ramen and pickles

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Monthly Archives: May 2013

Physician Political Activism

A few weeks ago, I participated in a health advocacy day in Sacramento, where those involved in public health issues could meet with state senators and assemblymen.  I mostly followed around people who work for Community Health Partnership and some of their patients who had come up to the Capitol to advocate for the community clinics.   I went because it was a required activity as part of population health in my practice of medicine course at Stanford.  We were given a list of possible activities, and this one struck my fancy.  I’ve lived in California since 2005, and I had never been to Sacramento.  I was even confused about whether it should be spelled Capitol or capital.  Prior to visiting Sacramento, my primary understanding of the legislative process could probably be best summarized by this Schoolhouse Rock video, I’m Just a Bill:

Actually, that’s not entirely true.  In high school, I took part in Youth in Government and was one of the justice’s on the mock version of the state’s Supreme Court.  Frankly, the judiciary branch has always been more interesting to me, primarily because appellate law involves more logic, puzzles, and problem solving, and legislation seemed more like endless arguing and bargaining.

However, I found being in the state Capitol to be exhilarating.  We mostly met with staff members, who listened politely, and only briefly got to talk to Assembly members, but the committee meetings were open to the public, and I go to go hear public testimony on a variety of measures.   It was very exciting, but I could see where doing it every day could become tedious, and I’m not sure how much information was actually conveyed, as everyone very briefly summarized key points while trying to appeal to sentiment.  It actually felt like things were going very quickly, as measures were brought up, briefly discussed and voted on very quickly. It felt like quite a bit of activity was rapidly occurring.  I know that much of that activity represents many days, weeks, months of work on someone’s part drafting a bill and getting it into the committee and probably many “back room” meetings, but the actual discussion was very rapid.  The final vote is in the main Assembly, but the committee is an essential part of the process. It had a bit of an arbitrary feel to it in some ways, the legislator can’t be well educated on more than a handful of serious issues (for example people spend lifetimes trying to understand how taxation works), and so their voting is inherently poorly personally informed, relying as it does on executive summaries, despite the great importance of their decisions to the lives of huge numbers of people.  It’s how representative democracy works, and somehow it works incredibly well.

The purpose of the course exercise was to learn a little bit about how healthcare providers, in particular physicians, can do healthcare advocacy and be involved in policy making.  It is true that physicians have a little bit extra bit of voice particularly on healthcare issues, given their advanced training and having essentially undergone a vetting process through passing boards, although this is of course tempered by individual personality and temperament.  However, I’m not sure how strong a voice they actually have, as you can almost always find someone to give a differing expert opinion when it comes to anything even a little bit vague.  I’m unsure how much impact a physician can have casually.  Large groups of physicians can form trade unions like the AMA, which are able to hire lobbyists at the state and federal level, and certainly seem to have some public clout.  As part of the same class, I also interviewed Ann Lindsay, former public health officer for Humboldt County and now on the Stanford faculty.  She is certainly someone who has been active in policy making, working directly with legislators, both as part of her official duties and also because of her personal interests and dedication.  However, it obviously took a large amount of time and energy on her part.  All this leads me to think that a physician, you might have a tiny bit of leverage in trying to get a meeting with someone, particularly if you have a prestigious position or association, but I’m not convinced that having an MD or DO gives you a substantial bit of leverage in political activism.  When I read the biographies of state legislators of California, I see that they were mostly regular citizens who started becoming involved in local politics, school boards, planning boards, and the like and just became more and more active in politics.  If a given physicians wants to make that level of commitment and involvement, they can certainly do so, but so can most citizens.  That’s what makes the system work.  Advocacy is open to anyone who wants to try.

Biomedical and public health research may give us many answers, but that is not the same thing as deciding policy.  We may know that alcohol and tobacco are the cause of significant amounts of morbidity and mortality.  However, smoking and drinking are very popular activities which many people enjoy and feel it is their innate right to continue to enjoy.  They are also the source of huge amounts of revenue, particularly for the state in the form of taxes and are represented by huge lobby groups.  Attempts at regulation are met with large amounts of resistance.  Policy is not necessarily set by science or research.  C. Everett Koop was instrumental in governmental policies reducing smoking in the US, but again this was in his capacity as a public servant and as the surgeon general.

