Taking a break

Hello loyal readers.

I've been working hard to post 2-3 times a week.   Some of my friends have told me they can't keep up.  I thought I would give you some time to peruse.

I'm in Chicago spending time with family and friends this week and then off to Dallas to look at housing this weekend.  I bought a wedding dress yesterday and planned my upcoming trip to Mexico.  I'm having other people cook for me or eating out and enjoying the time I have with the people I love. 

I may post once this week, but I thought this would be a good time to put some of my favorite posts thus far if you feel like you want to look back.  Hope that all is well and that the sun is shining wherever you are.

I'll see everybody next week.

Elizabeth

The big bad brussel
One of my first posts, but also one of my favorites.  The genetics behind why some people hate bitter foods

And the Beet Goes On
Why some people, including me, pee red when they eat beets.

A Shout Out to Kraut
Reminiscing on a microbiology lab disaster making sauerkraut and why I still love it.

Why Chai--Caffeine as Medicine
A recipe for fragrant homemade chai and a discussion of the therapeutic uses of caffeine including a cure for headaches. 

Maple Syrup Pork Roulade--homage a Maillard
A recipe for a beautiful spicy marinated stuffed pork roulade and a gracious thanks to my college adviser for all he did for me.  Thank God I never have to use a test tube again. 

Spicy caramel corn and my reading list

When I am blessed with a moment to spare and to consciously wrestle myself away from the computer or television, there is no greater moment spent than entwined on the couch, floor or bed arranged in some unnatural body position enraptured by the pages of a book or magazine.  These are some medical/food books that I’ve read lately that I would highly recommend.  They’re all quick reads and will leave you thinking.  And don’t worry; you can eat while you read.

Homebirth in the Hospital by Stacey Marie Kerr, MD. 

A family physician in northern California, Dr. Kerr outlines birth stories of women who gave birth in the hospital, but with minimal medical intervention.  The world of medical obstetricians and proponents of natural childbirth and homebirth are often portrayed to be on opposing battlefields.  Dr. Kerr suggests combining these two worlds for safe and happy delivery of babies, especially of high risk women.  The diversity of women outlined in the book goes beyond telling the story of the birth of their babies and beautifully portrays the meaning of motherhood for women from all backgrounds.

The Reach of a Chef by Michael Ruhlman

The third in a series of books on chefs, the Reach of the Chef discusses the impact of celebrity of chefs and cooks today on the culinary industry.  He profiles many different chefs who have found extreme success in their field.  Often success is countered with a chef’s personal loss of his craft as he shifts to a more managerial position.  The overlying theme, to me, was that not unlike being a doctor or surgeon, being a chef involves an incredible amount of sacrifice, hierarchy, and diligence, mental, physical and emotional energy.  The difference is that nobody dies in the kitchen.  Personally, if I’m going to work that hard, I’d rather be in the OR than chopping carrots and planning menus. 

A Year of Magical Thinking by Joan Didion

This heart-wrenching memoir examines the year after writer and novelist Joan Didion’s husband died instantly at the dinner table while their only daughter was intubated in the ICU from severe sepsis.  Didion employs hard evidence from medical literature combined with fantasy and poetry to understand and cope with such tremendous stress and loss.  She grows to understand the science but also the “magical thinking” behind dealing with tragedy.  I read the whole book in five hours and could not put it down. 

French Laundry at Home by Thomas Keller and Michael Ruhlman

While this beautiful book is primarily a cookbook, it is much more than that.  French Laundry at Home, through photography, montages and incredible recipes outlines the intense amount of perfection and wonder that goes into making Thomas Keller’s Napa restaurant run smoothly and deliciously.  I haven’t cooked any recipes from it yet, but it is marvelous just to peruse.

Any other books that you’ve read lately that you recommend?  I have three months before I start residency, and in that time I plan to pack a lot of reading in.  Let me know!

What’s better than reading with a snack?  I struggled for a long time to think of a snack that would be delicious, easily reachable and in small bites, and perfect to eat while reading along.  Then it hit me--caramel corn! This caramel corn is amazing; salty, sweet, and spicy.  I think that cayenne pepper is a welcomed addition because the spice is the only thing that slowed me down so I didn’t eat all of it before my fiancé even got home from work (he would be very upset with me if I had made caramel corn and not shared). 

