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It’s Match week.

 

If you know a fourth year medical student (or recent med school graduate like myself), you might have noticed them looking a little frazzled this week.

 

I’ve written previously about “speed dating for medical students”, where I briefly discussed the process by which recent (or pending) med school grads find their first jobs as interns and resident physicians.  The process starts when students apply to programs in their specialty (or specialties) of choice, at the end of the summer.  Pretty soon (hopefully) offers to interview come in.

 

Interviewing is an educational, though stressful, experience.  You get to see how different programs and different hospitals are run, you get to hear about life as a resident from new young doctors, and you get to meet fellow applicants who aspire to specialize in the same discipline.  Throughout the interview season you develop a bit of a patter- you come to expect some questions and you recognize what are the interesting elements of your personal story that people want to know about.  Interestingly, at least to me, very few people were interested in hearing about my PhD research.  Rather, they wanted to know how I intended to use my skill set in my future career.  “Where do you see yourself in 5 years.”

 

Of course, it’s kind of hard to say where you see yourself in 5 years when you don’t know where you’ll be in 6 months.

 

New physicians are assigned their internship and residency positions through a process called “The Match”.  By the end of the interview season, a student creates a rank list, in which they order the training programs for which they would be willing to work. This list must be eventually be finalized and “certified” (this year the deadline was 9pm EST February 26th).

 

Students aren’t the only one’s making rank lists; programs rank applicants in the order in which they want to employ them.  Once the student and program lists are certified, they are sorted by an algorithm designed to fit a theory that won Alvin E. Roth and Lloyd S. Shapley the Nobel Prize in economics.  You can read more here.

 

Once lists are certified and the deadline has passed, computers whir and crank to determine where students will be heading come June.  Students and programs get the results this week: “Match Week”.  The process starts on Monday, when students get an email answering the question “Did I match”.  At this point, residents are much like Schrödinger’s cat- simultaneously matched and unmatched, hanging in limbo until the email is opened.

 

I’ll admit that, despite being someone who tries to remain rather cool, calm, and collected (ok, that’s a lie, but I try not to worry about things that are outside my control), I experienced a significant amount of stress leading up to Monday.  Blame it on the fact that last year I was in the room when a generally very competent future physician received a “you did not match” email, but I couldn’t help myself from running through the series of events that would see me unmatched (I didn’t rank that many programs and all it takes is being one slot too low on each programs rank list and you find yourself scrambling for a supplemental offer).  Fortunately, Monday’s email brought me good news, and I am now on the eve of finding out where I will spend the next 3-4+ years of my life.  I, along with the majority of med students around the country, will be receiving my match information tomorrow at noon EST at a match ceremony at my school.  At this point I know I’ll be headed to 1 of 7 programs in 1 of 6 states…

 

Have stethoscope, will travel...

Have stethoscope, will travel…

 

Schrödinger’s resident is matched, tomorrow we’ll know where. Stay tuned!

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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).

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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!

 

Image

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.

 

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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! 

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I have spent only 5 of the last 25 nights in a bed (4 different beds, to be precise). At this point I feel a touch claustrophobic in bathrooms and feeling clean is certainly a novelty.  My Wilderness Medicine elective is over and I have had an exceptional visit in Moab (more on that in another post). Tomorrow I head to the mountains of Colorado for one last stint in the wilderness before heading back to New Jersey where I will start a radiology elective on June 3rd.  From a month in the wilderness to an elective spent in dark, windowless rooms- the change in environment couldn’t get much more extreme (which is saying a lot, coming from someone who has gone from alpine camping to desert camping in the course of 3 weeks).

 

This is the final installment of “Pic of the Day”, at least for the Wilderness Medicine Elective.  I may not be able to resist a “Pic of the Day, Moab edition”… we shall see.

 

For the desert portion of the course we headed to Canyonlands National Park, specifically The Needles District of the park.  We spent 4 nights in 3 different sites, hiking up to 12 miles a day with heavy packs.  I found this portion of the course the most physically demanding, but at the end of the day it was unquestionably my favorite section.

 

I’ll write details in future posts, but for now: Pic of the day- desert edition.

