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Thanksgiving

There are so many things that are worth writing about on and around Thanksgiving. 

 

For those of us interested in ancestral health and evolutionarily-appropriate eating it’s fun to explore what a pre-pilgrim Thanksgiving feast might have been.  Yesterday I spotted this article on Twitter discussing what a pre-pilgrim dinner would have looked like in Portland (the location of my penultimate residency interview!).  It is well worth a read.

 

My Thanksgiving feast this year is certainly of the ‘more traditional’ pilgrim/post-pilgrim variety, and will consist of a locally raised wild turkey and a Bourbon Red – a heritage breed turkey.  Incidentally, I don’t expect any Wild Turkey Bourbon will be consumed…

 

Thanksgiving is also a great, and thoroughly appropriate, time to talk about what we are each thankful for.  Family, friends, food, shelter, health; even the ‘least fortunate’ amongst us in the developed world are incredibly blessed when we look around the world and see those without access to clean water, basic medical care, or basic freedoms and security.

 

As I reach the end of my med school career, and pathologically over-think my future options, it seems like a very appropriate time to look back and think about what I am most thankful for from this rather lengthy journey.  Without a doubt, the thing I am most grateful for during the last 8.5 (*gulp!*) years is people.

 

As some of you may know, it was never my intention to be a doctor.  Truth be told, I never would have taken the MCATs (Medical College Admission Test) if my summer roommate hadn’t dared me to do it.  Nipa, though you won’t be reading this, Thank you.  On the day that I took the test I met a charming and chatty pre-med while we waited in line.  She thought my light-hearted approach to the MCAT was hilarious and offered me her AIM screen name so we could chat if I decided to apply to med school.  Without Jackie my AMCAS (American Medical College Application Service) application would have been submitted sans-personal statement, an act that certainly would have doomed my efforts.  Incidentally, Jackie and I ended up attending the same medical school, so I’ve had the opportunity (even as recently as a couple of months ago, since she pursued residency training locally) to express my thanks to her.

 

My large university had a “Pre-health” office that assists aspiring health professionals prepare their application for medical school.  When I called to ask if they would help me (only a month or so before applications were due), they told me that they could help me get my application ready… for the next year.  Fortunately the pre-health office at the woman’s college campus was willing to take me on (despite the fact that I wasn’t from her college), making my application to medical school a reality.

 

The day before my first medical school interview my college roommate asked me what I was planning to wear for my interview, telling me “I think people wear suits for med school interviews.”.  I laughed this off, but after a last minute email exchange with my advisor my roommate went shopping with me to help me find an appropriate suit.  I alternate between cringing and chuckling when I think about the response I would have received had I shown up to a med school interview in a tank top and cool Malaysian Sarong, my original plan!  Incidentally, prior to my residency interviews I headed to Long Island to meet up with this same friend for another suit-shopping experience (this suit is much sharper, if I do say so myself!).

 

I applied and interviewed for more PhD programs than I did MD/PhD ones (though since I only interviewed at four PhD programs that’s not saying much!).  I was very tempted by two of the stand-alone PhD programs, and my decision to pursue the combined degree literally came down to the final day.  I remember the day before the decision was due I met with an MD/PhD student who sold me on the virtues of a combined program.  Without Jay, it’s entirely possible I would have opted for a non-clinical route.  Another good friend, who’s opinion I still very much value, had warned me that “No sane person puts herself through the torture of med school unless she’s sure she really want to be a doctor.”.  I’m not saying he’s wrong- I’m sure there’s quite a list of people who have questioned my sanity over the years!

 

Someone who has contributed more to my medical education than he shall ever know is Russell.  I thank “Russell”, though I shall never know his real name.  Russell was a 74-year-old man who died of “coronary artery disease”, at least that’s what his cause of death was listed as.  While I became very familiar with his body, I will never know anything about his life.  From his lean and muscular body (Russell was short for “Russell the muscle”), I imagined him as a fit and active man, but I shall never know.  Books have been written about gross anatomy lab (including one written about the experience at my school- my anatomy teacher is on the cover of this book!), and I’m sure every student has a slightly different experience of this ‘right of passage’.  I feel safe saying that we are all, uniformly, thankful for the gift that our donors gave.

