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Archive for the ‘Med school’ Category

There are a lot of smart people who are interested in ancestral and evolutionary health. Personally, I find it very encouraging to see people from various backgrounds thinking deeply about how looking back into human history can help us improve our present-day wellbeing.  These people come from all walks of life and each person has come to this way of thinking by a unique path, but many have similar stories.  Sharing a story breeds camaraderie, and I think part of the reason the “paleo” movement has developed such a strong online community is because of the solidarity that comes from sharing a similar personal journey (that’s not to say there isn’t division and strife in the community- there is plenty!).  Sharing core principles also promotes professional camaraderie. Alas, few of us in the medical profession share an interest in ancestral and evolutionary thinking.

 

I have been very fortunate in my brief clinical experience to have worked alongside and under (medical academics is definitely a hierarchy) people who have indulged me in conversations about how evolutionary and ancestral theories apply to modern medicine. But while some are happy to talk about select topics in ancestral health, few think about it deeply or use ancestral thinking in their medical practice.  There are physicians who think about ancestral health and evolutionary medicine, and I am always enthusiastic (perhaps a little bit too enthusiastic?) to meet and interact with physicians who share my academic interests.

 

As I said above, sharing a journey breeds camaraderie (that definitely seems to be the “word-of-the-post”), and it frequently seems that the tougher the journey, the greater the camaraderie. Medical training is a gauntlet. After an undergraduate degree, medical degree, internship, and residency (to say nothing of longer residencies, an added fellowship, or additional degree(s)), a physician in the US has spent a minimum of 11 years in “higher education” to become a practicing clinician. As I wrote in my last post, “nocturning“, clinical training is physically and mentally exhausting (and decidedly unhealthy). Other allied-health and research professionals also travel long academic roads, and surely the trials and tribulations of the academic journey of each profession fosters camaraderie within each group.  Similarly, for those of us who have achieved a PhD- we may have done research in different labs, under different mentors, and in very different fields, but there is a mutual understanding of what one endures to finally earn those three letters after one’s name.

 

I have been fortunate that I have built some strong personal relationships in the ancestral health community.  One of the first “ancestrally minded” people I met in real life was Dr. Emily Deans– a psychiatrist with a deep interest in the interaction between nutrition and mental health.  While we are separated by some distance, it is good to have a friend who not only shares my passion for ancestral and evolutionary health but who also understands the arduous journey of becoming a physician. In the past couple years I have also met a number of other physicians; first online, and then last August at the Ancestral Health Symposium (AHS) I had the pleasure of meeting many in person.  Less than a year ago, a few likeminded physicians thought it would be beneficial to form an organization for physicians (MDs, DOs, and international equivalents) interested in ancestral health. This idea blossomed at AHS, and in the last few months a meeting was organized to bring such an organization into fruition.

 

This past weekend I travelled to Salt Lake City for the Physicians and Ancestral Health (PAH) Winter Meeting.  Leaving the northeast as a blizzard approached to head to snowy Salt Lake City seemed a bit like jumping “out of the frying-pan and into the crockpot” meteorologically speaking, but personally and professionally the trip was fantastic (and people in Utah seem to handle the snow in stride, quite unlike home in the northeast!).  This was the first official meeting of PAH, and twelve physicians from around the county (and Canada) got together to discuss what we know, what we’d like to know, how to share our information, and what we need to do to grow. We discussed different types of research, the need for more research investigating and supporting an ancestral approach to medicine, and the importance of producing and publishing results.

 

A word on research…  Physicians are not scientists (save for physician scientists, a truly minuscule blip in the Venn diagram of the ancestral health community) and while anecdotes can be powerful, they are not the kind of evidence that will sway physicians, scientists, and practice.  I recognize that as an MD/PhD student I am well positioned to make some waves in this area- I’ll try not to get too overwhelmed by the thought!  Fortunately, there are already some physician scientists producing data and publishing papers, one of whom I got to meet this weekend.

 

I had a bit of fun making a Venn diagram… nothing is to scale, but you get the idea…

 

venn

 

A slightly more amusing diagram might looks something like this… 

 

I highly recommend checking out PhDcomics.com, and “What should we call med school” as well as “What should be call paleo” if you find yourself represented above. (Sorry, I'm not blog-literate enough to hyperlink from the image!)

I highly recommend checking out PhDcomics.com, and “What should we call med school” as well as “What should be call paleo life” if you find yourself represented anywhere above. (Sorry, I’m not blog-literate enough to hyperlink from the image!)

 

In addition to setting up the framework for our nascent organization and discussing how we might foster ancestral-thinking in modern medicine, this meeting was an opportunity to form new friendships and strengthen old ones.  As the lone medical student at the meeting, I felt very fortunate to interact with enthusiastic and supportive physicians from several different fields who all share an interest in ancestral health.  I enjoyed talking about research with Dr. Lynda Frassetto, who’s papers I frequently reference when talking about the benefits of an “ancestral” diet. It was great to get a chance to talk about functional movement with Dr. Jacob Egbert and then go to Ute CrossFit where he led a practical session.  I’m straight out of my Ob/Gyn clerkship, so I loved sharing stories with Dr. Don Wilson, an Ob/Gyn from Canada with first hand knowledge of the health of indigenous First Nation people.  I had the chance to talk about the opportunities I’ll have if I decide to pursue a residency in family medicine with Dr. Rick Henriksen and other family docs.  It wasn’t all a rosy picture (though Rick is nothing if not enthusiastic), but I got a lot of honest and useful information from these physicians. There was also a preponderance of psychiatrists (or is that a contemplation of psychiatrists?), including my good friend Emily Deans, as well as a cardio-thoracic surgeon. I’m glad to have met Dr. Ede, and to have been introduced to her impressive website Diet Diagnosis.  It was also a pleasure to catch up with Dallas Hartwig, from Whole9 Life, who spoke with the group about functional medicine.

 

A nature break- some ancestrally minded physicians snowshoeing in Wasatch National Forest.

A nature break- some ancestrally minded physicians snowshoeing in Wasatch National Forest. From left to right, Polina Sayess, me, Don Wilson, Emily Deans, and Jacob Egbert

 

A lot of knowledge and information was shared this weekend, and I think we all walked away from the weekend with new friendships, a renewed sense of camaraderie with fellow physicians, and thoughts on how we can each do our part to help promote ancestral health.  Personally, I have a number of goals, not all of which I need to share.  I will say, however, that I feel there is a strong need to champion non-nutritional aspect of ancestral and evolutionary health. As the Hartwig’s book beautifully argues- It Starts with Food– but there are many other ways to incorporate ancestral and evolutionary thinking into modern medicine. That is one of my goals on this blog, though of late I have been writing more random ramblings than thoughts on distinct elements of evolutionary medicine.

 

As I officially make the transition from MSIII to MSIV (as of today I have completed all the 3rd year requirements of my medical degree), I hope that I’ll have more time to write about a number of topics in evolutionary medicine. Until then, I appreciate that readers follow along with my random ramblings, and am very glad that there are physicians who share a passion for understanding human health in the context of our evolutionary past.

 

PAH doesn’t have a website up yet, but for more information you can go here.

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I have been a zombie today.

I’ve wanted to write this post all day, but I’ve been spinning my wheels, unable to find the focus to sit and write.

I know where my inability to focus comes from. It’s the same thing that’s been causing my insatiable hunger and serious sweet-tooth.

I had a night shift on Thursday night.

