Archive for the ‘Principle into Practice’ Category

I’ve been hesitant to write this post.  This blog is certainly not a travel blog, and it was never intended to be a place where I posted my exciting travels (and to be honest, during the final years of my PhD and third year medical school I didn’t really have any exciting travels to write about).  That being said, I can’t help but post about my adventures in Moab.  If my antics encourage just one person to get outside and enjoy time in the great outdoors, I will consider this post a huge success…



After completing my Wilderness Medicine Elective, I opted to take two weeks of vacation time (4th year medical students can get a rather absurd amount of vacation time if we play our cards right) to recoup, relax, and since I was already out west, spend time in Colorado with my best friend.  With over 100lbs of luggage to lug around, I managed to sweet talk my best friend into picking me up in Salt Lake City (where my elective wrapped up), instead of hopping a plane to Denver.


My best friend is a good sport about road trips (I suppose she should be, as I once drove 28hrs straight with her when she moved cross-country to Colorado), and she was happy to come pick me up, suggesting that we route our trip back through Moab for a bit of outdoor adventuring before heading back to Colorado.  I didn’t know much about Moab before I got there, but I knew Arches National Park was right next door and that the desert portion of my course was in Canyonlands National Park, so I thought it might be fun to swing back through and at least check out Arches on our way back.


That was before heading west… Once I met and talked with the river guides who work out of Moab and spent a “transition” day there between the river portion and the desert portion of the Wilderness Medicine elective, I was counting down the days until I would be back.


Moab is a stunning place- the rock formations and geology surrounding the town are truly “other worldy”, with the red rock shaped by time and weather into precarious and beautiful structures.  There is also a LOT to do in Moab for people who enjoy the outdoors.  The Colorado River can be enjoyed from rafts, boards, boats, or the shore, there seems to be a new hike for every day of the year, biking (mountain and road) is king, and the weather in May is wonderful for camping (sans-tent, for those-like myself- who are so inclined).


There are plenty of places to stay in Moab, but being on a budget and having spent the majority of the prior 3 weeks sleeping outdoors, I was more than happy to camp in Moab.  There are many campsites with RV hook ups, tent sites, and amenities such as showers, but I’m a fan of primitive camping.  Fortunately, for those in the know (or those who get the scoop from knowing river guides), there is plenty of dispersed camping to be had in spots around Moab.


view from one of our camp sites up off Klondike Bluffs, about ten miles north of town.

The view from one of our camp sites up off Klondike Bluffs, about ten miles north of town.


We spent out first morning in Moab getting coffee (“That Paleo Guy”, Jamie Scott, would swoon at all the coffee spots in Moab) and sorting out plans for the next couple days.


Wicked Brew- home of a mighty fine shot of espresso

Wicked Brew- home of a mighty fine shot of espresso


After a morning in town we headed out for a hike at Fisher Towers.  This hike, while popular, is a bit off the beaten track (at least in comparison to the tourist heavy hikes in Arches National Park).  The rock formations are stunning and the plant life was beautiful. This place is popular for rock climbers, and it was breathtaking to see them atop the tallest towers.


Fisher towers- if you go on this hike, make sure you get on the proper trail… we ended up scrambling quite a bit looking for a trail on various dead ends when we erroneously got started on a “photograph trail”.

Fisher towers- if you go on this hike, make sure you get on the proper trail… we ended up scrambling quite a bit looking for a trail on various dead ends when we erroneously got started on a “photograph trail”.


“The Titan” is the tallest structure at Fisher Towers, and is very striking.

“The Titan” is the tallest structure at Fisher Towers, and is very striking.



Alas, I seemed to have a knack for attracting rain on this trip… As we rounded the turn at the top of the hike, we were greeted by storm clouds and a flash of lightning.  Needless to say, we made a rapid retreat (I did learn about lightning strikes on my Wilderness Medicine course, but like almost all aspects of medicine, the best solution is prevention, prevention, prevention!)

Alas, I seemed to have a knack for attracting rain on this trip… As we rounded the turn at the top of the hike, we were greeted by storm clouds and a flash of lightning. Needless to say, we made a rapid retreat (I did learn about lightning strikes on my Wilderness Medicine course, but like almost all aspects of medicine, the best solution is prevention, prevention, prevention!).


After our hike, we headed back towards Moab, making one stop at a local vineyard and a detour down Onion Creek Road.  If you are around Moab and have an AWD vehicle (or are comfortable taking your vehicle through multiple stream fords), definitely check out Onion Creek Road.  If you’re really lucky, one of the dispersed camping sites might be open and available (we didn’t have any luck on that front).


My best friend is an avid paddle boarder, and she’d contemplated packing her paddle boards down to Moab for us to use on the Colorado River.  It seemed that renting boards in Moab was a much better option, so after making some inquiries, we ended up renting two inflatable boards (Badfish MCIT) from Canyon Voyages, strapping then to our car, and driving them up river to our drop-in point.  We’d scouted the river the day before and had decided to drop in at Take-out beach and to get out at Lion’s Park: a ten-mile paddle downstream (with my friend opting for the hitchhikers shuttle after parking her car down at the pull-off site. Pro-tip: carry your PFD (personal flotation device) and catching a ride is pretty easy).


Boards- Ready for adventure.

Boards- Ready for adventure.


While a road parallels the Colorado River the length of our ten-mile paddle, the trip was still very calming.  I’ll be honest- I went through our lone rapids and a couple of the choppy fast-water sections firmly on my knees.

While a road parallels the Colorado River the length of our ten-mile paddle, the trip was still very calming. (Though I’ll be honest- I went through our lone rapids and a couple of the choppy fast-water sections firmly on my knees.)


The rest of our day was spent driving out to Dead Horse National Park, seeking out dinosaur footprints (yes really), cooking dinner at our campsite, and then meeting up with a new friend from my Wilderness Medicine Elective- one of the river guides from my travels down Desolation Canyon.


I can’t tell you if they’re Therapod or Sauropod footprints, but they were pretty cool!

I can’t tell you if they’re Therapod or Sauropod footprints, but they were pretty cool!


As much fun as the previous two days had been, the real adventures began when we started hanging out with a local… My river guide friend was just back from another long trip down Desolation Canyon, which meant that he had a bit of time off before heading back to the river.  The next morning he took us on a hike up to Cable Arch, an arch off the beaten track on an unmarked trail.  Our drive out to the trailhead took us past quite a few petroglyphs, including one that I found very interesting.


The birthing rock- my picture isn’t the best, but this petroglyph seems to show a breach position birth.  Some readers may remember that I’m interested in “traditional” positions for giving birth, so I found these depictions particularly interesting.

The birthing rock- my picture isn’t the best, but this petroglyph seems to show a breach position birth. Some readers may remember that I’m interested in “traditional” positions for giving birth, so I found these depictions particularly interesting. (Here’s a better picture.)


An arch all to ourselves… something you seldom get in Arches National Park

An arch all to ourselves… something you seldom get in Arches National Park


Not another person for miles...

Not another person for miles…


Scrambling up and down rock faces is a lot of fun (and an excellent work out)…

Scrambling up and down rock faces is a lot of fun (and an excellent work out)…


After a relaxing lunch in town, we headed up to the Sand Flats for an afternoon adventure of rappelling.  I’ve never been rappelling (save for the ~15’ rappel we played with up in the alpine on the Wilderness Medicine course), and I’ll admit that at the top of our first descent I was more than a little nervous.  However, as I lowered myself into the slot canyon (into an area aptly named “the medieval chamber”), my fear was replaced by exhilaration.


