principleintopractice

Yesterday, with my bike and a friend, I took a peddle down the Little River Rail Trail, starting in Motukarara and going just over 22km to Little River where we stopped for lunch before peddling back. Little River is a typical stop on the route from Christchurch to Akaroa, and there are a couple of small stores (including one with a co-op where I bought some local lemons and hazelnuts) and a bustling café and gallery. My lunch at the café including a side of Quinoa, which left me reminiscing about a month of my residency training spent in Peru where I worked to improve my medical Spanish.

During residency training there are a number of required rotations. Family Medicine Residents must have adequate experience in hospital medicine, obstetrics, pediatrics, and a host of other fields of medicine (and of course adequate out-patient Family Medicine practice). There is, however, elective time given to pursue non-required interests. Doing a Medical Spanish elective gave me the opportunity to brush up on my Spanish and, as I chose to pursue this training abroad, fed my wanderlust.

My Spanish education started in 7^th grade. I wasn’t very good. In fact, despite taking 2 years of Spanish before going to High School I placed into Spanish 1 as a freshman in High School. I trudged on through 4 years of Spanish, and as a freshman in college placed into something equivalent to Spanish 3. Languages really aren’t my forte!

Being a part of the horse world, I had quite a few opportunities to practice my Spanish, as many immigrants from Central and South America work in the horse industry. In college I also did an elective on “The Culture and Ecology of the Yucatan Peninsula” where we spent three weeks on the Yucatan Peninsula in Mexico and also took a spring break trip to Spain. My Spanish certainly wasn’t stellar, but it was good enough to get around and get me home when I inevitably became lost (I could do a whole series on being lost in foreign countries). I also spent a couple of weeks in Ecuador before starting residency.

It should surprise no one that Spanish is a useful language for doctors in the United States. In Utah 13.7% of residents were Hispanic as of 2016 , and that number is increasing. While most speak English, many don’t, so it was easy to make a case to my residency program to take some elective time to brush up on my Spanish and spend some time dedicated to learning Medical Spanish (something I had never specifically studied before).

There are lots of programs that offer Medical Spanish training. I looked into going to Columbia (a country I have wanted to visit for many years), as well as returning to Ecuador (a country I fell in love with during my earlier travels), but after spending some time looking at airfare and various Language Schools I settled on a program in Cusco Peru. The price was right, the flight from Salt Lake wasn’t too atrocious (though not short by any means) and Cusco looked to be a beautiful city with easy access to amazing places such as Machu Pichu.

In January 2016 I packed up my bags and headed to Cusco. Just before 5am on a Saturday I arrived in Cusco, was picked up by taxi, and dropped off with my host family. “Mi Madre Cuzqueña” (My Cuscanian Mother) met me outside, insisted I have a cup on Mate de Coca (Coca Leaf Tea), a rest, and then at 9am we would drive out to “El Valle Sangrado”-  the Sacred Valley to site see. I couldn’t believe my good luck to explore the local sites my first day in Peru.

5 hours after stepping off the plain in Cusco I was in the Sacred Valley (El Valle Sangrado), at amazing sites like this. Moray is believed to be an Incan agricultural research center, studying the microclimates of terraces

My time in Peru was amazing. The school experience was good, and the teachers were excellent. In addition to group classes (there were only 2 of us in my class the first week, and 4 the second), there were various experiences through the school such as dancing classes, cooking classes, and walking tours. As part of my medical Spanish training I worked one-on-one with one of the teachers who had formerly worked as a dentist, and in addition to working on medical lingo he took me to medical sites including the local public hospital, the local private hospital, and a local free-standing medical center. The private hospital seemed to have all the trappings of a good medical facility, but what I saw of the public hospital was pretty scary with a floor that looked like it hadn’t been cleaned in the last year, poor lighting, and crowded facilities. Perhaps the medical care was good, I didn’t get to see that, but the facility itself was in great need of care. I also spent a couple of days per week at a local clinic seeing patients.

