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Posts Tagged ‘medicine’

A New Year’s Update

I struggled with the title of this post for a while. It’s a long time since I’ve written anything (for the blog), and I wanted the title to be catchy, edgy, maybe even with a touch of double entendre. Alas, my creative mind has failed me. Perhaps this is a consequence of writing nothing but clinical notes for the past 6+ months- a result of being in the intern year of my medical residency. There is no need for provocative language, crafted sentences, or grammatical subtleties in medical notes. On a good day, clinical notes are composed of brief and simple sentences. On a busy day, notes are often composed largely of sentence fragments and phrases. On a bad day, notes may largely consist of abbreviations and acronyms.

Residency: Where to begin? I suppose at the beginning.

I haven’t tried this on older, more seasoned, docs, but it can be a bit of fun to ask a young doctor about the first order they ever gave as an MD. I come from a generation of medical students that did not give orders as students (I may have written out a paper order on occasion, but these were never acted upon until cosigned by a supervisor), so on July 1st, my first day of my residency, I showed up at 5 am eager (and somewhat petrified) to start my first rotation on Labor and Delivery- never having given a “medical order” to anyone. That morning, a nurse snagged me outside a patient’s room and said “Oh, she’s having some heartburn, can you write an order for Tums?”

“Sure”, I said calmly- while on the inside I felt like a deer in the headlights, trying to think of anyway possible that giving a lady Tums might lead to her demise. I stressed, I fussed, and then- as many interns do- I consulted a fellow resident. “Can I just write this lady for Tums?”

“Sure- but she should already have them ordered in the admission order set.”

How anticlimactic…

For a lot of young doctors that I’ve talked to, that first order request is for Tylenol.

The story usually goes something like this: patient’s nurse sees new resident. “Hey- Mr. Smith in room 14 has a headache. Can I get some Tylenol?”

New resident “Sure… Give me a minute?”

New resident then scurries off to the work room to check the patient’s allergies, liver function tests, alcohol history, etc, etc, etc. Resident then checks dosing, route of administration, frequency, and scans a med list wracking his brain for anything that might cause an interaction… I have heard this story many times- plus or minus a consult with a fellow resident.

That is on July 1 (or perhaps the end of June, as many programs now jump the gun on the July 1 residency start date). Hop forward a few weeks and the same resident will likely respond to the nurse “Sure- need a written order or can you take this as a verbal?”

Back to July 1: As I mentioned- I started my residency on labor and delivery. As a family medicine resident my intern year is a mix of some obstetrics, a pinch of surgery, a dose of pediatics, a healthy whack of in-patient medicine, and a sampling of various other areas of medicine (as well as a consistent stream of out-patient clinic). I started on Ob- one of the most challenging and grueling rotations in our residency. I’ll admit that I was initially scared but ultimately pleased that my medical career started on labor and delivery. My days of shadowing and standing in the background were gone. As a medical student I was allowed to stand in the room during a delivery and catch the occasional placenta, but as an intern I was expected to manage a patient from admission to discharge, with a labor and delivery in between. As my skill set and confidence grew, so did my autonomy- I was really someone’s doctor!

Of course, claiming that title was something I was hesitant to do…

As medical students, some people introduce themselves as “Student Doctor So-and-so”. I found this verbiage absolutely ridiculous, and instead went with the line “Hi- I’m Victoria, a medical student on the team looking after you.” I often followed this with the pseudo-apology “I can’t write you a prescription for any of the good drugs, but if there’s something going on and you feel like no one’s listening to you, I promise I’ll listen.”

Back to July 1- Do I actually introduce myself as “Doctor”? Who do I think I’m kidding?!

Folks, I’m here to tell you that the “Imposter Syndrome” is real. On July 1, there was no way I was introducing myself as “Doctor”. Instead, I modified by student script and said “Hi- I’m Victoria- one of the residents on the team looking after you.” I’m pretty sure I never introduced myself as “Doctor” that whole first month.

For my second month of residency I moved to a community hospital where I was doing in-patient medicine. There, my attending physician (my supervising physician) heard my introduction and said “Your life would be much easier if you introduced yourself as ‘doctor’”. Innately, I hate this reality. Despite working hard for many years to earn a slew of letters after my name, I’m not comfortable with the reality that saying that gets me more respect.

