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Archive for October, 2013

Tomorrow is my last day of medical school.

 

Ok, I don’t actually graduate until December, but as of tomorrow I will have completed all of the requirements for graduation from my school (because of my PhD I am half a year out of sync with the majority of my classmates).  I had initially planned to schedule a few more electives (might as well get as much hands on experience while I am still covered by liability insurance!), but interviews for residency programs have rapidly filled my schedule.

 

In the next couple of months I’ll be travelling around the country interviewing at various residency programs.  Many new doctors restrict themselves to geographic location when they apply to residency (the next phase in medical education- “Graduate Medical Education”), choosing to apply to programs in areas they are familiar with, have connections to, or where they have family.  I am applying widely- generally (though not exclusively) at academic programs, and with little thought to geography.  I’m fortunate to have friends in many of the places I’m applying (I actually think that visiting with friends when I travel to interviews is going to be one of the major perks of interview season), though certainly not all of them (any friends in Rochester Minnesota I’m not aware of?).

 

The “matching” process that graduating medical students (and some who have already graduated) go through seems rather odd to many people outside the medical community.  While I apply to and interview at many programs, ultimately I do not accept or reject a job offer from a residency program.  Medical students and residency programs enter into a system known as “the match”.  Through this process students apply to programs using an online application, programs offer interview invitations to selected students, students interview, and at the end of the day (or February 26th 2014 at 9pm EST if you’re being specific) medical students submit a “rank list” stating their preferences for residency.  Residency programs make similar rank lists, and using an algorithm a computer program determines our fates.  Putting student’s preferences first, the system determines where graduates will be headed for their internship in June or July.

 

March 17, 2014 is the start of “Match week” for my peers and me.  On that Monday we will get an email telling us if we “matched”.  There won’t be any specifics (you don’t find out where you matched until that Friday- “Match Day”), but that Monday marks a day when most med students around the country breathe a massive and collective sigh of relief.  On that day, Facebook is flooded by waves of status updates informing friends and family that “I’ll have a job in July!”, and “I’ll finally be making money” (though arguably not that much as a PGY1 (post graduate year 1).

 

Of course, a small minority of students will get emails that Monday informing them that they have not matched.  In the past these individuals have then “scrambled” for open positions, though now the system has been formalized into a process known as the SOAP (Supplemental Offer and Acceptance Program).  I won’t elaborate, but no student wants to use SOAP.

 

I’ve written before about speed dating for medical students, but then I was talking about the rapid-fire clinical rotations that medical students take in third year.  The interview process is also a “speed dating for medical students” experience, culminating with an arranged marriage of sorts.  While some students opt to do “away rotations” at programs they are very interested in for residency, you can’t possibly do rotations everywhere you hope to interview.  Spending a month at a hospital tells you a lot about the program you would be joining as a resident, but it can be hard to get a real sense of a program in just one day (or half a day, as the case may be).  Some programs offer dinners with residents, or extra time visiting a program, but it is truly a “speed-dating” experience.

 

These “speed dates” are important, since they determine how you choose where you hope to spend at least the next year of your life.  Some new doctors must do a “transition year” before heading off to their specialty of choice, but most new docs are interviewing for positions at hospitals where they will be based for anywhere from 3-7 years (residency training length varies with specialty.).

 

So that’s what I’ll be up to for the next few months- speed dating my way around the country. I’ve been invited to give a talk for the evolutionary medicine program when I’m out interviewing at UCLA, which should be fun, and I’m looking forward to visiting with friends and seeing the sights as I travel around the country.  I’m excited to visit lots of different hospitals and see what different programs have to offer.  Hopefully, when this round of speed dating comes to a close, I’ll have figured out how I want to write my dance card, and hopefully the programs I like find the feelings to be mutual.  If not, I guess there’s always a future in bovine obstetrics!

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Just a quick post that my talk from the 2013 Ancestral Health Symposium is up.  Alas, there were some technical difficulties and the last few minutes weren’t recorded, but most of the meat of the talk is there.

 

**Apparently the video has been set to private.  I’ll update when it’s back!

***Update 11/4- It’s back!

 

Also, the slides are up on Slide Sharer here (there were a few reveals/animations that didn’t make the upload, but again the meat of the topic is there!).

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Where’s the beef?!

Yesterday I helped bring a baby calf into the world.  Today I was at the other end of the spectrum, taking a trip to our butchers to see four sides of our beef cut into retail cuts.  The circle of life. (Apologies if you now have scenes from The Lion King flashing before your eyes!).

 

For the last few years I have been the point person for selling our family’s beef. Whether it’s friends from college or people from the gym, I have a pretty good pool of people who are interested in locally-raised grass-fed beef.

 

If it’s not obvious, I LOVE beef.  I like to cook it (all of it, including the odd bits!), I like to eat it, I’m interested in the ethics of it, I’m keen on the impact of local grass-fed beef for the economy and the environment, and I’m interested in the potential health benefits of grass-fed beef.  Oh, and I’m all about saturated fats.

