New Year, New Goals

Each year I take a look at what I’ve cooked/baked and what I’m hoping to learn in the future. This year I was unpleasantly surprised to find that I barely made any of my 2018 goals.

  1. Pulled Pork
  2. Roast Chicken
  3. Sourdough
  4. Quesadillas
  5. Scones
  6. Trifle
  7. Madelines
  8. Quiche
  9. Cocktail
  10. Salad with Homemade Dressed
  11. Cinnamon Rolls
  12. Steak and Mashed Potatoes
  13. Frittata
  14. A Homemade Condiment
  15. French Press Coffee

Out of these fifteen goals, I made roast chicken, quesadillas, scones, and mashed potatoes. I’ve never met every single goal in a year, but I’m usually more dedicated to my goals.

This year I’ll be trying something a little different. Keep following and I’ll be less mysterious! Updates to come soon!

Paleo Pumpkin Pie

I’m sure many of you remember that I have a very close friend who suffers from a variety of issues which prevent him from eating many foods. For his birthday last year, I made a gluten-free, dairy-free, nut-free, and soy-free carrot cake.

One of my friend’s favorite dishes used to be pumpkin pie. The challenge this time is creating such a classic dish without gluten, dairy, nuts, soy, and as little processed sugar as possible. Because I use real eggs, it is paleo, but it is not vegan. For the same reason I say it is mostly allergen-free. You should be able to use an egg substitute if you have an egg allergy or would prefer a vegan recipe. (I hear flax eggs are a good substitute.)

I hope this Thanksgiving, those of you with allergies and dietary restrictions are still able to enjoy some of your favorite American comfort foods. If you’re looking to avoid the holiday weight gain, these paleo options might help you enjoy holiday treats without overindulging.

As this is dairy free, I used 20 Tbsp of soy-free, vegan shortening. You can find the paleo pumpkin filling recipe here.


Ingredients

For the crust:

  • 1 bag of Bob’s Red Mill gluten-free pie crust mix
  • 20 Tbsp soy-free, vegan shortening cold
  • 6 Tbsp ice water
  • Extra gluten-free flour for the rolling pin and rolling surface

For the filling:

  • 1 15 oz. can of organic pumpkin puree
  • 1/2 cup full-fat coconut milk, stirred
  • 3 large eggs
  • 1 Tbsp pumpkin pie spice
  • 1/2 cup 100% maple syrup
  • 1 tsp vanilla extract
  • 1/4 tsp sea salt

Instructions:


1) Make sure your counter, ingredients, bowls, and utensils are as cold as possible.

I like to keep my mixing bowls in the freezer prior to starting.

2) Using a food processor, pulse until the pie mix and shortening are in dime-sized pieces. If you don’t own a food processor, mix with a fork until the shortening is fairly well incorporated.

I tend to use my hands because the fork is more cumbersome.

3) Add 6 Tbsp of water, one a time. Mix after adding each tablespoon.

If the dough is too wet, add more flour. If it is too dry, add more ice water.

4) Roll the dough into a ball and flatten slightly into a disc. Wrap with saran wrap and place in the fridge for at least an hour (a day max).

5) After the hour is up, preheat the oven to 350 F.

6) Press the dough into a pie plate.

Rolling the dough may be difficult due to the consistency. You can smooth out the fingerprints with parchment paper.

7) Poke holes in the bottom of the crust with a fork. Place back into the fridge for about 30 min.

8. Line the crust with parchment paper. Pour pie weights onto the parchment paper. Bake for 15 min. Set aside.

If you don’t have pie weights, you can use dry, uncooked beans. This process is called “blind baking.” The weights keep the pie crust from puffing up while it bakes.

9) Combine all of the filling ingredients. Mix with a hand mixer or whisk.

10. Remove the parchment paper and pie weights. Pour the filling into the crust. Bake for 50-60 min. The pie is done when a toothpick can be put in an inch away from the crust and comes back clean.

11. Remove from the oven and let cool 30 min. Then place in the fridge for 2 hours so it firms up.

It is important to let the pie cool before refrigerating so the filling doesn’t pull away from the crust.

Final Thoughts: He loved it! Luckily enough, he had a wedding to go to (where he can’t eat the cake) so he still got to enjoy dessert. He even shared with a girl with a gluten allergy and she loved it too! The crust was great, not very flaky (hard to do with GF), but crisp and still a little buttery.

