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When I tell people that I’m interested in evolutionary medicine, I sometimes get the response “Evolutionary medicine? Or the evolution of medicine?”.

 

I’ll admit, I’m actually interested in both, but my interest in Evolutionary Medicine is much stronger than my interest in the history and progression of medicine, though this subject can be rather fascinating.  I’ve listened to a course on the history of medicine, attended some extra lectures, and occasionally pick up a book to indulge this interest, but as a third (soon to be fourth, in 2 weeks!) year medical student, I generally have a hard enough time trying to make sense of our modern medical practices without spending too much time thinking about medical history.

 

Sometimes, however, the evolution of medicine plays out right in front of your eyes.

 

Today I took the end-of-clerkship exam for my obstetrics and gynecology rotation.  I actually enjoyed this clerkship a lot more than I had initially anticipated (a good thing, as I am increasingly thinking that I will pursue a residency in Family Medicine, which includes obstetrics).  I found myself a lot more enthusiastic to go to the OR to scrub in than I was during my surgical clerkship many months ago (it’s amazing what a year of clinical medical education will do to you).

 

This clerkship was split into a number of portions: labor and delivery (L&D), night float, women’s health clinic, maternal-fetal medicine (MFM), reproductive endocrinology and infertility (REI), gynecology, and gynecologic oncology… Quite the smorgasbord! On night float and L&D I would frequently end up in the OR to scrub in on a cesarean delivery, on gyn and gyn onc I was in the OR daily for a range of procedures from small biopsies to extensive tumor staging cases.

 

Major advancements in surgery include the discovery and utilization of anesthesia (Imagine being awake and able to feel everything in surgery! Better not, actually…), and the acceptance of germ theory (for which we should thank John Lister (1827-1912), namesake of Listerine!). Many other discoveries, techniques, and inventions have changed the practice of surgery, but these two are biggies.  The third, looming, problem that needs to be addressed is the perturbation of cytokines during and after surgery, but that is a story for another day!

 

An interesting progression of surgery is the way in which surgeons gain access to the abdomen and pelvis. Traditionally, as one might imagine, the easiest way to visualize and manipulate the internal organs was to do an open procedure, literally cutting a person open to directly access the area to be operated. In the 1980s, gynecologists started to train in a new technique- laparoscopic or “minimally invasive” surgery- in which a small camera is inserted into the abdomen (which has been inflated with an inert gas to create space*) so that surgeons can visualize the internal structures without opening the belly. Instruments can be introduced into the abdomen through small incisions, and organs and instruments can be manipulated inside the body** and visualized on a screen.

 

Initially this technique was used for only very small procedures (such as a tubal ligation, “having your tubes tied”), but as surgeons became more proficient, the complexity of the cases that could be performed in this manner increased.  The utility of this technique was recognized, and in the 1990s, general surgeons started to train in laparoscopic techniques.  Now, many surgeries, both gynecologic and general, are performed laparoscopically (somewhere along the way, urologists started using this technique as well).

 

To be a good laparoscopic surgeon takes a lot of time and training. Cut yourself a 31 or 42 cm stick and imagine trying to do small and precise tasks with the end, which you can only visualize on a screen. Now imagine you have to dissect out delicate pieces of anatomy, correctly identify them, preserve or remove tissue accordingly. As a student on the gynecology service, there was really no reason to scrub into “lap” cases (though they were generally good cases to observe, since the screens make the procedure easy to follow), but on surgery I would sometimes scrub in and occasionally be allowed to steer the camera or “bag” a specimen for removal (really, the resident would drop the sample into the endocatch bag, but they would generally act like it was a great triumph for the student!). It all looks fairly easy until you actually have your hands on the instruments and have to find your way around the belly (or if you’re the med student with the camera, make sure the surgeon is seeing what she wants to see!).

 

Once you are proficient with laparoscopic techniques, there is a lot you can do. One of the fellows on the Trauma service was a specialist with laparoscopic techniques, and he could “run the bowel” (visualize it from end to end) more rapidly laparoscopically than many surgeons could do open.  Getting proficient, however, takes a lot of time, especially if one is to master skills such as laparoscopic suturing.

 

Many gynecological and general procedures are now done using laparoscopic techniques. If you have your gallbladder or appendix removed, it’s likely you will have a “lap-chole” or a “lap-appy”, and the offending part will be removed with only a few small incisions visible.

 

In the last 10 years (I think), there was been “the next step” in laparoscopic surgery… the invention and utilization of a laparoscopic robot.  I should be clear that surgery is still under the control of a surgeon, and no one has “robot surgery”, but the “latest and greatest” (though is it really?) advancement in surgery is “robot assisted laparoscopic surgery”.

