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Kiwi Wonderland

Bell Birds Sing,

Are you listening?

Tuis ring,

Did you miss them?

The Sandflies may bite,

But the evenings are light,

Walking in a Kiwi Wonderland.

 

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Cathedral Gully on Christmas Day.

 

Merry Christmas!

 

The last three years in Utah we’ve had snowy Christmases (and they’ve had another this year!). Christmas in New Zealand this year was sunny and hot. With Jamie and Anastasia of AHSNZ I just spent a couple days in Kaikoura, a beautiful coastal town north of Christchurch. Kaikoura (Maori translation ‘Meal of Crayfish’), was struck by an Earthquake just over a year ago, and the main road that connects Kaikoura to Christchurch was only recently reopened.

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“Meal of Crayfish”

Kaikoura is a gem, with activities including scuba diving, fishing, whale watching flights and cruises, and opportunities to swim with dolphins or explore the coast on foot. We spent a great couple days camping, tramping (that’s hiking to many of your), kayaking, and wildlife spotting.

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Kayaking to visit one of the Seal colonies.

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Wildlife spotting: a Shag in the foreground and a Fur Seal in the background. Not pictured: the huge pod of Hector Dolphins we saw on our drive out of town.

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Tramping in the bush.

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The seabed rose up with the recent earthquake

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Exploring the raised seabed

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Not exactly roughing it- a delicious camp breakfast!

 

It’s not wintery, but New Zealand certainly is a wonderland…

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The beach at our campsite: a nice place for an evening drip after a hot day!

 

I’m not the first to rethink this Christmas classic. This Air New Zealand take is ‘Sweet As’.

 

 

I hope you all find some joy and fulfillment this holiday season, whatever season it is where you life!

 

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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 7th 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.

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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.

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

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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.

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

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

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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…

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There were countless types of potatoes in the market.

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Quinoa

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Tarwi- the tasty (and pretty) Lupin

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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).

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

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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!

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

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

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

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

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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.

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

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The view from Huayna Picchu.

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

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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.

 

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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.

 

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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).

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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!

5 months ago I finished my residency training in Family Medicine at the University of Utah in Salt Lake City. During my three years of residency training I posted to this blog three times- mea culpa! There definitely wasn’t a lack of things to write about in residency- and I regret not jotting down notes of stories to recount or emotions to unpack- but sadly my urge to write during residency faltered and was replaced with an urge to… survive.

 

Residency is hard. It’s wonderful, amazing, at times exhilarating and at times demoralizing, and it is definitely hard. There’s a reason people have written books (fact and fiction) about residency, and sadly there are also reasons why there is a deluge of mental health problems in residents [1-2]… I hope I’ll get back to writing about some of my experiences soon, but only time will tell!

 

In the 5 months since finishing residency I’ve done a lot! Historically, residency ends June 30th (or more precisely STARTS July 1st, so you finish X years later), and a few days into July I was winging off to Japan with my boyfriend to explore Japan. The motivation to visit Japan was the promise of a bike tour around Hokkaido, the northernmost island in Japan. For over a decade my brother has taken time every summer to tour Hokkaido by bike, and thanks to various academic obligations I’ve never been able to join him – until this year.

 

I’ll try and flesh out this adventure at some point in the future, but to cut a long story short, we biked and ate our way around 900km of Hokkaido in 10 days. It was exhausting (and as expected somewhat uncomfortable at times), but it was a wonderful adventure. We visited a historic soba house, took a tram up a mountain, visited a lavender farm, tasted expensive (and delicious) melons, feasted on delicious food, and ate more ice-cream than is probably reasonable…

 

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My trusty steed for our 900K adventure.

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Part way through a 76K day along the northern coast of Hokkaido.

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Quite a bit of our cycling was on nice bike paths.

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Stunning flower farm in Bie.

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One of our many traditional dinners.

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One of many not-traditional icecreams. Lavender flavored at the Lavender farm, of course!

 

In August I invited myself up to Canada to spend time with my friend and fellow ancestrally-minded MD, Don Wilson. He graciously put me up in Calgary, Vancouver Island, and his home reservation of Bella Bella. Not only did I get to tour Calgary, visit Banff, and see Vancouver Island, but I got to drive up to Port Hardy and take the ferry up to Bella Bella where I got to experience a bit of rez-life and the wonderful hospitality (and traditional foods) of the Heiltsuk people. The experience, and the wildlife, were incredibly memorable.