Rappelling down into the "Medieval Chamber".

Rappelling into the “Medieval Chamber”.


The second rappel, off a natural bridge, landed us at the focal point of a somewhat well travelled out-and-back hike.  My best friend went first, and her adventures were well documented by some of the sightseers below!


Kate, headed down off the natural bridge

Kate, headed down off the natural bridge


The next day found us rappelling again, this time in Arches National Park.  We were truly spoiled to have a local show us yet another awesome spot, for while we left our car in a crowded parking lot, we quickly backtracked along the road and scrambled up a rock fall to find ourselves isolated atop a large mesa.  Hundreds of feet above the other tourists below us, we spent much of the morning relaxing above Arches, in our own world, away from any other visitors to the park.


Above Arches- We spent quite a bit of time wandering around the top of the mesa, but eventually we settled down to soak up the sun, talk, and relax.

Above Arches- We spent quite a bit of time wandering around the top of the mesa, but eventually settled down to soak up the sun, talk, and relax.


Above Arches- I’m not sure the scale comes through…

Above Arches- I’m not sure the scale comes through…


After an hour or so of basking on the rocks, we started our descent back down into the canyons.  This (again, unmarked) path took us down a number of small descents before finally putting us atop a 100’ wall down to the canyon floor.  The rappel was a rush.


Can you find me? Hopefully the scale comes through now!

Can you find me? Hopefully the scale comes through now!


My best friend and I did plenty of other things in Moab, including taking a drive and some hikes through Arches National Park. Arches IS stunning, but after getting an insiders-tour to some stunning and relatively unknown-to-tourists spots, hiking along crowded groomed trails to ogle at postcard views lacked some luster.  I don’t mean to sound snooty, and I hope it doesn’t come across that way, but I think my favorite moments of this trip to Moab were the moments with friends around bonfires, scrambling up rocks, and quietly taking in all that our surroundings have to offer.


After more than a month away, I am finally headed home to New Jersey.  I am heading home physically tired but psychologically refreshed.  I have always believed that nature is *good* for humanity, but I have never experienced this goodness so intensely as in the last month.


Through the wilderness medicine elective, my trip to Moab, and then a Memorial Day Weekend camping trip in the mountains of Colorado, I have experienced many different environments.  A big part of experiencing these environments, to me, is learning to be present in the moment- to quiet the mind of all the banality and drama that so easily catches us and to really appreciate what surrounds us.  In the hustle and bustle of normal life this skill takes practice, but it is practice that pays back in dividends on the principle that nature satisfies a deep and primal part of our humanity, and we should seek it out and absorb it whenever possible.


Memorial Day Moonrise over Twin Lakes in Colorado- Not sure I can think of a better way to end the day…

Memorial Day Moonrise over Twin Lakes in Colorado- Not sure I can think of a better way to end the day…


Find your people, find your places, and enjoy the moment…

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I’ve previously written about the benefits of squatting for ailments of the gastrointestinal tract, specifically diverticulitis and hemorrhoids.  Some argue that squatting to defecate can prevent all manner of illness and while there are some clinical conditions I’d like to explore further in the squatting-in-the-bathroom paradigm, today I want to write about something quite different.


I finished my Obstetrics and Gynecology clerkship 5 weeks ago. I did my clerkship at a large, and rather posh, private hospital that is affiliated with my medical school.  There are some great doctors there, but I was sometimes aghast at the rather aggressive approach to delivery that many took.  The cesarean section rate for the last year was 47%, well above the national average of 33%, and most labors were artificially augmented.  I did not witness a single VBAC (Vaginal Birth After Cesarean), and was told that only one of the house attendings would perform them.


On the first day of my clerkship, I asked the clerkship director if women delivered in a variety of positions or if they were restricted to delivering in lithotomy (what many today think of as the “traditional” birthing position with the mother on her back with her feet in stirrups).  The director seems to be a rather progressive woman (she is the driving force pushing the hospital to become a “baby-friendly hospital”) and she gave me a rather knowing look and said “I know what you’re getting at, but unfortunately everyone here delivers lying down”.


Indeed, as I went through my rotation, all the vaginal deliveries I saw were done in the semi-reclined position that is common in western hospitals.  This is not universally true.  When I ask my family physician (who actually delivers babies- quite a rarity in this day and age) what position her patients delivered in, she immediately responded “whatever position they’re most comfortable in!”, a response I have heard from a few other MDs as well as many midwives and labor coaches.


Birth is, of course, a risky thing… Death in childbirth was historically a significant cause of mortality, and the rates are still high in some countries.  I think it’s important to recognize that birth is still a risky endeavor, and while pregnancy and labor is a normal human experience, it is one that comes with real dangers. Nonetheless, just because historic rates of maternal demise were much higher than they are today does not mean we should not cast an eye to historic practices when thinking about birth.  As I’ve argued before, I think modern medicine (in obstetrics and in most fields) could greatly benefit from casting an eye to evolution and our ancestors to further improve our current medical system by combining ancestral and evolutionary knowledge with modern technology and science.


I planned to write a significant argument for the consideration of “non-traditional” (though they are, in fact, traditional) positions for laboring, but then I came across a book from 1883 that said it all already. The book, entitled Labor Among Primitive Peoples (with the subtitle Showing the development of the obstetric science of today from the natural and instinctive customs of all races, civilized and savage, past and present.) by George Julius Engelmann MD, is available in it’s entirety thanks to the power of Google Books.


This book is fascinating, and at many times frightening (more on that later), but I found the “Posture in Labor” chapter of particular interest for this post.  There, the author divides the positions into 3 main categories: Perpendicular (including standing, partially suspended, and suspended), Inclined (including sitting erect, squatting “as in defecation”, kneeling, and semi-recumbent), and horizontal (on the back, side, or chest and stomach (!)). He also goes through the then common birthing practices of countries in Europe, Asia, Africa, North America, Central and South America, and Australia and the surrounding islands [1].


Curious?- here are some highlights from the book, but I highly recommend you take a scroll through the book to at least see the illustrations!


The squatting position of the Tonkowas- a Native American group indigenous to present-day Oklahoma and Texas.

The squatting position of the Tonkowas- a Native American group indigenous to present-day Oklahoma and Texas.


The squatting tradition of the Pawnee Native Americans- the laboring mother squats with her back to a female assistant while someone (in this case a shaman) assists with the delivery. This position (with an assistant acting as a back support) was apparently popular in many cultures around the world.

The squatting tradition of the Pawnee Native Americans- the laboring mother squats with her back to a female assistant while someone (in this case a shaman) assists with the delivery. This position (with an assistant acting as a back support) was apparently popular in many cultures around the world.



If you’re curious (as I was) this is what a “suspended” birth looks like, here you go.

If you’re curious (as I was) about what a “suspended” birth looks like, here you go.


