Haikus to Internal Medicine

Oops, I kind of disappeared.  No worries, I'm around, just got busy.  Doing internal medicine right now.  While I might have liked it in medical school, no more.  I miss the operating room.  

Haikus to Internal Medicine

Pager, I hate you

You beep constantly at home

You are here to stay

Thirty hour call

You suck. I am so sleepy

Who invented this?

Potassium, you

Are always low, I am sick

Of repleting you

EKG, no clue

How to interpret you but

I pretend to know

Volume overload

Bores me, they should sell lasix

Over the counter

Sticking needles in

Fluid collections is fun

Cytology pending

Black and White Cloud Pudding

It's been an interesting month.  I wrote about my experiences as a "black cloud" and what that means as a resident here on Kevin MD.  In honor of my first post to KevinMD, an awesome medical blog with significant collaboration from health professionals all over the country, and my new black cloud status, I made a dark chocolate and whipped cream pudding parfait.


The dense, rich chocolate pudding is layered with a fluffy white cloud of homemade whipped cream.  Are you a black or a white cloud?

Dark Chocolate Pudding and Whipped Cream Parfait
(pudding recipe adopted from Bon Appetit)

For the pudding:
1/2 cup sugar
1/3 cup unsweetened cocoa powder
2 tbsp cornstarch
1/4 tsp salt
1 3/4 cups milk divided
1/4 cup heavy whipping cream
3 oz very dark chocolate (such as 88% cocoa) finely chopped
1 tsp vanilla extract

For the whipped cream:
1 cup chilled heavy whipping cream
1 tsp vanilla
3 tablespoons powdered sugar

Whisk sugar, cocoa, cornstarch and sal tot a blend in a heavy medium saucepan.  Gradually add 1/3 cup milk, whisking until smooth paste.  Whisk in remaining milk and cream.  Using wooden spoon or heatproof spatula, stir mixture constantly over medium heat, scraping bottom and sides of pain until pudding thickens and begins to bubble at edges, about 5 minutes.  Add chocolate; stir until mixture is smooth.  Remove from heat and stir in vanilla.  Allow to cool to room temperature and then refrigerate.

For whipped cream, in chilled bowl, whip ingredients until stiff peaks form.

From The Board to Bored—a month of sleep

This month has definitely been a change of pace.  From running around non-stop, I’ve switched from the crazy county to the cushy private hospital.  From not eating to over-eating, watching movies and napping, the mania has definitely ended. 

I’m really tired.  That’s that.  I was feeling really good, but I’m positive that even with a week vacation thrown in there, there is no way I’ve caught up on sleep constantly flipping from days to nights and working my tail off.   I’ve had a little mini-vacation at home and I’ve found myself surprisingly waking up at 11 or noon everyday.  I have only slept until noon once in my life before.

Is the concept of sleep debt real?  Scientists argue that, in fact, yes, sleep debt is a true concept.  In one recent study, scientists chronically sleep deprived a study arm of subjects, similar to resident hours.  They found that even if those subjects slept 10 hours one weekend, they were only wakeful for a few hours before performance again began to decline [1].   An editorial article in Scientific American suggests that it is possible to regain sleep debt, however it must be done hour per hour of sleep lost [2]. 

HA! Even after 3 ½ months of residency, I’m positive that the amount of sleep I need will never be reconciled.  However, my body is telling me to relax, so I oblige.   Another perk of a couple of extra hours of free time is time in the kitchen.  I made lovely little ravioli “pillows” the other night.  This recipe takes a bit more work, but the simple, rich fall flavors are certainly worth it.   You don’t need a pasta maker, in fact I found having a pasta maker to be equal work to simply giving it a go with the rolling pin. 

Butternut squash ravioli pillows

Pasta

1 cup semolina flour

¾ cup all purpose flour

1 egg and 2 egg yolks

1 tsp salt

Glug olive oil

Water as needed

Filling

1lb ricotta

¾ lb butternut squash cut in half

12 sage leaves

¼ tsp nutmeg

¼ cup grated parmesan

Pinch red pepper flakes

1 tsp salt

1 egg

To top

1tbsp butter

1tbsp olive oil

~6 sage leafs

2 tbsp pine nuts

salt, pepper and parmesan cheese to taste

To make pasta:  In bowl add flour and salt and combine.  Make well and add oil, eggs and yolks.  With fork, start to combine.  Bring together with hands.  Add water as needed to bring the dough together so it is slightly moist but not tacky.  Knead with hands a couple of times and then either keep kneading with hands or transfer to Kitchen Aid with kneading attachment.  You can add water or flour depending on whether is dry or wet.  Knead for about 10 minutes or until dough is smooth and very stretchy.  Break dough into about 4 pieces and either roll with pasta maker or the OLD FASHIONED way, with a rolling pin until dough is thin enough to be slightly transparent. 