 

Day 1- Canyonlands

 

The geology of Canyonlands (actually, the geology of much of Utah) is stunning and fascinating.  This is in the needles are, near Lost Canyon, where we spent our first night in the park.

The geology of Canyonlands (actually, the geology of much of Utah) is stunning and fascinating. This is in the Needles District, near Lost Canyon, where we spent our first night in the park.

 

Day 2- Perspective

 

Looking back at Lost Canyon as we hike out to Elephant Canyon, our next campsite. From many vantage points in the park you could see the snow capped La Sal Mountains.

Looking back at Lost Canyon as we hike out to Elephant Canyon, our next campsite. From many vantage points in the park you could see the snow capped La Sal Mountains in the distance.

 

Day 3- Druid Arch.

 

Before we packed hiked our big packs out to Chesler Park, we took an early morning park out to Druid Arch.

Before we hiked our big packs out to Chesler Park, we took an early morning hike out to Druid Arch.

 

Day 4- The Joint Trail

 

Probably one of the coolest trails I have every hiked, winding through a narrow slot canyon.

One of the coolest trails I have every hiked, The Joint Trail winds through a narrow slot canyon.

 

 

Day 5- Sunrise and out.

 

We left camp at 4am for the 3+ hour hike out.  I led the group of 19 by head lantern for 2 hours before stopping on a bluff to watch the sun rise around 6am.  Pre-dawn hikes are something I will be adding to my repertoire.

We left camp at 4am for the 3+ hour hike out. I led the group of 19 by head lamp for 2 hours before stopping on a bluff to watch the sun rise around 6am. Pre-dawn hikes are something I will be adding to my repertoire.

 

I did not expect to fall in love on this trip, but I have certainly fallen in love with the desert.  I don’t know when I’ll be back, but I hope it is soon…

 

Chesler Park.

 

Chesler Park

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Truth in Fiction

A few months ago I did a two-week elective with our hospital’s Emergency Medical Services. Over those two weeks I saw all manner of medical “emergencies”.  Some were true emergencies, but plenty were BS calls where first responders and ambulances were called into action when what was really needed was an $8 taxi ride to the emergency room (or even better, $8 worth of broth and a couple days in bed to get over the flu, but I digress).

 

I met some wonderful first responders on this rotation. People that really want to help others and who obviously get a high from the adrenaline of being called to duty in an emergency.  As I saw bits of the recent Boston and Texas events unfold I imagined how the EMTs and medics I worked with would have jumped to duty in these situations.  Indeed, many of them did 11.5 years ago when they responded to the attacks on the World Trade Centers.  One of the women I worked with lost a friend who was responding that day.

 

Unlike the hospital environment, where people usually avoid any controversial conversations, I frequently found the topics of religion, politics, taxation, healthcare reform, and gun-control being discussed. The disagreement was sometimes vehement, and the conversations often heated, but there were never any hard feelings at the end of the day.

 

I worked with a number of EMTs and medics on my 2-week elective, but I bonded with one in particular. I think we had matching (or perhaps complementary) streaks of cynicism and optimism (yes, you can be both a cynic and an optimist. In my case, I think my cynicism protects my optimism from being snuffed out by reality).  He asked if I had read The House of God [1], by Samuel Shem, (the nom de plume of psychiatrist Stephen Bergman), and when I said I had not he insisted that I must.

 

I ordered the book right away, but like so many excellent book recommendations, it took me a while to get around to reading it.  I finally started a couple weeks ago, and quickly devoured the whole book.

 

The House of God is a satirical novel that portrays the life of a medical intern in the early 1970s.  A lot of things have changed for interns since this book was published- the most notable (for the sake of this novel) is work hour restrictions. Nonetheless, there is much about this novel that made me, even as a mere medical student, laugh, cringe, and nearly cry.  I have since recommended it to many other medical students and residents with the description that it is “brilliant, hilarious, and terrifying”.

 

The book is, of course, fiction, but it is, in essence, true.  It is as poignant today as when it was first published in 1978.

 

Some of the scenes are things that I can relate to, if not describe verbatim, from my experience as a third year medical student.  Some of the patients I have seen are the embodiment of the caricatures described in this novel. “The Yellow Man” with his failing liver, the (relatively rare) young patient who invariably has some condition we can not treat and who sadly dies, the (common) old patient that we can not treat effectively but that we can patch up well enough to carry on… These are patients I know, even though they are fictional.