There is plenty to be said on each of the positions mentioned, but for the sake of this post I will focus on what the author says on squatting.  He states that squatting


is hardly to be defined with exactness, yet we may, in a general way, consider all postures as squatting which resemble that assumed in defecation. Though apparently inconvenient, and repugnant to the refined woman, this position is certainly the most natural one for expulsion from the abdominal or pelvic viscera, and will certainly, in many cases, facilitate labor. (72)


He documents the experience of another physicians, saying:


“… he tells me of attending a lady of good position in society in two labors. ‘In her first labor, delivery was retarded without apparent cause. There was nothing like impaction, or inertia, yet the head did not advance. At every pain she made violent efforts, and would bring her chest forward. I had determined to use the forceps, but just then, in one of the violent pains, she raised herself up in bed and assumed a squatting position, when the most magic effect was produced. It seemed to aid in completing delivery in the most remarkable manner, as the head advanced rapidly, and she soon expelled the child by what appeared to be one prolonged attack of pain. In subsequent parturition, labor appeared extremely painful and retarded in the same manner; I allowed her to take the same position as I had remembered her former labor, and she was delivered at once squatting.” (73)


Information on traditional birthing positions can also be wrought from the Old Testament. The King James translation of Exodus 1-16 says “When ye do the office of a midwife to the Hebrew women, and see them upon the stools…”. However there is some scholarly debate about the translation of the word “stools”, as a more accurate translation might actually be “stones”.  You might wonder what stones have to do with birthing, until you see this depiction of a popular Persian birthing position.


If you’re curious (as I was) this is what a “suspended” birth looks like, here you go.

If you’re curious (as I was) this is what a “suspended” birth looks like, here you go.


A friend recently shared a video of women delivering in the squatting position.  I post this video with the STRONGEST OF WARNINGS. I warn (only slightly jokingly) that that which is seen, cannot be unseen*. Proceed at your own risk! Birth is magical (though not mysterious), but some people find the imagery rather disturbing.


With that warning in place, I present the following video:



Those that have seen (or perhaps experienced) birth in the modern conventional position will probably agree that these women make labor look somewhat easy…


It’s also interesting to explore the delivery position of some of our closest living ancestors.  It appears that chimpanzees naturally deliver in a squatting position (with a similar “occiput anterior” presentation).



One of the most basic elements of obstetrics that we learn in medical school is the “7 cardinal movements” of delivery. Medical student must know these movements- engagement, descent, flexion, rotation, external rotation, and expulsion- and on the labor and delivery floors we are expected to participate in and assist with deliveries.  I remember watching many of my classmates “air-deliver” babies- going through the maneuvers of “catching” (a much more honest term than “delivering”) a baby, as we discussed these cardinal movements. While I understand that it is important to know these normal movements, the idea that a physician actually guides these movements is laughable. Truly, in most deliveries, our hands are there to catch and support. In fact, they are likely only necessary because of the position that we have developed for women to deliver.  In this youtube video explaining the 7 cardinal movements, the doctors hands only show up once the head is expulsed so that the baby’s head does not rest on the perineum. Indeed, “protect the perineum” is the mantra chanted to med students and novice doctors learning to deliver babies in a reclining position.  In the squatting position, gravity protects the perineum.


Support is needed because of maternal positioning, not intrinsic necessity.

Support is needed because of maternal positioning, not intrinsic necessity.


Gravity isn’t the only reason to consider delivering in a squatting position. I’ve heard it said (though haven’t found a reliable source) that squatting not only increases a woman’s ability to push (allowing her to better utilize her abdominal muscles), but also helps the pelvis open wider for delivery (due to the pull of abducting muscles).  In this position, and with the aid of gravity, it seems (and again I’ve heard it suggested) there is a lower risk of a perineal tear, something that I saw all too frequently during my Ob clerkship.


Squatting is by no means a perfect solution to birthing.  According to at least one study conducted in Nepal, squatting deliveries (along with multiparity and early age of first birth) are associated with an increased risk of pelvic organ prolapse later in life [2].  Also, opting for a squatting delivery removes the option of an epidural for pain control. An epidural causes a loss of sensation below the level of anesthesia, thus making walking (and squatting) impossible.


Squatting is not the only traditional (though now it would be classified as “non-traditional”) birthing position that women can consider.  I whole-heartedly appreciate my family physician who encourages women to find a position that is most-comfortable for them.  Hands-and-knees (exactly what it sounds like), has actually been studied in the first stage of labors for mothers whose babies are delivering in the occiput-posterior position.  While the study was small, the findings were encouraging [3].


Sometimes when I talk about evolutionary and ancestral medicine people assume that I am anti-modern medicine.  I am not. In childbirth in particular, modern advances in general health, pre-natal care, diagnostics, medicine, and surgery have saved countless lives. I am, however, in favor of assessing (and re-assessing) our beliefs (new and old) about how to best obtain and preserve health.


I find Dr. Engelmann’s book fascinating, and while there are elements that are rather disconcerting (the traditions of male and female circumcision, a surgery performed on men to decrease fertility, and the tradition in one culture of removing one testicle to prevent the conception of twins to name a few), I find his observations and his humble admissions (as well as his love of commas) lovely.  His conclusions are well worth reading (emphasis mine):


Abler obstetricians than myself have undoubtedly understood the movements of women, and the positions which they assumed in the agony of the expulsive pains. As regards myself, I must candidly confess this was not the case; and it was not until I had undertaken this work, and had begun to study the positions assumed by savage and civilized people during labor, that I began to understand that there was a method in the instinctive movements of women in the last stage of labor. I had seen them toss about and sought to quiet them; I bade them have patience and lie still upon their backs; but, since entering upon this study, I have learned to look upon their movements in a very different light. I have watched them with interest and profit, and believe that I have learned to understand them. It has often appeared to me, as I sat watching a tedious labor case, how unnatural was the ordinary obstetric position for the parturient woman; the child is forced, I may say, upwards through the pelvic canal in the face of gravity, which acts in the intervals between the pains, and permits the presenting part of the child to sink back again, down the inclined canal. If we look upon the structure of the pelvis, more especially the direction of the pelvic canal and its axis, if we take into consideration the assistance which may be rendered by gravity, and, above all, by the abdominal muscles, the present obstetric position seems indeed a peculiar one.


The contractions of the previously inactive and rested abdominal muscles are a powerful adjunct to the tired uterine fibre, in the last prolonged and decisive expulsory effort, and in the dorsal decubitus they are somewhat hampered; they act to the best advantage in the inclined positions, semi-recumbent, kneeling, or squatting. We know that the squatting position is the one naturally assumed if an effort is required to expel the contents of the pelvic viscera; we, moreover, all know how difficult, even impossible, it is for many to perform those functions recumbent in bed, and mainly because they have-not sufficient control of the abdominal muscles in that position. Much more is this the case in the expulsion of the child; but the recumbent position is sanctioned by custom; it is pointed out as apparently convenient; it is imperatively demanded by prudery; and by a false modesty which hides from view the patient’s body beneath the bed clothes; and above all it is dictated by modern laws of obstetrics, the justice of which I have never dared question; we have all been taught their correctness, and we all thoughtlessly follow their dictates. There is no reason for assuming this position, though we are taught it; it is not reason, or obstetric science, but obstetric fashion which guides us,- guides us through our patients; and blindly do we, like all fashion’s votaries, follow in the wake. (140-141)


Obstetrics is a specialty where many do not want to question the norm. Indeed, fear of litigation generally pushes physicians to be overly aggressive in managing labor and quick to opt for cesarean delivery. Randomized controlled studies that push the boundaries of modern “obstetric fashion” are unlikely to be performed for fear of litigation, but observation of mothers who choose to deliver in various positions as well as consideration of ancestral practices can potentially help drive modern medicine to a higher standard.