To make filling: Preheat oven to 400.  Place sliced squash on baking sheet.  Bake until very tender, about 1 hr.  In cast iron pan or other heavy bottom pan, coat with vegetable and olive oil and heat until oil is rippling and smoking.  Add sage leaves and fry until starting to brown and crispy.  Drain on paper towel.  In bowl place ricotta, egg, sage, nutmeg, parmesan, salt and pepper flakes and mix.  Once squash is cooked, remove from oven and mash with fork.  Add to filling. 

Put about a tablespoon of filling on the dough and fold in half crimping down with water to seal the edges.  Cut the raviolis with either a cutter, a crimping roller, a pizza cutter or simply scissors.   Add to a pot of boiling, salted water and cook until water reboils about 2-3 minutes.

In pan, heat up oil and butter, add pine nuts and sage.  Add raviolis and toss.

1. Cohen, DA, et al.   Uncovering residual effects of chronic sleep loss on human performance. Sci Transl Med. 2010 Jan 13;2(14):14ra3.

2. http://www.scientificamerican.com/article.cfm?id=fact-or-fiction-can-you-catch-up-on-sleep

Full Moon Pies

AAOOOOOOOOOOOOOOO!  The 23rd is a full moon.  Time to get your werewolf self ready for the big howl.  Besides bringing out beasts and goblins, full moons are thought in the obstetrical world to bring out babies.  As an already overworked and overwrought poor little intern running around labor and delivery, this can’t be a good thing.

But are full moons actually related to the onset of labor? Most studies suggest that, in fact, they are not.  A 1979 study of 11,681 live births at UCLA hospital showed that there was no correlation of lunar cycle to births.  These results were reproduced in a smaller study of 3706 births in the 1990s in New York City.  However, some studies suggest otherwise.  One small Italian study suggests that there might be a small effect on multiparous patients (those that have had more than one baby) with the lunar cycle. 

Not only is tonight/tomorrow (the calendar says tomorrow but it looks full tonight) a full moon, but it is also a harvest moon.  Besides being a great Neil Young album, a harvest moon is when there is a full moon at the autumnal equinox.  Supposedly the harvest moon appears bigger and brighter than a normal full moon.  Time to get out the scythe and start farming.  

To celebrate the full moon, I made a traditional southern classic, the moon pie.  A moon pie is 2 graham cracker cookies filled with marshmallow and topped with chocolate.  To celebrate my day off, I made my own graham crackers and my own marshmallow.  Although it seems difficult, it isn't too tough.  Just takes a candy thermometer. Graham crackers require graham flour, which I know some people have had trouble finding.  I like Bob's Red Mill which is in the health food section with the other whole grains.

Full Moon Pies

For the cookies (adapted from Martha Stewart's baking)

1 1/2 cups all purpose flour

1 1/2 cups graham flour

1tsp baking soda

2 tbs cocoa powder

1/2 tsp salt

1 1/2 sticks unsalted butter at room temp

3/4 cup packed light brown sugar

2 tbsp honey

Preheat oven to 350.  Combine flour, baking soda, cocoa powder and salt and set aside.  In mixer, beat sugar, honey and butter until fluffy.  Slowly mix in flour, stir to combine.  On floured surface roll out cookies thin about 1/8 inch and cut with 1.5 inch round cookie cutter (or glass or jar which is what I used).  Place on baking sheet and bake about 7 minutes until brown and crisp.  

For the Marshmallow (from Food Network)

1/4 cup water

1/4 cup light corn syrup

3/4 cup sugar

2 egg whites

1 packet plain gelatin

2 tbsp cold water

1/4 tsp vanilla

Combine the 1/4 cup water, the corn syrup, and the sugar in a saucepan fitted with a candy thermometer. Bring to a boil and cook to "soft-ball" stage, or about 235 degrees F.