I battled on for a day or two, with my attending introducing me to patients as a doctor and hissing over my shoulder “doctor”, when she heard me call the lab, introduce myself as Victoria, and then sit on hold for 5 minutes waiting for a result. It didn’t happen quickly, but bit by bit, either by repetition or by the slow growth of the belief that maybe- just maybe- I was actually “doctoring”, I started to become comfortable with the term. I frequently couch the introduction with “one of the residents”, but I’m now comfortable introducing myself as Doctor, and have even found myself briefly annoyed when someone introduces me to a new patient by my first name. Outside of a patient’s earshot I have no need for a title (unless it bumps me to the front of the line when calling in to make an appointment for a patient or if I call in for a lab result), but I’ve come to learn that while the title doctor may give you respect, it also gives your patient confidence in you- and that is something incredibly valuable.

And what of Evolutionary Medicine and Ancestral Health?

If you’ve read many of my old posts (save those on travel), you’ll know that I have a passion for evolutionary medicine and ancestral health. One of the reasons I chose the residency program I did was because I knew it was a place I could explore those interests. That being said- my ability to explore and practice that kind of medicine has been quite limited. In my 8 weeks of Ob I had 49 vaginal deliveries: not one of which was done in a non-conventional position. I’ve probably prescribed more probiotics than most, though how much good a bolus of pure Lactobacillus does in a gut that has been firebombed with antibiotics I’m not really sure. (Strangely people rarely seem interested in eating Kimchi to replenish their gut flora… )I’ve also probably prescribed as much Tylenol as everyone else, despite believing that fever is a symptom (and a useful infection-fighting one at that) of illness and not something that needs to be treated in-and-of-itself. I’ve had small victories, discussing the potential benefit of fevers with some patients and families, and having them agree that they don’t need or want their fevers treated unless the discomfort is such that they can’t sleep or rest. I’ve also had these plans thwarted by covering residents and nurses who can’t stop their desire to “fix a number” and “fix a fever”.

Clinic is a bit of a different picture. There I’ve recommended, sleep remediation (sans medication), exercise, and books such as “It Starts With Food” to a number of patients, and been pleased to have the occasional one come back reporting success with lifestyle intervention. I’ve also had occasional welcome surprises, as I meet new patients who (sensibly) CrossFit or embrace a high-saturated fat/whole food diet who usually look shamefacedly at their doctor saying “My family wants me to come see a doctor because they know you’ll tell me this is a bad idea…”. Connecting with those patients- ensuring proper rest in one, recommending Kerry Gold Butter to the other- is an unexpected but welcome pleasure.

6+ months in…

I’m 6 and a half months into my intern year of residency. I have worked harder, put in more hours, and been more stressed than I ever have been before (the stress of writing a PhD thesis was quite different). Having written (and then retracted, since it was a duplicate order) my first order for Tums, I have gone on to write hundreds more orders. I still get nervous with firsts, but my comfort level is rising. Yesterday I did a thoracentesis for the first time. One day I will inevitably run my first code- this thought terrifies me.

I have also made some wonderful connections- with fellow residents, nurses, and patients. I continue to believe that doctoring is about people, not just illness, and while some patients come through as just another case that is quickly gone from my mind once the discharge is dictated, others have forever shaped who I am as a person and a doctor.

And Utah- oh Utah. There is not a day I have regretted moving to this state or choosing this residency program. I work with great people who love what they do but also value having a life outside of work. I work hard, but have the opportunity and ability to play hard as well. In the longer days of summer I was taking evening hikes some nights after work. With a tank of gas and some motivation I’ve been able to put 1-day weekends to good use, and have explored many of the national and state parks. Now that winter has come, I’ve used my rare day off to take to my cross-country skis, and am in the process of rediscovering my downhill ski legs, having hit the slopes for the first time in 13 years.

So here I am- half way through my first year of residency. I’m a doctor, and I no longer feel like a fraud when I say that. Many of my academic interests have been put on hold, but I have faith that I’ll be back to them as time allows. I’ve learned a lot since I moved to Utah in June: about medicine, myself, and others. There is so much to learn, so much to think about, and so much to explore, in medicine, wilderness, and life!

Little Cottonwood

View from Little Cottonwood Canyon, near the summit of Pfeiferhorn.

(more…)

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“Doctor! Heal thyself!”

 

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

 

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

 

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

 

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

 

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

 

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

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

 

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

 

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

 

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

 

Healing takes time.

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

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OK- enough (for now) of the photo documentation of my past month of explorations!  While I am keen to write more about the environment, wildlife, and general experience of my last month in Utah, it’s time for me to get back to the reality of a med student and think (and write) about medicine.