 

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Don and I enjoyed a great hike up Sulphur Mountain in Banff.

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They were all over in Bella Bella.

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I had the privilege of being invited out salmon fishing with a couple of the locals and helped the pull in hundreds of pounds of Silver, Chum, and Coho Salmon that was eaten, frozen, and smoked. Yum!

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“Old Sam” or “The Watcher”. Whatever you call him, he is striking. The men who took my out fishing also brought me to this island for a visit.

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Great Blue Heron

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A reason not to hike alone… This bear was out with her two cubs.

 

In September I took some time to travel back to New Jersey where I caught up with friends and family. I have loved my 3+ years in Utah, and think there’s a good chance I’ll be back in the Bee Hive State in the future, but New Jersey will always hold a place in my heart and may one day call me home.

 

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Cow and calf at my parents farm.

 

In between all these trips I would head back to Utah, a state which I love to call home. I have never regretted my choice of residency programs: I had wonderful mentors and a great education in a place that allowed me to savor every free moment I had. It’s the place where I learned to love mountain biking, the place where I rediscovered alpine skiing after a 13-year hiatus, the place where I learned that rock-climbing doesn’t play to my strengths but is worth a go anyway. The people are friendly, the academics are excellent, and the wilderness is world class.

 

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Cartwheels over Canyones… Capitol Reef is one of the “Big 5” National Parks in Utah. Definitely worth saving.

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Canyoneering in Arches National Park (Spot the person on rappel!). Another great adventure in another great Utah Park.

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Mountain biking in the Wasatch- one of the new hobbies I took up while a resident is slowly peddling uphill and then speeding down through single track faster than is probably advisable…

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It may just be marketing, but sometimes it certainly seems like Utah has “The Best Snow on Earth”.

 

So where am I now?

 

After a brief stint moonlighting in some Urgent Care clinics in Salt Lake City, I’ve moved onto the next chapter in my life as a GP (General Practitioner) in the South Island of New Zealand, not far from Christchurch. I’ve been interested in practicing medicine in New Zealand since early in residency, having had a great trip here before starting residency and then hearing from a couple of physicians who enjoyed their time as GPs in the New Zealand system. I’ve signed on for a year and will see where the future takes me!

 

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Mt Cook from the Hooker Valley Track.

 

I arrived in New Zealand mid-October and shortly thereafter spoke about Ancestral Health in Academic Medicine at the Ancestral Health Symposium New Zealand in Queenstown. I started practicing at the beginning of November and am just rounding out my first month of practice in New Zealand.  It’s exhilarating, interesting, and at times a little intimidating (as I imagine all new-graduates find their post-residency jobs).

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A bit of lunch-time exploration at AHSNZ

 

So that’s a quick update from me- I hope to get back into a swing of writing about life, medicine, and ancestral health. Watch this space!

 

  1. Mata DA, Ramos MA, Bansal N, Khan R, Guille C, Di Angelantonio E, et al. Prevalence of Depression and Depressive Symptoms Among Resident Physicians: A Systematic Review and Meta-analysis. JAMA. 2015 Dec 8;314(22):2373.
  2. Yaghmour NA, Brigham TP, Richter T, Miller RS, Philibert I, Baldwin DC, et al. Causes of Death of Residents in ACGME-Accredited Programs 2000 Through 2014: Implications for the Learning Environment. Acad Med. 2017 Jul;92(7):976–83.

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…

 

I struggled with the title of this post for a while. It’s a long time since I’ve written anything (for the blog), and I wanted the title to be catchy, edgy, maybe even with a touch of double entendre. Alas, my creative mind has failed me. Perhaps this is a consequence of writing nothing but clinical notes for the past 6+ months- a result of being in the intern year of my medical residency. There is no need for provocative language, crafted sentences, or grammatical subtleties in medical notes. On a good day, clinical notes are composed of brief and simple sentences. On a busy day, notes are often composed largely of sentence fragments and phrases. On a bad day, notes may largely consist of abbreviations and acronyms.

Residency: Where to begin? I suppose at the beginning.