 

I’m not going to go through and thank all the people who helped me survive (I would not call it thrive) in medical school.  Completing my PhD was a particularly stressful time, and I am forever thankful for the many people who supported me through that experience.  Returning to medical school (after 4.5 yrs in the lab) was difficult, but made much easier by classmates who did their best to get me up to speed on the floors.  The three guys I did my first neurology rotation with were particularly kind in helping me hold-it-together while stressing out about how to present a patient to our attending physician for the first time.

 

I would be remiss for not recognizing the role that many of my residents played in my development as a future physician.  Some residents love to teach while others barely tolerate students, but even the grumpiest and most sleep-deprived resident shaped my experience in someway (for better or worse).  Likewise, various attending physicians have been mentors that I struggle to recall while others have truly fashioned some aspect of my clinical or personal development.

 

It takes a village to raise a child, but it takes a hospital to make a doctor.  When you are a medical student or resident-physician, nurses, physician assistants, therapists, and social workers can make or break your day.  The reality is that these people frequently know more than you about what your patient actually needs.  Speaking of patients- they are, of course, an integral part of medical education.  Many are lost in my memory, but others will stay with me throughout my clinical career, for the impact they had on my medical knowledge and the impact they had on me personally.

 

As important as all of these people have been to my development as a clinician and a person, I am most grateful for my friends. I have loved the poem “A Prayer” by Frank Dempster Sherman (1860-1916) since college, and as I travel around the country interviewing for residency programs (and catching up with friends along the way), it has never struck so true.

 

Screen shot 2013-11-27 at 3.10.34 PM

 

I have a fantastic network of friends, one that I am truly thankful to have nurtured over the years.  In an era when the word “friend” may conjure up thoughts of a virtual connection on facebook (especially when in the same sentence as the word “network”), it can be easy to lose touch with people that matter or let friendships devolve into a series of “likes” and “pokes”.  On the other hand, online social networks can help make connections that have been lost.

 

When I interviewed in Vermont I met up with a friend I have not seen since High School. On my way home from an interview in New Hampshire I spent the weekend catching up with friends in Boston. Before heading to Colorado for an interview I went to play polocrosse (imagine a combination of polo and lacrosse) for the first time in 2.5 years, in Texas.  There I saw friends that I have literally not seem for years, but who opened their homes and stables to me without hesitation.  With the exception of one upcoming interview, all of my interview travels are combined with a visit with one or more friend.

 

When I entered medical school I was unsure whether I would ever use my clinical degree in practice.  The medical knowledge would be useful for asking relevant research questions and the clinical knowledge would be useful when friends and family needed phone-a-friend medical advice, but I certainly was not sold on the idea of being a clinician when I entered medical school.

 

Now I am sold- I do want to practice clinical medicine (as well as be involved in research and academics), and I am forever grateful to all the people who have helped me find my way along this path.  My desire to be a fount of knowledge for my friends and family is still one of my greatest drivers, and it is certainly a large part of why I have chosen to pursue family medicine.  I’ve been warned many times that friends and family make the worst patients- they’re notorious for not listening to someone they’ve known since “way back when”. That’s fine- I really am OK with that (just keep your griping to a minimum when your low-fat, low-cal, low-“food” diet fails to leave you feeling great.). I do hope, however, that when my friends do need me, I can live up to the last line of that fantastic poem.

—————–

Oh, and if you’re curious, this is polocrosse.  Check out americanpolocrosse.org for more info. 

Playing this horse (Cripple Gray Zeta) was a privilege and a thrill. Thank you, thank you, Susan and Paul!

Playing this horse (Cripple Gray Zeta) was a privilege and a thrill. Thank you, thank you, Susan and Paul!

Tomorrow is my last day of medical school.

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

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

 

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

***Update 11/4- It’s back!

 

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

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

 

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

 

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

 

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

 

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

 

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

 

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

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

 

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

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

 

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

 

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

 

T-bones-

T-bones

 

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

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

 

Roasts, steaks, or stew…

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

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

 

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

 

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

 

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

 

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

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

 

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

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

 

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

 

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

 

Tallow in the making.

Tallow in the making.

Rendering down trimmings for tallow

Rendering down trimmings for tallow

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

 

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

 

This morning was a misty fall morning at our farm.