 

A number of schools (and programs) offer Wilderness Medicine electives for medical students, but I chose (and was fortunate to get a spot in) the elective offered by UMass Medical School.  A few things drew me to this program.  First- it has been running for 20 years, so I initially suspected they were doing something right.  Second- many Wilderness Medicine courses are taught in classrooms with field trips and forays “into the wild” for practical experiences.  The UMass course is taught in the wild. With the exception of our first day of lecture, conducted in a hotel meeting room, all our lectures were done outside on snow, in boats, on beaches, or sitting in the desert.  Thirdly- we got to experience three different environments in the course of three weeks.  A few other courses are taught in the wild, but they are taught in a single environment.  Utah gave us access to three, very different, environments (as shown in my previous posts: alpine, river, and desert).

 

This was our main classroom in the alpine section.  We'd just arrived and are taking a quick break before setting camp, but this area was left open and we would congregate here for lectures.

This was our main classroom in the alpine section. A classmate snapped this shortly after we arrived when we were taking a quick break before setting camp, but this area was left open and we would congregate here for lectures. 

 

When I initially described this course to friends and acquaintances, many suggested that this course was basically Outward Bound for doctors.  The answer, I suppose, is yes and no.  There was certainly a lot of medical learning done in this class, but we also gained life skills that will not only help us in future endeavors in the wild but will also give us confidence as we go forward in our medical careers.  Broadly, it taught us to have confidence in our decisions and to use what we have available to do the best that we can.  I’m unlikely to ever have to improvise a splint in the Emergency Room, but knowing that I can, and having that confidence, will carry me and my classmates a long way as we progress to interns, residents, and one day attending physicians.

 

As you might expect, the medical topics that we covered were married to the environments and activities we were doing.  Before heading out on our first big trek we had a thorough lecture on blister pathophysiology, prevention, and treatment. Once in the alpine, we promptly learned about hypothermia, and how to create a hypowrap to help someone with hypothermia.  We learned about frostbite and non-freezing cold injury, as well as thermal burns, sunburns, and sun blindness.  While in the mountains, we also discussed various problems that occur at high altitude.

 

A lot of injuries in the wild are orthopedic, so we had multiple sessions on splinting, immobilizing, and caring for these injuries.  We also learned various lifts, rolls, and carries, utilizing minimal equipment- since you don’t always have a backboard and a team of people to help you.  Along those lines, we learned just how difficult it is to litter carry someone out of a bad situation (you need about 18 people to go 1 mile, and it will take you a LONG time).

 

It's not what you would do in a hospital setting, but how do you get someone with a potential cervical-spine injury free after you’ve just dug them out of an avalanche slide? Stabilize their neck with their arms and drag them! (And kudos to our instructors.  Not only did they dig a deep snow cave for us to locate with avalanche beacons, but one of the brave residents agreed to be buried down there for one of our “scenarios”. I wish I could have seen the look on my face when we realized there was a person 5 feet under the snow!)

It’s not what you would do in a hospital setting, but how do you get someone with a potential cervical-spine injury free after you’ve dug them out of an avalanche slide? Stabilize their neck with their arms and drag them. (And kudos to our instructors. Not only did they dig a deep snow cave for us to locate with avalanche beacons, but one of the brave residents agreed to be buried down there for one of our “scenarios”. I wish I could have seen the look on our faces when we realized there was a person ~5 feet under the snow!)

 

 

The slope that we dug our patient out of- the instructors made the scenarios very realistic while keeping everyone safe.

The slope that we dug our patient out of- the instructors made the scenarios very realistic while keeping everyone safe.

 

Injuries in every settings... here I’m sporting a mid-humeral splint fashioned out of a camping chair (in the rain and on the river).

Injuries in every settings… here I’m sporting a mid-humeral splint fashioned out of a camping chair (in the rain and on the river).

 

A number of dermatologic conditions occur in the wild, so we discussed their various etiologies.  We also discussed methods of wound management, including wounds caused by snakebites, insect stings, and mammalian injury.  (On that note, during our time in the desert our group spotted rattlesnakes, scorpions, and a black widow spider.)

 

A trio of beasties spotted on our trip.

A trio of beasties spotted on our trip.

 

Many of the topics we covered are much more likely to be encountered in the wilderness than in a clinical setting, but some topics are ever-present in any setting.  Anaphylaxis and allergies can occur at any time, and while you may acquire tick-borne illnesses or infections diarrhea in the wild, the incubation time for many of these mean that they frequently present at a primary care office.  Nonetheless, these were topics we covered on this course, frequently harking back to the “bible” of wilderness medicine: Wilderness Medicine written by Paul Auerbach.

 

Thus far I’ve mainly focused on the didactic portion of the course, but much of the learning took place in “scenarios”.  I’ve never participated in simulation medicine, save for the standardized patients we get on our OSCE (Objective Structured Clinical Exam) at the end of most clerkships. While at first it can be awkward to “practice” medicine on people that you know are acting, once you get into the part it is a wonderful way to learn.

