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(I wrote this a few weeks back as I was just starting the first portion of my internal medicine clerkship. I was obviously rather energized at the time, though my thoughts now remain generally the same. More science-y posts to come, I promise, but for now it’s hard to find time to put together such posts!)

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Our current medical system does not fit our current medical condition.

Our health-care system was built on the premise of people being relatively healthy until they became significantly sick.  By those standards, our medical system has been hugely successful. Antibiotics routinely save people who would die without medical intervention. Trauma surgeons routinely put people back together who would have died 100, or even 10 years ago (and put them back together better and faster with improving technology).  Today, conditions that used to be major killers- meningitis, endocarditis, pneumonia- are usually (though not always) successfully treated.  The pediatrics floor of my University’s hospital is frequently almost empty- most serious diseases of childhood are now prevented.

Yet people see our medical system as a failure.

And it is.

Our medical system fails to prevent the preventable.  Rates of diabetes, cardiovascular disease, and “diseases of civilization” are increasing exponentially.  The expense of our medical system is unaffordable. As much as we are able to treat the sick, we often fail the ill.

Different doctors have different views towards medicine. Some are rather paternalistic; some are loud proponents of patient autonomy. For the most part, however, all hospital-based doctors know they can’t keep their patients in the hospital until they are healthy. They treat them, and when they are ready to go home (or to a rehab center or nursing home), they are discharged. The problem is- you can treat an infection or a crisis, but you can’t treat a lifestyle.

When a patient comes in with Acute Coronary Syndrome (ACS- a term that refers to a spectrum of cardiac conditions from unstable angina to a severe myocardial infarction) and four risk factors (let’s say diabetes, hypertension, dyslipidemia and a history of smoking), what is the job of the hospital team?  They CANNOT fix all the underlying factors. Their job is to stabilize the patient, make a diagnosis, and treat their current condition.

Who is “to blame” for this situation?  Is it the patient that lived a lifestyle full of cardiovascular risk factors? Is it the fault of the patient’s family that never taught the patient, as a child, how to cook and care for themselves? Is it the fault of the community for not providing safe playgrounds for the patient when they grew up, leading to a sedentary lifestyle? Is it the fault of the education system, which might have fed this patient disastrous food while preaching the benefits of the food pyramid (if they taught anything nutrition-related at all)?  Is it a lack of physician availability, which leads to ‘dead zones’ where no primary-care physicians can be found, even if you have insurance or can pay for care?  Is it the failure of the patient who took at face value all the ill-guided “health-care” advice they were given (or perhaps, is it their fault for blatantly pursuing a lifestyle that no one would suggest is healthy)?

Our system was built around the premise of people being healthy until they got sick. We currently live in a world where most people are chronically ill.

It’s a fun thought-experiment to imagine what we could do with modern medical tools and technology with the patient base of 100 (or 10000?) years ago.  What would the hospitals look like in a world where patients ate real food, moved, lived, and interacted like humans, but with all the marvels of the modern world?  It’s a pretty dream to dream- especially if you are a physician (or future physician).  Helping people return to health is rewarding. Patching people up to die another day is exhausting, and frequently demoralizing.

Some say the system is broken.  I wouldn’t necessarily disagree, though I’d be apt to argue that we have some pretty amazing skills and tools, but we’re working in a broken world.  No one person can fix this. No one profession can fix this.  What are you doing to make things better?

Imagine there’s no diseases of civilization
It’s easy if you try
No collapsed arches below us
Above us only Vitamin-D producing sky
Imagine all the people living for today

Imagine there’s no diabetes
It isn’t hard to do
Nothing to chronically treat or amputate for
And no exogenous insulin too
Imagine all the people living life in peace

You, you may say
I’m a dreamer, but I’m not the only one
I hope some day you’ll join us
And the world will be as one

 

(Humblest apologies to all John Lennon fans… I couldn’t help myself)

There will always be disease. There will always be trauma. The question is: how do we handle these things, minimizing illness and maximizing the enjoyment of life?