The caramel corn is easy to make, but does require a candy thermometer to heat up the syrup to the right temperature (the soft-ball stage).  Because I make the sugar sauce with equal parts of white and brown sugar, gauging the degree of cooked-ness of the caramel by its color simply doesn’t work.  You can get a candy thermometer cheaply probably at the grocery store, and I think it’s a good investment anyway.  The one that I got for a dollar works better than the fancy-schmancy one my dad got at Crate and Barrel that I used to make Christmas candy. As a suggestion borrowed from the lovely Orangette, I baked the popcorn for a bit to make it crunchy and delicious. 

Caramel Corn (I’m honestly not sure how much it makes because I ate half of it before I was done but it makes about 6 cups.  If you want to make more, the recipe is easily doubled)

½ cup un-popped popcorn
3 tbsp veggie oil
(or 1.5 bags regular microwave popcorn)

Over medium heat in heavy bottomed pot/pan, pop corn shaking occasionally with lid slightly cracked until most kernels popped.  Or just use an air-popper or microwave if you have one. 

For caramel:
½ cup granulated sugar
½ cup brown sugar
½ tbsp salt
1 tsp cinnamon
¼ tsp cayenne pepper
1/3 cup water
3 tbsp softened butter (very important to soften)

Preheat oven to 250.  In heavy bottomed sauce pan, over medium heat, mix sugars, salt, cinnamon, pepper and water and bring to a boil.  Boil, stirring frequently, until candy mixture reaches 240 degrees or the soft-ball stage.  Turn off heat, and whisk in butter.  Add popcorn to saucepan (if it fits) and mix thoroughly.  Add corn to baking sheet and bake for 10 minutes, stir and bake for another 10 minutes.  Allow to cool (if you can wait) and enjoy!

Time to Uproot

I’m feeling a little stuck right now.  I think since match day I’ve lost my motivation.  That match day envelope contained my entire future.  The day after match day I received a Fed-Ex envelope requesting my scrubs sizes, my white coat inscription and my vacation requests.  Being a doctor is no longer some fantasy, some far away goal that I’ve been slowly working towards for the past ten years.  My MD is coming fast, and it’s about to slap me in the face.

As excited as I am to leave Cleveland, I am mourning the end of my Midwestern life.  I will miss the cool summers, the proximity to my family, and most importantly, all the people I have met here from classmates to friends to mentors to patients.  It will be a drastic change to transform from medical student to doctor since the only difference I see in myself is two more letters on my white coat. 

More than anything, I hate moving.  The act of sorting through all of one’s things and carrying them down three flights of stairs and back up again is not only emotionally dreadful, but physically exhausting.  Psychologists show that moving is a draining time in people’s lives.

In a survey of 111 relocating professionals in the UK, well over 75% of the subjects found the experience to be somewhat stressful to very stressful [1].  Those moving great distances and those who had spouses who needed to find new jobs (that's us!) had significantly more stress than those moving short distances and spouses that did not need to find jobs. Another study conducted in England showed that between those moving, those that were greater prepared before they moved had better post-move adjustment [2]. 

Whether I’m ready or not, it’s time to pull up my roots and plant them in the hot Texas soil.  They’ll probably grow faster there anyway.  The potato is as uprooted as I am, and I’ve invited him for a warm dinner. 

Fortunately, the potato makes delicious soup for a cold, rainy, disgusting Cleveland day like yesterday.  There’s nothing better to make than a slow soup to un-stick my stuck self hour by hour.  I started with chicken bones that have been accumulating in my freezer, simmered them leisurely into stock, and then strained the stock to cook with hearty vegetables.  The soup was pureed and topped with a vinaigrette of bacon, green onions, white wine vinegar and olive oil which gave a nice boost of texture and flavor. 

Let me tell you guys, if you’re going to make any of the recipes on this silly blog, make this one!  My fiancé pooh-poohed the idea of potato soup and then ate three whole bowls and licked them clean…and then took the leftovers for lunch.  Simplicity and heart taste the most delicious.

Uprooted Potato Soup

7 cups chicken stock (try not to use canned broth, recipe below) or water
1 tbsp butter
1 large onion diced
1 large carrot diced
1 rib celery diced
3 cloves garlic diced
1 sprig rosemary chopped
1 tsp salt
6 medium potatoes peeled and diced into 1” pieces
1 cup low fat sour cream
Salt and pepper to taste

For vinaigrette
4 pieces thick cut bacon (optional)
3 green onions finely chopped
3 tbsp white wine vinegar
1 tbsp olive oil

Chicken stock
2-3 lbs chicken bones (I have accumulated about 3 chicken carcasses from roast chickens over time.  Don’t throw them away!  If you don’t have these, you can use chicken backs.  They make great stock and are very cheap)
1 rib celery
½ onion
1 tsp salt
1 carrot
Sprig rosemary, sprig thyme
10-12 cups water

To make stock
Preheat oven to 425.  Place chicken pieces on baking sheet and bake until golden brown (I just put them in frozen and they turned out great) about 35-45 minutes.  Add chicken and all other ingredients to large stockpot.  Bring water to boil, boil for one minute and reduce heat to low.  Cover, and cook for 4-6 hours until flavorful. 