Choosing a Medical School

This weekend I listened to one of my favorite podcasts – Pre-med  hosted by Dr. Ryan Grey. Dr. Grey and I have actually spoken before. He’s a kind man dedicated to helping pre-meds get into medical school. He has several books, podcasts, and forums. If you’ve never listened, I highly recommend it.

The topic for discussion was stats. As pre-meds, we tend to hyper-focus on our GPA and MCAT scores. A bad grade can send us into a panic. We send questions to our advisers with “what-ifs” about how to handle a bad MCAT score before we’ve even taken it.

The problem is that these numbers are not as important as we think.

These scores are to get you through what Dr. Grey calls “the shredder.” It gets you into the pile for consideration. But from there, your application depends on a number of aspects: your personal statement, your extra-curriculars, etc. The most important consideration is your school list.

When I first started my pre-med journey, I started a list of med schools. I looked at the best-of-the-best and quickly realized that very few of them would accept my non-trad AP scores, online courses, and community college classes. Nevertheless, I made a list. I brought it to my pre-med adviser, who told me to throw it away.

Throw it away? Wasn’t I supposed to be finding my schools and working towards making it into those schools? No. I had it backwards. I was looking at schools for the wrong reasons. There’s a strategy to finding the right schools. It does not involve specific specialties or even rankings. It involves school environment, cost, city life, and competition level. If I apply to 6 California schools out of 12, I’ve already made it harder for myself. I followed my adviser’s instructions and shredded the first list. Since then I’ve made a long, long list and continue to do research.

Fortunately Dr. Grey made another (long) podcast about making your med school list. The average student applies to 14 MD schools and 9 DO schools. Though Dr. Grey recommends applying to both, I’ll likely only be applying to MD schools. I also can’t afford applying to 23 schools (think AMCAS fees, secondary fees, and travel for interviews). I’ll likely apply to somewhere between 12 to 14 schools.

My primary consideration is that as a non-traditional applicant, not all schools will be willing to accept my AP, online, and community college credits. (You can check with AMCAS’ MSAR service). After that, location and curriculum are my priorities. Without my MCAT, it’s difficult to figure out which schools may be out of my reach. For now, I’ll focus on learning about the schools.

Dr. Grey recommends you avoid basing your school list off of World News ranking, tuition costs, and residency/Match trends. Focus on finding a school where you can thrive. For me, I prefer a non-trad friendly school that accommodates to different learning styles and strives for balance between my medical training and my personal life. That may steer me away from “prestigious” and more traditional institutions like Mayo or Harvard (though those would be a bit of a reach for me anyway).

Would you guys like me to share my preliminary list? What are your criteria for deciding where to apply?

 

Reading List: Smoke Gets in Your Eyes

I majored in Anthropology during college. (That’s the study of human beings for those of you who have never heard of it). Coursework can be focused on anything from the cultures of modern people to the evolution of the human being from our ancient ancestors. During my junior year, I enrolled in a class called “Death & Dying: a Cross-Cultural Perspective.”

The course covered the various religious and cultural practices and beliefs of people around the world, as well as how they had evolved over time. “Smoke Gets in Your Eyes: And Other Lessons from the Crematory” by Caitlin Doughty reminds me greatly of this class. The author recounts her first job in the “death industry,” cleaning and cremating bodies at a funeral home in San Francisco, followed by building her career in the funeral industry.

Image result for smoke gets in your eyes book

Her book offers the reader a glimpse the evolution of her experience with death: from young child to experienced funeral director. Then, finally, she ends with the founding of the Order of the Good Death, a “death positive” organization of people who want our modern culture to embrace death and encourage environmentally-friendly and natural funerary practices.

Though it may seem a macabre topic, physicians cannot avoid death. This is a topic she even covers in her book. She meets a medical-school professor who laments that his students do not want to deliver the news of a fatal diagnosis. His reasoning is that they fear their own death, and therefore do not want to confront their patient’s mortality (so as to avoid confronting their own).

My father’s side of the family does not avoid the topic of death. My grandmother (still living) enjoys exploring cemeteries and eating lunch on one of the benches. My father has always been explicitly clear on what he expects for his “funeral.” I guess you could say my family is fairly death positive. We prefer to be cremated and scattered or perhaps buried in one of the “green” tree pods that have been popular on the internet.

My primary concern with medicine is dealing with death. I have had patients die, but never in front of me and never as the result of care that I personally provided. Physicians are face-to-face with death every day. They may prevent death, delay death, or bring death closer (whether or not this was intentional). A rotation in palliative care particularly concerns me.