It’s certainly possible for medical students and physicians to be highly effective at working in healthcare advocacy and policy change, but like everything worthwhile, it takes hard work and diligence.

 

 


 

 

 

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How to look good 101: Learn to tie a bow tie

Lucky Levinson of Columbia, South Carolina gives a great tutorial on how to tie a bow tie.  Apparently bow ties are “Famously Hot” in South Carolina.

There is also this closeup video to help you tie a proper bow:

Of course, if you want to go the master, Bill Nye the Science Guy gives this tutorial of a slightly different tying style with a lot of good technical vocab:

And finally, what does Dr. Who have to say on the matter?

Is Medical School a Cult?

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Stanford is affectionately called, The Farm.   But that got me thinking that it sounds a bit like the site of a cult.  How do you know a cult when you see one?

Luckily, you can find anything you want online, including this checklist to help determine if something is a cult from the International Cultic Studies Association.  Let’s see how medical school stacks up.

  • The group displays excessively zealous and unquestioning commitment to its leader and (whether he is alive or dead) regards his belief system, ideology, and practices as the Truth, as law.
    Meh.  There is a bit of a cult of personality around deans, department chairs, and so on.  
  • ‪ Questioning, doubt, and dissent are discouraged or even punished.
    No. Medical school administrators are relatively open to feedback and critique.  It’s unclear if you will be punished later though.
  • ‪ Mind-altering practices (such as meditation, chanting, speaking in tongues, denunciation sessions, and debilitating work routines) are used in excess and serve to suppress doubts about the group and its leader(s).
    Meh. Define debilitating work routine?  Some of the work is certainly spirit crushing and going long periods without sleep is mind altering.
  • ‪ The leadership dictates, sometimes in great detail, how members should think, act, and feel (for example, members must get permission to date, change jobs, marry—or leaders prescribe what types of clothes to wear, where to live, whether or not to have children, how to discipline children, and so forth).
    Meh. They do tell you what clothes to wear, and there are special clothes for members of the group.
  • ‪ The group is elitist, claiming a special, exalted status for itself, its leader(s) and members (for example, the leader is considered the Messiah, a special being, an avatar—or the group and/or the leader is on a special mission to save humanity).
    Yes. 
  • ‪ The group has a polarized us-versus-them mentality, which may cause conflict with the wider society.
    Yes. Patients and providers are considered very different.
  • ‪ The leader is not accountable to any authorities (unlike, for example, teachers, military commanders or ministers, priests, monks, and rabbis of mainstream religious denominations).
    No.  The leaders can get sued or fired.
  • ‪ The group teaches or implies that its supposedly exalted ends justify whatever means it deems necessary. This may result in members’ participating in behaviors or activities they would have considered reprehensible or unethical before joining the group (for example, lying to family or friends, or collecting money for bogus charities).
    Yes.  I’m giving this a yes because you are being allowed/taught to do things that otherwise would be illegal, unethical or rude.  You’re taught how to cut into people, how to drug, how to ask people personal/invasive questions, how to examine/touch people in private parts of their bodies, and just generally given permission to do weird stuff to people. 
  • ‪ The leadership induces feelings of shame and/or guilt in order to influence and/or control members. Often, this is done through peer pressure and subtle forms of persuasion.
    Yes.
  • ‪ Subservience to the leader or group requires members to cut ties with family and friends, and radically alter the personal goals and activities they had before joining the group.
    Yes.  You certainly have less time to have interact with your friends and family and any hobbies you might have had.
  • ‪ The group is preoccupied with bringing in new members.
    Yes.  Medical school spends a huge amount of time on interviewing, recruitment.
  • ‪ The group is preoccupied with making money.
    Yes. 
  • ‪ Members are expected to devote inordinate amounts of time to the group and group-related activities.
    Yes.
  • ‪ Members are encouraged or required to live and/or socialize only with other group members.
    Yes.  There are lots of med student only social activities and it can easily take over all your social interactions.  Non med students also get sick of hearing about medical school things.
  • ‪ The most loyal members (the “true believers”) feel there can be no life outside the context of the group. They believe there is no other way to be, and often fear reprisals to themselves or others if they leave (or even consider leaving) the group.
    Yes.  Gunners gonna gun.