To make soup
Add 1 tbsp butter to large pot on medium high heat.  Melt butter, add carrots, onion, celery, garlic, herbs and salt.  Sauté veggies until onions are soft, about 10 minutes.  Add potatoes and stock.  Cook on medium high until potatoes are very tender, about 20 minutes.  Turn off heat, add sour cream and puree in blender or with immersion blender. 

To make vinaigrette
Cook bacon until crispy on medium high heat.  Strain on paper towel and chop into small pieces.  To small bowl stir onions, bacon, vinegar, add oil and add 1 tbsp to the top of each bowl of soup.

1. Munton, A.  Job Relocation, Stress and the Family.  1990.  Journal of Organizational Behavior.  11; 5: 401-406.
2. Martin. R.  Adjusting to job relocation: Relocation preparation can reduce relocation stress.  1999.  Journal of Occupational and Organizational Psychology.  72;2: 231-235.

The (not so) Rote Oat

I have a lifelong bond with oatmeal.  It’s a special one that I inherited as a child, without choice.  You see, my father used to work for Quaker.  Not only did he work for the company, now long swallowed up by PepsiCo, but he worked diligently for the cereal division.

My father’s job made us three little girls (me and my sisters that is), the princesses of Cap’n Crunch, Life cereal, and most importantly Quaker Oats.  The relationship with Quaker was deep: we appeared on the back of the Cap’n Crunch box in Hawaiian muumuus, my dad’s co-workers crafted a carton of oatmeal long buried in the basement with his picture overlaying Mr. Quaker, and we tested products such as Toasted Oatmeal in white unlabeled boxes long before they were released to the public. 

My dad still diligently eats oatmeal everyday, although my feelings for oatmeal are a little more tenuous.  I don’t think there is any scientific evidence that it “sticks to your bones”.  If it did, I think that orthopedists would have their patients avoid it.  It would make surgery very gooey.

Oatmeal has staged various health claims, including the ability to reduce both blood pressure and cholesterol.  In a 2001 study in the Journal of Nutrition, those that were put in a trial group of oatmeal consumption on a low calorie diet versus those that were simply on a low calorie diet had a significant reduction in both blood pressure and total cholesterol [1].  Although similar health benefits have been shown in other studies, in the 2007 Cochrane Review “Wholegrain cereals for coronary heart disease” suggests to interpret these findings cautiously.  The studies on oatmeal were underpowered, conducted over the short term, and only showed their effect on individual risk factors of coronary artery disease.  None researched oatmeal’s effects on overall morbidity and mortality of heart disease [2].  

Regardless of whether or not oatmeal prevents heart disease, it still contains healthy amounts of soluble fiber and most importantly, can be quite tasty.  I think the best way to celebrate oatmeal is with cookies.  My friend Beth asked me to make cookies as my next recipe since my name is “OB Cookie” and I’ve only featured one cookie recipe.  These cookies are a spin on the classic oatmeal raisin.  Instead of plump raisins, I added chopped up candied ginger, and to accompany the spice and kick of the ginger, I added orange zest to the batter.  In attempts to make the cookies a bit healthier (although no less fatty) while still keeping them rich, I substitute almond butter for a lot of the butter normally added to oatmeal raisin cookies, and I use whole wheat white flour.

Whole Grain Oatmeal Almond Orange Ginger Cookies

½ cup (1 stick) butter softened
1/3 cup unsweetened creamy almond butter
Zest of one orange
¾ cup packed brown sugar
1 tsp vanilla extract
1 egg
1 cup whole wheat white flour
¼ tsp salt
¼ tsp baking soda
1 ¼ cup oatmeal
1/3 cup candied ginger finely chopped

Preheat oven to 350.  With mixer cream butter, almond butter, orange zest, sugar until creamy.  Add vanilla and egg, beat until mixed.  In medium bowl, combine salt, flour and baking soda and add slowly to butter mixture, beating until combined.  Add oats and ginger, mix until combined.  Drop ~1/4 cup mixture onto baking sheet.  Bake about 8 minutes or until golden brown on top.