Cusco is a sprawling city, high in the Andes (3,399m, just over 11,000′). 

Spanish lessons would sometimes morph into civics lessons…

When I wasn’t in school or learning about the medical system I would explore the city (Cusco is beautiful), the local archeological sites (they are innumerable), or relax at my host families house. I could have stayed at the school’s boarding house, but staying with a family was a great part of my trip. My family was welcoming and kind, and very good sports about taking me out and about to sites in the Sacred Valley. It was also a great change of pace from life as a resident. In the mornings I would have breakfast with my family, go to classes, and come home for lunch. After lunch my host mother would tell me it was time to rest, and I would – reading or napping (an activity I rarely partake in) before heading back for afternoon classes.

My host mothers trusty bug. It took us on some good adventures!

Maras De Sal- Salt evaporation pools that have been in use since Incan times.

Terraces make the steep slopes arable. You still see Incan terraces being used by farmers today. 

Of course I was interested in Peruvian food.

It should go without saying that potatoes are a staple of the Peruvian diet, and they were frequently eaten three times a day. There are over 4000 types of native potato in the Andes of South America, and they come in all shapes and sizes. Quinoa, the food that jogged my memory yesterday, is another traditional food, though thanks to the popularity of the crop worldwide it has become a lot more expensive (the price tripled between 2006 and 2013). While there have been concerns that the increase in popularity abroad, and thus an increase in price, may have a detrimental effect on those who grow it and eat in its native environment, other reports disagree (My host family bemoaned the increase in price and said they eat less of it now).  Another crop that my host mother introduced me to, that I found delicious, was Tarwi- the seeds of an Andean Lupin. I loved the flavor, which oddly reminded me of pesto…

There were countless types of potatoes in the market.

Quinoa

Tarwi- the tasty (and pretty) Lupin

Tarwi (on the right) for sale in the market. Also Quinoa on the left, and I think a seaweed from Lake Titicaca at the top right. 

Meat was a relatively rare feature at my host families table, especially red meat. When meat was served, it tended to be chicken, though Guinea Pig (cuy) is another traditional meat. Alpaca and llama, while plentiful, are predominantly used for textiles and not eaten. Cusco is in the Andes, and thus seafood was limited, though some restaurants serve Ceviche, a specialty on the coast in places such as Lima.  Corn was often featured (boiled, roasted, and even as a drink) as was rice. Soups were common, and fruits and veggies were plentiful. While general recommendations (and perhaps common sense) recommend against adventurous eating in countries such as Peru, I generally don’t follow that advice and enthusiastically tried Chicha (a traditional fermented corn drink) from roadside stands, lots of raw fruits and veggies, ceviche, and all manner of street food. I paid the price, getting EPEC (Enteropathic E coli) once and another stomach bug later (I know it was EPEC because the Doctor associated with the Spanish School recruited students for a study looking at what gastrointestinal infections befall travelers to Cusco).

A traditional plate at the Festival of San Cristobal. Note the whole roasted Cuy (Guinea Pig) in the foreground. 

The final plate, complete with roast guinea pig, roast chicken, dried alpaca, roast corn, a corn bread, sea weed from Lake Titicaca and fish roe!

One of many types of corn- this one grown on my host families property in the Sacred Valley. We ate this boiled.

This purple corn is used to make Chicha Morada- a sweet non-alcoholic drink. 

A Frutillada (mildly alcoholic strawberry/corn drink) from a road side stand. 

Lots of fruit at the market, including some I’d never seen before.

This was a great stall for hot chocolate in the market. In the foreground you see bowls of Crema (essentially clotted cream) which is spread generously on a bun. The hot chocolate is made from a paste of pure cacao and milk- sweetened to your liking. 