The health industry is notoriously unhealthy. Even during the best of times the medical community tends to get things wrong with seminars on preventative health being coupled with breakfasts that consist of pastries, margarine to schmear on bagels, and fat-free non-dairy creamer to opacify a foul smelling substance that masquerades as coffee.

Practicing medicine is not easy on the body.  Being a doctor is stressful and, of course, spending your days around people who are sick makes you prone to getting sick yourself.  Lack of sleep is another big problem.

Of all the clerkships that medical students rotate through, the surgical ones- surgery and obstetrics/gynecology- have the worst hours. Depending on a school’s program, this is where students first get to experience the joys (by which I mean terrors) of 24+ hour call and “night float”.

At my school, the surgery clerkship has maintained the traditional call schedule (you work a day and then when you’re on call you stay for the night and finally go home the next morning when you are “post call”), while the ob/gyn clerkship has adopted a “night float” schedule for students, where we switch from day service to night service for a few days running during the clerkship.  These two clerkships were separated by 8 months in my schedule, so it’s perhaps hard to accurately compare them.  Nonetheless, I’d like to write about my experience with these two notoriously rough clerkships.

Surgery…

My school still follows a traditional call schedule for students on the surgery clerkship: every 4th or 5th day we would be “on call” after our normal day in the hospital. For the first half of this clerkship I was at a hospital 45 minutes away from my apartment. I was up between 4:25 and 4:30 each morning to be in the hospital by 5:30 to round on my patients before we “ran the list” as a team shortly after 6 and then headed to the OR for the day.

My problems on this clerkship started early. I had just come off my psychiatry clerkship where I’d been enjoying the psyche hours of 9-4… surgery hours were a big change. I couldn’t convince myself to eat breakfast before 4:30 and instead started my mornings with 1 or 2 double-shot espressos before heading to the hospital. The hospital to which I was assigned doesn’t have great quarters for medical students on surgery, so I was left to share a miniscule locker with 3 other students.  We barely had space to store our clothes, let alone space for real food. While there was a residents’ lounge, it was adorned with a large sign warning “Med students- do not leave your shit here”, and we didn’t have access to a fridge or a microwave. Lunch was a hit-or-miss occurrence, and the general mantra for med students during a surgery rotation is “eat when you can, you don’t know when you’ll have the opportunity next.”

Here’s a classic from Whatshouldwecallmedschool

During that first month I subsisted on my morning espressos and my best attempts at healthy snacks- unsweetened banana chips, jerky, nuts, and 85% chocolate. In the evenings I’d eat a proper dinner before putting myself to bed before 9 on most nights. I occasionally managed to make it to the gym, but I tended to feel rather weak and pathetic when I managed to get in a workout. Every 4th or 5th night I was on call, and instead of heading home around 5pm as per usual, I would grab dinner in the hospital cafeteria and see patients in the emergency department and go to the OR for emergency cases.  At some point during the evening (usually between 11pm and 1am) the night resident would tell the med students to retreat to our on-call room for some sleep, promising to page us if anything interesting came through. For me, at that hospital, I was never paged during the night.

My second month of surgery was on the trauma team at our university hospital, which is a level 1 trauma center.  Start time was similar at this hospital, but I was now 25 minutes closer, giving me 25 more blissful minutes of sleep. Also, at school we have a students’ lounge with a fridge and microwave, and I was able to start eating real lunches again. I also had realized that going to the gym in my stressed and sleep-deprived state was doing me no favors so I put my gym membership on hold.  Our call schedule was similar on trauma service, but unlike the general surgery service at a community hospital, the trauma team at our inner-city hospital was constantly getting paged in the wee-hours of the morning. I don’t think I ever got more than 2 hours of sleep when I was on call, and was always woken by the screams of the pager rather than the dulcet tones of my cell phone’s alarm (I occasionally hear a pager with the same ring-tone as the trauma pager and it still sends chills down my spine).

At the first hospital, after being on call, we were usually dismissed after we “ran the list”- frequently being on the way home shortly after 7am. On trauma we would run the list, go to radiology rounds, and then physically round on our patients as a team before being sent home.  Alas, our list of patients grew malignantly during my month of trauma and at one point we had over 30 patients, with some on each floor of the hospital. After a night on trauma I would usually find myself driving home after over 30 hours in the hospital (sometimes with no sleep) willing myself to get home safely (I really didn’t want to end up in the trauma bay as a patient- nothing like the fear of having your classmates cut your clothes off with shears to keep you awake!).

It’s amazing what lack of sleep does… I remember being asked a simple question one post-call morning on rounds and completely drawing a total blank. The funny thing was, it was a simple question that I actually felt very strongly about (Why do so many of our hospitalized patients have messed up electrolyte levels? We do it to them by flooding them with fluids!). Also, despite eating a lot less than I usually do, I definitely put on weight during my surgery clerkship.

Eight months later, as I faced the prospect of another notoriously rough clerkship (ob/gyn), I prepared myself a bit better.  While I was again stationed at the hospital 45 minutes from my apartment, this time I made sure that I ate breakfast before starting each day. I had also weaned myself completely off coffee before the start of the clerkship and never drank more than a single double-shot espresso each morning. I also preemptively put my gym-membership on hold.

We didn’t have call on ob/gyn and instead had a brief stint of “night float”, where we were in the hospital from 7pm-9am for a number of days consecutively.  This is a more realistic experience of life as an intern (with current intern rules), and has the advantage of allowing you to “switch over” from days to nights. I did a bit of research and when I switched over to nights I did a combination of fasting and napping that saw me switch over easily.

During ob/gyn I didn’t have much of a social life- I was going to bed between 8:30 and 9:30 most nights and most of my time was spent in the hospital or sleeping, but all things considered I think I held up very well.  I’ve long liked ending showers with a brief cold-water rinse (I think of it as a healthy bit of hormesis), but during surgery I lost the ability to tolerate cold showers.  Actually the worst part of being “post call” was the dreadful, inescapable cold that would come over me early on the post-call morning.  I’ve always been a warm-handed person, but on surgery I developed cold hands on a regular basis. While my hands weren’t always warm, I didn’t develop terrible chills on ob/gyn.

Med school is, of course, a learning experience, and a big part of the experience is learning what your body can handle and what it can’t (and what you need to do to keep yourself healthy, happy, and sane).  I’m not looking forward to the rough hours of residency, but I know the importance of prioritizing sleep, food, and socialization and I’m learning how to balance these things to keep myself well.

Alas, just after celebrating my successful navigation of ob/gyn (at least on the “feeling good” front, I’m still waiting for grades to be posted), I was knocked almost flat by a night shift on my current EMS elective.  While a night shift is not *required* during this elective it is strongly recommended, and I went out with the night crew on Thursday night to get an idea of what night-life on an ambulance in a rough inner-city is like (short answer- it does not disappoint).  While I was out with a great team and saw some pretty interesting things, I’ve been suffering the consequences since.  On Friday morning I had an insatiable appetite and was battling sugar-cravings (something I don’t usually have) for the rest of the day. Even after getting 11 hours of sleep last night I was still pretty groggy and fairly useless most of today.

There are no more night-shift in my foreseeable future (though I know we’ll meet again during my Emergency Medicine clerkship) and I’m confident that with another good night’s sleep I’ll be back to normal, but this has been a good reminder of just how brutal sleep deprivation can be.  My time with EMS (though only brief) has also reminded me that being in the health profession is often not a healthy practice. The people I’ve been working with sometimes risk their lives to save a stranger, but they also risk their health on a daily basis by living a lifestyle for which our bodies are ill-suited.