Meanwhile, in a standing mixer fitted with a whisk, whip the egg whites until soft peaks form. Sprinkle the gelatin over the 2 tablespoons water and let dissolve. When the syrup reaches 235 degrees F, remove it from the heat, add the gelatin, and mix. Pour the syrup into the whipped egg whites. Add the vanilla and continue whipping until stiff.

Transfer the mixture to a pastry bag fitted with a round tip. Pipe a "kiss" of marshmallow onto half of the cookies, and top with the rest to make sandwiches. Let set at room temperature for 2 hours.

For the Ganache

8 oz chocolate chips

1 cup heavy cream

Over double boiler on medium heat, melt chocolate and cream, stir together.  Dip cookies in ganache.  Also can make white chocolate for an extra drizzle

Abell, GO.; Greenspan, B. “Human births and the phase of the moon.” New England journal of medicine, v. 300 issue 2, 1979, p. 96.

Joshi, R.; Bharadwaj, A.; Gallousis, S.; Matthews, R. “Labor ward workload waxes and wanes with the lunar cycle, myth or reality?.” Primary Care Update for OB/GYNS, v. 5 issue 4, 1998, p. 184. 

Gabriele Ghiandoni, Roberto Secli, Marco B. L. Rocchi, Gilberto Ugolini, Does lunar position influence the time of delivery? Eur J Obstet Gynecol Reprod Biol. 1998 Mar;77(1):47-50.

Tik Tok Board Doc

This month has been awesome.  I'm what is called board doc which means I run the labor and delivery board making sure everybody has been examined, monitors are placed and all of them are delivered.  It's been a blast but it's probably the most crazy experience of my entire life.  There is no time for sitting, or eating, or thinking.  In honor of board doc, I have re-written the words to a favorite pop song, Tik Tok by Kesha.  In medical school we used to have a show Doc Opera with a very similar feel to it, and I used to direct the band.  Since there's no Doc Opera in residency, I've spent my few minutes of free time re-crafting the song.  So here ya go!




Wake up in the morning feeling oh so S%ty
I got my glasses, I’m out the door, I’m lookin oh so gritty
Before I leave, brush my teeth and I pull my hair back
Cause when I leave for the night, I ain’t coming back

I’m talking danskos on our toes toes
Scrubs instead of clothes, clothes
Blood all over ourselves, selves
Pulling out all the babies
Sewing up all the ladies
Trying to get a little bit messy

Don’t stop, make her pop
Nurse will you run my pit up high
Tonight, push it right
Till that baby sees the light
Tick tock on the clock
But the babies don’t stop, no-oh-oh no-oh-oh-oh

Don’t stop, make her pop
Turn the epidural up to high
Tonight, imma write
Notes til I see the sunlight
Tick tock on the clock
But the pager don’t stop, no-oh oh oh

Ain’t got no sense in the world but got plenty of fear
Ain’t got no food in my belly but nobody cares
Now the tasks are lining up, can I work any faster?
There are 8 million things I’m not sure I can master

I’m talking about everyone running around round
Feet never leave the ground ground
Gonna pit her if she’s moving too slow
Decels so she can’t no second miso-so
Can’t wait until she crowns crowns
Wait until she crowns crowns
Wait until she—

Don’t stop, make her pop
Nurse will you run my pit up high
Tonight, push it right
Till that baby sees the light
Tick tock on the clock
But the babies don’t stop, no-oh-oh no-oh-oh-oh

Don’t stop, make her pop
Turn the epidural up to high
Tonight, imma write
Notes til I see the sunlight
Tick tock on the clock
But the pager don’t stop, no-oh oh oh

I’m cramping up
I might break down
The heart, it pounds
FSE
With my hands in
I got it through
I think we’ll know
IUPC
Let’s build it up
Head come on down
We’re hoping for
Adequacy
With my hand in
With my hand in
Get your hand in

No the party don’t stop when I walk in

Get On Your Feet

HOLY HOLY!  Sorry for that more than brief absence.  I am glad I bought comfortable shoes because they are the only thing keeping me standing--along with fear, adrenaline, motivation and a healthy reliance on Diet Dr. Pepper (love this Texan Dr. Pepper phenomenon).   The theme of my residency seems to be MOVE!  GO! GO! GO! Faster, faster, faster.   Don’t breathe, don’t stop, don’t sit down.   As one of my senior residents told me, “Don’t tell me you’re going to do it, just do it!”