The history of Peru, and the Cusco area in particular, is fascinating. The native Inca built amazing structures, which stand to this day. Machu Picchu is the most famous, but other sites are equally awe-inspiring (and often mind boggling). The Spanish showed up in 1530, and proceeded to devastate the Incan Empire. Amongst other things, the Spanish brought Catholicism, European architecture, and European art to the region, and as a result Peru is home to stunning old cathedrals and churches filled with art from the Escuela Cuzqueña. 85% of religious people in Peru identify as Catholic, though they do so with a South American flare. I was in Cusco for the Festival of San Cristobal, and the parades, festivities, and costumes were stunning.

Machu Picchu. We got tickets to climb Huayna Picchu, the mountain in the background.

The view from Huayna Picchu.

La Plaza de Armas in the center of Cusco. My host family and school were very close. 

A Spanish monastery built on the foundation of an Incan structure. 

My month in Peru improved my Spanish, and certainly missing a month of Salt Lake City Inversion while exploring Peru improved my mental wellbeing. I doubt I’ll use my Spanish in New Zealand much (though I have had a Mexican patient that I chatted with in Spanish), but I’m happy that little things like a side of Quinoa salad can take me back to a month well spent in the Andes.

Are there any foods you eat that take you back to another place and time?

This is a question I get a lot…

If you’ve followed this blog for a while (including through a long hiatus), or you know me, you’ll likely know I grew up in New Jersey, went to university in New Jersey, went to medical school (where I got an MD/PhD) in New Jersey, and then moved to Utah for my residency training. People were often curious why I moved to Utah, though people who have visited, and have an appreciation for the outdoors, usually understand pretty quickly. Living in Salt Lake City I could work at a big academic center and have the benefits of urban living (a super market within walking distance, an airport 15 minutes from my house, and, err- whatever other benefits you get from urban living (ok- so I’ve never exactly been a person who enjoys urban living)) while still having access to world class outdoors activities. With less than a 40-minute drive from my apartment in downtown Salt Lake City I could be skiing at any of 6 ski resorts, riding on multiple mountain bike trail systems, or exploring seemingly endless trails for hiking.  Sure, my paddleboard didn’t get a ton of use, but if I had a long weekend (or even just a precious 2-day weekend) I could explore one of the five National Parks, numerous State Parks, or a growing number (and hopefully not shrinking size) of National Monuments. Utah was a great fit for me, so why did I leave?

Three and a half years ago, between finishing medical school and entering residency I had 6 months of time with no real obligations (because of the timing of my PhD I was off-cycle with my classmates). I spent this time recouping and travelling. I visited Belize, Ecuador (including The Galapagos), Turkey, England, and topped it all off with 5 weeks of Antipodean adventures, spending 3 weeks in New Zealand and 2 weeks in Australia. I never posted about those 5 weeks (though I think I had at least 4 posts started- this was the start of my long blogging hiatus). It was a great adventure, complete with polocrosse, riding horses on beaches in Australia and New Zealand, walking on the Franz Josef Glacier, wildlife, excellent coffee, and friends. For me it was a great “last hurrah” before buckling down to the work of residency.

Pre-Residency NZ adventures, in front of the Franz Josef Glacier. 

Residency WAS work, and while I do still plan to pursue research and academic medicine (the long-term “plan” since I first decided to get an MD/PhD), during residency I realized I didn’t want to go straight from training into a long-term position. There were a few reasons for this. First- finding a “permanent” position is daunting, and while many new grads go straight from residency to a permanent job, I didn’t feel like I was in the right head-space to make long-term decisions during residency. Second- while I think I want my first “permanent” position to include a substantial amount of research and academic time, I also want to keep a hand in clinical medicine. While I’ve learned an unquantifiably-large amount in residency, most physicians that I’ve spoken with agree that you really form your practice “style” the first few years post-residency. I felt (and continue to feel) that immersing myself in full time primary care practice, at least for a while, would make me a better clinician and researcher for the long run.  Third- I may want to stick around in Utah eventually, but my wanderlust really started to act up in residency!