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It’s currently the time of year when the Student Affairs personnel at my school people are rallying the troops (third year medical students) to start thinking about what we want to be when we “grow up”. It’s early days yet, but the words “personal statement” seem to inject fear into my classmates. I guess most of them don’t write a blog for a hobby…

 

I haven’t started to write a statement yet, and I’m sure it’ll be an angst filled experience when I finally get down to it, but mulling it over got me thinking back to the personal statement I submitted when I first applied to medical school.

 

I was not a traditional med-school applicant. I was not “pre-med” (a major I would discourage anyone from pursuing) and I had never shadowed a doctor nor shown any interest in a medical profession.  I had a broad interest in all things scientific. I took the MCATs on a dare and did well enough to consider applying to medical school.  My love of science made the MD/PhD route intriguing to me, so I decided that in addition to the PhD programs I was interested in I would also apply to a few MD/PhD programs.

 

A couple weekends ago I was up in Boston and enjoyed a dinner with Kamal Patel of Pain Database and others. It was an enjoyable evening, and while discussing the merits and perils of being a med student I somewhat jokingly suggested to Kamal that I should dig up my old personal statement and post it on my blog.  He thought it seemed like a great idea (surprisingly, alcohol was not involved in this discussion), so now that I’ve had a bit of downtime I’ve dug it up and given it a look over.

 

In hindsight, I seem a little overenthusiastic (so many exclamation points!!!!), but generally I think that my enthusiasm for life is genuine.  One of the closing lines is something that I still deeply believe. In fact, it is a sentiment that comes through in the name of this blog.

 

I believe that the practical application of knowledge is the most rewarding result of study and curiosity.”

 

 

Even 8 (eek!) years ago, I wanted to put principles into practice.

 

Without further ado…

(Unedited, except to abbreviate the names of the professors I worked with)

_____________________________________

 

Until a few years ago I could still see the remnants of my first “experiment” in my garden every spring: red tulips growing along the fence line of the vegetable patch. As long as I can remember, I’ve been asking questions and trying to figure things out. The directions on a pack of tulip bulbs told me to plant them six inches deep, six inches apart. But at five I had to ask… why? Luckily I’ve been blessed with equally inquisitive parents, so my father indulged me, and the next day we were digging holes ranging in depth from one inch to two feet. The next spring I waited expectantly. Somewhat to my disappointment, they all came up! That wasn’t supposed to happen! Only the next year did it become clear that six inches seemed about optimal for a perennial show.

 

My quest for understanding and knowledge through experience has been a lot of fun, taken me many places, and introduced me to many people. As a child I would spend days in the woods and fields around my house exploring and trying to understand nature. When I wasn’t out adventuring, I was home reading books; I was amazed at what there was to learn! When I first started riding horses it was hard to find me away from barns, vet offices, or anywhere else I could learn about horses. While this led me to compete at national quiz competitions, I have most enjoyed becoming a thoroughly knowledgeable horse person. I apply what I know to working with my own horses and those of others, and enjoy teaching and helping local kids and even adults with general equine knowledge and veterinary care.

 

I particularly enjoy teaching others about polocrosse, an exciting combination of polo and lacrosse. I started playing on my first pony, a well-trained, athletic pony that did everything I asked her to do. When it was time for me to get a bigger horse, I looked at a number of horses that were ready to play, but eventually decided to buy a young ex-racehorse with a lot of potential and very little training. At times it was hard to watch my peers get better so quickly on their well-trained horses, and at times I thought I should give in and get a horse that was ready to play, but the challenge excited me, and I stuck with it. After four years of hard work, a lot of sweat, a few falls, and occasional bouts of anguish, I’m proud to play on a horse that I brought to the game on my own, and I know that I am a better rider because of the experience.

 

Now in college, I still can’t learn and do enough. I have joined a number of groups on campus, and am on the executive boards of the campus-wide Programs and Activities Council, the Biochemistry Club, and Alpha Zeta, a co-ed honors/service/social fraternity. Going to a large state school, I have had the opportunity to take a wide range of classes that apply to my major, my interests, and things that just seem neat! During the fall of my freshman year I became SCUBA certified so that I could travel to Little Cayman during the winter break to study coral reefs with a marine geologist. I was so enthusiastic that she invited me to apply for a summer internship studying the reefs around the island. I applied, got the position, and spent two weeks documenting species diversity, morbidity and mortality of coral around the island.

 

A fascination with Moorish architecture and Picasso’s Guernica, and a desire to test my Spanish on its home ground, led me to drag my mother to Spain. My basic grasp of the language and her ability to rent a car made for an incredible trip. For ten days we traveled in the south of Spain, seeing architecture and experiencing the culture. Similarly, a fascination with Guinness Stout, Ireland, and the Irish led me to take a youth-hostelling trip to Dublin. These and other trips have heightened my curiosity and driven my desire to see and experience more of the world.

 

During college, the curiosity that my parents initially encouraged when I was a child developed into a desire to do scientific research. In addition to the coral reef project, I am glad to have had several other exciting research experiences. I was fortunate to receive a Center for Bioinorganic Chemistry summer grant to work in the laboratory of Dr. GZ on the biodegradation of aromatic hydrocarbons by Pseudomonads. Another year I got funding to study the incidence of Lyme disease in mice and their parasites along a rural to urban transact in New Jersey in the laboratory of Dr. MS. I am now conducting my senior thesis work in the toxicology lab of Dr. LW, studying the effects of 2,3,7,8-tetrachlorodibenzo-p–dioxin, an environmental contaminant, on developing fish embryos. The curiosity that once inspired me to plant rows of tulips has brought me to believe that medical science is the most exciting and dynamic field I could hope to enter, yet I am hesitant to devote my life purely to lab work and research. I believe that the practical application of knowledge is the most rewarding result of study and curiosity. I want to enter the medical field to combine my drive to discover and understand with my love of people, and become a doctor working at the frontiers of clinical science.

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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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As an evolutionarily minded medical student, you can sometimes feel a bit alone in the crowd of conventionally minded medical practitioners and students.  I’ll admit that I’ve been repeatedly impressed with the interest that many of my fellow med students (as well as residents and even some attendings) show the ancestral/evolutionary ideas that I sometimes talk about, but most generally find an evolutionary approach to health and wellness interesting, rather than integral, in the consideration of health, wellness, and disease. 

 

I am not, however, alone.  There are a number of MDs and DOs who are interested in bridging the gap between ancestral health and western medicine.  There is a budding new organization of Physicians and Ancestral Health (with a winter meeting in February that I hope to attend), and there are other medical students who share a passion for thinking about modern medicine in the context of ancestral health. One such medical student is Angela Arbach, a student at Cornell Medical School currently doing research during a year long sabbatical between her third and fourth years of medical school, who I had the pleasure of meeting at the Ancestral Health Symposium in Boston in August.  There we had a long chat about our shared interest in evolutionary and ancestral medicine, as well as our specific areas of focus (she is passionate about women’s health and infectious disease).  I didn’t know it at the time, but Angela would soon be winging her way to Africa, where she would be involved in an international nutrition research project. When we recently caught up over e-mail I asked if she’d be interested in sharing her experience on my blog.  Her travels and observations are something that so few get to experience but so many could benefit from pondering. 

 

With out further ado: an ancestrally minded med student abroad.