The “progression” of the obstetrical chair. The first stool is not unlike some modern  birthing stools, while the final incarnation is not too far displaced from the modern delivery-room bed.

The “progression” of the obstetrical chair. The first stool is not unlike some modern birthing stools, while the final incarnation is not too far displaced from the modern delivery-room bed.


*A brief story from when I was on an Emergency Medical Services elective.  The ambulance I was on was called to back up another team that had gone to attend at precipitous delivery. When we arrived, it became apparent that we were not there to assist the patient (it was her fourteenth (!!!) delivery), but rather to make sure that the EMT who had just witnessed his first delivery did not pass out.  He had a very pale and shocked look to him, and he just stared at us blankly as we helped the mother with her new child. After a couple minutes, he looked at us and asked “does the mental image ever go away?”. He later admitted that he didn’t want to sleep with his girlfriend for at least two weeks… I believe this is what a good male friend of mine describes as figuring out the difference between “medical vagina and sexy vagina”. 


1.            Engelmann, G.J., Labor Among Primitive Peoples. Second ed. 1883, St Louis: J.H. Chambers and Co.

2.            Lien, Y.S., G.D. Chen, and S.C. Ng, Prevalence of and risk factors for pelvic organ prolapse and lower urinary tract symptoms among women in rural Nepal. Int J Gynaecol Obstet, 2012. 119(2): p. 185-8.

3.            Stremler, R., E. Hodnett, P. Petryshen, B. Stevens, J. Weston, and A.R. Willan, Randomized controlled trial of hands-and-knees positioning for occipitoposterior position in labor. Birth, 2005. 32(4): p. 243-51.


And finally, for your viewing pleasure, this classic:


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1-year Blogiversary


It has officially been one year since I started blogging (1 year and 4 days if you’re being exact).  Starting blogging as I started third year medical school was probably not one of my smartest moves.  Third year medical is tough, mainly by being incredibly demanding of your time and sanity. All the same, I’m really glad that I finally started putting words-to-website and getting some of my thoughts out there for others to read.  Blogging is something I had wanted to do for a while, but wonderful people though they are, I think my parents might have disowned me if I’d started writing a blog before I’d finished writing my thesis!


Starting blogging during my clinical years has led to a couple things. First- I haven’t been able to put the requisite time into a number of the topics I originally wanted to write about (though I plan to get to these topics eventually!). Second- I’m surprised by how much I want to write about clinical situations and my general experiences on the floors. Together, this means that my blog is slightly different that I had initially imagined and that I have a long list of potential future blog posts (as well as a folder on my desktop with a significant number of “started posts” that may never see the light of day or the glint of a readers eye).


I sincerely want to thank everyone who has joined me over the past year on my blogging journey. I deeply appreciate that you take the time to read my musings. I really enjoy getting comments and I apologize that I sometimes get too caught up to reply to all the thoughtful responses.


I also want to thank everyone who has shared my blog and my posts.  I’ve had a couple big days when some rather “big shot” bloggers have shared my posts (most recently Mark Sisson gave me a big bump when he shared my snuggling post in last week’s “Link Love”) but I really appreciate (and am humbled) that readers like my posts enough to share them on facebook and twitter . One of the fun elements of having a blog (at least for those with a significant nerdy streak) is keeping an eye on the statistics generated by your blog host… more on that later!


Exciting News…


I’m very excited to announce that I have been invited to speak at the 2013 Ancestral Health Symposium this August in Atlanta.  I attended the last year’s conference in Boston, and am excited to be speaking on one of my favorite subjects, lipids and liver, at this year’s event.  Tickets are already on sale for society members and early registration starts for non-members on March 15th. The symposium sold out the last two years, so if you plan to attend make sure you reserve your tickets early!


In addition to giving a talk on liver and lipids, I’ll also be heading up a panel of ancestrally minded physicians.  The details are yet to be settled, but with a panel including Dr. Emily Deans (of Evolutionary Psychiatry), Dr. Anastasia Boulais (of Primal Med Ed), Dr. Jacob Egbert, and Dr. Don Wilson, I’m sure there will be some interesting discussion exploring how to use ancestral and evolutionary thinking in a variety of clinical fields including psychiatry, hospitalist practice, physiatry, and ob/gyn respectively.  More details to follow!


Fun with Stats…


As I mentioned above, one of the joys of having a blog (at least for those of us with a nerdish interest in numbers) is keeping an eye on the blog’s stat page.  In addition to showing me which posts are popular and why, it also shows me the search terms that navigate people to my page.  “Principle Into Practice” is a popular google search that navigate people to my page.  Some of the more obscure ones are a little more puzzling (and amusing).  Here are some favorites:

Help me, I’m dating a medical resident

– “Dating in medical school”, “dating a medical student”… some variation on this theme is one of the more popular phrases that gets people to my blog, no doubt linking them to this post . I’m sure that’s not the kind of dating advice the googlers were looking for- sorry!  As for actually dating a med student? Good luck… the first two years are probably more “dating friendly” as the schedule (at least at my school) is quite flexible, but my experience with third year is that your time is generally spent in the hospital or sleeping.  Date a med student at your own peril- they will undoubtedly want to practice physical exam skills on you and they’re probably a bit short on time for making much of a relationship. Also, if you think dating a medical student is bad, I can only imagine the horror that is “dating a medical intern”. Their schedule makes a med-student’s schedule look like a walk in the park!

Can you burst your appendix by eating a lot of pickles

-Umm… no

Can you get out of the country if you have c difficile

– Actually, a lot of people are walking around with C. diff in their system. Problems arise when you have an overgrowth, at which point you probably can’t be anywhere too far from a toilet… (and you need prompt medical attention)

Victoria Principle nude

-This web-surfer undoubtably went away disappointed…


Asparagus therapy and human parasites


C. diff and asparagus

-I got nothing…

How to sleep during medical school

– My answer? As much as you can, whenever you can.  Refer back to “dating a medical student” if you’d like.

What speciality [sic] in medicine combines clinical practice and evolutionary theory

– I’m not sure, but if you figure it out, please let me know! (Actually, as I’ve argued before, I think there’s a need for an evolutionary perspective in ALL fields of medicine, though perhaps some have more opportunities for evolutionary thinking than others.)


Most search terms guide the seeker to appropriate pages, and I hope that my posts enlighten and entertain.  Many of my favorite posts, some of which are also my most popular posts, can be found here on my “Favorites” page, if you’re ever looking for some interesting posts you might have missed!


A final thanks….


I said it before; I’ll say it again.  Thank you to everyone who reads, shares, and/or comments on my blog.  It’s been a fun year of blogging and I’m looking forward to more posts, speaking at AHS 2013, and continuing to interact with readers, friends, and those who share an interest in ancestral health and evolutionary medicine… and also those who are curious about dating in med school! 🙂

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‘Tis the season for cheesy cards, overpriced restaurant dinners, flowers, chocolates, jewelry, and stuffed animals.  I’ll admit that I’ve never been a huge fan of Valentine’s Day.  We started off on the wrong foot, with those awkward grade-school valentine exchanges, and I’ve never seen eye-to-eye with Valentine’s day over the crass-consumerism that seems part-and-parcel with this holiday.  That, and even in my most desperate days I could never understood the gustatory appeal of candy hearts.


This year, instead of doing my best to ignore the day, I thought I’d have a little fun. I’ve said it before and I’ll say it again: evolution is everywhere. This is never more true than in the bedroom!


Snuggling, cuddling, spooning… name your term.  


