013;10(9):4086-4103.
[2] Nieuwenhuijsen MJ, Kruize H, Gidlow C, et al. Positive health effects of the natural outdoor environment in typical populations in different regions in Europe (PHENOTYPE): a study programme protocol. BMJ Open. 2014;4(4):e004951.
[3] Cohen DA, Ashwood JS, Scott MM, et al. Public parks and physical activity among adolescent girls. Pediatrics. 2006;118:e1381–389.
[4] Toftager M, Ekholm O, Schipperijn J, et al. Distance to green space and physical activity: a Danish national representative survey. J Phys Act Health. 2011;8:741–749.
[5] Mytton OT, Townsend N, Rutter H, et al. Green space and physical activity: an observational study using Health Survey for England data. Health Place. 2012;18:1034–1041.
[6] Astell-Burt T, Feng X, Kolt GS. Green space is associated with walking and moderate-to-vigorous physical activity (MVPA) in middle-to-older-aged adults: findings from 203 883 Australians in the 45 and Up Study. Br J Sports Med. 2014;48:404–406.
[7] Richardson EA, Pearce J, Mitchell R, et al. Role of physical activity in the relationship between urban green space and health. Public Health. 2013;127:318–324.
[8] Barton J, Pretty J. What is the Best Dose of Nature and Green Exercise for Improving Mental Health? A Multi-Study Analysis. Environ Sci Technol. 2010 May 15;44(10):3947-3955.
[9] Daniels AH, DePasse JM, Kamal RN. Orthopaedic Surgeon Burnout: Diagnosis, Treatment, and Prevention. J Am Acad Orthop Surg. 2016;24: 213-219.