Fresh from the Ancestral Health Symposium (AHS), after several days home in NYC and then a national boards exam in Philly, I was on a 4-hour bus trip to upstate New York to finalize plans for a research project in international nutrition.  A month later, I was on a plane to Northern Uganda: a nation in the global south, devastatingly resource poor, with an uncomfortably recent history of conflict.  [Check out the doc Uganda Rising, on youtube, for more history and a quick but imperative summary of colonialism in Africa].  It’s also a beautiful place.  From polychromatic garb to the giant layered sky underscored by the surrounding savannah, there is no shortage of images to appreciate.  The Acholi people, the dominant ethnic group of Northern Uganda, are still close to their traditional roots despite colonization and the recent influx of modern technologies.  When the English arrived, they left their development plans out of the north, making it easier to forcibly enlist Acholi men in the security forces.  And then, after independence (50 years, last month!), the north remained isolated and underdeveloped due to the LRA insurgency.  The Nile River, separating Acholiland from the rest of the country, only aids in this political and cultural divide.  For these reasons, an AHS-primed brain finds many cultural practices as fodder for rumination, along with prompts for contemplating our role in a global context.  Below, I will describe some of my earliest observations in this complicated milieu.

First, of course, the food.  It starts with starchy staples, mostly sweet potatoes, millet, rice, maize, sorghum, cassava, squash, and plantains.  These starches are used to scoop up, usually by hand, some combination of beans, peas, sesame seed paste, and, if you’re not incredibly food insecure, goat, fish, chicken, beef, or offal. The modicum of nonstarchy vegetables is nearly always cooked: the beans and meat stews are boiled with small pieces of tomato, green pepper, and onion, and a common side dish is boiled leafy greens.  I recently read an account of a Ugandan grandmother’s reaction to Western salads, laughing and asking how people can be healthy eating these raw foods since humans are not goats or cows.  The author explained how cooking all vegetables is a protective tradition, as soil and water is often contaminated by waste, but I wonder if there is more to it.  Fruit is eaten raw, however, and the most common fruits I see are bananas, oranges, jackfruit, mangos, avocado, passion fruit, and watermelons.  In terms of ferments, I’ve only heard of bongo (fermented milk) and the various alcoholic homebrews, usually from banana, maize, sorghum, or millet.

Example meals:  a plate of sweet potato and posho (stiff maize porridge) with a bowl of beans in a sesame paste sauce; kwan kal (stiff millet porridge) with boiled greens, tahini mixed in the green water; rice with a bowl of smoked goat meat stew.

fresh fish, sesame pasted greens, stiff millet porridge, sweet potatoes

One of my favorite meals, also an Acholi staple, is sesame paste mixed with mashed, cooked pigeon peas (dek ngoo) drizzled with dark shea nut oil (moo yaa).  Eat this by dipping in pieces of sweet potato or kwan kal.  These are typical lunches and dinners.

dek gnoo and moo yaa, with stiff maize porridge rice on the right

Breakfast is varied.  Some skip it, especially if they live in poverty and work all day (sure, call it a “feeding window, or just malnutrition).  Milk tea and milk instant coffee are very popular, with a milk-to-water ratio of 1:1 loaded up with table sugar.  The milk here is delicious– largely local and grassfed, it tastes so rich and sweet (a Ugandan colleague’s wife, who lived in the US for a year, told me “American milk doesn’t taste like milk”).  Millet porridge is served in some schools for breakfast.  A popular drink for children is milk, fermented or fresh, mixed with some kind of grain (I’ve heard millet or corn).  More common outside of the north, but still present here, is katogo:  stewed plantain or banana with offal or groundnuts.  Groundnuts are very similar to peanuts, and people buy them roasted for breakfast or snacking.  Groundnut stew (similar to a mild peanut sauce) is common elsewhere, but sesame paste stews are more common here.  Overall, the food variety is less than other places I’ve traveled, and the dishes are quite plain with little spice or herb additions– low food reward, perhaps.

That all sounds wonderful, but I left out a big part of the common diet:  wheat, vegetable oils, and soft drinks.  All new additions to the food tradition, sometimes supplanting old foods.  Indian influence means chapati and samosas are common street foods, cooked in vegetable oils, of course.  Loaves of bread are becoming a staple, as well, and some people eat it with a schmear of sesame seed butter for breakfast.  I was happy to discover how common eggs are, but if I eat out, they are always fried brown in veg oil.  So it goes.  Within the ubiquity of food insufficiency in a context of very limited healthcare, I fear the implications of substituting already meager dietary items with these industrial foods.

Modern staples: vegetable oils, toilet paper, and soda

Walking around, I see people in positions that could be in Gokhale’s book.  The women work hard– constantly bent over to cook, wash dishes, do laundry, and clean floors (brooms are 2-3 feet long and made from reeds, mops are rags that you move with your arms).  They stay bent at the waist with perfectly straight backs, motivating me to keep stretching the hammies…

Women at work

 Some of these chores are done squatting, too.  Otherwise, the women can be seen transporting heavy objects on their heads, from 5 gallon jugs of water to sacks of grain.  This is all done with a baby wrapped to their backs.

I could be wrong, but perhaps these practices are the reason I see less postural kyphosis in the elderly ladies.  Also, I should mention that gyms are nearly nonexistent, and the only time I see running is when people get caught in the rain, are playing football (soccer), or are white people doing aid work or research (that’s me! But my research involves too much time at a desk).  Strenuous jobs are the norm, and most people don’t have cars.  Walking and bicycling are the rule.  Most of the footwear I see are thin sandals (minimalist), and it’s common to see barefooted people walking around, especially outside the towns (poverty).

About 100 years old, but I’m told these are still made in some villages

The lack of street lamps, along with daily power outages, and the fact that the vast majority of homes don’t have access to electricity, means that people generally experience natural darkness as the sun sets.  I’ve been heading to bed much earlier, especially since I cannot sleep past 5 or 6 am due to the roosters.  If I go to bed early enough, I often wake up in the middle of the night for an hour or so before a “second sleep”.  One of my colleagues (a Ugandan) does this, too, but I cannot generalize beyond us.  He and his family sometimes take a little siesta after lunch, too, which I can certainly get behind.  I can also check off items from the recent MDA post on hormesis.  I already mentioned the exercise and calorie restriction, and sunlight exposure is a given in a country on the equator.  Also, without modern conveniences such as electricity and hot water heaters, all showers are cold showers!

Another topic I want to touch on is Acholiland’s continued tribal culture.  Traditional dance and music is at the heart of this.  I frequently hear drums in the distance as I walk, and I’ve seen groups of students in universities meet up for dances in the grass.  For more on the healing power of traditional music and dance, track down the 2007 film War Dance, an incredibly beautiful but heartbreaking story about school children in Northern Uganda.  I have yet to read my book on the history of the Acholi tribes, so the majority of my info is from conversations with Ugandan friends, one of whom is the designated leader of his clan.  The presence of tribal culture is strong, the sense of belonging is crucial, and excommunication from your clan is considered a punishment worse than death.  Clan leaders are still called upon to resolve disputes or offer advice.  [See the Al Jazeera documentary, Bitter Root, for how these traditional practices lead to reconciliation, rather than retribution, for former abducted-children-turned-rebel-soldiers, taking the justice system from the hands of the government to the realm of tradition].  Distant relatives are sometimes described using nuclear family nouns– the son of your grandpa’s cousin’s kid is your brother– and everyone feels a sense of responsibility and goodwill towards other members of their clan.  This sounds like ubuntu, the topic of Frank Forencich’s talk (Africa reference?) at AHS, which I missed because I had to run back to New York that day.  I should mention that everyone here was thrilled when Obama won, and they often cite that sense of brotherhood they get from him, along with his more skillful way of taking care of the poor.