A misty fall morning at our farm.

 

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

 

2/3 of our new heifers.

2/3 of our new heifers.

 

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

 

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

 

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

Poor Snowflake couldn’t make any progress past this…

 

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

 

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

 

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

 

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

 

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

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

 

 

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

 

Success!

Success!

 

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

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

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

Good to see our young calf up and nursing!

Good to see our young calf up and nursing!

 

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

 

The cuteness factor is a little overwhelming!

The cuteness factor is a little overwhelming!

 

 

Time to heal…

“Doctor! Heal thyself!”

 

Those were the words of the orthopedist as he entered my room in the Emergency Department.

 

Two weeks ago, while taking a break from working on residency applications, I decided to go ride one of my horses.  Alas, as I was leading him and his pasture-mate to the barn they spooked and one of them literally jumped on my foot.  I’ve been around horses for decades (eek!), and have had my toes crunched many times, but I immediately knew this time was different, not least because he had landed on the side of my foot not my toes.  The pain was instantaneous and overwhelming, I was doubled over and hyperventilating within seconds (at which point I realized that the horses hoof had actually torn my leather boots- let this be a lesson to ALWAYS wear boots around horses, a lesson I’ll admit that I haven’t always followed).  After taking a couple of minutes to catch my breath I hobbled to the barn, optimistically hoping I’d still be able to go for a ride.

 

Once in the barn, with the horses secured, I pulled my boot off and had a quick palpate. One good squeeze and I knew I needed to make a trip to the hospital for some X-rays. *Sigh*  This was NOT how I had planned to spend my evening!

 

A little later, at the community hospital, the X-ray tech snapped a few angles.  I asked if I could see the films before hobbling back the waiting area and immediately spotted two, slim, hypodensities in my 4th and 5th metatarsals.  With an expletive, I pointed to one of the lucencies. The tech tried to reassure me that it wasn’t anything significant: “just an artifact” because there was a similar line in the adjacent bone…

 

After the Physician’s Assistant examined me in fast track, he went to go check out the X-rays.  I asked if I could take another look, admitting that I was a med student (and currently on rotation in this community hospital for my sub-internship!). When he came back to pull the images up on the computer, he let me know that he and the ED doc agreed that I did, indeed, have non-displaced fractures of the 4th and 5th metatarsals.  There wasn’t really much they could do, but the orthopedist was coming into the hospital to see a couple other patients and if I was willing to hang out for half an hour he’d take a look at my images as well.

 

They don't look like much, but those two little lines are really cramping my style!

They don’t look like much, but those two little lines are really cramping my style!

 

Half an hour later, the cheery orthopedist came in, chatted with me about my future plans in medicine, and told me to follow up with him if things got worse instead of better.  I headed home with a walking cast, crutches, and a few Percocet.

 

This was two weeks ago, and while my foot is by no means “fixed” it is certainly getting better.  Hobbling around to take a shower the first morning was rather excruciating, but the walking cast was my saving grace in the hospital and I’ve been able to do more normal activities without the boot with time (though I think I may have pushed my limits last night heading into the city for a book release party and am paying for it today- on that note, definitely check out John Durant’s book The Paleo Manifesto).

 

So why am I writing this, other than catharsis? (It’s perfect fall hiking weather and I’m out of commission- boo.)

 

Healing takes time.

 

With things like a fractured bone people know this, but sometimes we (“we” the public, and “we” the medical community) seem to forget that healing takes time.

 

There’s no denying that I am “into” preventative medicine.  However, as much as we can try and prevent injury and illness- something is bound to happen.  In that vein, I don’t think preventative medicine is only about avoiding problems, but encouraging a physiology where healing is promoted.

 

I’ll admit that I’ve been frustrated at times in the hospital when my stable patients have complained to me on morning pre-rounds that they had a horrible nights sleep because someone was taking vital signs every couple hours, and the phlebotomist came for morning labs before 5.  Vital signs are vital for the management of some patients, but others would benefit much more from a good nights sleep. Of course, making the decision that your patient needs sleep more than monitoring is not an easy one- no one wants to find that their patient is hypotensive on morning rounds and not know when the problem occurred, but for some patients the risk seems quite low.  On my neurology clerkship I remember thinking that what many of our stroke patients needed most was a good night’s sleep.