So, medical school does not seem to exhibit all the properties of a cult, but it is certainly very cultish.

Next time maybe I need to talk about Deprogramming.

 


 

 

Secret History of the Menlo Park VA

Electric Kool Aid Acid TestThe Menlo Park VA has a Veteran’s Hospital and is the site of the Willow Clinic and currently the Arbor Free Clinic.   The Arbor Free Clinic is staffed by volunteers from Stanford’s Medical School, and I’ve spent hundreds of hours working there.   Although it is likely that the Arbor Free Clinic will move in the next year to new outpatient facilities being constructed at the newly renovated Hoover Pavilion (the original Palo Alto Hospital), Stanford students still spend a considerable amount of time at the Menlo Park VA, and most are unaware of the important role of the Veteran’s Hospital in psychedelic and literary history.  It was the crucible in which much of the counterculture of the 1960’s was formed.

The Stanford alumni magazine gives some background:

http://alumni.stanford.edu/get/page/magazine/article/?article_id=38411

In 1958, rebellious young student Ken Kesey came to Palo Alto to pursue postgraduate study in creative writing.   Although I’m sure he learned a lot in his educational program, it was his experiences at the Menlo Park Veteran’s Hospital which seem to have had a much more strongly catalytic effect on his life.  For extra money, he began to work at the VA as a night attendant and also volunteered to take part as an experimental subject in the CIA’s MKUltra studies on psychoactive drugs.   His experiences with the psychiatric patients at the VA, along with the drugs he was receiving, particularly LSD, inspired him to write One Flew Over the Cuckoo’s Nest, which became wildly successful and led to the 1975 film, staring a young Jack Nicholson and swept that year’s academy awards (Best Picture, Best Actor, Best Actress, Best Director, and Best Adapted Screenplay), Golden Globes, and BAFTA’s.

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The money gained from the success of this novel supported Ken Kesey’s new interest and activities which included massive parties where he gave other people access to the psychedelic drugs he had discovered and the new style of music from the Warlocks/Grateful Dead.   In the most famous example, he collected a group of friends, “The Merry Pranksters”, who travelled across country exposing people to their drug fueled psychedelic ethos, contributing a big part of what led to the hippie movement in the United States.  This period was chronicled in the 1968 book The Electric Kool-Aid Acid Test, by Tom Wolfe, which itself proved to have a very strong influence on the counterculture of the late 60’s and early 70’s.   Their adventures are also profiled in the 2011 film, Magic Trip which was composted of old footage from their journeys.

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An important member of the Merry Pranksters was Stewart Brand, who went on to create the Whole Earth Catalog.   Given the important influence that this had on Steve Jobs (Steward Brand conceived of the expression “personal computer”), might attribute a lot of the way we interact with computers to those early experiences of Kesey at the VA hospital.  So, from the simple confines of the humble Menlo Park VA was spawned one of the greatest films of all time, a whole American subculture and aesthetic that continues today, and even a genre of music.  The next time you see a dayglo tie-dyed t-shirt or a MacBook Pro, think of Menlo Park, CA.

Stay hungry.  Stay foolish.

Whole Earth Catalog



DEVELOPING APPLICATIONS FOR GLASS IS ACTUALLY MORE SIMILAR TO BUILDING A WEBSITE THAN IT IS TO BUILDING AN ANDROID APPLICATION.

Jon Gottfried has written a little bit about his experience developing for Google Glass.  Unfortunately, although he makes a few good points, such as the nerdgasm he gets from working on new technology that will potentially change how people interact with the world, he is remarkable light on details, which maybe ironically makes it more hype about hype:

http://techcrunch.com/2013/05/24/theres-a-computer-on-my-face/

However, does make an interesting point that that the development process is more like developing a website than a mobile app, and that it currently only allows building asynchronous applications basically pushing and pulling the equivalent of web forms.

 

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Human Pincushion: Mirin Dajo

I’m sure you’ve seen examples of “human pincushions“, namely people putting spikes, hooks or other sharp objects through their skin. Often it is part of a circus sideshow type of performance, or maybe part of a religious rite. Usually the spikes are put through the cheeks, or through layers of skin on the back, but there are very few examples of these spikes apparently going through solid organs. One startling counter-example is Mirin Dajo, who repeatedly put swords (primarily fencing foils) straight through his abdomen.