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An addendum…

A friend and classmate made a good point over on my facebook page. I’ll paraphrase.

Our hospital’s pediatrics ward is empty because we’re not a peds specialty hospital and all the intense cases get shipped to a hospital with more pediatric specialists or to a children’s hospital.

It’s a good point, but if anything I think it strengthens my argument. We no longer have the bread-and-butter pediatric diseases of yore. Our pediatricians aren’t managing polio, treating a bunch of meningitis, or rehydrating children with rotavirus. On the other hand- the children’s specialty hospitals are now treating things that were previously unseen because children died. Children with rare and complex disorders now survive and are treated at specialty hospitals, while the run-of-the-mill pediatric illnesses fall into distant memory (though Pertussis is making a nasty comeback).

When it comes to pediatrics, we’re making great headway in keeping children healthy (though the rates at which our children are getting “adult” diseases such as Type II Diabetes are terrifying). What we do see, at least at our hospital, is a failure of good pre-natal care, leading to complex and problematic pediatric conditions… Again- it’s the lifestyle stuff that we struggle with!

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Odd Bits

Earlier this week I received a newsletter from PaleolithicDiet.com that included the challenge to write a blog post about what you would cook if you were selected to receive a copy of Jennifer McLagan’s book Odd Bits: How to Cook the Rest of the Animal. In all fairness, I don’t need a copy of McLagan’s book (I already own one), but I like having a topic that I’m enthusiastic about and that doesn’t require I pull any scholarly papers and reference my sources! I like to write, but I haven’t had time to really research some of the more academic topics I’m interested in recently. I accept Patrik’s challenge, and if he wants to send me another copy, I’ll make sure to share it with someone that will love, appreciate, and use it!

Perhaps more important that what I would (or do) cook from Odd Bits, is why I cook offal. To me there are three main reasons (in no specific order).

1: It’s the right thing to do, in respect for the animal you are eating.

As I mentioned in my post on the ethics of eating meat, I have raised (and slaughtered) my own chickens for a number of years.  When I learned to “process” chickens, I was taught to save the heart and liver, both organs that I knew I should eat, but ones I’d never eaten before. My parents are British, and while it may have deeply pained them, I’d never been one for steak and kidney pie, nor had I been one to eat other ‘odd’ bits of animal. I, like so many, fell victim to the ‘eww’ factor of eating odd bits and stuck to the traditional muscle meats. This changed when I started killing my own chickens. First- I knew how much time and effort went into raising and butchering these animals, and throwing away edible bits just seemed wrong. Second- and more importantly, I was taking an animals life, and while I had done my best to make their life (and death) as pleasant as possible, it only seemed right that when I killed them, I used all the bits I could. Third- at that point I was well on the slippery slope to “evolutionary wellness”, and had been reading up on the nutritional benefits of eating organs.

I’ll admit that the first time I cooked chicken livers and hearts I needed a bit of Dutch courage. After imbibing a couple glasses of a delicious Marlborough region Sauvignon Blanc (my weakness when it comes to white wine), I briefly sautéed fresh livers (cut into bite sized pieces) and hearts (halved) in a generous portion of butter and then topped them with salt and fresh pepper. With my Dutch (or perhaps I should say Kiwi?) courage, I took my first bites and was hooked. While I rarely eat chicken these days, if I spot hearts and livers from pastured chickens for sale at the farmers market I usually nab a couple pounds. Not only are they delicious, but it seems only right that if we kill an animal, we should make the most of that sacrifice.

The same concept applies to the cattle that my family raises. I think the old guy that runs the slaughter house we go to gets a kick out of me and my enthusiasm for odd bits (or at least he’s good natured about humoring me- I can imagine him telling his friends about some ‘young woman with a hankering for weird cow parts’), and it seems like each year my list of ‘bits to save’ gets longer. Along with the cut sheets for our animals I include a cover sheet that includes all the extra bits I want to make sure he saves for us. Usually this butcher will return the heart, liver, tail, and tongue, but I’ve added sweet breads, kidneys, marrow bones, and fat to the list. This generally adds a couple extra boxes to my pickup run, and he had a funny smile last time he handed over a 40+ lb box of suet, but he complies (and I think I might need to start making soap- I probably already have a lifetime supply of tallow!). Much like with the chickens, I feel it is important to get the most out of the animals that my family has cared for that have died to feed us.