 

I recently read, at the recommendation of my favorite cardiologist, the book Cutting for Stone.  It is amazing, in many ways. I particularly loved a short passage that talked about the success one person had in improving women’s recovery from fistula surgery.

 

Hema shared with us that she and Shiva had operated on fifteen successive fistula patients with not one recurrence.  ‘I owe this to Shiva,” she said. ‘He convinced me to take more time preparing the women for surgery. So now, we admit the patients and feed them eggs, meat, milk, and vitamins for two weeks…. We work on strengthening their legs, getting them moving.’…

 

‘Can’t get them to walk after surgery if they won’t walk before.’ Shiva said.

 

When I was on my anesthesia clerkship I saw how hard it is to manage a “sick” patient, and how easy it is to intubate and anesthetize a healthy one (a complicated cardiac patient vs a young ortho patient, for example).  On surgery, you see how well some people tolerate surgery and how poorly other do- how some heal quickly while other seem incapable of healing.  One’s underlying “health” certainly affects one’s ability to heal.

 

This is one of the many reasons I like primary care.  A good primary care doc makes everybody else’s job easier.  They can keep their patients healthy and out of the OR and specialist’s office, and if misfortune strikes, a patient in the best of health is almost always set up to fair better (the only example that I can think of where this is not the case is the pandemic flu of 1918, where the robust immune systems of young, healthy, adults was actually their demise).

 

Injury and illness, at some level, are inevitable.  A healthy lifestyle and good genetics can go a long way to keeping you out of the hospital, and they can also go a long way towards helping you heal if you do find yourself in harms way.  As the Dos Equis man might say “Stay healthy my friends.”.

It’s been a busy month since my last post.  I’ve studied for and taken the United States Medical Licensing Exams (USMLE) Step 2 CS and (on Friday) USMLE Step 2 CK, two parts of what most people know as “the boards”.  I’ve attended and spoken at the 2013 Ancestral Health Symposium (AHS) and moved out of the apartment I lived in for the last 18 months.  I’m also half way through my “Acting Internship”, a clerkship most medical schools call a Sub-Internship, where I basically function as an intern (a first year medical resident).  I’m doing this rotation at a local community hospital and I’m really enjoying the atmosphere, personnel, and patients.  The hours are long, but not as long as for many of my classmates doing acting internships in Internal Medicine, Surgery, and Ob-Gyn (mine is in Family Medicine, the specialty I am pursuing). Applications for residency programs go live in just over a week which finds me struggling to write (for the fourth time) a personal statement that embodies me

 

Needless to say, things have been hectic , and the last month has been a touch overwhelming at times.  I’m certainly looking forward to some downtime after I finally complete my remaining med school requirements (just 8 more weeks!), have my residency lined up, and am able to catch my breath. 

 

I really shouldn’t complain.  Even in the last, relatively crazy, 6 weeks I’ve still had some good times.  The week of AHS in particular was one for the books.

 

I’ve written before about destinations and journeys.  The destination for AHS was clear- Atlanta Georgia- but the journey I took to get there wasn’t what you might expect. 

 

Many, many, months ago, when the location for AHS was first announced, I made a rather rash statement that Atlanta was almost close enough for a road trip.  While I had no real intention of road tripping to Atlanta, my longtime Twitter friend @PrimalRush (henceforth known as James) said he was keen to tag along for the journey.  At the time I thought an actual road trip was unlikely (it’s a good 13 hour drive and airfare isn’t that expensive), but as the time got closer I realized I would regret turning down the opportunity to create an excellent story (those that know me know all too well that I’m a fan of adventures and stories). 

 

Since I took 4 weeks off from school to prepare for the boards and attend AHS, I was able to take some extra time travelling to AHS.  About a week out, I vaguely mapped a path to Atlanta, made plans to pick up my Canadian travel buddy from the bus stop, and hoped for the best!

 

Three days before we planned to pull into ATL, James and I hit the road with camping gear, a cooler, and a tank of gas.  After making a stop at one of my favorite butchers to fully stock our cooler, we made tracks to Shenandoah National Park in Virginia.  We travelled the length of the park on Skyline Drive, stopping about midway to camp for the night. 