Death, to me, is a private matter. I never want a large funeral with hundreds of people weeping over a preserved corpse then buried in a big, expensive box. I want to have as many parts of me donated as possible (if possible) then planted or buried in a green cemetery by private memorial with only the closest family and friends. Discussing funerals, burials, and end-of-life care seems to be something involving family and possibly friends. I feel that in palliative care I would be placing myself into an intimate situation.

Overall, I want to strive for a “good death” for my patients when necessary. I am not so naive as to believe that I can defy death in every case. In fact, in some cases I would consider a gentle, painless death to be preferable to a short, futile struggle against, say, an aggressive cancer. There are some people who want “whatever means necessary” to prolong their lives. If that’s what my patient wanted, that’s what I would provide.

Physicians are often burdened emotionally with the death of their patients as a “failure” of their care. What we must realize and accept is that death is an inevitability, especially when we place ourselves in the position of a physician. Our jobs are to treat, cure, and prevent death and disease when possible, but our job is also to assist our patients in accepting their death and providing them a dignified death that respects their personal beliefs and desires whenever possible.

A Beautiful New Question

I am in clinic Monday through Friday. During the week I can see anywhere between 100-200 patients. Many of these patients have similar problems, which can make clinic seem a tad monotonous. Every once in a while, a patient will surprise me.

I had a patient in clinic the other day who impressed me. She was an advocate for herself. She asked about possible treatments and stated her questions clearly. “Walk me through that” is not a phrase that I hear as often as I should. She changed the standard explanation to suit her learning style and her understanding. After about an hour, she was finally satisfied. Before she left, she had one final question:

“If I were to meditate on or communicate a message to my cells, what should I be saying to my body?”

The mind-body connection has been studied in depth. Biofeedback through meditation has been shown to help control heart rate, respiration, and other mechanisms of the body. If patients are not doing well emotionally, it can be detrimental to their recovery and/or overall health.

I may not exactly be a naturopath, but I believe in the power our minds have over our bodies. Stress, grief, pessimism, depression, and anxiety can be just as hard on our bodies. I also believe that patients can best improve when their mental health is optimal.

Lack of control can be an agonizing fear for many patients. They want to know what they can do to improve themselves, because taking prescribed medication or trying to combat genetics can seem futile. Telling them “It’ll be okay” or “Don’t worry” isn’t really enough to soothe their fears.

Somehow I’ve never thought to meditate on a healing thought. Meditation has worked for me to an extent. When I’m anxious, depressed, or stressed, I use it to relax. I find it difficult otherwise. Either my brain refuses to settle down or I’ll fall asleep. Meditating on a specific healing thought or energy may make a large difference in my own life.

I thought I would share this interesting insight with you all. Perhaps I’ll make a post about a meditation on this.

Reading List: In Shock

Image result for in shock rana awdish

Following on the trend of my last reading list book, In Shock is written by a physician who finds herself in the position of a patient. Unfortunately for Dr. Awdish, she is a critical patient who actually has an out-of-body experience as she codes during emergency surgery.

Following her surgery, the book covers her excruciating recovery from an unknown disease wreaking havoc on her body. This unknown disease cost her her unborn child. While her doctors and nurses struggled for answers, they took out their confusion and frustrations on her. Dr. Awdish became intimately aware of the manifestations of the wall many physicians put up to “be better doctors.”

My favorite habit that she points out is the power of words. Physicians are taught to empathize, but at the same time, cannot take a patient’s pain as their own. Emotionally compromised doctors are not good doctors. Unfortunately, this leads to bad habits. We make macabre jokes and say insensitive or flippant comments that ultimately harm our patients.

One of the phrases she pointed out as harmful was “You kept trying to die on us.” It seems harmless. The physician tries to seem lighthearted about a serious matter. Unfortunately, Dr. Awdish took these words to heart. She felt physicians blamed her for being sick and coding. I know I have said this phrase, maybe not to patients, but definitely when discussing patients with my providers.

The common theme throughout her book is the way that doctors speak to their patients. Now she has made a career of teaching healthcare professionals to watch their words, to think before they speak. I, for one, would love to attend one of her sessions.

Patients trust doctors they can connect with. It’s important to acknowledge their feelings and put them at ease, while acknowledging a patient’s goals and desires. This must be balanced with medical necessity and treatment. It’s difficult, but we’re not becoming doctors because it’s easy.

Have you said any of the phrases that Dr. Awdish condemns? Have you experienced burn-out that manifests itself in blaming patients or venting to them? Let me know how you feel about this book. Is Dr. Awdish right? What changes do you need to make in speaking to patients?