2: Offal is darn nutritious!

Not only do I think it is morally appropriate to eat ‘nose to tail’, it’s also an excellent nutritional choice. Organ meats are rich in compounds that are lacking (or low) in other parts of the animal. Liver, for example, is very rich in vitamin A (although you should never eat Polar Bear liver- it is so rich in Vitamin A it is toxic!), many of the B vitamins, and iron (to only list a few). Heart, kidney, marrow, and sweet breads all offer different nutritional profiles. I’m generally not joking (nor am I alone) when I refer to liver as “Nature’s multivitamin”.

3- Odd bits are tasty!

Once you get over the ‘weird’ factor of eating different bits of animals, you’ll start to realize they’re really not so odd and that they can be VERY tasty. Tongue tacos, grilled heart, sautéed liver (+/- bacon), steak and kidney… these are all very cookable dishes that can be very delicious. Just like anything else in the kitchen, you can mess them up, but cooked right, these dishes are a delicacy! There’s a reason that some of the fanciest restaurants serve offal, and it’s not just the ‘wow’ factor of serving something unique- offal is delicious!

In conclusion…

It’s only in our modern society that ‘nose to tail’ eating is not the norm. I’d wager that for most of our evolutionary past, humans have taken advantage of all the edible bits an animal had to offer. While many still find ‘odd bits’ off-putting, the interest in them is growing. That’s not only obvious by the publication of books such as Odd Bits, but also by observing changes in the people around me.  When my family sold our first beef cattle, few (if any) customers wanted ‘odd bits’.  As I find customers that are interested in evolutionary eating, my stash of unclaimed offal diminishes (I think I miss the extra tongues the most!). I’m happy, however, if others start to embrace offal, in it’s many forms. Eating offal is delicious, nutritious, and shows respect to the animal you’re eating.  If you’re intimidated by the idea of cooking offal at home, order out (Korean BBQ is a great way to have tongue (and if you’re brave, intestines-yum!)) or you can go the route I travelled and obtain a bit of liquid courage*!

*attempt at your own risk!

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I’m currently on my surgery rotation, which has left me with little time not spent in the hospital, driving to the hospital, or sleeping (in the wee hours of the morning I will be found making coffee and when I get home in the evening I make a good dinner… that about fills you in on my life for the past few weeks and the ensuing month.). Surgery is an exhausting clerkship, and for the most part students are kept pretty busy during the day running around the floors checking up on our patients, tracking down information, seeing consults, or “scrubbing in” in the OR. Sometimes, when I have a chance to slow down (or when scrubbed in on a case where there isn’t a lot to see) I’ll find myself mulling over the system in which I’m working. I’m sure I’ll write about my thoughts and experiences on surgery at some point, but recently I’ve been thinking about medicine in general. I don’t think it’s much of a secret that my real interest is health, which for some reason often seems to be conflated with medicine, though it is increasingly obvious that the later does not always beget the former.

I am, by no means, anti-medicine or anti-medical technology. I am, undyingly, a nerd, and when I see what “we” can do, and how we do it, I am often amazed and in awe. Surgery is full of “I can’t believe we can do this!” moments, and the technology that has been developed, and the knowledge that has been discovered, is truly staggering. Yet sometimes this amazement leaves me feeling hollow. There are procedures, devices, and medicines that cure, reverse, prevent, and heal, but often it seems like we’re doing a lot of work to fix problems that should never happen in the first place. We can do so much, but maybe we shouldn’t have to.