That’s my account so far, but remember that some of this information came from people who may want to tell the foreigner something interesting, rather than common, and then that data is filtered through my biased brain.  And of course, I can’t talk about these things without sprinkling in some political, economic, and social issues facing the Acholi.  An ancestral health picture is nice, but it’s not complete.  Acholi tradition has been undermined by forced migration into internally displaced peoples camps for over a decade, ending merely a few years ago, preventing the practice of many cultural rituals.  They were without land, independence, and other means to continue traditional livelihoods.  On a few occasions, I’ve been able to informally talk with Acholi elders.  They never fail to remind me how the IDP camps destroyed their peoples’ culture and morals, as well as fostering drug abuse, rape, and disease.  And yes, the foodways and hormesis sound great, but people are starving here.  Naturally active livelihoods are awesome, but not when they are the result of extreme gender inequality where women have no choice.  It’s sweet and heartwarming that man-on-man handholding is so common– brotherhood, right?  But it’s scary that the same affection towards your wife is risqué, or that you could be killed or imprisoned if you engage in love outside the bounds of heteronormativity.  Blame it on the proximate lack of education, former colonialism, or widespread Christianity, but it’s happening.  And let’s not start on the infectious diseases, government corruption, illiteracy rates, motor vehicle accidents, and lack of good healthcare.

So what can we learn from these people, a group so geographically close to the Hadza, Batwa, and Karamojong, close to some of the earliest human remains in the archaeological record?  The answer seems largely irrelevant.  We have a lot of the answers we need about diet and lifestyle.  Perhaps this is a case where we should ask:  what can we give of ourselves?  The ancestral health community has gained a lot from the study of indigenous groups, so what can we do in return?  How will we enable empowerment and protect culture?  American health trends have a global effect, so how can we be the example of doing this in a positive way?  Why was the apropos panel on Reclaiming Latino Health so under-attended, compared to the lamentable, stale debate on… potatoes?  Were we fighting with the Pima to protect their water?  Has anyone heard of the Decolonizing Diet Project?  And for the egocentric: more preservation of cultural heritage means more research opportunities to figure out the perfect post-workout meal…  I mentioned missing Forencichs’ talk, but when I read how greatly he inspired people, I looked him up and found this relevant post.  Adele Hite, a speaker at the symposium, gave a list of ways to become more involved than just frequently-commenting-on-blogs.  Her examples largely involve the USA, but I don’t see why our scope cannot transcend self-created national borders.  This already happens in research and blogging, so why not in action?  Involvement in other cultures demands care and scrutiny (you want to avoid dead aid), but I think this community is smart and thoughtful enough to create a significantly net-positive effect.  We’re crafty people, and we’ve already accomplished so much.  Some organizations are doing exciting, ancestral-health-minded things, like this medical clinic in Burundi.  They started a native foods garden, along with the administration of agriculture education programs, to combat widespread food insecurity that took place after the civil war and genocide– a nice solution to what many food aid programs stick a bandaid on by creating relationships of dependency using their culturally inappropriate bags of wheat and jugs of vegetable oil.

I’m merely a student, so I cannot provide all the answers, but I hope the bulk of my career will work on these issues.  I think this community is also up for the challenge, as evidenced by the last symposium.  The blogging about micro/macronutrients is dying down, and our focus is getting bigger:  public policy, remarkable research projects, interventions, activism, creation of med student electives, and the introduction of evolutionary health into workplaces and grand rounds.  I’m not saying that global issues and cultural preservation need to supplant the other amazing endeavors born from the synergy in the ancestral community, but I look forward to more attention to these topics.  They are not tangential, but fundamental, to progress for us all.

Angela is a medical student at Cornell in NYC. If you’d like to read more of her observations (with less focus on ancestral health) you can check out her travel blog, I highly recommend it!  

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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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…thoughts on hiking, med school, and life…

The last couple of weeks have been a bit of a whirlwind.  First there was the Ancestral Health Symposium (more on that later- if I ever get my thoughts together), then there was the flurry of activity that marked the end of my Family Medicine Clerkship (topped off with a nice 2.5 hour exam), and before the dust settled I was off to the airport to make the most of every hour of the one-week vacation that my school grants third year medical students at the end of the Family Medicine Clerkship.  I spent that week touring Colorado with my long-time best friend.

I expect that everyone has heard the phrase “It’s the journey, not the destination”.  A quick internet search suggests that this gem comes from Ralph Waldo Emerson (1803-1882), though this is unsubstantiated by any reference… Sourced or not, it seems to be a sentiment that most people can get behind.  My recent mental meanderings- while hiking, while musing about med school, and while thinking about life- have me wondering otherwise.

I enjoy hiking.  As the demands of my degrees have changed I’ve had to take a step back from my equestrian endeavors and embrace other activities that can be picked up and put down a little more easily.  I’ve had a pretty good season for hiking thus far- hitting up a number of beautiful locations.  Some, like my recent trek up Matterhorn Peak in Colorado, were out and back trips, while others, like Falls Trail at Rickets Glenn in Pennsylvania, were scenic loops.  When it comes to hikes, these two adventures were very different.  Climbing the Matterhorn was, in all honesty, a grueling trudge through rather stark scenery to “bag” a 13er (a peak over 13,000 feet- Matterhorn is 13,590).  The Falls Trail at Rickets Glenn, on the other hand, is a non-stop feast for the eyes of waterfalls and lush greenery that takes you back where you started, with no single “goal” for the trip.  In the context of this post, one could easily argue that the former was all about the destination while the later was about the journey.

I said that the trek to the top of Matterhorn was a grueling trudge.  I’ll admit that I was rather ignorant of what I was getting myself into when I boldly posited that “We should climb Matterhorn.” Honestly, I made this statement based on the general location (in the San Juans near where we wanted to camp) and the name (named after the Swiss peak- which has a much higher death toll!).  I didn’t quite realize when we set out the magnitude of the mountain we were climbing, nor the type of country we would be traversing.  Unlike the lush countryside I am used to exploring back east, much of the hike up to the summit was above the tree line, in alpine tundra.  While the trip to the top was interspersed with pauses in which I appreciated the absolutely awe-inspiring views, it was a hike that in all honesty was rather dull.  The top, however, was anything but dull. Visually, the uninterrupted views of the Rocky Mountains extending for miles were breathtaking. Personally, the satisfaction of successfully climbing (I’m mildly averse to the term “bagging”) a large named mountain was immense (and I did it in Vibram Five Fingers- an additional triumph).  Was the journey worth these end satisfactions? Yes! But in this circumstance- the destination certainly trumped the journey.

View from Matterhorn

View from Matterhorn: A place to think…

Med school is also a journey.  Much like the climb up Matterhorn, parts of it are grueling and significant portions are unpleasant.  There are, however, moments of awe and wonder.

There are people that grew up knowing they wanted to be a doctor; I was not one of them.  In fact, I actively told people I would not be a doctor when I was asked the dreaded “What do you want to be when you grow up?” question.  Even as I completed college my inclination was always towards research and not clinical practice, and I committed to an MD/PhD program with the thoughts of using the clinical knowledge (and the professional clout of the MD) to pursue medical research.  Much like climbing Matterhorn- I really didn’t know what I was getting myself into when I signed on to attend med school.  The MD/PhD degree was a destination, something to be obtained without much thought to the journey.