 

When I talk to friends and potential customers about our beef I can talk about our animals, recipes, or anything else on the list above, but when it comes to discussing the traditional bits of the animal I sometimes find myself woefully unprepared.  Yes, I can explain that you either get T-bones and Porterhouse or Filet and Strip Steak (those are the options when it comes to the loin of the animal- we’re not going to discuss grinding it!), but quite how you break down the round, chuck, and rib is a topic I sometimes skirt around (though I don’t skirt around skirt steak- it’s probably my favorite cut!).

 

Today was the day the butchers were cutting the last four sides of our beef, which had been dry aging in their cooler for the last two and a half weeks.  I just started an EMS elective that has me doing six 12hr shifts and I had today off, so I asked my butchers if they would mind me hanging out and hopefully learning a thing or two as they finished the work on our animals.  They kindly obliged, and I think they actually quite liked having a young lady around the place to liven things up!

 

When I first showed up they were half way through butchering the first side, which was now broken down into a number of primal cuts.  Primal cuts are large sections of the animal that are then cut down further into retail cuts.  Some of the names will be familiar. “Chuck” is the shoulder, “rib” is the next area back, followed by the “loin”, “sirloin”, and then the “round”.  On the underside of the animal, starting from the front, you have “brisket”, “plate”, and “flank”.  You also have the shanks, and some people break the sirloin down further.  The round is broken into a top round and a bottom round.  These are all names you may see slapped on a piece of meat in the supermarket, but seeing a carcass go from a hanging side to a retail steak helps put it all in perspective.

 

This is what a 400# side of grass-fed beef looks like!

This is what a 400# side of grass-fed beef looks like!

 

The rounds... Eye of round, bottom round, and top round from front to back.

The rounds… Eye of round, bottom round, and top round from front to back.

 

The butchers we go to have been in operation for 75 years.  They service the local farming community, and are butchers for people who raise a single animal for themselves as well as farms that are sending multiple animals to the butcher every week.  While there has certainly been an increase in nose-to-tail eating, I think my “paleo”/“foodie” customers are still somewhat in the minority in their preference to have tail, shin and marrow bones, and offal… “Everything but the squeak”, one of the old guys said.  These guys are good at doing simple, standard cuts, and if we ask for something special they try and oblige, but requests for flat-iron steaks and flap steaks have gone unanswered.  When I made a plea for the hanger steak today they gave me a questioning look, but obliged (I think many of their customers don’t even want skirt steak- the horror!).

 

Some beef options- the loin can be cut into T-bones and Porterhouse (bone in) or Strip Steak and Filet

 

T-bones-

T-bones

 

Strips- the other option (with filet mignon) for cutting the loin.

Strips- the other option (with filet mignon) for cutting the loin.

 

Roasts, steaks, or stew…

Some people want the big roasts all cubed for stew meat.

Some people want the big roasts all cubed for stew meat.

 

One of our other topics of conversation was the difficulty of USDA inspection.  Our butchers have a USDA inspector onsite 8hrs per day, 5 days per week, but for smaller butchers that is a burden they can not shoulder.  Likewise, while our butcher has stayed up to date with regulations and standards, some smaller butchers have not been able to keep up and have dropped their USDA inspection or closed.  It also seems that the mountain of paperwork is a real burden- taking the boss one full day per week to handle.

 

Talk of USDA was a bit demoralizing, but it was fun to chat with the butchers about meat.  I recently had a patient on the floors who had been a butcher (he was 85).  We talked about a number of things over his extended hospitalization, but if I really wanted to get him talking all I had to do was get him talking about meat…  Ask him about his favorite steak and he was off telling you about the best way to age things, the best part of the country for raising beef, and how he liked to cook things.  On the other hand, one of the guys I worked with today admitted that he sees too much meat during the day and doesn’t care for it much at home (this was not my problem- I was very keen to head home to a steak lunch).

 

I also asked the various butchers about their thoughts on grass-fed beef.  They laughed and said it was all the rage, but if they wanted something grass-fed they’d just walk outside and eat the grass themselves- give them corn-fed beef any day! They commented that grass-fed meat smelled different, looked different, and tasted different.  When I asked one of them how our grass-fed meat faired in comparison to other grass-fed animals the guy gave me a shocked look and said “This is grass-fed? I had no idea… All grass-fed? How’d you get all that fat on it?”  It is true that our beef had quite a bit of fat on it*, and for grass-fed meat had quite a bit of marbling.  British Whites are supposed to do well on grass, and my mother is very proactive with rotational grazing, so hopefully this is a testament to how good grass-fed meat is good meat!

 

London Broils being cut from the top round.  Good marbling for grass-fed beef.

London Broils being cut from the top round. Good marbling for grass-fed beef.

 

Short ribs. Our butchers tend to debone these and grind it all, but some people asked for them to be kept whole. They'd be trimmed, but it's still a high fat cut.

Short ribs. Our butchers tend to debone these and grind it all, but some people asked for them to be kept whole. They’d be trimmed, but it’s still a high fat cut from our grass-fed animals.