I haven’t tried this on older, more seasoned, docs, but it can be a bit of fun to ask a young doctor about the first order they ever gave as an MD. I come from a generation of medical students that did not give orders as students (I may have written out a paper order on occasion, but these were never acted upon until cosigned by a supervisor), so on July 1st, my first day of my residency, I showed up at 5 am eager (and somewhat petrified) to start my first rotation on Labor and Delivery- never having given a “medical order” to anyone. That morning, a nurse snagged me outside a patient’s room and said “Oh, she’s having some heartburn, can you write an order for Tums?”

“Sure”, I said calmly- while on the inside I felt like a deer in the headlights, trying to think of anyway possible that giving a lady Tums might lead to her demise. I stressed, I fussed, and then- as many interns do- I consulted a fellow resident. “Can I just write this lady for Tums?”

“Sure- but she should already have them ordered in the admission order set.”

How anticlimactic…

For a lot of young doctors that I’ve talked to, that first order request is for Tylenol.

The story usually goes something like this: patient’s nurse sees new resident. “Hey- Mr. Smith in room 14 has a headache. Can I get some Tylenol?”

New resident “Sure… Give me a minute?”

New resident then scurries off to the work room to check the patient’s allergies, liver function tests, alcohol history, etc, etc, etc. Resident then checks dosing, route of administration, frequency, and scans a med list wracking his brain for anything that might cause an interaction… I have heard this story many times- plus or minus a consult with a fellow resident.

That is on July 1 (or perhaps the end of June, as many programs now jump the gun on the July 1 residency start date). Hop forward a few weeks and the same resident will likely respond to the nurse “Sure- need a written order or can you take this as a verbal?”

Back to July 1: As I mentioned- I started my residency on labor and delivery. As a family medicine resident my intern year is a mix of some obstetrics, a pinch of surgery, a dose of pediatics, a healthy whack of in-patient medicine, and a sampling of various other areas of medicine (as well as a consistent stream of out-patient clinic). I started on Ob- one of the most challenging and grueling rotations in our residency. I’ll admit that I was initially scared but ultimately pleased that my medical career started on labor and delivery. My days of shadowing and standing in the background were gone. As a medical student I was allowed to stand in the room during a delivery and catch the occasional placenta, but as an intern I was expected to manage a patient from admission to discharge, with a labor and delivery in between. As my skill set and confidence grew, so did my autonomy- I was really someone’s doctor!

Of course, claiming that title was something I was hesitant to do…

As medical students, some people introduce themselves as “Student Doctor So-and-so”. I found this verbiage absolutely ridiculous, and instead went with the line “Hi- I’m Victoria, a medical student on the team looking after you.” I often followed this with the pseudo-apology “I can’t write you a prescription for any of the good drugs, but if there’s something going on and you feel like no one’s listening to you, I promise I’ll listen.”

Back to July 1- Do I actually introduce myself as “Doctor”? Who do I think I’m kidding?!

Folks, I’m here to tell you that the “Imposter Syndrome” is real. On July 1, there was no way I was introducing myself as “Doctor”. Instead, I modified by student script and said “Hi- I’m Victoria- one of the residents on the team looking after you.” I’m pretty sure I never introduced myself as “Doctor” that whole first month.

For my second month of residency I moved to a community hospital where I was doing in-patient medicine. There, my attending physician (my supervising physician) heard my introduction and said “Your life would be much easier if you introduced yourself as ‘doctor’”. Innately, I hate this reality. Despite working hard for many years to earn a slew of letters after my name, I’m not comfortable with the reality that saying that gets me more respect.

I battled on for a day or two, with my attending introducing me to patients as a doctor and hissing over my shoulder “doctor”, when she heard me call the lab, introduce myself as Victoria, and then sit on hold for 5 minutes waiting for a result. It didn’t happen quickly, but bit by bit, either by repetition or by the slow growth of the belief that maybe- just maybe- I was actually “doctoring”, I started to become comfortable with the term. I frequently couch the introduction with “one of the residents”, but I’m now comfortable introducing myself as Doctor, and have even found myself briefly annoyed when someone introduces me to a new patient by my first name. Outside of a patient’s earshot I have no need for a title (unless it bumps me to the front of the line when calling in to make an appointment for a patient or if I call in for a lab result), but I’ve come to learn that while the title doctor may give you respect, it also gives your patient confidence in you- and that is something incredibly valuable.

And what of Evolutionary Medicine and Ancestral Health?