 

At times, we were in the clouds driving on Skyline Drive.  Driving the length of the park added a few extra miles to our trip, and certainly slowed us down a bit (the speed limit is 35mph and you can't help but pull over and ogle at the views), but it is certainly worth it!

At times, we were in the clouds driving on Skyline Drive. Driving the length of the park added a few extra miles to our trip, and certainly slowed us down a bit (the speed limit is 35mph and you can’t help but pull over and ogle at the views), but it was certainly worth it!

 

Without going into detail, our time in Shenandoah involved meeting some mushroomers who confirmed my Chanterelle (and Chicken of the Woods) identification, cooking a truly excellent camp dinner (with Chanterelles), having a run-in with a slightly disgruntled ranger, hiking part of the Appalachian trail in the dark, pitching a tent in the dark, waking up and breaking down camp in the dark, and then scrambling to a 360o viewpoint to watch the sun rise.  When we were finally able to tear ourselves away from our solitude and sunrise we hiked the couple miles back to the car and made tracks through the rest of the park and onto our next destination in Mortimer North Carolina.

 

A delicious addition to our dinner (good thing I had some Kerrygold butter in the cooler!)

A delicious addition to our dinner (good thing I had some Kerrygold butter in the cooler!)

 

I'll take this over dehydrated rice and bean camp dinners any night!

I’ll take this over dehydrated rice and bean camp dinners any night!

 

The view at dawn from Bearfence mountain.

The view at dawn from Bearfence mountain.

 

It was certainly worth waking up at 5, and hiking in the dark, to watch the sun rise over Shenandoah.

It was certainly worth waking up at 5, and hiking in the dark, to watch the sun rise over Shenandoah.

 

How could I resist?

How could I resist?

 

Mortimer North Carolina holds a special place in my heart.  One of my longtime friends has a family cabin in Mortimer, and I’ve twice travelled with her for an escape to the mountains and the beauty of Wilson’s Creek.  Mortimer is also home of Betsey’s Ole Country Store an establishment owned by my friend Bruce.  The address to Betsey’s is a little deceiving- let the record show that “Highway 90” is a gravel road where you need to pull over to let oncoming traffic pass. 

 

Anything I say about Betsey’s or the owner/operator of the establishment, Bruce, would sound like a paid advertisement, so I’m not going to even start.  What I will say is, if you want to visit a beautiful part of North Carolina- visit Mortimer. And if you visit Mortimer- visit Bruce.  He’s got cabin rentals, inner tube rentals, and more knowledge of the area than you’ll find anywhere else.  If you ever find yourself that way, tell him Victoria sent you… Seriously!

 

With Bruce’s back yard as our home base (he is a gracious host), we put in many miles of hiking, had numerous dips in local swimming holes, and managed to spot some of the Perseid meteors.  It was hard to tear ourselves away in order to make it to Atlanta on schedule (we actually didn’t make it to Atlanta on schedule because we opted to take a morning hike before we hit the road).

 

Betsey's. "Peace and Love, Y'all"

Betsey’s. “Peace and Love, Y’all”

 

Putting in some miles in Pisgah National Forest...

Putting in some miles in Pisgah National Forest…

 

I was keen to keep my socks dry, and I did! At least for the first half of the hike (darn slippery rocks)...

I was keen to keep my socks dry, and I did! At least for the first half of the hike (darn slippery rocks)…

 

My new favorite swimming hole, at the top of Gragg Prong fall.

My new favorite swimming hole, at the top of Gragg Prong fall.

 

The reason we didn't make it to Atlanta on schedule- I had to introduce James to one of my favorite spots- Big Lost Cove.

The reason we didn’t make it to Atlanta on schedule- I had to introduce James to one of my favorite spots- Big Lost Cove.

 

It goes without saying that Atlanta was a big change of scenery in comparison to the preceding few days.  I actually didn’t see much of the city, save for the inside of the Sheraton Conference center, a few of the fine dining establishments, and Boyd Eaton’s gorgeous house where the presenters dinner was held.  Prior to the official start of AHS, a number of the Physicians and Ancestral Health docs got together for a brief meeting.  It was great to catch up with these like-minded Docs, and I was reminded, again, how refreshing it is to spend time with people who share passions and interests. 