Why do humans like to cuddle?  There are a number of arguments that can be made for snuggling.  Physical contact in the form of massage increases levels of the “love” hormone oxytocin [1] and decreases cortisol [2] (though some of the data on massage is fuzzy, perhaps because massage, especially in a research setting, can be a rather impersonal experience in comparison to cuddling).  More frequent hugs increase oxytocin levels and lead to lower blood pressure and heart rate in premenopausal women [3]. An interventional trial that looked at the effects of “warm touch” (including hand-holding, hugs, and “cuddling up”) in married couples showed an increase in salivary oxytocin (in husbands and wives) and a decrease in systolic BP (in husbands only) in the treatment group [4].


Increased oxytocin seems to enhance the effects of social support on stress responses [5].  Oxytocin also plays a role in the early stages of romantic attachment, and encourages pair-bonding (and parental attachment) [6]. But oxytocin isn’t the only compound that is altered by cuddling-up or that affects the way we feel about other people. There is also evidence that touch alters the release of endorphins[7], and that neuropeptides may play a role in the beneficial nature of physical touch [8].


On a day like Valentine’s Day, which purports to revolve around the concept of love (and chocolate sales), the arguments that physical contact reduces stress and increases the hormone associated with pair-bonding are probably king.  Recently  (and I did warn you I’m a bit cynical about this holiday), I’ve been wondering if there is something a little more… “anatomically practical” about cuddling.


Why you (men) shouldn’t “hit it and quit it”.


Anyone that has spent anytime thinking about human pair bonding has spent time thinking about short-term vs. long-term interests when it comes to the mating game. Yes, humans are predisposed to long-term bonding, but that doesn’t mean that there isn’t a significant role of short-term mating in human procreation (perhaps not as much now, thanks to social norms and the potential for paternity tests, but sources frequently cite that ~10% of children aren’t actually the offspring of the father that raises them, though a more thorough investigation shows that the rate is probably closer to 3% [9].).  As an aside, while on my EMS elective I was repeatedly subjected to the Maury Povich show and it’s ilk while hanging out at headquarters (the lounge TV was usually blaring in the background). I doubt that Frederick Sanger imagined how his great discovery of DNA sequencing would be used when he developed the method in 1975 (for which he later won a Nobel prize in Chemistry- his second). “You are NOT the father!!!” But I digress…


Different species have various ways of decreasing paternity uncertainty.  Some animals- canines for example- have a very… awkward (maybe I’m being anthropomorphic, I apologize) way of increasing the likelihood of paternity. After the completion of mating, the male doesn’t leave the female’s side. He can’t. Seriously. He is physically attached.


Dog mating is significantly different from that of humans. When the dog’s penis is first inserted into the vagina it isn’t actually erect and is only able to penetrate thanks to the penis bone, also known as the baculum. After insertion, the penis swells and the bulbus glandis at the base of the penis literally locks the penis in place, preventing the removal of the penis. This is known as “knotting” or “tying”.  This cumbersome position usually lasts 5-20 minutes after ejaculation.


At least one book on dog genetics says that this process seems “quite irrational”, but the authors submit that it “must serve a purpose as it has remained despite apparent drawbacks, such as vulnerability to attacks during the act.” [10]. I doubt I’m the first to suggest that the advantage of this prolonged intimacy is an increase in certainty of paternity.  It seems rather obvious that this method of copulation gives the lucky suitor’s sperm time to gain advantage in the race to fertilization, before another competitor’s sperm can enter the race.


Fortunately, humans have not evolved this mechanism of assuring paternity. Instead, I’d argue that post-coital snuggling can offer some of the advantages of canine-coupling.


Some people might think that humans are above such an animalistic tendency. If a man doesn’t stick around long enough to ensure that his sperm have time to reach their destination, would another man’s actually get the chance?


Well maybe…  It has actually been argued that the human penis is evolutionarily shaped (literally) to help a man get his semen where it needs to be, even if it didn’t actually get there first.  In the article “The human penis as a semen displacement device*”, researchers argue that the shape of the human penis is “designed” to remove semen from the vagina during sex, clearing the way for new semen to be deposited in the most advantageous location (increasing the likelihood of paternity) [11].  This strengthens the argument that if you’re a man, and you want to ensure paternity, it’s probably best you hang around to make sure your sperm doesn’t have any competition in reaching it’s goal.


So there you have it, the “principle into practice evolutionary argument for snuggling”.  Sure, in the modern world men may not WANT paternity with every sexual encounter, but that doesn’t mean that the evolutionary mechanisms and behavioral predispositions aren’t already in place to improve paternity-certainty.  On a day like Valentine’s day, you might rather focus on how cuddling increases oxytocin, leading to emotional bonding.  Just remember that snuggling also physically bonds you, and that may not be such a bad thing…


*This paper wins the award for most giggle-worthy methods. Some of the lines could be right at home at #overlyhonestmethods. E.g.: “… this recipe was judged by three sexually experienced males to best approximate the viscosity and texture of human seminal fluid.”



1.            Morhenn, V., L.E. Beavin, and P.J. Zak, Massage increases oxytocin and reduces adrenocorticotropin hormone in humans. Altern Ther Health Med, 2012. 18(6): p. 11-8.

2.            Rapaport, M.H., P. Schettler, and C. Bresee, A preliminary study of the effects of repeated massage on hypothalamic-pituitary-adrenal and immune function in healthy individuals: a study of mechanisms of action and dosage. J Altern Complement Med, 2012. 18(8): p. 789-97.

3.            Light, K.C., K.M. Grewen, and J.A. Amico, More frequent partner hugs and higher oxytocin levels are linked to lower blood pressure and heart rate in premenopausal women. Biol Psychol, 2005. 69(1): p. 5-21.

4.            Holt-Lunstad, J., W.A. Birmingham, and K.C. Light, Influence of a “warm touch” support enhancement intervention among married couples on ambulatory blood pressure, oxytocin, alpha amylase, and cortisol. Psychosom Med, 2008. 70(9): p. 976-85.

5.            Heinrichs, M., T. Baumgartner, C. Kirschbaum, and U. Ehlert, Social support and oxytocin interact to suppress cortisol and subjective responses to psychosocial stress. Biol Psychiatry, 2003. 54(12): p. 1389-98.

6.            Schneiderman, I., O. Zagoory-Sharon, J.F. Leckman, and R. Feldman, Oxytocin during the initial stages of romantic attachment: relations to couples’ interactive reciprocity. Psychoneuroendocrinology, 2012. 37(8): p. 1277-85.

7.            Keverne, E.B., N.D. Martensz, and B. Tuite, Beta-endorphin concentrations in cerebrospinal fluid of monkeys are influenced by grooming relationships. Psychoneuroendocrinology, 1989. 14(1-2): p. 155-61.

8.            Dunbar, R.I., The social role of touch in humans and primates: behavioural function and neurobiological mechanisms. Neurosci Biobehav Rev, 2010. 34(2): p. 260-8.

9.            Anderson, K.G., How Well Does Paternity Confidence Match Actual Paternity. Current Anthropology, 2006. 47(3): p. 513-520.

10.            Ruvinsky, A. and J. Sampson, The Genetics of the Dog. http://www.google.com/books?id=bgZwjdB4xgEC&source=gbs_navlinks_s ed. 2001: Google Books.