 

In robot cases, the abdomen is accessed similar to a traditional laparoscopic case, except the various instruments are subsequently attached to a robot, instead of being wielded by surgeons (though an assistant was needed at the patients side in the cases I saw to swap out instruments and to suction).  Using “the robot” allows surgeons a lot more precision and accuracy, and according to one of the surgeons I observed, you become proficient much more quickly on the robot than you do with traditional laparoscopic techniques.

 

Is it progress? 

 

On my week of gynecology, I witnessed the same surgery (supracervical hysterectomy) done open, laparoscopically, and with a robot-assist.  Some cases, due to the underlying pathology or anatomy, must be done open.   If the uterus is too adherent to other structures or if there might be malignancy that could spread if not removed in one piece, open surgery is probably the best option.  All things being equal, recovery from an open procedure is much longer than for the other options.

 

When it comes to laparoscopic surgery, robotic surgeries can potentially accomplish much finer tasks than general laparoscopy with significantly less blood loss (the robotic hysterectomy that I observed had an estimated blood loss of 20cc- they probably take more at your annual physical).  The laparoscopic case I saw also had minimal blood loss and was accomplished very quickly- the surgeon has decades of practice under his belt.

 

So- is this the evolution of medicine? Will robots fill every OR, and will the best surgeons be those who spent many hours as a child (or as an adult, as often is the case) playing video games? (I had to have a quick google, which resulted in this.).

 

Who am I to say? I’m just a MS3.97 (yes I calculated), with no great knowledge of surgery.  All I can say is that the progression of medicine is amazing.  We (generalists, specialists, surgeons, and other health care practitioners) have amazing technology at our fingertips. We have access to impressive diagnostics, powerful drugs, and amazing technology that allow us to diagnose, treat, and definitively fix disease.  But we must be judicious. Diagnostics and treatments (pharmacologic and surgical) have consequences- some big and some small.

 

Sometimes the question shouldn’t be “what type of surgery”, or “which drug”, but rather “is surgery necessary?” or “how will treatment help” (I don’t think the cases I described above were unnecessary, but Obstetricians/gynecologists, because of the horrible state of medical-legal affairs, often seem to err on the side of doing too much and/or acting very quickly).  We can do amazing things with medicine. Contrary to how this may sound, I’m not acquiring medical knowledge with no intent of using it. Rather, I think that those with medical knowledge have a responsibility to help patients decide what is the best option for them– physically and personally. At least that’s the kind of doctor I want to be…

 

But hey- we have some pretty cool tools out there to help us when we need them!

 

courtesy of wikicommons

A surgical robot- Courtesy of wikicommons

 

*It’s amazing how laparoscopy can pervert your perception of anatomy. When the abdomen is pumped full of gas it looks like organs are flopping around with lots of space, when in reality everything is rather tightly packed during day-to-day living.

** I write abdomen or “belly”, but I generally mean abdomen and/or pelvis.

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This one isn’t exactly “evolutionary medicine”, but it sure is a smart, cheap, and (in my experience) unheard of little tip for shortening hospital stay (and thus cutting the bill) for some surgery cases.

Surgery comes with innate risks. Bleeding and infection can occur with any surgery, but operations that affect the bowel come with additional risks and concerns. One frequent complication of abdominal operations is postoperative ileus- a temporary paralysis of the intestinal tract after surgery that is usually related to the degree of surgical trauma and bowel manipulation.

When you are part of the surgical team, an important part of post-surgical care is keeping track of the workings (or lack thereof) of the patients’ digestive system. A typical morning check-up on a patient might go something like this:

“Hello! How are you feeling this morning?” (This exchange usually takes place around 5:30 in the morning… Anyone who says “good” is obviously bluffing!

“Sleep well?” (I think I may be the only student that cares about this question.)

“Any pain?”

“And have you had a bowel movement? No? Ah- have you passed any gas? Above or below?”

Yes, when you enter the world of medicine, the taboos of normal conversation (indeed, many social graces) are quickly forgotten.  Gone are the tendencies to giggle when someone says “fart”. Instead, the return of a patient’s bowel function can become a celebrated event amongst the team.

Post operative ileus is likely caused by a number of factors, including increased sympathetic activity (the fight-or-flight side of our autonomic nervous system) which overpowers the parasympathic (the rest-and-digest) system, as well as inflammatory mediators.  Additionally, some of the drugs that are used before, during, and after surgery may also inhibit bowel motility [1].

Ileus can delay patient recovery and increase the length of patient hospitalization, which leads to greater healthcare care costs. So how can we decrease ileus?