 

Seeing a side of beef broken down into retail cuts is quite sobering. For every 1000# animal there are only a few pounds each of skirt steak and flank steak.  For those who like these cuts, and eat them on a regular basis, it’s good to realize quite how limited they are (and to be thankful that there are those who don’t care for them!).  As delicious as some odd bits are, a commitment to eating nose-to-tail frequently means eating a lot of roasts and ground meat…

 

*As I said, there was quite a bit of fat on our steer.  I asked the guys to save me a couple boxes of trimmings so I could render it down for tallow.  I’ve done this the past few years.  It’s a messy task, but grass-fed tallow isn’t easy to come by and I like to use it in cooking and as gifts!

 

Tallow in the making.

Tallow in the making.

Rendering down trimmings for tallow

Rendering down trimmings for tallow

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*I suppose some warnings are in order.  Some might consider one or two of the following pictures graphic.  In comparison to my post on human delivery, however, this is totally G-rated!

 

My family boasts the largest herd of British White Cattle in the state.  I should probably admit that it’s also the only herd in the state and that up until a week ago that herd was an impressive five heifers (we recently sent 7 animals off to the butcher).  In the last week the herd has almost doubled (and should be truly doubled by mid November when our last heifer is due to calf).

 

This morning was a misty fall morning at our farm.

A misty fall morning at our farm.

 

Over the last week, while I have been on a palliative care elective having a lot of ‘end of life’ discussions, my mother has been keeping a dutiful eye on “our girls” and their ‘beginning of life’ activities.  As of this morning we had three beautiful heifer calves added to our herd.  Though my mother lost a lot of sleep (and a touch of her sanity) worrying, nature took its course and our first three heifers delivered unassisted.

 

2/3 of our new heifers.

2/3 of our new heifers.

 

That changed today.  I happened to be on my way home to visit my parents when I got word that Snowflake, the smallest of our heifers, was in active labor.  There’d been signs of labor (bulging membranes, and even a foot or two) for a while: my mother actually thought the calf would be delivered overnight, but dawn broke without a new addition to the herd.  I hoped I would be able to make it to the farm before the calf was born.

 

When I reached our farm I found the three post-partum mothers peacefully grazing with their youngsters resting quietly nearby.  Our heifer that is due in November was also grazing peacefully.  The heifer in labor was pacing around the field, obviously uncomfortable.  At time she would lay down and strain, and you would see feet and membranes protruding, but despite her best efforts she didn’t make any progress.

 

Poor Snowflake couldn't make any progress past this...

Poor Snowflake couldn’t make any progress past this…

 

After an hour or so, and after a phone consultation with our bovine vet (who was away on another call and couldn’t come to the farm), we decided to move Snowflake up to the barn and get her in the chute.  We were concerned there might be a malpresentation (the feet were coming out first, but we couldn’t tell the orientation and it was possible the calf was upside down), and at this point we were concerned that our little heifer needed assistance.

 

We got her to the barn and in the chute easily. It happened that a pair of locals (new acquaintances) stopped by the farm to pick up some equipment just as we were getting Snowflake situated, providing an extra pair of hands (and a willing photographer, which makes this post much more interesting!).

 

While our vet wasn’t able to make it, Snowflake was rather well attended.  My mother is a veterinarian (though as a pathologist she hasn’t managed a delivery in many decades), one of our visitors had been a vet tech at an equine hospital for many years, and I’m a fourth year medical student.  Not exactly your A-team for a bovine delivery, but you could do worse.

 

Fortunately my mother had prepared for a labor dystocia (a difficult delivery) and had the requisite calving chains on hand.  Quite how I, as the medical student, got the job of doing the internal examination and heavy lifting of the delivery I’m somewhat unsure, but it is certainly a task I will remember for quite some time!

 

With the calving chains in place, it was time to pull.  So maybe this is why I crossfit. As I pulled the calf out today our observer commented "Wow you're strong!"

With the calving chains in place, it was time to pull. So maybe this is why I crossfit. As I helped pull the calf out today our observer commented “Wow you’re strong!”

 

 

After quite a bit of sweating, grunting, and the occasional obscenity, a healthy bull calf was born.  Our smallest heifer was carrying our biggest calf (82 pounds), and while the calf was in a normal presentation, she couldn’t get him out without some extra help.  Just as in humans, delivery is determined by the three Ps: the power (the pushing power of the uterus), the pelvis (size of the outlet), and the passenger (the size of the fetus). *

 

Success!

Success!

 

The calf was vigorous- mooing within minutes of birth and nursing within the hour.  He now has the distinct pleasure of being the lone British White bull in New Jersey!

It doesn't take long for Mum o get pretty protective...

It doesn’t take long for Mum to get pretty protective…

Good to see our young calf up and nursing!

Good to see our young calf up and nursing!

 

*An interesting aside when it comes to comparative obstetrics- in humans and horses we frequently use oxytocin to induce or augment labor.  According to our vet it is NOT used for these purposes in cows (though we did have some oxytocin on hand in case it was needed for expulsion of the placenta).  Apparently in cows the risk of uterine rupture is quite high with oxytocin use.

 

The cuteness factor is a little overwhelming!

The cuteness factor is a little overwhelming!

 

 

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