If you’ve read many of my old posts (save those on travel), you’ll know that I have a passion for evolutionary medicine and ancestral health. One of the reasons I chose the residency program I did was because I knew it was a place I could explore those interests. That being said- my ability to explore and practice that kind of medicine has been quite limited. In my 8 weeks of Ob I had 49 vaginal deliveries: not one of which was done in a non-conventional position. I’ve probably prescribed more probiotics than most, though how much good a bolus of pure Lactobacillus does in a gut that has been firebombed with antibiotics I’m not really sure. (Strangely people rarely seem interested in eating Kimchi to replenish their gut flora… )I’ve also probably prescribed as much Tylenol as everyone else, despite believing that fever is a symptom (and a useful infection-fighting one at that) of illness and not something that needs to be treated in-and-of-itself. I’ve had small victories, discussing the potential benefit of fevers with some patients and families, and having them agree that they don’t need or want their fevers treated unless the discomfort is such that they can’t sleep or rest. I’ve also had these plans thwarted by covering residents and nurses who can’t stop their desire to “fix a number” and “fix a fever”.

Clinic is a bit of a different picture. There I’ve recommended, sleep remediation (sans medication), exercise, and books such as “It Starts With Food” to a number of patients, and been pleased to have the occasional one come back reporting success with lifestyle intervention. I’ve also had occasional welcome surprises, as I meet new patients who (sensibly) CrossFit or embrace a high-saturated fat/whole food diet who usually look shamefacedly at their doctor saying “My family wants me to come see a doctor because they know you’ll tell me this is a bad idea…”. Connecting with those patients- ensuring proper rest in one, recommending Kerry Gold Butter to the other- is an unexpected but welcome pleasure.

6+ months in…

I’m 6 and a half months into my intern year of residency. I have worked harder, put in more hours, and been more stressed than I ever have been before (the stress of writing a PhD thesis was quite different). Having written (and then retracted, since it was a duplicate order) my first order for Tums, I have gone on to write hundreds more orders. I still get nervous with firsts, but my comfort level is rising. Yesterday I did a thoracentesis for the first time. One day I will inevitably run my first code- this thought terrifies me.

I have also made some wonderful connections- with fellow residents, nurses, and patients. I continue to believe that doctoring is about people, not just illness, and while some patients come through as just another case that is quickly gone from my mind once the discharge is dictated, others have forever shaped who I am as a person and a doctor.

And Utah- oh Utah. There is not a day I have regretted moving to this state or choosing this residency program. I work with great people who love what they do but also value having a life outside of work. I work hard, but have the opportunity and ability to play hard as well. In the longer days of summer I was taking evening hikes some nights after work. With a tank of gas and some motivation I’ve been able to put 1-day weekends to good use, and have explored many of the national and state parks. Now that winter has come, I’ve used my rare day off to take to my cross-country skis, and am in the process of rediscovering my downhill ski legs, having hit the slopes for the first time in 13 years.

So here I am- half way through my first year of residency. I’m a doctor, and I no longer feel like a fraud when I say that. Many of my academic interests have been put on hold, but I have faith that I’ll be back to them as time allows. I’ve learned a lot since I moved to Utah in June: about medicine, myself, and others. There is so much to learn, so much to think about, and so much to explore, in medicine, wilderness, and life!

Little Cottonwood

View from Little Cottonwood Canyon, near the summit of Pfeiferhorn.

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Hello all!

 

Many apologies for my long absence! Believe it or not- moving across the country and starting your intern year as a medical resident is incredibly time consuming! Add to that, my gnawing guilt about not completing an academic chapter (Aaron, forgive me, but I am working on it!), and writing for pleasure keeps getting postponed.

 

It’s a rainy day in Salt Lake City, so instead of getting out to explore I’m trying to buckle down to finish some academic writing. To refresh my memory I pulled up my PhD thesis to review a couple chapters and happened to glance at my chapter on the history of alcohol. While the majority of my thesis is rather dry, focusing on liver pathology and cell-signaling intricacies, this chapter might actually be interesting to those with an interest in history (and/or booze). For those interested, I’m posting it below!


 

History

Fermentation of foods and beverages is intricately woven into human history and culture, with archaeological evidence of intentional fermentation dating back almost 10,000 years. The biochemistry behind the process was finally elucidated by Louis Pasteur in the mid 1850s [1, 2].