There is some evidence to suggest that therapies such as early postoperative mobilization (getting up and walking) and early feeding may decrease post-operative ileus [1].  I’m particularly interested in early post-operative feeding, which seems to come with a host of benefits in comparison to “NPO” (nil by mouth) that is common after surgery.  In fact, in a meta-analysis of 11 studies including 837 patients, early post-operative feeding significantly reduced the risk of any type of infection and reduced the mean length of stay in the hospital.  It also reduced (though not statistically significantly) the risk of anastomotic dehiscence (the breakdown of the site where bowel was sewn together), wound infection, pneumonia, intra-abdominal abscesses, and mortality. The down-side of early post-operative feeding is that the patients have an increased risk of vomiting [2].

But is there a way to get the benefits of early feeding without the risk of vomiting? Is there a cheap and easy way to increase the rate at which bowel function returns?  It appears the answer is yes, and it is incredibly cheap and easy: Gum.

Gum chewing works as a type of sham-feeding that promotes intestinal motility. It seems that chewing gum causes our brain to pass the signal to our stomach that food is on the way. In normal volunteers, gum chewing stimulates gastric secretions. In patients, gum chewing appears to wake the GI tract up more quickly than if their mouth stays idle [1].

A meta-analysis of 9 trials including 437 patients showed a reduction in time to first flatus (the medical term for fart), time to first bowel movement, and reduction in hospital stay in patients in treatment groups versus controls. The treatment groups chewed sugarless gum at least three times a day for 5-45 minutes starting on the first post-operative day [1]. While early post-operative feeding seems to offer a number of benefits in comparison to fasting, it can be poorly tolerated and only taken in small amounts. Chewing gum is a method of sham-feeding that stimulates bowel activity, without the possibility of vomiting or the limited intake of food seen in some patients.

I have heard surgeons at our University talk about the data regarding early-feeding. I have not heard anyone talk about the benefits of gum chewing.  The data is out there, but unlike pharmaceutical interventions which have drug-reps proclaiming their benefits, simple interventions such as these are not widely promoted.  Who would benefit from promoting this information?  Even if every hospital ward in the country started stocking gum, I doubt the gum-makers would notice an uptick in their bottom line- this isn’t exactly a high dollar intervention. In fact, the meta analysis suggests that chewing gum can reduce the length of hospital stay by a mean of approximately 2 days at the average cost of $0.60 per patient [1].

It is important to mention that many of the studies included in the meta-analysis were conducted in Africa, where the risk of complication and the subsequent length of stay are much higher than in the US.  While on my surgery rotation, I saw some patients go home less than 24 hours after having their appendix removed. One paper from 2006 shows that the mean hospital stay after appendectomy at a teaching hospital in South Africa was 10.6 days [3]. Indeed, much of the primary data that I read about surgery in the developing world leaves me cold.

Laparoscopic surgery (performed through small incisions in the abdomen and visualized with a small camera), means that simple procedures such as the removal of an appendix or gallbladder can be done with minimal trauma and scarring. In developing countries, these operations are still done with open incisions, in operating rooms that lack many of the most basic tools necessary for good surgical care.

Angela’s recent guest post has inspired me to think more about the great disparities in health, disease, and medical care in the developed and the developing world.  As I read more about surgery and medical care in Africa, I realize that even the simplest of interventions can have a huge impact on health care, especially in developing areas. This was also brought through in Atul Gawande’s book The Checklist Manifesto, which I read recently.

It is unrealistic to think that hospitals in developing nations will be equipped with cutting edge technology to perform minimally invasive surgery any time in the near future. Such technology is expensive, and it requires surgeons who have been trained to use it (not to mention reliable sources of electricity to power the equipment).  Yet simple solutions, such as post-operative gum chewing, can offer serious benefits that should not be ignored [4].  And if I find myself on the other side of an early morning post-op check-in, I know I’ll be requesting something to chew on*!

*It should go without saying that this post is not meant as specific medical advice, but as an exploration of a potentially useful therapy that doctors should consider. If you find yourself on the wrong side of the operating table, work with your medical team to get yourself on the road to recovery ASAP.

 

1.            Noble, E.J., R. Harris, K.B. Hosie, S. Thomas, and S.J. Lewis, Gum chewing reduces postoperative ileus? A systematic review and meta-analysis. Int J Surg, 2009. 7(2): p. 100-5.

2.            Lewis, S.J., M. Egger, P.A. Sylvester, and S. Thomas, Early enteral feeding versus “nil by mouth” after gastrointestinal surgery: systematic review and meta-analysis of controlled trials. BMJ, 2001. 323(7316): p. 773-6.