Now that I am in med school, and I recognize the magnitude of the effort required to reach this goal, I wonder- if I knew what I was getting myself into when I embarked, would I have started?  While it is surely not the case for everyone, I entered med school with my mind on the destination, with almost complete ignorance of the journey that entailed.  It has been, and continues to be, one hell of a journey.  There are many aspects of this adventure: the people I have met (classmates, friends, professors, and patients), the events I have experienced, the emotions I have witnessed, the intimate details of their lives that patients have shared… These have made for an incredible experience, and are things I would never have experienced without the end destination of a degree in medicine.

Playing at Rickets Glenn

Playing at Rickets Glenn: Sometimes it’s about the journey, and sometimes the journey is more fun when you go off trail!

Destinations change.  Sometimes they are unreachable, sometimes they are not what you expect, and sometimes they are just a point on the way to a yet further destination.  They do, however, inspire journeys.  Journeys vary based on destination, and while life is not a destination, one might argue (and indeed I do) that the journey of life gets more interesting when you choose a destination.

Choose a destination. It can be big or it can be small, but it should be something you choose. The journey of life seems much more interesting when you are chasing your own goal than when you are treading the path of someone else’s expectations. And don’t worry too much… you can always change your destination if a better one comes into view.

En route to Diamond Lake (Colorado): What you find on the way to your destination, and what you do with it, is all part of the fun.

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Last week I gave a talk on evolutionary medicine to a group of ~50 medical students at my school. I really enjoy public speaking and I love talking about evolutionary medicine, so I had a blast (and the talk seemed to be well received).  I won’t try and recount exactly what I said in my talk, but as people seem to be interested in what I had to say I’ll try and provide a general idea of how the talk flowed, sharing the things that I think medical students should keep in the back of their mind as they go through their medical training.

I started with an introduction to evolutionary medicine…

An image from a 2010 Nature article on Evolutionary Medicine. (Particularly fun as Darwin did start to train as a physician at one point!) 

The term “Evolutionary Medicine” is rather broad, and can mean anything from how and why our enzymes work a specific way to why we respond to our modern environment (or a medicine, stress, or toxin) the way we do.  It stresses (to me at least) the fact that natural selection is everywhere, and we would do well to remember this (in medicine, business, policy, and life!). The term “Evolutionary Medicine” is sometimes used interchangeably with “Darwinian Medicine”, and is often mentioned during the discussion of “Ancestral Health”. These are all terms I hope that we will hear more of as medical education continues to evolve (selection pressure is everywhere, right?)

Speaking of med schools- I just read that the first lecture new med students get at UCSD is a lecture on evolutionary medicine [1]. Very cool! I like the idea of introducing the subject to med students before the onset of clinical training, as it offers a paradigm in which to think about health and disease, instead of trying to learn everything from a purely mechanistic perspective.

As med students, we are already familiar with some selective pressures that alter human health. Microbial resistance to antibiotics, sickle cell anemia, and lactose intolerance (though perhaps more accurately, “lactase persistence”) are all things we learn about, and are probably (hopefully?) taught with an emphasis on the selection pressures that brought these things to prevalence. These three examples, however, are just the tip of the iceberg.

We can use evolutionary medicine (and indeed I think we should) at all levels of human health and disease, but I think that an excellent starting point for this discussion is to take a step back and look at the bigger picture of “what it is to be human”.

So what is “being human”?

I find the easiest way to look at this question is to ask “how does a human live ‘in the wild’”. I’m not talking about a weekend camping trip, or even a half-year adventure through the rugged arctic, but rather, what can we glean from archeological evidence, our closest hominid relatives, and native peoples about how humans evolved? Alas, many native cultures are converting (or already have converted) to a more modern lifestyle, but there is a lot that we can learn from the lifestyle of people such as the Australian Aboriginals, the New Zealand Maori, Native Americans, Kitavans, Inuit, Maasai, and others.  Even though much cultural identity has been lost in recent generations, memories and documentation exist that we can use to better understand traditionally living humans.

I should say, at the outset, that this is not a plea to return to a traditional lifestyle (nor do I think people living in traditional cultures should be barred the opportunity to adopt aspects of our modern life). This isn’t about “going back” or recreating a specific lifestyle. Instead, this is about understanding our past so we can thrive in the present (and beyond).

Perhaps first and foremost (and indeed, my starting point into evolutionary wellness (there I go using yet another term)) is the food that humans thrive on. It is increasingly evident that there is not one “perfect human diet” that we evolved to thrive on. Rather, there are a number of foods that nourish and sustain our body in a healthy way. Humans evolved eating (and indeed some of these things truly ‘made us human’) meat, seafood, eggs, vegetables, fruits, nuts, and tubers.

What about grains and dairy? This is inevitably the cry we will hear from patients, friends, family, and hospital nutritionists! To hear these people talk is to think that humans cannot exist without these two staves of life. As much as people think of these things as staples of the human diet, the reality is that they were most likely not consumed in any real quantity until the agricultural revolution, a mere 10,000 years ago (not much time when you consider the span of human evolution). While it is true some people do well on these foods (and indeed, lactase persistence gave some a significant reproductive advantage at some point in the last 10,000 years), many people do not. Even those that seem to tolerate these things well are often surprised by the benefits they experience when these things are eliminated from the diet. Not everyone does poorly on these foods, but it definitely seems that many have not evolved to thrive on them.

Perhaps more important than thinking about what humans evolved to eat is thinking about what is truly novel in our modern diet. Unnatural trans-fats (not all trans-fats, as there are natural ones such as conjugated linoleic acid (CLA), which appears to have significant health benefits) have been shown to be particularly evil, and a campaign has been waged (mostly successfully) to rid them from our modern diet. With unnatural trans-fats mostly out of the way, the worst of our modern novelties (in my opinion) is the excessive amount of linoleic acid (found in vegetable oils such as corn oil and soybean oil) in our modern diet. I could write a book about the evils of linoleic acid (who knows, maybe one day I will), but without going into detail, excess linoleic acid is associated with increased gut permeability, increased inflammation, and increased fatty liver, just to name a few conditions off the top of my head.  I think the westernized world would be a much healthier place if we would eliminate all the modern sources of linoleic acid and again embrace sources of omega-3 fats such as fatty fish and grass-fed meats (but that is enough information for another talk entirely!).

{Ed. Note- I can find it difficult to keep myself on task as I talk about evolutionary health. Since it really gives you a paradigm in which to think, it is so easy to branch off at any place to explore other venues that benefit from an evolutionary approach.}

When considering the declining health of the western world, other culprits in our modern diet are likely excessive sugars, additives and preservatives, soy, hyper-palitable processes foods, a host of other things I can’t think to list right now and, though it is debatable for some as mentioned above, grains and dairy.

Going beyond food- what else makes us human?

A topic that I have been meaning to write on for ages, but that “That Paleo Guy” Jamie Scott has recently been writing quite a bit about, is Sun.

Humans evolved outside, under the sun. Our lives, both daily and seasonally, were controlled by the rising and setting of the sun. Most of us know that UV radiation from the sun is responsible for starting the conversion of precursor compounds into active vitamin D, but how many of us actually get enough sun to be replete in vitamin D, and how much do we actually need? Looking at this from the evolutionary standpoint, we can determine that appropriate vitamin D levels are extremely important for human health and survival. Indeed- it is believed that the drive for adequate vitamin D levels is what drove lighter skin pigmentation in humans as they migrated away from the equator (lighter skin meant that people could still make adequate vitamin D despite the decreased UVB exposure at northern latitudes and the decreased skin exposure due to increased clothes in colder climates).