Mirin Dajo (Arnold Gerrit Henskes) was a post WW2 performer and spiritualist who had a brief (1946-1947) career focussed in Holland and Switzerland where he would do performances and give talks/lectures about his spiritualist/paranormal philosophy.

There is a lot written about him on the web. Of course, you need to take all of it with a good dose of skepticism, but there is a decent amount of (silent) footage of him doing his feats.  Some accounts describe how he was invited to perform demonstrations at medical schools and hospitals in Leiden, Bern, Basel and Zurich.  According to one account, during a demonstration, the physicians and surgeon in attendance wanted to X-ray him to see the passage of the sword, but were somewhat confused about how to transport him to the radiology equipment, as he couldn’t easily fit on a stretcher or gurney with the foil protruding through his midsection.   However, he easily obliged them by just walking to the instrument.  Their immediate assumption was that the sword was acting as a tamponade on the puncture wound and providing compression.  They, naturally enough, believed that when the sword was extracted, he would begin to hemorrhage and need immediate surgery.  However, the sword was extracted without significant ill effect.  In any event, you can look at some of the (silent footage yourself), including watching him jogging around with the sword piercing straight through.  In some examples, there seems to be some fluid coming out of the puncture, but there definitely is not a ton of bleeding.

In the beginning of this video he can be seen to be sweating quite a bit, although it is unclear if that is from the stress and pain or if he is under very bright/hot lights:

Another one shows similar footage, including a piercing going through the coronal plane instead of anterior/posterior.  The X-ray shown seems to be taken with the sword in that position:

There is a lot of overlap in the videos, showing the same material.

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So the question is, how did he do it?  There is a lot of discussion on the web about this and that, but most of the consensus seems to be that he had established a fistula through his abdomen over a long period, and that is what we are seeing in the videos and that presumably even had to do things like sleep with a rod through this fistula to keep it open.  The many scars on his back are taken as evidence of failed attempts at establishing a fistula.  This is a plausible hypothesis, however, we must conclude that created several different fistulas, as we can see the swords passing through him in two perpendicular directions in the videos.

MirinDajo-GettingXrayed

He was known for having pierced himself through with three hollow tubes, allowing flowing water to pass through them turning himself into a human fountain, something shown in this photograph.

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The multiple scars on his back although taken to demonstrate numerous failed attempts to establish a successful fistula, but it is important to keep in mind that his filmed demonstrations are not his only performances.  He gave many public demonstrations, perhaps up to 500 different ones with different assistants, and in the different videos and pictures the swords often seem to be passing through quite different regions.  People in the piercing and body modification community seem to dispute the fistula idea and given modern examples of “skewer play“.  Again, he may have established many different fistulas, or at least established tracks for passage of the swords.  In some of the videos and pictures the sword passes up through his chest, in one case emerging directly under the right nipple. Presumably this is passing right below the diaphragm, as passing above would cause a pneumothorax.  However, the blade would also have to avoid the liver and gallbladder.

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If he was creating fistulas before performances, this would have to be done very carefully and slowly, as a puncture of his intestines would lead very rapidly to sepsis as the bacteria filled contents fill his peritoneum.  Also, rupturing the gallbladder, stomach or pancreas would leak very dangerous material (acid or powerful enzymes) in the same space.  As mentioned, he would also have to avoid getting into the pleural space (where the lungs are in the thorax), as that would likely collapse his lung.

According to profiles online, he died of an aortic rupture at the age of 36.  One might think that he might have damaged his descending aorta in the course of his piercings.  However, aortic rupture at this (relatively) young age also raises in my mind the idea that maybe he suffered from some sort of genetic disorder of his connective tissue making the establishment of the fistulas or passage of the swords in general more easy.  For example, in Ehlers-Danlos syndrome, characterized by variation in one of the collagen subtypes or Marfan syndrome.  On the surface, these syndromes which increase blood vessel fragility, would seem counter to the ability of Dajo to deal with puncture wounds without massive hemorrhage, and I’m not claiming propose an exact mechanism, but it is possible that he had some sort of variation in the fibers of his connective tissues making his body more tolerant or more likely to establish scarring around attempts to establish fistulas.  In any event, an autopsy was apparently done, and I would like very much to learn more about what was found in his abdomen.