 

I won’t write a review of the book- it is brilliant, and I think everyone involved in the medical community should read it. I find myself wondering what non-medical people think of the book… I suspect it would be hard to decipher satire from actuality- the line is definitely not clear, even for those who work in the medical community.

 

The House of God uses terms that are familiar to those who work in a hospital- and I’m not talking about words you find in a medical dictionary. The term “turfed” is when a patient is moved from one medical team to another (such as from a general team to a specialty team, or vice versa), a “bounce back” is a patient that your team treated who was then transferred to another team or discharged from the hospital, only to “bounce back” to your service.  The term “gomer” is one that I write with some reluctance.  It is a word that I have never heard uttered in the hospital, and have only heard in “humanism” lectures (in which it was made clear that no one should ever use the term), which describes “a human being who has lost-often through age-what goes into being a human being”.  The House of God is how this term first became well known, a term that is an abbreviation for “Get Out of My Emergency Room”.

 

The same author, again under his pen name, published a piece in 2002 in the Annals of Internal Medicine entitled “Fiction as resistance” [2], in which he describes using storytelling to illustrate, and retaliate against, the brutality and inhumanity of medical training and the practice of medicine. Fiction makes reality palatable.

 

In this article Shem writes about how he encourages people to resist the inhumanities of medicine. The keys, he believes, lie in (1) learning our trade and being aware of the world around us and our patients, (2) avoiding isolation, (3) speaking up, and (4) learning empathy. I am not sure how one learns empathy.  Sadly, some aspects of medical practice almost seem designed to dispatch it.

 

Just as I finished The House of God, my mother sent me a book for my upcoming birthday.  I’ve quickly read about half of On Call: A Doctor’s Days and Nights in Residency [3], written by Emily Transue, an internist on faculty at the University of Washington.

 

Reading these books in immediate succession is powerful.  One is satirical fiction while the other is reality, but if you changed the writing styles you could easily swap the real stories for the fiction.  Both write of the dehumanization that occurs during medical training, but Shem follows the adage “if you want to tell people the truth, make them laugh, otherwise they’ll kill you”.

 

Sometimes I think I’m too young, too “wet behind the ears”, to write about dehumanization in medicine.  I’m only a fourth year medical student, how much have I really seen.  Other times (well, most of the time), I worry that expressing my feelings, especially in writing especially on the internet, is just asking to have things I say come around and bite me at some point in the future…

 

Another part of me, however, thinks that medical students are best positioned to recognize dehumanization in medicine.  We are the least indoctrinated, the least hardened.  As students, we also know that there’s a lot we can’t do. The idea, of course, is that with training we will be able to fix people, heal people, make things better.  Sometimes we can; frequently we cannot.

 

As students, we know that we are fairly powerless in the management of a patient’s medical care.  This can be frustrating when you think there is something that could be done that might help a patient, but also leaves you in a position where you don’t feel like you’re personally failing a patient when there is little to be done (at least medically speaking).  When those with more medical clout, more medical ability, are faced with a situation where the best medicine we can offer will do little good, they sometimes have a hard time letting go.  As if saying “there are no more medical options we can try” or “this isn’t going to get any better” is admitting defeat.

 

Perhaps it is defeat. But maybe in this circumstance admitting defeat makes you better.  When you realize that you have exhausted your medical options, perhaps you can finally treat the person, not the disease.  It’s just a shame that we don’t always treat the person first.

 

1.            Shem, S., The House of God. 1978, New York, New York: Dell Publishing.

2.            Shem, S., Fiction as resistance. Ann Intern Med, 2002. 137(11): p. 934-7.

3.            Transue, E.R., On Call: A Doctor’s Days and Nights in Residency. 2005: St. Martin’s Griffin.

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

 

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

 

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

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

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

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

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

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

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

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

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

Modern staples: vegetable oils, toilet paper, and soda

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

Women at work

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

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

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

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

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

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

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

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

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

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…thoughts on hiking, med school, and life…

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

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

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

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

View from Matterhorn

View from Matterhorn: A place to think…

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

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

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

Playing at Rickets Glenn

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

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

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

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

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