 

AHS itself was fantastic, save for a few AV snafus. I thoroughly enjoyed some of the plenary talks: namely Nassim Taleb’s antifragile talk, Gad Saad’s talk on The Consuming Instinct, and Geoffrey Miller’s talk on Sexual Fitness (not talking about “reps for time”).  I was a bit surprised by Mel Konner’s and Boyd Eaton’s talk on the history of modern “paleo” diets, where they repeatedly said that our modern diet is much higher in saturated fat and lower in polyunsaturated fat than historic diets… I find it hard to believe that any diet that contains modern vegetable oils has anything other than an excess of polyunsaturated fats. 

 

There were many excellent talks over the course of the conference, and it was often hard to pick which talk to attend out of a very tempting schedule.  I look forward to catching some of the ones I missed online when the videos are posted.  On that note, my talk on Dietary Fats and Fatty Liver Disease, went well.  When the video becomes available I’ll try and post it here!

 

As much as I enjoyed the various lectures, workshops, and posters, the highlight of AHS was catching up with friends and making new ones.  There is quite a vibrant online community of those interested in evolutionary and ancestral health, and AHS can sometimes seem like the interwebz in 3D.  As someone who would happily trade days of online interactions for even brief face-to-face encounters, AHS was a social occasion that refilled my tanks and renewed my enthusiasm. 

 

Back in May, on the Wilderness Medicine elective in Utah, our instructors expressed that one of the goals of the elective was to “stock good memories” for the rough times that were to follow in residency (all but 2 of the 12 students would be starting internship in the next month).  I still have quite a bit of time until I start residency (though the march towards June of 2014 soldiers on), and my goal between now and then is to bank as many good memories as I can.

 

Stashing good memories (and looking for Hobbitses).

Stashing good memories (and looking for Hobbitses).

I always get excited when I meet a fellow student in the medical world who has an interest in evolutionary and ancestral thinking. It doesn’t happen often, but I’ve twice run into students who, by subtle hints, have let on that they think our current thoughts on health and nutrition are seriously broken. The back-and-forth as we suss out whether we’re on the same team is like an ever-escalating dance. First someone drops the line “nutrient dense food”, then the other says something along the lines of “I don’t think saturated fats are evil”, and before you know it we’re lauding the benefits of egg yolks and liver. 

 

In a culture that tends to focus on treating illness rather than preventing it, and in an environment where we’re frequently so busy trying to fix something that we don’t take the time to step back and wonder why it broke in the first place, it is refreshing to find people who like to think deeply about human evolution and ancestry when talking about health and disease. These people are rare in most clinical settings. When I find others who share these interests I generally wish I’d discovered our common interests earlier- I wish we’d had a secret handshake to tip each other off.

 

In just over a week I’m heading to Atlanta Georgia for the 2013 Ancestral Health Symposium.  There, no secret handshake will be needed to ID those who are interested in evolutionary and ancestral health, as interest in this subject is a prerequisite for attending the symposium.  I’m excited to catch up with old friends, meet new ones, and also to speak at this year’s symposium. 

 

I’ve written before about alcoholic fatty liver disease (the subject of my PhD research), and I’m looking forward to talking about the role of dietary fats in fatty liver disease at this year’s symposium (though the time slot is shared with some other interesting talks, so I’m not sure I’ll garner much of an audience).  I’m also hosting a panel of ancestrally minded physicians who will be talking about the successes and challenges of using evolutionary and ancestral thinking in their own clinical practice.  They’ll be taking questions from the audience, so if you’re in attendance come prepared- it should be fun!

 

If you’ll be at the symposium, please say hello!

 

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A good morning of Wilderness Medicine out in Canyonlands National Park,

 

 

Here’s the short abstract for my presentation:

 

Fatty liver disease is a growing epidemic in the developed world, with some estimating that over 40% of the US population have some amount of disease.  The general recommendations for those with fatty liver disease include avoiding saturated fats, though research does not support this recommendation. In fact, saturated fats have been shown to be protective against fatty liver disease with some even having a therapeutic effect. Conversely, consumption of large amounts of polyunsaturated fats that have only recently become abundant in western diets plays a key role in disease development.