Overall, it is an interesting example of the resilience of the human body.  We also can’t exclude that it may be a clever illusion.  Tahir Shah accounts many such illusions done by fakirs in India, such as stopping the heart, stopping breathing, etc. that are often cited as examples of miraculous control of human physiology which are essentially done as magic tricks (e.g. stopping the radial pulse can apparently be done by putting a rock in the armpit and cutting off some of the arterial flow to the arm by pressing down).  However, that seems unlikely given the widespread documentation, evidence and medically skilled eyewitness reports.

Although Dajo seems to stoically accept the piercings, there are some signs of discomfort.  There is a good example of how humans can resist pain, including serious punctures in the British television program Medicine Men Go Wild, featuring twin physician brothers Chris and Alexander (Xand) Van Tulleken.  Episode 2 of Season 1 is about pain resistance without anesthetic and shows the two brothers going to India to take part in a religious ceremony where they are each pieced in the face and tongue.  I found the narration and description of their different preparations very insightful.

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Real life Bioshock armor

An interesting piece of maritime history is this piece of Victorian technology.  This French hard helmet diving suit/armor designed by the Carmagnolle brothers (Alphonse and Theodore).  You can read more about this awesome pice of Steampunk history here.

Real life Bioshock

When med school got real

I was recently asked about my favorite class in medical school.  At Stanford, the courses can be do diverse from day to day that it would be hard to really characterize one as being my favorite.  Overall I love the courses, and even when there elements I don’t like, I often understand the importance and value to those experiences later on.  However, I can comment on the single lecture which was the major turning point in my education, and when the whole experience “got real”.

When I was first accepted to medical school, it was a bit surreal, as something that I had wanted and worked toward for a while which involved a huge amount of uncertainty was actually going to happen.  It is worth mentioning something about the way medical education works in the US.  Getting accepted to medical school is by far the hardest part.  Once you are accepted to a highly ranked program (like Stanford), it is very difficult to actually fail out.  It’s like enlisting in the Marines and going into bootcamp, once they have you in the program, they invest a lot into you and although parts of it very stressful, brutal and demanding, they shape and remold you into a physician.   You just have to keep forging ahead during the process.

I received my acceptance letter and packet on Thanksgiving morning, which is very early in the application cycle, so I had almost a full year to ruminate on the fact that I was starting medical school the following August.   I read a lot about medicine, read biographies/memoirs of physicians, went to internal medicine grand rounds in Weds mornings, even go to start going to neuropathology brain cutting sessions.  Once you’re accepted to medical school, even before you start, you’re in the club and start getting access to physicians as teachers.  I could learn about new things that interested me at a leisurely pace.  It almost felt like a time to be self congratulatory, and that I was being rewarded for hard work.   It was a sort of warm, happy period.

Before we started classes, the school arrange lots of group activities and fancy dinners where I got to meet my new colleagues.   There were ceremonies where we were presented with white coats and stethoscopes in front of our families.   We got to meet famous, important people, were assigned prestigious faculty as our mentors, and just generally treated like little princelings and princesses of the medical establishment.

One the first day of classes, we started a molecular biology and biochemistry course, it’s called “Molecular Foundations”, which also goes by the somewhat unfortunate moniker of “MoFo”.   It was the first day, and we were all collected and intently paying attention, trying to take notes and figure out what sort of note taking and study style we wanted to adopt.  One of the professors, Gilbert Chu, spoke the first day.  As aside he’s an amazing professor, and much could be written about him beyond his Wikipedia entry; indeed, my colleague, Michelle Nguyen has written on her experiences shadowing him in the magazine H&P.  However, what is important to know is that in addition to being very active in basic science and teaching, he is a practicing oncologist.