 

The beauty (and perhaps the terror?) of our scenarios was that our instructors would let us “play it out” in the field.  In clinical settings, while students may participate in discussions about patient care, they are never in the driving seat.  In our wilderness scenarios we were allowed to make the decisions and deal with the consequences.  At times this was frustrating (can’t I just ask the Wilderness Fellow standing over my shoulder what I should do), but it also allowed me to make mistakes that will stick with me for years to come.  For example, if a “helpful” stander by hands your patient some food, make sure they’re not allergic to it before they take a bite (that’s how a painful case of sun blindness can progress into life threatening anaphylaxis).

 

The scenarios also allowed (or I should say made) students make decisions about evacuation. Do we evacuate the patient? How? Can they walk? Do they need a litter? Do they need cervical-spine protection? Do we leave now or hunker down for the night and head out tomorrow? What’s the best evacuation route? Could a rescue team get a helicopter in here? A snowmobile? Maybe we should send runners to a ranger station? Where’s the closest location we can get cell phone reception?

 

The scenarios progressed with our wilderness medicine knowledge, as well as our knowledge of Incident Command Structure (ICS).  There were twelve medical students in our class, and when we had a scenario with one patient, it would be easy to have “too many cooks in the kitchen”.  On the other hand, when we had three patients, we could quickly run out of hands as people were relegated to “safety officer”, “equipment”, “communications”, and if the scenario necessitated it “runners” leaving the scene to make contact with civilization.

 

All in all, the medical education side of this course was excellent.  Some of the medicine was a review, but it was a much-needed review and one that frequently found we students (who are trained to practice medicine in well-stocked hospitals with multiple imaging modalities at our fingertips) asking “what do we have that we can use” and “how can we do what we need to get done”.

 

Medically, this class was a reminder of quite how much we’ve learned about medicine in the last few years.  It also emphasized that frequently there is no “right way” to handle a situation and your best guess and best efforts may save the day. We were also reminded of the reality that sometimes there is nothing you can do to save a life… and that is an important lesson to learn as well.

 

 

Not a bad place for a lecture...

Not a bad place for a lecture…

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

 

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

 

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

 

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

 

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

 

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

 

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

 

venn

 

A slightly more amusing diagram might looks something like this… 

 

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

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

 

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

 

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

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

 

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

 

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

 

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

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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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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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Medicine of the mind

While I am a medical student, the purpose of this blog is not (or at least it wasn’t when I envisioned it) to blog about my journey through med school. One of the first blogs I remember reading was called ‘Over my med body’ and it was a brilliant blog written by a (then) medical student. I’m sure there are blogs out there of med students telling their tales on the floors, but that’s not what I want to write about. I realize, however, that over the next couple years I will go through things that most people will never experience. I’m seeing things that people only hear about third hand or see dramatized on TV. Occasionally it might be fit that I share my experiences. Now is one of those times.

 

I’m currently on my Psychiatry rotation. I don’t wish to openly discuss the medical school I attend, but I’m currently doing a clerkship at a public hospital in one of the poorest cities in the country. In general, the people that we attend to are uninsured or underinsured. There are high rates of chronic disease such as diabetes and hypertension, infectious disease such as HIV and TB, and extensive drug use. Learning medicine in this kind of environment is learning medicine in the trenches- it is one hell of an education.

 

I’ll admit that I’ve always been a bit intimidated by psychiatry. I’m in awe of the brain, specifically its ability to control such complex tasks with the use of limited resources. When it comes to neurotransmitters, there really aren’t that many. The brain effectively controls all our thoughts and actions with an incredibly limited vocabulary (5 neurotransmitter “words”: GABA, glutamate, dopamine, serotonin, and acetylcholine). I’m amazed it works in the first place, and I’ll admit that I’ve long been apt to think “Glad you work- let’s leave well enough alone” when it comes to contemplating the brain. Of course, just because something is hard to study, doesn’t mean it shouldn’t be studied. Indeed, that’s the point a fellow MD/PhD student made to me when he tried to wipe the look of surprise off my face when he said he was going into psychiatry. We need more great minds in psychiatry- the specialty is lucky to have him!

 

If you’re interested in an evolutionary approach to psychiatry, you MUST check out Dr. Emily Dean’s fantastic blog (please do- it would be the least I could do to send a couple clicks to her blog when she refers so many to me!). There’s a lot to think about and talk about when it comes to an evolution-based approach to psychiatry, and while I think that good nutrition, good sleep, good exercise, and good stress-management are all important for good mental health, I’m going to leave the tricky stuff to Emily.