The Fifth Element has been one of my favorite movies for years. I probably haven’t watched it in almost a decade, but I still think of it fondly.  My recent musings on our capabilities (with a certain unease about how frequently and pervasively we feel the need to patch a problem instead of fix or prevent it) has left me thinking of this scene… it is a favorite.

The reality is, the study of disease and the development of techniques and technologies to treat preventable diseases frequently leads to the advancement of science and knowledge. In a way, science and technology ‘wins’ at the expense of the people who suffer from preventable diseases. I’m not a conspiracy theorist- I don’t think this is all a big cynical plot and I don’t think pharmaceutical companies are trying to prolong a problem- they’re simply filling the niche (oh natural selection, you are everywhere) that has been created by the lifestyle that we live.

This thought is a recurring theme as I become more immersed in hospital life, and it is not one I can easily disconnect. When you see a patient in her mid-forties with a list of medication longer than my college transcript (trust me, that’s saying something!), coming in for her fourth surgery (you can take out troublesome body parts like the appendix, gallbladder, and sigmoid (or more) colon, but, inevitably, surgery begets more surgery, and you’ll see someone coming back for a hernia repair at an old incision site or a lysis of adhesions from a prior surgery), you have to wonder- can’t we do better? I don’t necessarily mean “we” the medical community, but more “we the people”. Health is in our hands, and while we have been greatly mislead by (generally) well-meaning government and institutional suggestions, ultimately the pursuit of health is in our hands.

There is a lot of misinformation to overcome and a lot of intricacies that people like to fight about, but for a lot of people health IS simple.  Live like a human.  Eat like one, move like one, sleep like one, and interact like one.  Eat real food, get out and move, spend time with people that fulfill you, feel the sun on your face and get a good night’s sleep… it might just keep you out of hospital (though there’s little hope of that for a 3rd year medical student!).

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Some may be aware of a NYT contest that asked people to submit a brief essay on why it is ethical to eat meat.  Because I have an opinion on the topic (and because I occasionally enjoy exercises in futility) I applied myself to the task and wrote a response. Those of you that read my blog might appreciate that constraining myself to 600 words was difficult, but I managed! I was alerted by a post of Melissa’s over at Hunt Gather Love that the finalists had been announced, which meant it was time for me to publish my entry here!  I hope you enjoy…

Composing a convincing argument on why it is ethical to eat meat in less than 600 words is challenging, and by no means can such an argument be comprehensive. But few aspects of moral philosophy can be described with such brevity, and contemplating an issue as provocative as meat-eating under such auspices would take even longer. That’s not to say, however, that a brief and compelling case for the ethical eating of animals cannot be made, and I shall attempt to do so here, positing the (arguably utilitarian or hedonic) case that the appropriate consumption of well-raised and well-managed livestock maximizes benefits for humans, the environment, and animals. Considering the evolutionary context of the different components further strengthens the case.

Despite the occasional media hysteria over epidemiological studies, the argument that humans evolved to eat and thrive on meat is irrefutable. Anthropological evidence suggests that when our ancestors started to eat meat, our brains grew and our intestines shrank, starting the long road to making us human. As a result of millions of years of evolution, humans are “designed” to thrive on meat, and that is what modern research continues to show. While epidemiological dietary studies are notoriously difficult to interpret, the fact that meat is rich in compounds that the human body needs to survive and thrive is irrefutable. While humans can survive on a vegetarian diet (and, with supplementation of B12, a vegan one), we thrive on a diet that includes meat. The consumption of meat, in order for humans to prosper, is an ethical pursuit.

While eating meat has arguable benefits for human prosperity, there are also numerable ethical implications for the environment. Correct management of livestock can benefit the environment dramatically. Much as humans evolved to thrive on meat, our environment thrives when appropriately utilized by animals. Animals raised outside, on the products of the land on which they walk, give back to the environment by fertilizing the land with their manure and shaping the land with their habits. The (usually small-scale) farms that appropriately raise livestock are able to nurture (and often heal) the land that they manage. Furthermore, the purchase of local farm products greatly increases the economic health of the local community. These implications bolster an ethical argument based on maximizing benefits.