It’s been incredible.  I feel exhausted, but satisfied at the end of the day.  I’m learning how to give appropriate, effective care, and the whole environment of frenetic energy is encouraging the more manic side of my personality to emerge.   I really hated sitting around in medical school waiting for things to happen, and I’m happy to be working at work.   Besides, doing C-sections and deliveries couldn’t be more fun.

Didn’t you know standing at work is good for you?   Sure if I keep this up I’ll probably have varicose veins by the age of 30.  Even so, I feel energized.  A couple of months ago, the New York Times profiled a certain type of desk that is adjustable for people to work standing up.  One recent study from Canada showed that in a cohort of 17,013 people, those that spent almost none of their time sitting had a significantly reduced mortality rate compared with those that sat more, even when sedentary subjects participated in vigorous exercise (1). 

So, what to eat to keep you on your feet?  Well, I don’t get to eat much during the day, but I made some food that is great for any meal of the day be it breakfast, lunch, dinner or a midnight snack.  There is nothing quite as delicious as some high fiber, well seasoned black beans and brown rice to give energy and not drag you down. 

I know, if I were on Top Chef and I served canned beans I’d probably get sent home, but let’s be honest, I’m not the queen of dried beans and they take forever.   This recipe uses black beans and cooks them with veggies and spices, topped off with a little vinegar, fresh cilantro and queso fresco for a vibrant, warm and delicious meal. 

Black Beans and Rice

1 medium onion finely chopped

1 carrot finely diced

1 jalepeno finely chopped

2 cloves garlic finely chopped

2 tbsp veggie oil

salt to taste

½ tsp dried marjoram

½ tsp Mexican oregano

2 tsp ground cumin

2 tomatoes diced

2 cans 15 oz black beans drained and rinsed

¼ cup – ½ cup water (depending on how soupy you like your beans)

1 tsp apple cider vinegar

1 tsp (or more for spice) hot sauce

fresh cilantro and queso fresco for garnish

Over medium high heat, preheat the oil in a saucepan.  Add the vegetables, salt generously and cook until carrots are soft.  Add the spices and cook until aromatic about 30 seconds.  Add the tomatoes and cook until begin to release juices.  Add beans and water, salt to taste.  Turn heat down to medium-low and simmer beans for about 15 minutes until canned taste has disappeared and flavors are melded.  Add vinegar and hot sauce.  Serve with brown rice and garnished.

Or, just do what I do and shove a string cheese in your mouth when nobody is looking.

1.Katzmarzyk, PT.; Church, TS.; Craig, CL.; Bouchard, C. “Sitting time and mortality from all causes, cardiovascular disease, and cancer.” Medicine & Science in Sports & Exercise, v. 41 issue 5, 2009, p. 998-1005.

personal SOAP note

A SOAP note, for those not in medicine, is a progress note to assess and evaluate a patient.  First, one starts with the subjective, what the patient tells the provider.  Objective includes things that the provider notices and provide more information about the physical state including physical exam, vital sign, imaging, and lab reports.  Assessment and plan are more straight forward.  This is a personal progress note…

S: Feeling well today. 

Back aches, relieved by rest. 

Infrequent voiding, poor PO intake 

Occasional palpitations--worsened by pager, improved by alcohol.

Denies chest pain

No shortness of breath

Ambulating rapidly

O: Vitals:

Pulse 110

BP 120/80

Temp 37

General: alert, questionable orientation to time of day or day of week, smiling and grimacing simultaneously, pressured speech.  

Denies suicidal or homicidal ideation—usually.  Mood labile

Lungs: Clear

Abdomen: hyperactive bowel sounds

Labs:

Glucose 60

A: 26 y/o G0 s/p day #34 OB/GYN internship initiation. 

Patient making questionable progress in her treatment course resulting in exhaustion and occasional idiocy. 

Condition improving. 

Tachycardia secondary to physical exertion and anxiety. 

Hypoglycemia due to poor oral intake

P:

Residency is a condition that can only be cured with time, 4 years on average. 

Treatment guidelines include constant focus, increased caloric intake (perhaps a bag of peanuts in the pocket or a granola bar that can be rapidly consumed), increased fluid intake and very comfortable shoes.