Vitamin D is also a great opportunity to tap into Ancestral Health as a way to guide modern medicine. For lack of a better description, we in the western world are shooting blind when trying to figure out what is an appropriate target for blood levels of vitamin D. We currently base our studies off of epidemiological studies of humans living well-outside their evolutionary niche and laboratory studies using isolated cells and models quite distant from a living, breathing, human.  While these studies can provide us with interesting information (and quite a bit of garbage), can it really give us a good idea of what is optimal for human health? Might information from people living in a traditional lifestyle give us a better idea of how humans have evolved to thrive? A paper recently came out that looked at vitamin D levels in groups of Maasai and Hadzabe and found that the mean Vitamin D concentrations in these population is 115nmol/L (~46ug/L) [2]. Whether this level is “ideal” is uncertain, but it’s an interesting (and arguably more reasonable) place to get started than trying to tease out a reasonable target from the varying levels of insufficiency in most modern civilizations.

The benefits of sunlight aren’t limited to vitamin D. The sun plays other roles in human health, and I will make a strong (personal) argument that sun exposure does wonders for psychological wellbeing!

Humans were meant to move

This is, perhaps, something that everyone can agree upon. This, like food and sun, is something that can be looked at from many different angles under the lens of evolution. How has our body evolved as we became bipeds, and where are the weaknesses in our constitution? Bipedalism changed the shape of our hips, and with it the risks of childbirth. Our shoulders are wonderfully mobile joints, but with mobility comes potential weakness (hello rotator cuff injuries!). And what about feet? Through feats (heh- couldn’t help myself!) of natural selection, our feet have been crafted over millennia to support and move us unassisted, yet now we want to rely on highly engineered shoes to cushion, balance, and protect our feet. Interesting research our of Harvard by Daniel Lieberman’s lab shows some of the effects shoes have on the forces exerted on our knees (cliff notes versions- shoes aren’t doing us any favors). Furthermore, recently the floodgates have opened letting loose a stream of research showing the “dangers of sitting”. These are all elements of human health that can be  more easily understood when placed in the context of an evolutionary paradigm.

Humans sleep

This seems like such an obvious statement, but it’s probably one of the hardest things for people to implement. As budding health professionals, we are rarely able to set a good example in this aspect, yet we should realize that cutting short on sleep is detrimental to more than just our coffee budgets. As I mentioned above, until recently, our lives were controlled by the rising and setting of the sun- now we are able to extend our hours (not just of waking, but also working), probably at great expense to our health. Here, as in other aspects of evolutionary health, I’m not recommending that we shun our modern world, but instead that we should understand our modern situation in the light of our evolutionary past and our biology. An interesting evo-health aspect to consider here is the effect of blue light on melatonin production (melatonin is a hormone important in controlling our circadian rhythm). Exposure to blue light decreases the production of melatonin in the brain, thereby affecting our sleep-wake cycle. While we’re unlikely to convince many (indeed you won’t convince me!) to turn my computer off after sunset, we should consider reasonable “hacks” to work around it. For this example, the cool free program f.lux is available, which alters the amount of blue light emitted from your display based on the time of day and your local sunset and sunrise time.  If you don’t have it already, check it out!

Humans have friends, not “friends”

I’m not going to waste much time on this one, but real, legitimate human interactions are an important part of being human. I’m not saying you can’t make great friends on the internet- one of my best friends is an internet friend- but a real social bonds take more time and effort than a 140 character message or the occasional “poke”.  Meaningful relationships take time, which is something many are painfully short of these days.  Alas, the same modern life stresses that make strong social bonds hard to forge and maintain also make such support even more necessary.

 

Evolutionary Medicine isn’t just about preventative health.

I won’t go into it here, but in the closing minutes of my talk I went on to talk about some of the evo-med examples I have written about here before. First I discussed the likely role of the appendix (and why we should care) and then I talked about an alternative perspective on the etiology of diverticulitis. I also stressed that this talk wasn’t meant to be an all inclusive “this is evolutionary medicine” talk, but more of an opportunity to introduce a subject that I hope my peers will start to consider as they continue their medical education and eventually head off to their specialty of choice.

I’ve only referenced a couple papers in this post, but I did put up a number of papers throughout my talk to show that this is science. There is a growing body of evidence to support the importance of evolutionary thinking in modern medicine, and an increasing interest in teaching evolutionary principles to medical students. As for me- I continue to find great excitement and joy (two wonderful human pleasures) in thinking about these evolutionary principles and how we can utilize them in practice.

1.            Varki, A., Nothing in medicine makes sense, except in the light of evolution. J Mol Med (Berl), 2012. 90(5): p. 481-94.

2.            Luxwolda, M.F., R.S. Kuipers, I.P. Kema, D.A. Janneke Dijck-Brouwer, and F.A. Muskiet, Traditionally living populations in East Africa have a mean serum 25-hydroxyvitamin D concentration of 115 nmol/l. Br J Nutr, 2012: p. 1-5.

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No- this isn’t an addendum to the “spring mating games” I mentioned in my last post.  (I feel like I might have just lost half my readers…)

The third year of medical school is a hectic one.  For those that aren’t familiar with the system, the first 2 years of medical school (in the US at least) are “pre-clinical” years, where future physicians learn the ‘basic science’ behind medicine. The foundations of our clinical knowledge are fields such as anatomy, embryology, biochemistry, pharmacology, physiology, pathology, microbiology, immunology, and, at least in my school, some basic biostatistics.  The end of second year culminates with the first step of the USMLE Boards.  Those that aren’t daft enough to take a hiatus to do a PhD (and when those of us that were daft enough finally come back) then start clinical clerkships in the third year.

For lack of a better description- 3rd year medical school is like speed dating for future physicians, but we’re looking for a career not a partner.  There’s a lot to be learned in third year (there is a very steep learning curve when you finally step foot on the floors), and each clerkship (Psychiatry, Neurology, General Medicine, Surgery, Obstetrics and Gynecology, Family Medicine, and Pediatrics) requires the acquisition of new clinical skills and knowledge.  The idea, obviously, isn’t to make you a surgeon in 2 months, but to give you some basic knowledge in these fields and to give you an idea of what it is like to be a physician in each of these specialties.

Some students come into medical school knowing what they want to be (though even the most determined often change paths), but many (myself included- more so at the beginning of medical school than now) really have no idea.  Over the course of a clerkship you not only get the basic clinical knowledge of a specialty, but you also get a feel for the specialty itself. These clerkships are short- I had a month on both Psychiatry and Neurology, and two months on Surgery.  This is barely enough time to figure out what a specialty is all about, and of course your experience is very much determined by the hospital you work at and the people you work with, yet this is the system in which we work (and in this instance I’m not sure there’s a better option).  By the end of third year, medical students need to know what they want to be “when they grow up”.  That’s when you have to start getting ready for “The Match”, the process in which medical students and residency programs rank their respective top picks and a computer determines their destiny (think of it as speed dating meets arranged marriage).

As I come off my surgery rotation, now a third of the way through my third year of medical school, it seems like an appropriate time to take a look at the clerkships past, and to glance forward to those awaiting me.