 

Now, after a lengthy preamble, I get to the crux of the matter- my insight from the floors.

 

As one might imagine, the inpatient psychiatric ward at a public hospital in a poverty and drug-stricken community is… intense. I’ll admit to being thrown a bit off kilter by the bustle and (apparent) mayhem on my first day on the floor. You know you’re in a bad way when a fully psychotic patient gives you a look and asks ‘Are you ok?’. Aren’t I meant to be asking that question? Just how pale and wide-eyed am I? Inpatient psyche in this setting is not your aunt’s depression, or your roommate’s mania (not to belittle these conditions). The people we see on the floor are there voluntarily or involuntarily for a variety of reasons, but most frequently for schizophrenia, suicidal ideations or attempts, debilitating anxiety and depression, and/or delusions (frequently a combination). These patients are fascinating, and heart breaking. Some have insight into their condition (they understand that they have a mental illness), but many do not. On this floor you see how obsession can drive you to depression, and then to attempts to take your own life. You can see how delusions lead people to circumstances where they are at risk of hurting themselves and others. You see paranoia that cripples a person. These descriptions do not do the patients justice, but I don’t think any description would. It is something that has to be seen to even start to understand, and I am very grateful I have that opportunity.

 

Seeing these situations first hand is eye-opening. As I said, the first day I found myself overwhelmed. The psyche ward is a very different experience than medical wards. On medical wards, most patients are confined to their bed. You might see the odd patient out wheeling their IV around, or being taken for a walk around the floor by a therapist, but the halls are generally restricted to nurses, students, doctors, and visitors. The psyche ward is very different. These patients are almost all able bodied, and being out and about is good for them- many reap benefits from the group activities and sessions. We don’t want these patients in bed, but having them all up and about makes for a very interesting dynamic. It can get loud, it can get rowdy, and if you don’t know the patients, it can get scary (it can get scary when you know them too).

 

As I said, the first day I was overwhelmed. I saw patients only with my resident and attending (though I did have a very long chat (a real education for me) with one of our patients about the different street drugs she had taken and the various routes of administration (I learned more in that 10 minute chat then I did in all the years of drug education)). The second day I was cautiously curious, occasionally going out on my own to talk to a patient or do a mini-mental status exam, then seeking refuge behind the Plexiglas and locked half-doors of the nurses’ station. By the third day I was visiting patients on my own, and checking in on them for updates before we rounded… I think that was the turning point.

 

Psychiatry, especially in this setting, is all about observation. A patient may tell you one thing, but what you observe can give you much more information. Also, getting ‘collateral’ from family members, admitting physician’s notes, and lab results is very useful. A patient may tell you that he was brought in by the police after he called to complain about his upstairs neighbors (who frequently steal his stuff) getting in an argument, but a family member may later tell you he lives in an attic apartment and has no possessions. Equally, someone may report visiting an outpatient clinic regularly, only to name a hospital that closed years ago. These patients aren’t lying- or at least they’re not trying to. This is their reality. An accurate history is important in understanding the full picture of a patient, but obtaining one from a psychotic patient is often impossible.

 

Mental illness is not cool. It isn’t popular or sexy. I’ve received countless requests to participate in or donate to all manner of ‘walk for the cure’ events for juvenile diabetes, cancer, heart disease… chances are you’ve donated to these things if you haven’t participated in them directly. It’s an easy sell- everyone knows someone with diabetes, heart disease, or cancer. This IS your aunt, your roommate, your neighbor, and your friend.

 

Maybe it’s just me, but I’ve never seen an event aimed at raising schizophrenia awareness. Chances are, you DON’T know someone with schizophrenia, though the prevalence is actually not that low (perhaps around 1 in 100). While we’ve made great progress at eliminating gender, racial, and sexual inequalities, there remains a great stigma around mental-health. The heart is a pump, the liver a processing plant… the brain is ‘us’ and a disorder that affects who we are, without other signs of disease, can be hard to comprehend and accept.

 

Sometimes in the world of evolutionary health and wellness we like to get lost in the utopian ideal that an evolutionary appropriate lifestyle will fix everything. Overweight? Type II diabetes? Acne? Infertility? We’ve got lifestyle-modifications for that. But there are very real and very devastating conditions out there that will not and cannot be fixed with a change of diet and exercise. I’ve found the last week of my education amazing on so many levels- the patients, the staff, the doctors, and the drugs… I am in awe. I’ll miss the ward (and I will be back), but I don’t think it’s where I want to practice in the long run. I am very happy, however, that bright minds are tackling these issues and that there are people dedicated to helping a population that is often unable to ask for help.

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