Breathing is also advised

Will reassess

Cool as a cucumber—refreshing my Spanish on the job

A word to the squeamish or vaginally offended, this post is really about gynecology

I came to Texas for residency because I love taking care of Spanish speaking women.  For good reason, I’ve discovered.  There couldn’t be a more caring, kind, respectful and fun group of people to take care of than the Mexican and Central American patients that we take care of in clinic and on the wards.   Although I have spent multiple months perfecting conversational and party Spanish all over Latin America, my gynecologic castellano wasn’t quite all there when I started residency.  

It’s kind of funny to try and communicate clearly but still be professional and culturally sensitive when talking about private parts in another language.   Whereas in English I might just come straight out and ask patients about sexual activity, in Spanish, I seem to have better reception and communication if I ask about “relaciones”.    While I could literally translate the questions I ask in my history the same way I normally would, I have noticed that in Spanish, phrasing is more modest and more nuanced.   So, here below I have a list of common words and phrases used in OB/GYN that I have picked up over the past few weeks. 

Basic gynecologic Spanish, patient friendly edition:

Pain—dolor

Blood—sangre

To examine—examinar

My vagina—mi parte (or mi vagina)

Cervix—cuello de matrix (literally neck of the uterus)

Itching—comezón

Discharge—flujo

Pads—toallas

Contractions—contracciones

Cramps—cólicos

Pap smear—Papanicolaou

Speculum—especulo

IUD—dispositivo

Clots—coágulos

D+C—legrado (pretty awesome that there is one short word instead of dilatation and curettage)

Vaginal delivery—parto natural

You probably don’t want to eat after that, but hey, I do it everyday.   Even though my patients might be modest about their private lives, they certainly eat some very bold food.   The other amazing part about living in Texas besides fantastic patients is the fantastic food, and the large Hispanic grocery stores.  Limes are 20 for a dollar and the produce is fresh, diverse and abundant. 

One of my favorite Mexican inspired treats couldn’t be easier.  It’s a simple dressing put on all fruits, including cucumbers consisting of chile powder, salt and lime.  Just makes anything taste better.  Keeps me cool as a cucumber!

Mexican cukes

1 cucumber

chili powder

sprinkle salt

juice of 2 limes

Combine and enjoy

Ginger Ale for the Ailments

Growing up, when I was sick my dad made me drink Gatorade—he was convinced that Gatorade is the nectar of the gods with the perfect balance of carbohydrates and electrolytes to cure any ailment.  Most other parents immediately went for, and still go straight to the ginger ale.  Ginger ale is pretty much the only drink in the hospital wards as well.  Every medical student has probably overdosed on diet Shasta more than once.  Even though it is ubiquitous, does ginger actually calm the stomach?

Interestingly, when looking for studies of the effects of ginger on nausea and vomiting, many focus heavily on nausea and vomiting in pregnancy.  A review article in Obstetrics and Gynecology in 2005 analyzed four small randomized control trials that showed effectiveness of ginger for reducing nausea and vomiting over placebo [1]. Ginger has also been shown to reduce postoperative nausea and vomiting, although is not as effective in chemotherapy related nausea and vomiting [2,3]. 

I’ve been working in the OB/GYN emergency room for the past three weeks.  I’ve taken care of a fair amount of women with significant nausea and vomiting in their early pregnancy.  Usually we give them pretty strong anti-nausea drugs and fluids to help them to feel better.   Even though ginger probably doesn’t help for women who have severe enough nausea and vomiting to cause dehydration, it is good to know that ginger can probably help for women with more mild symptoms.   The best part about ginger is that is very safe to take in pregnancy, so there is no harm in trying it, and most importantly, it is delicious.

To drown out memories of late night Shasta on call in medical school, I made my own ginger ale.  It is based on a very pungent ginger syrup that can be added to club soda, or if you are feeling not nauseous (or pregnant) could use it as a base for a coctail with dark rum or whiskey.  Very refreshing!

Ginger ale

2 tbsp fresh ginger grated

1.5 tsp powdered ginger

1 cup sugar

1 cup water

Club soda

Ice (optional)

Lime wedge (optional)

Over medium high heat, bring all ingredients to a boil and allow to cook until syrup is reduced to half and begins to darken.   Allow to cool, add about ¼ cup syrup to 1 cup of chilled club soda.  Add ice and a squeeze of lime juice. 