Perhaps the hardest aspect of an ethical argument for the consumption of meat is the argument in favor of the animals. Unlikely though this may seem, I believe this is the strongest component of this argument. My family raises beef cattle. I have raised broiler chickens, and I continue to have a laying flock. These animals have good lives. Seeing a chicken enjoy a dust bath, watching a steer peacefully graze- it is hard to deny the inherent ‘goodness’ of seeing an animal thrive in their environment. The reality, of course, is that these animals would not exist if we did not eat them. Killing animals is not pleasant, but when done correctly can be less stressful and painful than common procedures we perform on pets and ourselves. Furthermore, the net benefit of allowing animals to enjoy life in their natural environment is, from my perspective, an ethical ‘win’.

In our modern world we have the luxury to argue about the ethics of eating meat. In the past, and in many communities today, such arguments would be frivolous. Nonetheless, when the evidence is considered under the auspices of the ‘the greatest good’, one can ethically argue that the consumption of meat leads to benefits for humans, the environment, and the animals that are consumed.

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The relevant factors…

I’m going to guess that many of those reading this are friends and family who feel obligated to feign a bit of interest in my attempt at blogging.  On the off chance that you don’t know me (or would like to know a bit more about me and what I hope to accomplish here), here are some of the relevant factors…

I’m an MD/PhD student who just started the clinical portion of my degree.  That means I’ve completed my undergraduate (a B.S. in biochemistry), the first two “pre-clinical” years of med school, my PhD (in pharmacology and physiology, specifically exploring the effects of chronic alcohol consumption on signal transduction in the liver (No, I didn’t study myself.  Yes, at times I probably could have.)), and am now on the floors learning how to put all this into action in the clinical setting.

An MD/PhD degree is an interesting combination of medicine and science, and many medical types will admit that “mud phuds”, as we are sometimes known, are a bit of an odd bunch.  Perhaps more interested in the basic sciences than most medical students and doctors, perhaps a bit more people-oriented than your typical lab type, we’re a mix of the academic and the clinical world.  We are also, unfailingly, rather nerdy.

The phrase ‘bench-top to bed-side’ is often used to describe the role of an MD/PhD.  ‘Physician scientist’ is another popular phrase.  In my writing I hope to take a slightly broader perspective on this role- hence the ‘Principle into Practice’ moniker.  While I like to look at basic research, and plan to explore and share interesting primary literature (scientific journal articles), I hope to be able to always hark back to basic principles that are applicable in day-to-day life.  Furthermore, as a budding physician, I hope to explore how these principles are applicable to medical practice.

I’m only at the start of my medical clerkships- the process by which I will expand my clinical knowledge and also get a flavor of multiple medical disciplines so that I can chose what avenue of medicine I wish to pursue.  MD/PhDs frequently (though not exclusively) opt to venture into some of the more academic and competitive specialties.  While I may well change my interests in the next year and a half, at this point I am most interested in primary care, most specifically in preventative medicine.

I want to make it clear here and now that I am in awe of what we are able to accomplish with modern medicine.  Some degree of illness and injury are unavoidable, and when these things strike, I am very glad we have the medical arsenal (of knowledge, techniques, and pharmaceuticals) to treat and manage these conditions.  That being said- many of the conditions physicians currently treat are wholly preventable- that is where my interests lie.  Furthermore, understanding the mechanisms by which chronic disease occurs, and exploring the evolutionary basis of these mechanisms, is a bit of nerdish fun.

So I suppose I should close with that warning.  In my writing I plan to explore and promote basic principles that are practical for everyday life and for the practice of medicine.  I tend to enjoy distilling things down to basics when possible, but I also can’t help but geek out a bit on the history, biochemistry, and general fun-factor of life… I hope you’ll join me for the ride!

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…is another paleo blogger.

Actually- I don’t think that’s the case, but here I am.  What the world might need, however, is a few more ‘paleo’-minded doctors, and I am one of those in the making.