Archeologists have discovered extensive evidence for the historic production of fermented beverages around the world, including in China, Egypt, Iran, Greece, and Georgia [3]. Ancient beverages were made from a variety of products, including rice (sake), honey (mead), fruit (wine), and cereal grains (beer) [4]. One of the earliest and most prevalent sources of sugar for fermentation was, and remains, grape juice (Vitis sp.), with the earliest evidence of large-scale wine production dating back to approximately 5400BC in the northern Zagros Mountains of Iran [5]. Indeed, it is likely that humans’ propensity for wine led to the domestication of Vitis vinifera and the global expansion of the species [6]. It has even been suggested that the earliest agrarian societies converted from their nomadic hunter-gatherer ways in order to increase their ability to produce alcohol [7]!

The first winemaking was probably a mistake, occurring when juice from stored grapes was exposed to natural yeasts that would have fermented in a matter of days [8]. Originally, fermentation was probably initiated by wild yeast, and it is not known when humans started to selectively add specific yeasts to their materials [3]. The success and popularity of the drink is evidenced by the vast and rapid expansion of viticulture throughout Mesopotamia and Europe [8]. It is currently believed that grapes were domesticated between the Black Sea and Iran between 7000-4000 BC [3, 5, 9]. From there, grape production and winemaking spread over the Mediterranean, reaching Greece in 5000BC, Italy in 900BC, France in 600BC and the Americas in 1500 AD [3]. The export of wine was a driving force behind the expansion of the Greek sea trade, and when Rome conquered Greece the Romans adopted winemaking. As the Roman Empire expanded, viniculture and viticulture spread with it. When the Roman Empire collapsed, wine’s place in Christian rituals helped to maintain production. While wineries in the Middle East and North Africa disappeared with the advent and spread of Islam, monasteries in Europe protected and refined the art of wine making. European expansion eventually carried wine production to the Americas, starting in Mexico and heading south into South America. European grapes could not survive in eastern North America, and native varietals were adopted and cultivated for wine production [8]. European cultivars thrived on the west coast of the US [10].

It is believed that the production and consumption of beer arose after the advent of wine, though like wine, the actual date when beer was first produced is unknown. The first beer may have been a result of a batch of porridge that was left to sit too long, and there is extensive archeological evidence of beer production and consumption dating from 4000 to 3500 BC. It is likely that the Sumerians were the first beer makers and it is believed that as much as 40% of their grain production was used to brew beer. While the Sumerians may have invented beer making, the process was quickly adopted by Egyptians [8]. Analysis of ceramics found in Egypt that date from 1500-1300 BC suggests that a combination of cooked and uncooked malt with water and an inoculation of yeast were used to make beer [3]. Most people drank beer daily, and it was used as an offering to the gods. Beer production spread from the Middle East to Europe and Africa, and also began spontaneously in other parts of the world. The Incas, for example, used corn, manioc, and peanuts as the starting material for fermentation in South America [8]. The introduction of hops increased the stability of beer and allowed for greater dissemination of the product because the phenolic compounds in the Hops prevents the growth of gram positive bacteria [11].

In addition to having social and religious implications, beer provided a valuable nutritional source to those that drank it. Only a small amount of the energy in grains is lost in fermentation and the growth of yeast provides a valuable source of B vitamins to an otherwise somewhat nutritionally barren substance. Additionally, in a time when drinking water was frequently contaminated by the products of civilization, brewing (and wine making) provided a valuable source of potable liquid [8].

Both beer and wine provide relatively low percentage alcoholic beverages because of the self-limiting nature of fermentation. As the alcohol concentration of the fermented substance increases, the yeast lose the ability to survive and continue fermentation, therefore, with a few exceptions, beers are generally 4-6% alcohol by volume (abv) and wines are generally 10-14% abv. Variations in alcohol content depend on the availability of substrate for the yeast to ferment and the type of yeast used for fermentation. The process of distillation, by which alcohol is physically separated from water by exploiting differences in the substances’ boiling points, allows for the production of liquids with dramatically increased alcohol contents. Distillation first appeared in Mesopotamia around 4000BC, and was primarily used for the production of perfumes. Sometime later, distillation was used to produce alcoholic beverages, and between 1000 and 1500 AD the distillation of wine in Europe led to the production of brandy [8].