1. Borrelli  F, Capasso  R, Aviello  G, Pittler  MH, Izzo  AA.  Effectiveness and safety of ginger in the treatment of pregnancy-induced nausea and vomiting.  Obstet Gynecol.  2005;105:849–56.

2. Chaiyakunapruk  N, Kitikannakorn  N, Nathisuwan  S, Leeprakobboon  K, Leelasettagool  C.  The efficacy of ginger for the prevention of postoperative nausea and vomiting: a meta-analysis.  Am J Obstet Gynecol.  2006;194:95–9.

3. White, B.  Ginger: an Overview.  American Family Physician. 2007 June 1; 75(11): 1689-1691

COOKIES!

Not much to say this week.  Still working, still surviving.  The highlight of my week was some delicious, crunchy, sweet, chocolaty, nutty, tangy cookies I stockpiled with unusual ingredients such as malt balls, malt powder, graham flour and pretzels.  I brought them to work to seduce the nurses to correct all of my poorly placed orders.  Seemingly it worked. 

Elizabeth’s slightly unusual but unusually good cookies

½ lb malt balls (such as Whopper’s)

1 to 1 ½ cup sourdough pretzel pieces

¾ cup butter (a stick and a half)
½ cup peanut butter

¾ cup brown sugar

½ cup granulated sugar

2 eggs

1 tsp vanilla

¼ cup malt powder

3/4 cup graham flour (or whole wheat flour)

½ cup oats

1 tsp baking soda

½ tsp salt

1 cup all purpose flour

Preheat oven to 350.  In food processor, pulse pretzels and malt balls until bite sized.  Alternatively, place in large ziplock bag and pound with rolling pin until bite sized.  In medium bowl, combine malt, graham flour, oats, baking soda, salt and flour.  Cream butter, peanut butter, and sugars until fluffy with mixer.  Add eggs and vanilla, stir to combine.  Stir in flour until well combined, then add pretzels and malt balls.  Using tablespoons, drop onto ungreased cookie sheets and bake until barely brown (8-9 minutes).  Cookies burn on bottom quickly so take em out fast!

Cool and enjoy.  

Suturing dinner—herbed ricotta chicken roulades

Still alive!  I’m a week and a half into it all.  Seems like a lot longer.  I feel like I know a whole lot more than I did just a week ago and that each day gets a bit more manageable.  Even so, as more straightforward patients seem easier, I am given more responsibility with more complicated patients.  I’m learning how to rule out ectopic pregnancies, diagnose all kinds of infections, and how to do endometrial biopsies.  I have become the queen of speculum exams; I even found somebody’s cervix in the dark as the exam room had no light besides the overhead lamp.

Along with responsibilities in the hospital on the job, we are required, thankfully, to perfect our surgical skills outside of the operating room.   We have a test in September on our knot tying and suturing (a fancy word for sewing).  Even though I grew up sewing, I definitely did not do so on a curved needle.  When you suture in the operating room, you hold the needle with a tool called a needle driver, which pushes the needle through the tissue.  I can do it, but I’m awfully slow.

Along with practicing in our surgical skills lab, I brought home some suture from the hospital to practice at home.  What better way to practice sewing flesh than on dinner?  Sewing meat simulates the operating environment a lot more accurately than the dry toys that we practice on.  Besides, when you make a lovely roulade, it keeps everything together really nicely—much better than interrupted knots. 

So for dinner tonight I made herbed ricotta and tomato stuffed chicken breast roulades with a yummy zucchini orzo on the side.  The only problem was that the suture was flesh colored and thus was difficult to find in the chicken.  I might have swallowed a knot.  If you don’t have suture and a needle driver you could use regular needle and thread, or just use toothpicks or kitchen string to tie it up.  If you are like me and trying to get better at sewing, this is a delicious way to improve.

