Posts Tagged ‘Med School’

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!



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! 

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

I started with an introduction to evolutionary medicine…

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

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

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

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

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

So what is “being human”?

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

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

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

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

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

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

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

Going beyond food- what else makes us human?

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

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

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

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

Humans were meant to move

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

Humans sleep

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

Humans have friends, not “friends”

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


Evolutionary Medicine isn’t just about preventative health.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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