 

***

Sorry for the slow rate of posts these days.  I’m reaching the end of my final year or medical school (I actually graduate in December), and while fourth year clerkships aren’t nearly as arduous as those undertaken as a third year medical student, all the other loose ends of medical school are piling up on me at the moment. I take the Clinical Skills portion of the boards next week, the Clinical Knowledge portion of the boards at the beginning of September, and I have to get my residency applications ready to go in the near future (which, of course, includes figuring out WHERE I want to submit applications to!).  Of course I also have a presentation to prepare and a trip to Atlanta to plan!  I have a long list of things I want to write about, but at the moment other things are taking precedence.  Thank you for your patience! 

Gather

Time to take a break from breasts- though I think I may have one more post in me on that subject.

 

I’m a fan of a paleo diet. There, I said it.  To me it is not “the” paleo diet, and there is no single set of “rules”, but I embrace the idea of thinking about our evolutionary past when talking about health and disease.  Like it or not, what we eat (and of equal importance, what we don’t eat) is one of the major forces that shape our health.  Let’s face it, it’s much easier to change what you eat than to change your genetics (and probably your job, your geographical location, and other things that affect health).

 

There’s been increased coverage of a paleo diet in the media of late- usually not a resounding endorsement, not that I’m surprised- and it’s sometimes referred to by other names such as “the caveman diet” (except our ancestors largely didn’t live in caves) or the hunter-gatherer diet.

 

I generally like (and use) the term ‘paleo’.  For me (and many others), it’s a term that has developed a definition that we all understand.  That being said, I also like the idea of talking about a ‘hunter-gatherer diet’.  It gives a nod to seasonality, encourages us to think about naturally available quantities, and a personal involvement in the food we eat.  Sure, a lot of people who “eat paleo” don’t hunt or gather their own food (though certainly some do), but it’s good to be mindful of when you might actually have access to different foods and in what amounts.

 

I’ve never been a hunter (though I love having friends that are, and appreciate the stock of venison I have in my chest freezer), but I’ve been gathering since I was little.  I’ve been involved in two different types of “gathering”- spending a portion of my summer childhood raiding (or being put to work) picking in my family’s garden and also time in the woods scouting for wild edibles.  It’s funny how times change: these days I love getting out in the sun to pick berries at a local pick-your-own place, but as a child I really thought of it as a chore (I’m guessing it’s mainly because when the plants are yours you don’t want to let anything go to waste so you pick whether you want to or not, and you also pick *everything* instead of just as much as you want).

 

Of course, picking quarts of strawberries at the local pick-your-own place is NOT gathering (in the truly ancestral sense of the word), but it’s fun (at least for me), and while I’m picking vitamin C I’m getting vitamin D for free.  I’m also supporting  local farming families, keeping money in the local community, and keeping an eye on how the food I eat is grown.

 

The farm I go to grows a variety of strawberries, I exclusively pick the “Early Glow” variety. They are, without a doubt, the best in the field, though arguable more tedious to pick since they are quite a bit smaller than most commercial varieties. They are well worth any extra effort, as the flavor is unparalleled (though their shelf life is very limited).

The farm I go to grows a variety of strawberries, I exclusively pick the “Early Glow” variety. They are, without a doubt, the best in the field, though arguable more tedious to pick since they are quite a bit smaller than most commercial varieties. They are well worth any extra effort, as the flavor is unparalleled (though their shelf life is very limited).

 

As a child, while I was duty bound to pick strawberries, raspberries, blueberries, blackberries, and whatever else we had in the garden, I still would go out “exploring” with friends and bring home wild bounty.  To this day wineberries are one of my favorite fruits. Seedy, waxy, and plentiful (if you happen to beat the birds to the punch), I would spend hours with my friends gathering these treats.  I still find it difficult to pass a stand without stopping for a snack.

 

Stopped for a snack- I’m being a bad Pony Clubber, allowing my horse to grab a quick bite with the bit in her mouth, but it seemed unfair to stop for a snack for me and not let her grab a mouthful as well!

Stopped for a snack- I’m being a bad Pony Clubber, allowing my horse to grab a quick bite with the bit in her mouth, but it seemed unfair to stop for a snack for me and not let her grab a mouthful as well!