 Herbed Ricotta and Tomato Chicken Roulades

3 large boneless skinless chicken breasts

½ cup all purpose flour

15 oz reduced fat ricotta

½ tsp fresh rosemary

2 tbsp fresh parsley

2-3 tbsp fresh basil

3 cloves garlic

½ shallot

¼ cup parmesan cheese grated

2 tomatoes thinly sliced

1 tbsp butter

2 tbsp olive oil

~1 cup white wine

2 tbsp balsamic vinegar

Cut chicken breasts in half horizontally and pound down until about 1/8-1/4 inch thick.  Dredge in salted and pepper flour.  Chop herbs, shallot and garlic finely, mix in with ricotta.   Add parmesan, salt, pepper and a splash of olive oil to ricotta mixture.  With each breast, spread a thin layer of cheese and a few slices of tomato.  Roll up widthwise and sew or tie up.  Preheat large skillet or dutch over over medium high heat.  Add olive oil and butter and sear chicken breasts for 3-4 minutes.  Add white wine to cover breasts about half way up, cover and reduce heat to medium low.  Cook until chicken cooked through, about 15 minutes.  Remove chicken from pan, add another tsp or so of salt to the sauce, add balsamic vinegar.  Turn heat up to medium high and cook sauce until reduced by about 50%.  Strain and serve with chicken.

Lemony Zucchini Orzo

½ lb orzo pasta

1 medium sized zucchini, grated

2 cloves garlic finely diced

1 medium shallot finely diced

Juice of one lemon

Splash of white wine

Salt and pepper

¼ cup grated parmesan cheese

Cook orzo in salted water according to instructions.  Over medium high heat in about 2 tbsp olive oil, sauté garlic, shallot and zucchini until zucchini cooked through about 5 minutes.  Turn heat off, add orzo, white wine, lemon juice, pepper and cheese.  Stir to combine and serve. 

Soft in the middle--Molten Chocolate Cakes

In my last year of medical school, we were required to do a month in the Emergency Room.  I would get frustrated sometimes when I wasn’t as thorough as I should have been in my physical exam or I didn’t consider every possible diagnosis.  One awesome attending that I worked with, an oddball of sorts who would wear camouflage hunting shirts underneath his white coat and would blast Train songs in the workroom, always reassured me: “You’re not supposed to know everything.  If you did, you wouldn’t have to go to medical school, and then do residency.  You’re like a muffin in the oven.  You just haven’t cooked yet.  You’re soft on the inside.”

If I’m soft on the inside this is how I feel:

After four days of residency, I definitely need more time in the oven.  This month I’m working in the Women’s Emergency Room, which is mostly gynecology and first trimester obstetrics.  It’s definitely a “learning on the job” kind of place.  Fortunately the second year resident I’m working with knows a lot and is helping me a ton and the nurses are very forgiving.   It’s amazing how much nicer people are to you when you can sign orders and write prescriptions.  (It’s also amazing that I can write prescriptions.)

So, all in all, work is scary at times and frustrating at times, but residency is awesome.  I finally get to do what I want to do and my patients consider me their doctor.  And, I also get days off, like today, to bake yummy lava cakes.   Sometimes it’s good to be soft in the middle, as long as you stop and reflect on it and get yourself cookin’.

Molten Chocolate Cakes

From Bon Appetit January 2001

5 ounces bittersweet (not unsweetened) or semisweet chocolate, chopped

10 tablespoons unsalted butter

3 large eggs

3 large egg yolks

1 1/2 cups powdered sugar

1/2 cup all purpose flour

Vanilla ice cream

Fresh rasberries

For cakes:  
Preheat oven to 450°F. Butter six 3/4-cup soufflé dishes or custard cups. Stir chocolate and butter in heavy medium saucepan over low heat until melted. Cool slightly. Whisk eggs and egg yolks in large bowl to blend. Whisk in sugar, then chocolate mixture and flour. Pour batter into dishes, dividing equally. (Can be made 1 day ahead. Cover; chill.)

Bake cakes until sides are set but center remains soft and runny, about 11 minutes or up to 14 minutes for batter that was refrigerated. Run small knife around cakes to loosen. Immediately turn cakes out onto plates.  Serve with ice cream and rasberries.

The July Phenomenon

While July 1 might just be another hot summer Thursday for most of America, for the world of medicine, it is the traditional day in which every teaching hospital in America initiates interns into the start their residency and all current residents move on to be higher levels.  July 1 signifies a new iteration of hierarchy within medicine and another year gone by. 

Internship, as I had suspected, and have confirmed during orientation, will be a lot of responsibility.   My pager is to be on my person, turned on, at all times so I can be reached in case of an emergency.  Just keeping my pager with batteries and on me is hard enough. There are an incredible amount of sick women to be taken care of and a vast amount of procedures to learn.  Mastering a system, especially a complex, extremely busy, county system, is seemingly impossible even without the massive patient load.