It was during the second hour of his lecture on our first day of classes that Dr. Chu got a call on his cell phone while he was discussing DNA replication, and he politely told us he had to take the call.  He went to the corner to speak into the phone briefly.  When he returned to the front of the class, he had become much more serious and told us that one of his patients, whom he had been treating for a while, had just died.    He took that time to talk to us about that fact that as an oncologist at a major academic and tertiary care center like Stanford, he typically only sees patients whose cancer has not responded well to treatment.   It was important he told us, to never tell a patient “there is nothing more we can do for you”, even when there is nothing that medical science has that can delay death, we can always try to relieve suffering and that the patient still needs a doctor, even just to bear witness and give support in a difficult time.  It is important to remember that physicians are experts on a number of topics, many of while involve healing patients when they have an illness, but another aspect that they unfortunately gain expertise with is death, and often that is an expertise that can help a patient and their family when death looms close, just helping them to understand the process and helping to guide the patient in their final months, days, moments.

That’s when it got real.  After years of sitting in classrooms, learning science; years doing research, and publishing papers; years volunteering in clinics talking to patients, now it was essential to learn and pay attention to what this man was teaching.  It wasn’t about paying attention to it because it was interesting, which it certainly was; it wasn’t about listening because I wanted to get a good grade on the exam, which I did want to do; it was about learning as much as I could because someday actual people were going to be depending on me to make the right decisions in their healthcare and relying on me to give the best advice possible.  It was up to me to work as hard I could, because it was going to matter, lives were at stake.  It got real.

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Starting homemade ume pickles

Ume plums from the farmer’s market, with 15% salt by weight. The plums were cleaned with vodka, and any with blemishes were removed, hence those on the dish.  All this to prevent any mold from forming.

Note the improvised pickle press with the glass of water providing the downward pressure.

Soon, with the addition of some red shiso, they will be umeboshi.

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GreeNoodle, healthfood ramen?

Today I tried GreeNoodle’s ramen made from Moroheiya. Moroheiya is the Japanese word for Egyptian mulukhiya, a green plant made into soups and other dishes.  It is used in a variety of dishes from North Africa.  It is supposed to have a somewhat slimy and “mucilaginous” consistency when boiled, which did not sound very promising.  That basically means it is sort of gluey, full of polysaccharide and glycoprotein.  This conjurs up thoughts of gooey seaweed mess in my mind.  However, the root of the marshmallow plant is also made of mucilage and can be used to make marshmallows.  Anyway, returning to mulukiya, it is supposed to be something like a cross between spinach and okra, typically used to make a range of green, North African stews.

Apparently, in Japan it is considered a superfood, full of vitamins and fiber.   As an interesting aside, it is fun to see an example of different kinds of pop-alternative health foods from different countries.  In the US we have our açai and goji berries.   In Japan they have their Egyptian greens.  However, each country/culture is able to put their own spin on things, and it has been introduced into a series of different kinds of ramen. Today I tried the version flavored like Thai spicy and sour soup, Tom Yum.  Tom Yum soup is flavored with lemon grass, keffir limes, and red peppers.

How do the green noodles stack up in terms of dietary features? How about taste? Lets go to the ramen lab to see.

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It comes with two flavor packets, one with a dried soup powder including some red pepper flakes and the other a small packet with a red, oily paste.

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I had it today with some salad eggs (aka deviled eggs), of course topped with little gherkin pickles.  The flavor powder took a little while to dissolve into the broth, and looked a little strange at first, but soon looked much like Tom Yum soup I have had before, minus the fresh cilantro.  The red paste dissolved into a nice oily droplets of goodness.  The broth was quite tasty, obviously not traditional ramen, but I enjoyed the change.  It was not too spicy, but still flavorful.  Much better spice level than some of the spicy Korean ramens I have had.

The important part however is the noodles.  They were actually pretty decent, with some good chewiness.  There was a little bit of gluey consistency as I neared the end, but overall they were acceptable for instant ramen.  I’ve had much worse noodles in instant ramen before.

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Healthwise, they stack up pretty well.  Of course, like all ramen, and pretty much all premade soups, it is super high in sodium.  However, it is relatively  quite low in fat (5 gm vs 20 gm).  It also has 8 gm of dietary fiber.  The sodium and still somewhat high carbs do not make this a health food, but it seems like a healthier alternative to many kinds of instant ramen, and I look forward to trying their other flavors.