Which brings me to New Zealand…

As I was thinking about “where next”, New Zealand kept coming to mind… I’d loved my time in New Zealand pre-residency. A senior resident from my intern year (first year of residency) took a locum position in New Zealand for a year after residency and loved it. I have some friends in New Zealand. It’s on the other side of the world, beautiful, and great for outdoor adventurers (big points for my wanderlust). I have friends and family in Australia- not close by any means, but being in NZ would give me better access to visit them and to visit other new locations on the other side of the world. Also, like the US, NZ has a primary care physician shortage and even has a government funded medical recruitment agency to bring primary care physicians [http://www.nzlocums.com/]. Also, New Zealand is an English-speaking country (while my Spanish can get me through some basic patient encounters, it’s not good enough for full time practice) and US qualifications are recognized in NZ.

As I worked my way through the second and third year of residency I would browse a small percentage of the job postings filling my inbox, but in my mind I’d essentially committed to moving to New Zealand and didn’t seriously pursue a job-search in the US. In the end, despite all the reasons to consider NZ, my choice came down to a gut feeling that a year as a primary care physician- a GP (General Practitioner) in NZ terms- would be an adventure, and it was one that really piqued my interest.

I took this photo on my first trip to NZ, and a large canvas of it hung on my wall throughout residency. Now I live less than an hour from these mountains…

Just over a year ago (the day before the presidential election, to be precise) I sent my letter expressing interest in practicing in NZ. NZ Locums was great to work with, though the whole process took longer than I had anticipated (largely because we couldn’t proceed until I was technically “board certified” by the American Board of Family Medicine). I knew I wanted to come to the South Island- it’s less developed with more access to my type of outdoor-activities (though unfortunately it seems that all the polocrosse is on the North Island)- and as the GP shortage is most severe in rural areas I knew I’d be heading somewhere rural. That being said, I ended up in historically farming country that is undergoing a boom of post-earthquake development, with large farms becoming large housing developments (not unlike where I grew up in rural New Jersey).  It leads to an interesting mix of patients and medicine (by the end of the year I’m sure I will be able to write the book 101 Ways to be Hurt by a Cows and Sheep).

A New Zealand traffic jam.

I’m one month into practice in New Zealand (and almost two months into living here) and so far I’m very happy with my choice to live and work here a year (or potentially more, though there are people in the US who don’t want to hear that). The outdoor adventures don’t disappoint, and I’m getting the intense clinical practice I was looking for, though in a very different environment and system than I trained in in the United States… More on that in later posts!

I’m approaching being 2/3 of the way through residency. *Gulp!*. My opportunities for writing have been fairly minimal for the last two years but, as ever, I am optimistic I’ll have more time in the future. This is something I wrote almost 4 months ago, which remains relevant, and which I’ve finally sat down to publish. I hope you find it thought provoking. 

I tend to be a pretty upbeat person. I’m not sure whether I have extra-sensitive serotonin receptors, or higher than average baseline dopamine levels, but I’m definitely someone who tends to be optimistic. Even working 80 hour weeks, I was recently described as “bubbly”.

That being said, it’s hard to stay positive these days when you tune into the news. With terrorist atrocities (international and domestic), attacks on women’s health, disregard for refugees, and stigmatization based on religion, race, or sexuality, it can be hard to stay positive in the face of so much hate.

I struggle to understand the hate that is freely and vitriolically expressed on social media, on some news outlets, and by some political candidates. As someone who finds solace in understanding, and also thinks that natural selection is everywhere, I’ve been trying to understand an evolutionary basis for this general grumpiness.

Before digging into this subject I think it’s necessary to preface the conversation with Hume’s Law aka Naturalistic Fallacy, or in plain English: the is/ought problem. Though we may accept that there is an evolutionary basis to this hatred, we are not saying their ought to be. On the contrary, I would argue that it is important to understand why this hatred exists so that we might better understand each other’s perspectives. I think we can all agree that the current plan of yelling at each other as loudly as possible isn’t moving the conversation forward in any meaningful way.