Initially, liquor was perceived as a healthy tonic, even being referred to as ‘aqua vitae’, the water of life.   Distilled liquor had the advantage of decreasing the volume of the initial substance, and improving stability, increasing the ability to transport alcohol throughout Europe and North America. Many liquors are distinctly identified with a geographical location, such as bourbon in the US, tequila in Mexico, Scotch whisky in Scotland, Gin in England, and Rum with the Caribbean [8]. Unfortunately, the availability of relatively inexpensive high alcohol beverages led to abuse and societal problems, and began to be blamed for social and medical problems. Indeed, the English artist William Hogarth depicted the evils of the consumption of gin in his print ‘Gin Lane’, which he compared to the merits of drinking beer in his print ‘Beer Street’.

 

 

The production and consumption of alcohol has had significant cultural, religious, and social implications for millennia and it continues to be important around the globe today. In addition to its roles in social and religious events, alcohol is implicated in a number of facets of human health and disease. Moderate consumption of alcohol has been associated with a decreased risk of certain adverse health events in comparison to those who abstain from alcohol entirely, while the over consumption of alcohol is associated with a number of pathologies and death. The pathologies and benefits of alcohol consumption are varied, as are the mechanisms by which alcohol acts in the body. While some effects of alcohol are due to the direct action alcohol, the process and products of alcohol metabolism are hugely important and warrant significant examination.

 

 

  1. Pasteur, L., Mémoire sur la fermentation alcoolique. . Ann. Chim. Phys, 1860. 58: p. 323-426.
  2. Barnett, J.A., Beginnings of microbiology and biochemistry: the contribution of yeast research. Microbiology, 2003. 149(Pt 3): p. 557-67.
  3. Sicard, D. and J.L. Legras, Bread, beer and wine: yeast domestication in the Saccharomyces sensu stricto complex. C R Biol, 2011. 334(3): p. 229-36.
  4. McGovern, P.E., J. Zhang, J. Tang, Z. Zhang, G.R. Hall, R.A. Moreau, A. Nunez, E.D. Butrym, M.P. Richards, C.S. Wang, G. Cheng, Z. Zhao, and C. Wang, Fermented beverages of pre- and proto-historic China. Proc Natl Acad Sci U S A, 2004. 101(51): p. 17593-8.
  5. McGovern, P.E., D.L. Glusker, and L.J. Exner, Neolithic resinated wine. Nature, 1986. 381: p. 480-481.
  6. Cavalieri, D., P.E. McGovern, D.L. Hartl, R. Mortimer, and M. Polsinelli, Evidence for S. cerevisiae fermentation in ancient wine. J Mol Evol, 2003. 57 Suppl 1: p. S226-32.
  7. McGovern, P.E., Uncorking the Past: The Quest for Wine, Beer, and Other Alcoholic Beverages. 2009: University of California Press.
  8. Wolf, A., G.A. Bray, and B.M. Popkin, A short history of beverages and how our body treats them. Obesity Reviews, 2007. 9: p. 151-164.
  9. Arroyo-Garcia, R., L. Ruiz-Garcia, L. Bolling, R. Ocete, M.A. Lopez, C. Arnold, A. Ergul, G. Soylemezoglu, H.I. Uzun, F. Cabello, J. Ibanez, M.K. Aradhya, A. Atanassov, I. Atanassov, S. Balint, J.L. Cenis, L. Costantini, S. Goris-Lavets, M.S. Grando, B.Y. Klein, P.E. McGovern, D. Merdinoglu, I. Pejic, F. Pelsy, N. Primikirios, V. Risovannaya, K.A. Roubelakis-Angelakis, H. Snoussi, P. Sotiri, S. Tamhankar, P. This, L. Troshin, J.M. Malpica, F. Lefort, and J.M. Martinez-Zapater, Multiple origins of cultivated grapevine (Vitis vinifera L. ssp. sativa) based on chloroplast DNA polymorphisms. Mol Ecol, 2006. 15(12): p. 3707-14.
  10. Soleas, G.J., E.P. Diamandis, and D.M. Goldberg, Wine as a biological fluid: history, production, and role in disease prevention. J Clin Lab Anal, 1997. 11(5): p. 287-313.
  11. Sakamoto, K. and W.N. Konings, Beer spoilage bacteria and hop resistance. Int J Food Microbiol, 2003. 89(2-3): p. 105-24.

 


 

I will be back, with more posts on evolution, medicine, evolutionary medicine, travel, Utah, and life!  Until then…

 

Corolla, we're not in NJ anymore...

Corolla, we’re not in NJ anymore…