My greatest concern however, is not for my own sanity or vanity (I’m sure I’ll recover), but for the safety and health of the patients.  My friends in medical school frequently joked during graduation week as we had parties and slept late that they hope “nobody gets sick in July”.   We all wonder how we won’t make people sicker when we really don’t know what we’re doing and feel even less knowledgeable and accountable than we did a year ago. 

Fascinatingly, the “July Phenomenon” as it’s so referred to, has actually been studied in depth in a number of specialties, referring to the frequency of medical errors and patient outcomes throughout the calendar year in teaching hospitals.  While some studies show that morbidity and mortality within teaching hospitals is much greater in the beginning of the academic year, some show no difference.  A study recently published from the University of California San Diego reviewed all death certificates in the US for the past 30 years (n=62 million!) and found that deaths from medication errors were much more likely to occur in July than other months [1]. 

Fortunately, there are a few large studies in the labor and delivery suite which found no difference in adverse outcomes between July and other months.  One nationwide study of about 300,000 women between 1998 and 2002 showed no difference between important complications like chorioamnionitis, C-sections, 3^rd or 4^th degree lacerations, or shoulder dystocia  [2].  Another smaller study showed a higher rate of infection during the July months, but other outcomes were similar [3].

How can we, as doctors and as broader society members, reconcile the fact that in some cases we may be putting patients at risk by allowing residents to truly “practice” medicine?  I recently read Atul Gawande’s excellent book “Complications” where he discusses this very quandary.   He suggests that there is no other solution to the problem of training new physicians without human experimentation, under supervision of course, and putting some people at risk.  He concludes, therefore, that training residents ultimately is for the good of everybody. 

The July phenomenon, in a more positive light, I think also refers to the burst of fresh veggies and eggs available as summer comes into full bloom.  I was blessed to be given freshly laid eggs by my new friend and classmate who has four lovely hens.  The beauty of an eggy tart like this is that even though it takes a bit more time than many dinners, it can be eaten for breakfast, lunch or dinner and can really have any fresh veggies, meat and cheese that you choose.  I list below what I used, but substituting almost anything appealing would be just as wonderful.  The whole meal comes together in a snap with a food processor but can just as easily be done the old fashioned way.  It’s the perfect meal to gear up for an insane week (WISH ME LUCK!)

Eggy veggie tart

In 9 inch tart pan or 8 inch pie pan

For crust

1 cup flour

1 stick ice cold butter

¼ cup ice cold water

½ tsp salt

Filling

5 eggs

¼ cup cream

Cut up cooked sausage

1 large shallot or half of onion

½ red pepper

4 oz goat cheese

Whole tomato thinly sliced

Chiffonade basil

To make crust.  Preheat oven to 425.  In food processor pulse flour and butter until butter is pea shaped about 5-6 times.  Add water and pulse a few more times.  Alternatively, you could use a pastry cutter or 2 knives.  Take dough out and bring together with hands.  Do not overmix.  Ideally, refridgerate for 2 hours, but I just rolled it out.  Put in tart pan and cover with foil.  On top of foil use beans, weights or another pan to weigh down.  Bake for 15 minutes.  Take off foil and allow to brown for another 2-3 minutes.  Remove from oven.  Turn oven temp down to 375

For filling, clean out the food processor, pulse eggs and cream with pinch of salt until foamy.  Over medium heat with 1 tbsp olive oil, cook shallot/onion and pepper with salt until shallot starts to brown, about 15-20 minutes.  In pastry shell, add sausage, onion/peppers, then tomatoes.  Add egg mixture, top with cheese and herbs, bake for 15-20 minutes until custard is set.  (sorry the picture is ugly)

1. Phillips, DP.; Barker, GE. “A July Spike in Fatal Medication Errors: A Possible Effect of New Medical Residents.” Journal of General Internal Medicine,, 2010.

2. Ford, AA.; Bateman, BT.; Simpson, LL.; Ratan, RB. “Nationwide data confirms absence of 'July phenomenon' in obstetrics: it's safe to deliver in July.” Journal of perinatology : official journal of the California Perinatal Association, v. 27 issue 2, 2007, p. 73-6.

3. Myles, TD. “Is there an obstetric July phenomenon?.” Obstetrics and Gynecology, v. 102 issue 5 Pt 1, 2003, p. 1080-4.