Docs vs Docs: No One Wins

I’ve had the privilege of working with some world-renowned, extremely talented doctors and surgeons. Patients often come to these providers when they’ve failed treatments, or if they’ve received recommendations and are unsure which treatment may be best for them. Unfortunately, the providers often find their patients’ previous treatment lacking. They ridicule the decisions of other doctors (sometimes even in front of the patient).

Why do doctors attack each other? Their goal is ultimately the same – to treat and/or cure their patients. If two doctors see the same patient for the same problem, there are bound to be differences in approached. Some physicians may prefer certain times of imaging over others. Some physicians may advocate for naturopathic or less invasive treatments to start, whereas some physicians may be more aggressive.

In my experience, primary care physicians (PCPs) receive the brunt of physician-to-physician criticism. The PCP is the jack of all trades, master of none. They are the first-line for their patients. They have a broad understanding of most problems, start with certain treatments, then refer to specialists. Specialists often roll their eyes when patients come in with unnecessary imaging or testing ordered by a PCP. But how is a PCP supposed to know that a spine surgeon prefers MRIs to CTs?

This criticism is not only limited to PCPs. My mentor has a habit of criticizing specialists in the same field of being overly aggressive or performing unnecessary procedures in order to receive additional compensation (which should be considered fraud). As a result, I’m suspicious of many of his colleagues. I question the treatments and decisions made by other specialists.  I may disagree with their decisions, but I wasn’t there to understand why the physician made that decision. In addition, I’m not a physician. I can’t understand their decisions because I am not a trained physician. I’m afraid that this suspicion could affect my ability and willingness to learn from other doctors.

I believe this animosity arises in part from the competition started in medical school. Pre-meds compete for the best grades, the best scores, and the best schools. When we get into medical school, we battle for the best rankings, the best opportunities. Then we compete to match. In residency we strive to out do each other to get better fellowships, better pay, better attending positions. Those attending physicians compete for patients. Throughout the entire journey, there is a strong focus on competition over collaboration.

This approach has been evolving over time as medical schools recognize the cut-throat environment they create. The older generations of physicians, however, do not have the benefit of this approach. What’s more is they teach their residents and fellows to treat their fellow doctors with suspicion.

It is important to address incompetency or intentionally endangering patients. If the decision of a physician intentionally harms a patient, it needs to be addressed through the appropriate channels. My primary concern is not this, but doctors mocking their colleagues because it is not how they would prefer to treat their patient.

What these doctors fail to recognize is that treatments are an agreement between patient and provider. A doctor analyzed a patient’s position, offered options to the patient, and the patient made a joint decision with their doctor. With this arrogance, we create distrust in the relationships with patients. We also erode the trust that another doctor has established with a patient. In the end, both doctors lose. Neither doctor communicates with the other, the patient becomes wary, and treatment may get delayed while the patient considers other options or another opinion.

How do we address this issue? It’s not as easy as accepting differences in treatment approaches. It is understandable to be frustrated by lack of proper testing or treatment. Doctors and patients may feel like they are starting over, which can frustrate the patient as well. I have a few ideas about how to treat this issue with patients.

1) Don’t scoff or mock a doctor in front of the patient.

Referring to someone’s doctor as an “idiot” or “untrained” is rude in general. It also makes you seem arrogant. There’s no need to take out your frustration in front of the patient – it’s unprofessional.

2) Remember your source.

The information provided to you is subjective. Patients can get confused. Records may indicate the exact opposite of what the patient is telling you. What you may mistake for the provider’s problem may just be a misunderstanding.

3) Try to look on the bright side.

Has the patient had testing that you needed? Is there extra imaging that rules out a diagnosis? It’s unfortunate that the patient underwent so much testing, but it saves you time and establishes a greater picture of your patient’s health.

4) Communicate with the provider, if needed.

You’re seeing a patient for an issue. They tell you another provider has ordered a battery of tests. You disagree with the need for some (if not all) of these tests. You tell the patient you don’t find them necessary. Now the patient is confused. They trust the doctor that ordered them, but they also trust your judgment. Speak with the provider, agree on a plan of action, then convey that plan to the patient.

5) Explain your treatment plan to the patient.

The patient has seen a physician with a different plan of treatment. Without belittling the patient or their provider, explain why you’re taking a different approach. The patient needs to understand what’s happening and why. They may be happy to avoid expensive or invasive testing.

Have you heard providers disparage other providers? Do you engage in the negativity? Are my suggestions naive? Comment with your thoughts!