When I first started to think about this subject I was immediately reminded of Baba Brinkman’s “Rap Guide to Human Nature”. (I’ve written about Baba and his Rap Guides here). One of his songs addressed the differences between conservatives and liberals, touching on xenophobia. True to form, the song is well researched and backed with science. You can hear the song here, or you can watch a live version here (which is worth watching at least for a couple minutes since his preamble nicely summarizes some important research).

Baba’s argument (formed from the work of a number of scientists) is that xenophobia is part of our Behavioral Immune System– an evolved psychological response to things that could threaten disease or illness. This is the mechanism that makes us averse to the smell of food that’s gone bad, people that look infectious, and (in the case of xenophobia) people that look foreign who may be carrying some foreign disease.

This argument is only one of many evolutionary ‘reasons’ that we may have a fear of outsiders. A very simple reason, and one we frequently see cited by those opposing aid to refugees, is the conservation of resources. If you have only limited resources, there is an evolutionary benefit to sharing with those who are related to you, those in your in-group, instead of sharing with outsiders. You can see this theory in action in some of our more distant relatives. Chimps, for example, are very territorial, and are often horribly aggressive to members of outside groups in order to protect their territory and their resources. On the other end of the spectrum are Bonobos, who live in more resource rich environments and who are often friendly to outside groups. There’s a quick public radio piece on this subject here.

This is a very long lecture (or series of mini-lectures), but I thoroughly enjoyed watching and listening to this one quiet evening on night-float. If you have the time, it’s well worth a watch.

There’s far too much covered in these lectures to distill into a blog post, but I think the closing comments are very powerful.

“We have biology, and we have our brains. And we have this incredible problem of fear which has a real basis. But we need to overcome that to live together. But the only way we can really do that is to understand what it is that makes us afraid of others and how the biology works, and how the psychology works, and to try to answer those questions. And so the only way we can ever, it seems to me, move forward, is try to understand what makes us up as human beings.” -Lawrence Krauss

So how can move forward? I have touched on only a couple of the evolutionary reasons for fear, but even on those subjects there is a lot to be done. Baba brings up the point that for some countries wracked with social issues, the answer may (at least in part) be water sanitation and vaccination- protecting people from the things their behavioral immune system has evolved to fight.

Here in America (and in much of the developed world), I think the bigger issue is resources. A frequent cry one sees on social media is along the lines of “how can we care for refugees when we can’t care for our veterans”. Much as food scarcity in chimps can cause hostility towards outsiders, lack of access to secure housing and healthcare may be a major cause of hostility towards refugees in our society. It seems that many fear that something they pay very dearly for may be given for free (with their tax dollars) to outsiders. It certainly doesn’t help that we currently live in an economic environment where many are living paycheck-to-paycheck, and we are not far gone from the time with economic collapse caused many to lose their homes. I think it is no coincidence that the countries in Europe that are accepting the most refugees have solid national healthcare and safety-nets, where their citizens do not live in fear of paying their next bill, or not being able to care for themselves or their family. Obviously there is no easy fix for the situation we are in, though I think that access to healthcare is an important place to start.

From the lecture series above (it really is great):

“Simple assumptions: that trade or interdependence or interaction will be, by itself, sufficient is unfortunately too easy, but sets for us an important challenge. It seems like often in human society when there is plenty, everything is fine, and then when stress occurs, when there is limited resources, when there is a need to retract, if you take the crystal of human society and somehow hit it, group boundaries is where it breaks. But not always. And so what I think what we want most to know is what are the keys to resilience and resistance. How do you create a society that, when put under stress, doesn’t break along ethnic or descent based lines.” – Rebecca Saxe

And that, dear readers, is a question for another day…