11.            Gallup, G.G., R.L. Burch, M.L. Zappieri, R.A. Parvez, M.L. Stockwell, and J.A. Davis, The human penis as a semen displacement device. Evolution and Human Behavior, 2003. 24: p. 277-289.

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

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

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

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

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

“Any pain?”

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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Many people get their start in the ancestral health/evolutionary wellness world through food.  Be it “paleo” or “primal” (or perhaps the ever practical advice of Dr. Emily Deans: “Don’t eat like a Jerk”), most people start this journey with food, and then start to apply the evolutionary mindset to other aspects of life. Once the logic of “eating evolutionarily” sets in (and once you realize how good you look and feel while doing it), you might start to apply the evolutionary approach to other aspects of your life.

Once you’ve been at this long enough, you start to think about the evolutionary aspects of everything- food, movement, socialization, sex, sun, stress, and sleep (so many s’s!)- but it seems that the two that most frequently go together are food and feet.  The exact timeframe may vary, but there’s usually not a huge gap between someone adopting a “primal” or “paleo” diet, and someone purchasing their first pair of Vibram Five Fingers– and so your migration to the fringe begins…

The jump from an evolutionary approach to food to barefoot running is an appropriate one.  The evolution of the foot (and our ability to run) is often traced to the human ability to run down prey, and thus the evolutionary argument that meat is an important part of an appropriate human diet. From an evolutionary health perspective, the argument that “these feet were made for moving” (without the help of massive rocker-bottom shoes) just starts to make sense, and might just prevent (or explain) injury.

If you’re not familiar with the arguments for a barefoot approach (or if you are, but haven’t seen this video), I highly recommend the following brief video, made to accompany this paper [1], in the eminent journal Nature*.

It certainly makes sense that a forefoot foot strike pattern inline with our evolutionary “design” might be protective against running-induced injury.  Indeed, a small retrospective study that was published this July showed exactly that.  In cross-country runners, those with a forefoot foot strike had significantly less repetitive stress injuries than their rearfoot-striking counterparts [2].

Embracing the barefoot message does not mean you have to embrace actually going barefoot.  You can see from the VFF link above that there are options for those who want the barefoot experience without the unpleasant effects of doggie-doo.  For those worried about being labeled part of the monkey-foot army, have no fear- there are minimalist options out there that are relatively indistinguishable from *regular* footwear.

In the last few years there’s been an explosion of minimalist or “barefoot” shoes. Those in the market can chose from a number of mainstream or more esoteric brands.  From New Balance Minimus Zeroes and Merrel Gloves to Vivobarefoot and some of the Inov-8 options, there are many options for the barefoot enthusiast to try.

I’ve gone through a number of pairs of VFF at this point, with the rather simple KSOs being my style of choice.  I’ve endured the occasional joshing from friends and entertained many questions from strangers out on trails, and am generally enthusiastic about VFFs, but they’re definitely not a “stealth” minimalist shoe.  On the other hand, the Vivobarefoot sneakers that I wear in the hospital look like totally normal sneakers. [I’ll admit my favorite hospital “outfit” is the 4 S’s- Scrubs, Sneakers, Sweatshirt, and Stethoscope]

I’m not here to write a review of the Vivos I’ve been wearing (though they’ve been great for me). My advice for anyone looking to explore minimalist shoes is to go to a store and try on the different options. I know some people love the Merrel line, but they’re definitely too narrow in the arch area for me (they leave me feeling like I’m in shoes with big arch support).  I want to try the NB Mimimus Zeroes (the newest NB “barefoot” option with no heel drop) before I purchase my next pair of sneakers.

Shopping for a new pair of sneakers is definitely on my mind, as I’ve recently realized that my original pair of Vivos is on the way out. They’re had a good run, but some of the luggs are now totally worn down, and the sole is starting to erode too. I hadn’t noticed in the way they wore, but when I flipped them over I was initially surprised to see where there was wear.

Ever since I was a kid I’ve been “hard” on sneakers. I’ve worn through the soles of many shoes (and stomped down the back of many an unlaced sneaker- much to my parents chagrin). In the past, I’ve always noticed that it was the heels of my sneakers’ soles that went first.  With my Vivobarefoots, the wear is only prominent at the ball of my feet. I dug up an old pair of sneakers (not worn out, as I switched over to minimalist options before these were done) and you can clearly see that the greatest wear is in the heel areas. Yes- there is some wear in the toes, but not much. For contrast, look at my ailing Vivos.

The different wear patterns in my last pair of normal Merrels and my minimalist Vivobarefoots.

For me, this is pretty convincing evidence that minimalist shoes do, in fact, encourage the midfoot strike that is desired by those that go barefoot. That’s not to say that minimalist shoes are a cure-all for heel striking. You can check out this video from the 2011 NYC barefoot run to see the variety of footfall patterns- many of those with minimalist shoes have a different footfall from the truly barefoot, with a couple examples of heel-striking in minimalist shoes… ouch!

Some technical difficulties aside, minimalist shoes are definitely a step in the right direction (pun intended?) for those wishing to get a more “evolutionarily appropriate” footfall, without going truly barefoot (or for those who might like to go barefoot, but are constrained by social norms (or hospital policy!))

Lunch/sun break on a sunny day on my surgery clerkship.

Usual disclaimers apply- minimalist shoes are not for everyone. Getting accustomed to minimalist shoes can take time. Consult a medical professional before starting any exercise regime. Go in search of the Wizard of Oz (NOT DOCTOR OZ!) if you are in need of your own brain.

*For those keen on reading more about evolutionary medicine, Daniel Lieberman published an article on evolutionary medicine and barefoot running in April [3].

1.         Lieberman, D.E., M. Venkadesan, W.A. Werbel, A.I. Daoud, S. D’Andrea, I.S. Davis, R.O. Mang’eni, and Y. Pitsiladis, Foot strike patterns and collision forces in habitually barefoot versus shod runners. Nature, 2010. 463(7280): p. 531-5.

2.         Daoud, A.I., G.J. Geissler, F. Wang, J. Saretsky, Y.A. Daoud, and D.E. Lieberman, Foot strike and injury rates in endurance runners: a retrospective study. Med Sci Sports Exerc, 2012. 44(7): p. 1325-34.

3.         Lieberman, D.E., What we can learn about running from barefoot running: an evolutionary medical perspective. Exerc Sport Sci Rev, 2012. 40(2): p. 63-72.

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Sorry there’s been a delay in getting anything new out. I’ve had some exams, a quick trip to Colorado, and am now just finding my feet on my surgery clerkship. I have a bunch of things I intend to write about soon, but this paper popped up the other day and it ties in really nicely to some of the things I’ve already written about. I just had to write about it! I promise that in my upcoming posts I will get away from bowels and microbiota (though these subjects are incredibly important!).

You may remember Clostridium difficile from one of my previous posts on the appendix. C. diff is an anaerobic bacterium that frequently resides in the large intestine. After a course of antibiotics, when other gut-inhabitants have been killed, an overgrowth of C. diff can lead to a very nasty spectrum of symptoms ranging from mild diarrhea to death. Because of the frequent use of antibiotics and because of new hyper-virulent strains of C. diff, infection with this bacterium has reached epidemic levels. Alas, this is one of the most common infections found in hospitals, nursing homes, and other medical facilities.