I started with Neurology- a very cerebral specialty (pun intended), where, at least when I spent my time with the stoke team, we spent a lot of time doing very thorough histories and physicals, teasing out the specific deficits and abnormalities of a patient’s presentation to determine (“localize” is the medical term) where in the brain there was an issue.  This is a wonderful exercise, and a skilled neurologist can take a thorough physical and, based on presentation, precisely localize where in the brain the problem has occurred… Now a day, this is frequently done as somewhat of an academic exercise after the determination has already been made by a CT scan and/or MRI. While there definitely is space for aspects of neurology to be explored with an ancestral/evolutionary health gaze (more hemorrhagic strokes during the winter? Maybe there’s a role for Vitamin D?), for me I found the specialty one of “a lot of thought, not much action”. Engaging as the thought process is, and as cool as some of the physical-exam detective work can be, I’m fairly sure that on my speed-dating card, Neurology is a “No”.

I was surprised by my Psychiatry clerkship. I wrote about my experience previously and, from the assessment of the clinicians I worked with and my own thoughts, I’d say Psychiatry is a mutual “Maybe”.

As I reach the end of my two-month trial on surgery, I will mark, without hesitation but with definite heartache, “No”.  Had my surgical rotation ended after my first month, when I had experienced only general surgery, there would have been no hesitation nor heartache.  General surgery is, without a doubt, not for me.  Over that month I saw many surgical revisions of the human body that were necessary, almost exclusively, because humans are living outside of an evolutionary appropriate lifestyle.  The removal of large portions of bowel because of diverticulitis, appendices and gallbladders removed around the clock, amputations because of uncontrolled diabetes… It all seems so unnecessary (for the most part) if we figured out how to live within the confines of how our body evolved to thrive.  In many of these cases, surgery is a (hopefully) definitive treatment for a preventable disease that I would rather just see prevented.  Other specialties within surgery- such as vascular, transplant, and cardiothoracic, or totally different training programs such as neurosurgery or orthopedics- all have their place, but none of them enthralled me. The other major issue with surgery is the toll it takes on your body and your life.  Surgery is physically demanding, not just for the hours of standing in one place, sometimes hunched precariously or stooped over a microscope, but also for the hours it requires.  Surgical training requires residents spend very long hours in the hospital, and to be honest, it’s not a price I am willing to pay.

The reason my rejection of surgery turned from an adamant “No” to a sorrowful one is because of Trauma.  My second month of surgery was spent with the Trauma team at my university’s hospital, a level 1 trauma center in a very rough inner city.  In many ways, Trauma surgery is the antithesis of neurology.  No- the people I was working with are not “just dumb trauma surgeons” as one of our attending physicians liked to self-deprecatingly refer to he and his collegues, but they are men (and women) of action.  There is a standard protocol that you run through when a trauma comes in, the “ABCs” (Airway, Breathing, Circulation, Disability, Exposure (yes, if you come into the trauma bay, you will lose your clothes)), but when something needs to be done, a trauma surgeon does not stand on protocol and wait for the final assessment. Many of the cases we saw in the trauma bay were definitely not “traumas” (simple falls, bar fights and assaults are generally things that should be taken care of in the Emergency Department), but many were full of the excitement and noise that years of watching ‘ER’ might have you come to believe is the norm.  One night on call I was part of the team that picked up a Motor Vehicle Crash (MVC) patient from the helipad on the hospital roof.  I’ve now seen gunshot wounds to all different parts of the body.  Trauma surgeons (or the good ones, as I witnessed in our hospital) know when to let assessment carry on, and when they’ve seen enough and something needs to be done NOW.

There is an urgency to trauma surgery, an element of intuitive action, that is lacking in other fields of medicine.  When you go to the operating room with a trauma patient you will see things you’ll never see in a hospital surgery patient, like the milky lymphatic ducts of the intestines (in all other surgery cases, patients are kept without food for many hours before surgery so their bowels (and the lymphatics which carry the emulsified fats we eat) are empty.). In trauma surgery, you’re working on a running engine.  Also, there’s often a significant element of “unknown” when you go to the OR with a trauma patient. These cases are time critical, and often the only imaging study you’ll have is a simple X-ray (no CT scan or MRI to tell you exactly what’s going on- there’s just no time).  A quick ultrasound may tell you there’s fluid in the belly, but you don’t know what that fluid is until you see it, and you don’t know where it’s coming from until you poke around for the source.  Trauma surgeons live in the moment- identifying, controlling, and treating acute injuries at times when minutes can make all the difference.

Another thing I like about trauma surgery, which is so different from general surgery, is that you are treating an acute incident that brings your patient to the table, not a chronic lifestyle (though one can argue that the lifestyle that many of our patients live is what is responsible for their trauma.  This is undoubtedly true for many or our MVC patients (please people- DO NOT DRINK AND DRIVE!) and some of our gun shot wounds and stabbings (we have quite a few repeat customers coming into our hospital for these injuries…).  There’s something about taking an acutely injured patient and ‘fixing them’ (or I prefer ‘putting them back together so they can heal’) that I enjoy that is missing in general surgery.

This feeling, however, comes at a cost.  The hours for any surgeon are long and arduous, but those of a trauma surgeon are longer and harder.  Yes, general surgeons get 3am consults, but a gunshot would to the chest is a lot more time-sensitive than an acute appendix or an obstructed bowel.  The lifestyle of a trauma surgeon is hard and it is wearing, and it obviously takes its toll.

Not surprisingly, trauma calls to a certain type of person… I loved the trauma surgeons- they were all so different: unique in their own ways and so obviously Trauma surgeons. During the last week (prior to my surgery exam) all the students (from all the different teams, about 30 of us in all- 5 had been on Trauma) were lectured by a number of surgical faculty.  You could always tell the trauma surgeons (even if they didn’t introduce themselves as such).  They lectured off the cuff- dynamic and fast.  None of them sat or stood by the computer flipping slides (if they used them)- they paced, gesticulated, called people out and made bold statements… They’re a little wild, often quick to act, and if I ever need a trauma surgeon, I’m really glad they are the way they are.

It was my experience on trauma, and with the trauma surgeons, that makes my heart ache a little bit as I check “No” for surgery. I know I could not mentally or emotionally hack the surgical residency (the hours and the years of all the other surgical specialties that you have to endure in order to do a fellowship in trauma). I also know that I will not put my body and my mind through the rollercoaster ride that is the call schedule of a trauma surgeon.  I know I need sleep. I know I need good food. I know I need sun and socialization.  But I will miss Trauma…

With 4 months and three specialties down, I look forward to my remaining 8 months and 4 specialties of third year.  As far as my speed-dating card goes, I think the best is yet to come. I don’t think Pediatrics, my next clerkship, will be the right fit, but I’m optimistic for the Family Medicine clerkship that follows and then the tour-de-force that is the Internal Medicine 4-month marathon.

When it comes down to it, I don’t think I’m going to find my perfect match in the speed-dating clerkships of medical school. Evolutionary medicine is a yet-to-be-defined specialty, and no residency program offers training in this field (though I have hopes for a fourth year elective in this area!). Indeed- just yesterday NPR mentioned evolutionary medicine and somewhat scathingly pointed out that it was not a practical discipline and at this point “only a theory”.

Actually, when it comes down to it, I don’t really think evolutionary medicine should be its own specialty… Much as it has been said that “nothing in biology makes sense except in the light of evolution”, I think “most (dare I say all?) issues of human health are best understood in the light of evolution”. You can find aspects of each specialty that would benefit from the keen focus of evolutionary minded individuals who, with careful thought, research, and synthesis of new ideas, could push the standards of medicine to new heights.

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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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