3.            Ayoade, B.A., O.A. Olawoye, B.A. Salami, and A.A. Banjo, Acute appendicitis in Olabisi Onabanjo University Teaching Hospital Sagamu, a three year review. Niger J Clin Pract, 2006. 9(1): p. 52-6.

4.            Ngowe, M.N., V.C. Eyenga, B.H. Kengne, J. Bahebeck, and A.M. Sosso, Chewing gum reduces postoperative ileus after open appendectomy. Acta Chir Belg, 2010. 110(2): p. 195-9.

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Waste not, want not

As my part of the country battens down the hatches as Sandy approaches (all the businesses in my town have boarded or taped their windows and sandbags line the sidewalk), it seems appropriate to write about nature.

The changing of the seasons is always a beautiful sight here in the northeast US.  Early in the year, greens and yellows of spring welcome a new year of growth and productivity.  The banner at the top of this blog is a picture taken in my parents’ garden of aconites, a flower that blooms in February when the rest of the world is still brown and gray.  Now, in the throes of fall, the changing of the seasons is obvious in the reds, yellows, oranges, and browns of the changing leaves.  When you see the cycle of the seasons, with trees budding and leafing out in the spring only to see the leaves turn color and drop 6-months later, it can seem a little wasteful.  So much growth, only for the trees to be bare once more.

But what is waste, in nature?

One of the arguments frequently used against the eating of meat is the toll that animal waste takes on the environment. The run-off of nitrogen-laden (not to mention antibiotic-riddled) water from large-scale feedlots can wreak havoc on waterways and land (though it bears mentioning that run-off of nitrogenous fertilizer from crop land can be equally detrimental).  In a non-industrial setting, however, is “waste” really such a problem?

On the contrary- in a more natural world “waste” is not a toxic hazard, but rather an important part of life.  I snapped this picture at a farm near where I grew up. For as long as I can remember, this land has been “hayed” (in our area, farmers usually make 2, sometimes 3, cuttings of hay per year). In the last couple of years this land has changed hands, and now belongs to a vet with a great interest in grass-fed meats (as well as quality horses). The fields that have been farmed for vegetative crops will now be home to livestock… Just look at what their waste has done!

Animal impact: “waste” = growth

Look inside the fencing. See those dark green areas where the grass is particularly lush (and extra long)? THIS is what nature does with waste: nature turns waste into growth.

This land was productive as crop-land (you can see in front of the fenced land that part of this property is still in hay), but I suspect that with the return of animals to this land the grass will actually grow more, not less.  Hayed land can be (and should be) replenished with potash (for potassium), lime (to maintain an appropriate pH), and nitrogen (in some bioavailable form to help plants grow) to compensate for the nutrients being continually removed by the cutting and bailing of hay. While many farmers slack on replacing the more expensive lime and potash, most put down nitrogen to help the grass “pop” so they get a good yield (biomass). Putting animals on the land reduces (or eliminates- once the soil is replete) the need for added fertilizers, as the grass is not being shipped off the property as hay, but is rather being cycled right there on the property into biomass (beef) and fertilizer.

What our modern, industrial world sees as waste is really part of a natural (not to mention efficient) cycle…

This isn’t just true with animals.  I recently took a lightening visit to go hiking in the mountains of North Carolina. With a surprise 3-day weekend on my hands (my out-patient medicine preceptor was sitting for the boards), I couldn’t say no to a last minute invite.  With views like this- I’m very glad I said yes!

It was almost the perfect time to visit, with leaves seemingly changing colors in front of our eyes. The palette of fall colors was stunning, and led to an enjoyable arts and crafts session of the patio of my friend’s cabin while enjoying a post-hike cider.

Nature- embrace the rainbow

In the woods, these leaves lay where they fell (save the ones I carried back or the few the chipmunks and squirrels use to cushion their nests).  Again, it can seem like a dreadful waste, until you realize that this process, which occurs every year, feeds the insects, grubs, fungi, and molds that turns these leaves into rich topsoil to encourage new growth.

One childhood family activity that I remember was raking leaves. I somewhat fear that the advent of leaf blowers has replaced good old-fashioned rakes (and more importantly, good old-fashioned leaf piles that were great for jumping in!), but whatever the mechanism of collection, leaves are generally not abided in our modern world. While I take no issue with clearing leaves, it pains me to see leaves bagged up and put out to be collected as “trash”. There is definitely an increase in people composting “yard waste”, but the name, again, shows how people see the world and nature- a progression, not a cycle.

A bit of google-mining suggests that the saying “Waste not, want not” can be attributed to Benjamin Franklin (1706-1790), but it is nature that best embodies this philosophy.

(Stay safe out there- all my fellow northeasters in the path of Sandy!)

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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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