The incidence of C. diff is on the rise, with both the number of cases and the mortality from infection recently doubling. There are approximately 3 million cases of C. diff infection in the US each year, and it’s estimated that care for these cases is in excess of $3.2 billion. C. diff infection leads to a number of discomforts, including abdominal pain, diarrhea, fatigue, and flu-like symptoms. Alas, treatment can be difficult, and symptoms can persist for months or even years.

As I mentioned in a previous post, the usual treatment for C. diff is further antibiotic treatment. C. diff infection usually occurs after all the normal gut flora has been eliminated and further antibiotics (sometimes given with probiotics to encourage the return of commensal bacteria) are targeted at eliminating C. diff (there’s even a new antibiotic (Dificid) specifically targeted at C. diff). The problem, of course, is that IF these antibiotics are effective, you now have a relatively unpopulated gut that is barren and ready for the taking by whatever stray bacteria have survived the courses of antibiotics or whatever quick growing bacteria happens to make their way to the intestines to claim the empty territory- unfortunately C. diff is frequently the victor in this foot race!

Recurrent rates of C. diff infection range from 15-30%, and once you’ve had one recurrence, you’re more likely to have another: a 40% chance of having a second, and a 65% chance of having a third. Obviously antibiotics are of limited efficacy here, so what is an appropriate course of action?

In my previous post, I discussed a paper that showed that having an appendix (and thus having a safe house for normal commensal bacteria that can repopulate your gut after infection or antibiotic treatment), is protective against a recurrence of C. diff [1]. But what if you don’t have that safe house, or if you get a recurrence despite having an appendix? Again, as mentioned in a previous post, a Fecal Microbiota Transplant (FMT) seems to do the trick.

A paper published at the end of March [2], combined data from 5 sites and showed that FMT can provide RESOUNDING cure rates in people suffering from recurrent C. diff infections. Here’s a quick review: 77 patients, with average symptom duration of 11 months (range 1-28) underwent FMT at 1 of 5 medical centers in an attempt to cure their chronic infection. On average, these patients had already undergone 5 treatment regimes to try and cure their infection. FMT (most donors were family members, spouses, partners, or friends) was infused by colonoscopy into the terminal ileum, cecum, and (depending on the site) parts of the colon. Resolution of a number of symptoms- abdominal pain, fatigue, and diarrhea, were recorded.

In 70% of patients, pain resolved with FMT, while it improved in an additional 23%. 42% of patients saw a resolution of fatigue, with an additional 51% reporting an improvement. An astounding 82% saw a resolution of diarrhea and 17% saw an improvement within 5 days of FMT. These are patients, remember, that have been suffering from symptoms for an average of 11 months.

Alas, 7 patients (just under 10%) experienced an early recurrence (less than 90 days after FMT), and required a secondary treatment (either antibiotics targeted at C. diff or another FMT), which successfully treated the recurrence. Thus, the “primary cure rate” (resolution of diarrhea within 90 days of FMT) was 91%, and the “secondary cure rate” (resolution of infection after a further course of antibiotics or a second FMT), brought the cure rate to 98%. (It is worth noting that the one not “cured” patient died in hospice and was not re-treated after failure of a primary cure).

Some patients did have late recurrent infections of C. diff. Not surprisingly, these cases all occurred in patients that took a course (or multiple courses) of antibiotics to treat an unrelated infection. Recurrence occurred in 8 of the 30 patients that took a course of antibiotics. Interestingly, recurrence may also be associated with the use of proton-pump inhibitors (perhaps not a surprise, as PPIs inadvertently affect our microbiota [3])

This paper is excellent evidence to support FMT becoming a first-line therapy for the treatment of C. diff infection (and I will add especially for those that lack an appendix). FMT restores a natural biodiversity to the intestine of someone who has had their own microbiota disturbed by disease and/or antibiotics. For many people (those that experienced a primary cure), the restoration of the biodiversity was enough to overcome C. diff infection. For others, the restored biodiversity gave them the edge to overcome infection with a further targeted antibiotic or a second transplant. Remember- these are patients that had failed MULTIPLE treatments for C. diff and had been experiencing symptoms for an average of 11 months.

While there are definitely risks to FMT (it is important that donors be screened to rule out dangerous transmissible infections such as HIV, hepatitis, and parasitic infections), there are arguably additional benefits. One patient in this study reported a significant decrease in allergic sinusitis and another reported an improvement in arthritis. Both associated the improvement of symptoms with FMT. Indeed, FMT has been reported as a successful treatment for a number of conditions including inflammatory bowel disease (such as ulcerative colitis), irritable bowel disease, idiopathic constipation and insulin resistance [2].

It is important to recognize that some of the patients in this trial did suffer from subsequent disorders that should be further explored. While the conditions were not apparently associated with FMT, 4 patients that received this therapy later developed conditions including peripheral neuropathy, Sjogren’s disease, rheumatoid arthritis, and idiopathic thrombocytopenic purpura. Further studies need to determine if there is an association between FMT and autoimmune or rheumatologic disorders. If associations are found, I would expect that this would call into question the appropriate selection of donors for individual patients.

It is becoming increasingly obvious that an appropriate and diverse microbiome is important for health. When this microbiome is thrown out of whack, be it by an evolutionary-novel lifestyle, infection, or antibiotic treatment, the restoration of this environment should be the focus of medical treatment. Fecal Microbiota Transplant is a rational and effective method of restoring a healthy and diverse intestinal microbiome.

(It is worth mentioning that 97% of the patients in this study stated that they would undergo another FMT if they experienced a recurrence of C. diff, and 53% would choose FMT as their first treatment option before a trial of antibiotics. Yes, the idea of FMT may seem gross, but it is effective. For those that have suffered for upwards of a year, this treatment truly is a life-changing option.).

1.            Im, G.Y., R.J. Modayil, C.T. Lin, S.J. Geier, D.S. Katz, M. Feuerman, and J.H. Grendell, The appendix may protect against Clostridium difficile recurrence. Clin Gastroenterol Hepatol, 2011. 9(12): p. 1072-7.

2.            Brandt, L.J., O.C. Aroniadis, M. Mellow, A. Kanatzar, C. Kelly, T. Park, N. Stollman, F. Rohlke, and C. Surawicz, Long-Term Follow-Up of Colonoscopic Fecal Microbiota Transplant for Recurrent Clostridium difficile Infection. Am J Gastroenterol, 2012.

3.            Vesper, B.J., A. Jawdi, K.W. Altman, G.K. Haines, 3rd, L. Tao, and J.A. Radosevich, The effect of proton pump inhibitors on the human microbiota. Curr Drug Metab, 2009. 10(1): p. 84-9.

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If you’re just reading my blog for the first time, I’d recommend you go back and read the last two posts where I talk about the fallacy of the appendix as a vestigial organ and how and why this organ sometimes goes off the tracks in our modern environment.


In this final installment on the appendix, I’d like to explore how we can take what we know about the appendix, consider it in an evolutionary light, and think about the practical implication of this knowledge. As discussed in my first post, it has been proposed that the appendix evolved as a safe house for the commensal microbiota that live in our gut. This safe house is useful in undeveloped communities where enteric pathogens are common, but is probably not so important (or may actually be problematic) in today’s hygienic world. A recent paper, however, challenges the idea that the appendix is no longer useful in our modern world.