 

Wineberries are just ripening in my area, but I haven’t had a chance to get out and pick any yet.  However a couple weekends ago I was out hiking on the Appalachian Trail (AT) and came across blueberries- LOTS of blueberries.  I’d seen the green berries at other places earlier in the season, and fortuitously happened to be out on the Blue Mountain portion of the AT when the berries in the area were ripening.

 

These had caught my eye on the trail a week or so before I hit the motherload!

These had caught my eye on the trail a week or so before I hit the motherload!

 

I felt a little bad for my hiking partner, since I seem pathologically incapable of walking past a good stand of berries without stopping to pick.

I felt a little bad for my hiking partner, since I seem pathologically incapable of walking past a good stand of berries without stopping to pick.

 

For a bit of comparison you can see the wild blueberries (or are they bilberries? [ http://en.wikipedia.org/wiki/Vaccinium_myrtillus#Confusion_between_bilberries_and_American_blueberries]) next to some that I picked in my parents’ garden (this years crop are particularly large)

For a bit of comparison you can see the wild blueberries (or are they bilberries?)  next to some that I picked in my parents’ garden (this years crop are particularly large)

Out on the AT, I don’t look all that out of place gathering handfuls of berries, but in the park opposite from my apartment I get some weird looks when I stand on tiptoe to pick the ripening Mulberries.  As I’ve said, my drive to gather might be a little pathological, though I suspect it is a deeply human urge.  Most of the kids that I’ve met have loved to gather food (berries, vegetables, eggs, etc.), but perhaps it’s novelty not nature…

 

When I was up in Maine a few weeks ago I went beach combing with a friend. To our excitement, while we were out at low tide we came across a few pools that housed beautiful large mussels.  We were looking forward to cooking them up in some white wine until we discovered there was a red-tide warning for the area- what a shame!

 

Seafood can’t get much fresher than this…

Seafood can’t get much fresher than this…

 

Most recently I’ve been gathering watercress from a local stream.  I know the thought of this makes my European friends cringe, but the liver flukes that make this practice a hazard in other countries don’t live in the US- or so I’ve been told.

 

WaTERCRESS

 

In the fall I’ll be gathering chestnuts, a task I’ve been doing for years.  My neighborhood has quite a few old Chinese Chestnut trees- I wonder if there was a local craze to plant them some decades back.

 

Best roasted, though I have been known to make a dark chocolate/chestnut mousse at times- don’t tell the paleo police!

Best roasted, though I have been known to make a dark chocolate/chestnut mousse at times- don’t tell the paleo police!

 

A “paleo” diet isn’t about prehistoric reenactment. The point isn’t to only eat foods you’ve hunted or gathered, but personally I like having a role in sourcing the food that I eat, and I do enjoy time spent outside gathering foods.  The food “gathered” at a pick your own berry farm certainly isn’t the same as the food our ancestors gathered (I’ll refer you back to the post I did on bananas– check out the difference between the wild and the domesticated fruit), but what you pick yourself will be infinitely fresher than what you buy at the supermarket.

 

As I was finishing up this post, I heard an interview on NPR with the author of a new book, entitled Eating on the Wild Side. Her premise seems to be that the plants we evolved eating were very different from their domesticated ancestors that we eat today, and that somewhere in the mix foods have lost some of their most valuable micronutrients *.  I can’t speak on the book, but the interview is certainly worth a listen!

 

*Interestingly, some people have suggested that some of the nutrients that the author above touts can actually be problematic.  You can check out Dr. Ede’s talk from the 2012 Ancestral Health Symposium exploring the darker side of plant foods.

Happy Fourth of July to my American readers! I hope you get some rest, relaxation, socialization, and good food today!

 

I’m off to a friend’s BBQ where I’ll be partaking in lots of smoked pork shoulder and BBQ’d beef cheeks. I’ll be contributing towards dessert: red, white, and blue, of course!

 

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New Jersey has a reputation for being industrialized (or people associate “the shore” with all of NJ), but there’s a reason it’s called the Garden State!

 

Thanks for the comments (on the blog and on facebook) on the recent mammography posts- I’ll get back to them soon!