Many of my friends (and people that might actually read this) are familiar with the term ‘paleo’, though as it means different things to different people it’s only fair that I explain my interpretation of the word.  To be clear, I don’t use the term ‘paleo’ as a clear-cut definition of a specific diet, lifestyle, or perspective, but I think it is a useful term for describing a general set of principles that are loosely based on the evolutionary history of humans.

Like all species, humans evolved to thrive.  Like it or not, you are the result of millions of years of evolution.  While some species live in very precise niches in very particular circumstances (think, for example, of the thermophilic bacteria of the deep sea hyperthermal vents, or the limited diet of the eucalypt eating koala), the human species has evolved to thrive in a variety of environments and on diverse diets.  What has become clear, however, especially to those that pay attention to epidemiological trends or to those that marvel at the expanding waist lines, increased health costs, and mountains of prescription and over-the-counter drugs so many have come to rely on, is that humans are not ‘thriving’ as one might hope and expect in our modern world.

On a whole, the world in which humans evolved has not changed dramatically in the last couple of hundred years, but the environments in which many humans live-namely the civilizations which we have developed for ourselves- are incredibly different (there are certainly people living in traditional cultures, but they’re unlikely to be reading this on the internet.  If you’re reading this, this applies to you).  For hundreds of thousands of years, humans were hunters and gatherers.  Ten thousand years ago humans adopted agriculture.  The industrial revolution occurred a few hundred years ago, and the scale and rate of change of civilization has accelerated from there.

Darwin came to the theory of evolution after reading Principles of Geology by Charles Lyell while voyaging on The Beagle.  Lyell was a geologist who advocated the idea of uniformitarianism- the concept that the earth was slowly shaped by continuous forces over a long period of time that are still occurring today.  This was in contrast to catasrophism, which dictated the environment was shaped by a number of large, catastrophic events (in consonance with biblical stories).  The theory of abrupt, catastrophic changes to the environment is not conducive to the gradual change of evolution, but when one realized that the world was slowly changed by gradual processes, one might also realize that species might also slowly change to best fit their environment.  This realization is oft implicated as the seed that sprouted the principle of natural selection in Darwin’s mind.  The idea of uniformitarianism does not exclude catasrophism, and indeed aspects of our world were shaped by catastrophic events such as earthquakes and volcanos.  While species gradually evolve to fit their slowly changing environment, acute and catastrophic events introduce a strong selection pressure to survive (and then thrive) in such altered environments.  Catastrophic events can reverse the fortunes of species, creating environments where the former top-species can no longer survive or providing an environment where a previously marginalized group can now thrive.  As the poet Tennyson put it ‘Nature, red in tooth and claw’.

And where does this fit in the concept of ‘paleo’… For 200,000 years, humans evolved to thrive as hunter-gatherers.  This is the niche they evolved to fill.  One might suggest (and indeed I do), that the recent changes in the human environment (and yes, at 10,000 years, I consider agriculture to be a recent change, but I consider the developments of the last century even more pressing) should be considered a ‘catastrophic’ change in an otherwise fairly ‘uniform’ history.  Surely there are some among us that have won the genetic lottery to thrive in this modern world, but most of us did not.  This is evidenced by the growing amount of chronic disease in our communities.  Most of us are not capable of thriving as sedentary, indoor-dwelling, calorically over-nourished and nutritionally malnourished insomniacs.

Humans did not evolve to thrive in a limited niche, eating a specific diet, living and moving in one particular way (if you haven’t watched the BBC series “Human Planet”, I highly recommend it).  We are a species capable of surviving, and indeed thriving, in a multitude of environments and situations.  It seems, however, that the modern world has pushed our capabilities to a breaking point.  Not everything about our modern world is problematic- indeed, humans are better off because of many medical, scientific, technological, and cultural developments   Let us not, however, doom ourselves to lives of chronic disease and malcontent because we are all too eager to step outside the limits of our biology.

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