Clostridium difficile (or as it’s referred to on the floor ‘C. diff.’) is an unpleasant little bacterium that causes a condition known as pseudomembranous colitis. Many people carry around some C. diff, but an overgrowth can occur after a course of antibiotics kills off other bacteria or after infection with a particularly nasty strain of C. diff. In these situations, serious colitis can occur. Infection with this bacterium can cause anything from mild diarrhea to fulminant colitis with shock and death. C. diff is the most common form of hospital-acquired diarrhea in acute care settings, and the prevalence is increasing due to the emergence of particularly virulent strains. Unfortunately, once you’ve acquired C. diff, you’re significantly more likely to contract it again- with 20% of people getting a recurrence. Do you see where this is going? As my previous post suggested, the appendix is probably helpful in developing countries with widespread food and water-borne GI infections, but not so useful in the developed world where these things are less common. But what about in the hospital, where rates of infection are unfortunately rather high?


In those that have been infected with C. diff, it appears that having an appendix is significantly protective against having a recurrence [1]. This protection could be conferred by two potential mechanisms (or a combination). The GALT tissue may provoke the appropriate immune response, and/or, the normal microbiota that were kept safe in the appendix can repopulate the gut, protecting it from a recurrence. I’m not quite sure how to apply option (a) to a practical approach right now, but I think option (b) offers some interesting ideas. Full warning- this is about to get a little gross…


The standard treatment for C. diff is a course of serious antibiotics (the fact that C. diff overgrowth is frequently caused by antibiotics sometimes seems to be lost in the mix). One of my fellow med students informed me recently that there’s a brand spanking new antibiotic on the market that is specifically geared towards preventing the recurrence of C. diff, (Fidamoxicin, trade name Dificid) but I’m not familiar with that treatment. What I am familiar with, however, are fecal transplants.


Fecal transplants (bacteriotherapy sounds so much less… gross), are exactly what they sound like. You take the feces from a healthy donor, test them for all types of nasty pathogens, and then implant them in your sick recipient. I had been informed by an infectious disease doc that the preferred route of entry was a nasogastric tube, but recent studies seem to imply that transplantations via colonoscopy are very effective [2] (and I don’t know about you, but for this particular procedure, going ‘up the out-hole’ seems a whole lot more appealing that going ‘down the in-hole’). In either case, the large intestines are first flushed with an isotonic solution and then the donor material is transplanted. This procedure seems to be very effective in treating and preventing a recurrence of C. diff, though it has yet to become a common or generally accepted practice (they don’t do it at my medical school for example). The obvious advantage of this procedure is that it inoculates the gut with a population of healthy/normal bacteria after an infection (and probably some antibiotics) that has knocked down (or out) the native flora. Additionally, in a world with progressively fewer and fewer effective antibiotics, it offers a therapeutic option that does not rely on pharmaceuticals. The obvious disadvantages are the gross factor and the pressing question of ‘who is the donor’ (for the record- they usually look to your spouse if you have one). Also, the procedure remains rather expensive because of the expense of testing samples and the nature of the procedure, however efforts to streamline the process appear effective [3]. Also- if you happen to be going in for a procedure that will see your native flora eradicated, you can actually save your own sample for an autologous transplantation at a later date.


Fecal transplants seems to be an interesting and appropriate treatment after C. diff overgrowth, and could also be beneficial in other GI conditions that are caused by dysbiosis. There’s definitely reason to think it might also be useful for treating a number of gut conditions such as Crohn’s disease, ulcerative colitis, irritable bowel, and maybe even systemic problems such as allergies and auto-immune conditions [4]. These are all things that warrant more research.


But how does this all tie back to the appendix?


Principle into practice. If we believe that the appendix acts as a safe house for commensal micro biota that are capable of repopulating the gut when needed, we should take special consideration for those that have had their appendix removed. While I tend to think that fecal transplants could be an appropriate therapy for most people as therapy for a C. diff overgrowth, it might be an exceptionally good choice for those without an appendix who do not have a reservoir of healthy bacteria to repopulate the gut after C. diff is eliminated. Furthermore, while I’m uncertain how effective supplemental and dietary probiotics are, it would seem reasonable to encourage those without an appendix (I think it is reasonable to encourage everyone to eat these things, but I think special recommendations should be given to those without an appendix) to eat fermented foods rich in microbiota after episodes of diarrhea. Additionally- the incorporation of dietary prebiotics to encourage the growth of commensal bacteria is probably also a reasonable recommendation. If nothing else, I would suggest that these considerations warrant further thought and potentially some research.


It’s also interesting to consider the potential role of the appendix in inflammatory conditions that appear to have an immune component such as ulcerative colitis. It seems that a misfunctioning appendix may play a role in the etiology of these disorders. While removal of the appendix might not be ideal, if it offers a mechanism by which to control these otherwise rather devastating conditions, it should not be overlooked. In these conditions, I would approach appendectomy as a procedure of last resort, but if normal gut function cannot be achieved by normalization of gut flora through other methods, it might appear to be a reasonable approach.


Finally- while the appendix appears to be a highly specialized organ, with important and interesting functions, acute appendicitis is a very serious and life-threatening condition. Appendectomy has been the gold-standard treatment for appendicitis for years, however recent research suggests that medical-management (antibiotics) may be effective for some patients [5]. Medical management of this condition represents a serious shift in the approach to treating appendicitis. It also offers an opportunity to save an organ whose importance and function we are only just starting to understand. Again- appendicitis is a life-threatening condition, and not treating it is not an option (if you suspect a problem- get to an emergency room ASAP), but the understanding that this organ plays a real and important role in human physiology suggests that if we can save the organ, perhaps we should (this is in contrast to current trend of ‘if in doubt, take it out’).


Understanding that the appendix is a specialized organ that has evolved to play a role in maintaining the gut micro flora is an important development in the study of normal and disturbed gut function. The realization that the appendix acts as a safe house for normal gut flora that can repopulate the gut after disease offers insight into how we might preferentially treat those who lack an appendix after episodes of gut dysbiosis. Furthermore, studying the role of the appendix in maintaining and regulating the actions of the immune system in the gut may offer important insights into understanding and then hopefully treating, immune-based gut conditions. How we might study this, however, is a story for another day. Until then- I hope you’ve enjoyed these musings on the appendix- thinking about the little organ in principle and in practice



1.         Im, G.Y., R.J. Modayil, C.T. Lin, S.J. Geier, D.S. Katz, M. Feuerman, and J.H. Grendell, The appendix may protect against Clostridium difficile recurrence. Clin Gastroenterol Hepatol, 2011. 9(12): p. 1072-7.

2.         Mattila, E., R. Uusitalo-Seppala, M. Wuorela, L. Lehtola, H. Nurmi, M. Ristikankare, V. Moilanen, K. Salminen, M. Seppala, P.S. Mattila, V.J. Anttila, and P. Arkkila, Fecal Transplantation, Through Colonoscopy, Is Effective Therapy for Recurrent Clostridium difficile Infection. Gastroenterology, 2012. 142(3): p. 490-6.

3.         Hamilton, M.J., A.R. Weingarden, M.J. Sadowsky, and A. Khoruts, Standardized Frozen Preparation for Transplantation of Fecal Microbiota for Recurrent Clostridium difficile Infection. Am J Gastroenterol, 2012

4.         Borody, T.J. and A. Khoruts, Fecal microbiota transplantation and emerging applications. Nat Rev Gastroenterol Hepatol, 2011. 9(2): p. 88-96.

5.         Liu, K. and L. Fogg, Use of antibiotics alone for treatment of uncomplicated acute appendicitis: a systematic review and meta-analysis. Surgery, 2011. 150(4): p. 673-83.



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