1. Keenan, JM., et al. “Oat ingestion reduces systolic and diastolic blood pressure in patients with mild or borderline hypertension: a pilot trial.” The Journal of Family Practice, v. 51 issue 4, 2002, p. 369.
2. Kelly, SA., et al. “Wholegrain cereals for coronary heart disease.” Cochrane Database Syst Rev, issue 2, 2007, p. CD005051.  

To Corn Beef--Part 2

 

As I said, before, YEEHAW! Folks (excuse me, y’all), get ready. I’m moving to Dallas, Texas. Life is full of surprises, and this move is one of them. But as I come to understand the reality of the situation and the craziness and uncertainty of the match, I am getting very excited. I matched to the biggest OB/GYN residency program in the country, University of Texas, Southwestern. With lots of residents come lots of babies and lots of sick mommies. In fact, at Parkland hospital where we do almost all of our work, there are an average of 16,000 babies delivered a year! 16,000! Most large hospitals average around 3000 to 4000.

When I was looking for a residency, I wanted to go somewhere warm (I am a winter hater TO THE CORE), and I desperately wanted to work somewhere where I could take care of underserved Spanish-speaking women (ay si, senora!). As my mother told me yesterday, “This is where you were meant to be. You went to medical school to work with those that are often overlooked. You are going to be the doctor that you always dreamed about becoming.”

I don’t know if they eat corned beef in Texas, but I do know that they worship the un-cured cow meat there. I hope that my carnivorous habits, love of sausage making and new interest in meat curing will make me lots of friends. Look forward to lots of barbeque tips! I think barbeque ties in perfectly well with what I was originally going to talk about today, which was the question, “is sodium nitrite toxic”?

Sodium nitrite is rapidly converted to nitrous oxide when added to curing solutions. Nitrous oxide reacts with amino acids present in meat to form potentially cancer causing agents called nitrosamines; the formation of these compounds is accelerated by the heating of meat, particularly in high temperature situations like grilling [1]. It was discovered that adding vitamin C derivatives to nitrite-cured foods reduced the nitrosamine concentration. Now foods are required by the FDA to have anti-oxidants added to them. In a recent excellent review by the Journal of Food science, authors discuss toxicity of nitrated foods, and how addition of citrus compounds to these foods could potentially reduce nitrosamine concentrations [2].

My solution to neutralizing the nitrated corned beef, in the form of a rich corned beef hash, was to make a bright and tangy, vitamin C rich citrus salad. The citrus salad is a variety of pink to orange fruits dissected and bathed in simple syrup infused with ginger and rosemary. The rosemary adds an herbal earthiness while the ginger adds the slightest pungent kick. The corned beef hash contains not only potatoes, onions and meat, but also sweet potatoes and red and green peppers. It was the perfect treat for my perfect friends, who I am so proud of for all of their amazing residency matches. I love you ladies, and I can’t wait for us to become the best doctors in America!

Corned beef hash
2 cups corned beef, cubed
2-3 medium potatoes
1 medium sweet potato
½ green bell pepper diced
½ red bell pepper diced
1 medium onion diced
1 tsp salt
1 cup cooking liquid from corned beef
½ tsp ground marjoram
1 tsp butter
1 tsp vegetable oil

In a 400 degree oven, bake potatoes for 45 minutes or until easily pierced with knife. Peel and dice. Keep oven on. In large pan, heat oil on medium heat, add onion, salt and peppers, cook until soft about 15 minutes. Add potatoes to pan, cook until potatoes are soft, about 10 minutes. Add corned beef and cooking liquid. Heat through, about 5 minutes. Add mixture to casserole dish, bake at 400 degrees for about 15 minutes or until brown and bubbly on top. Serve with eggs, cooked to order.

Citrus salad (serves 3, I made a batch about 3 times the size)
1 ruby red grapefruit
3 clementines
1 navel orange
1 blood orange
¼ cup water
¼ cup sugar
½ sprig rosemary
1 inch ginger root grated
1 tbsp honey
Zest of orange
 

Section citrus. To cut up grapefruit, peel with knife, including the pith. Cut the sections vertically between the fibrous stuff. Cut clementines, oranges and blood oranges. To make syrup, boil water, sugar, honey, rosemary, zest and ginger. Reduce to a simmer for 5 minutes. Strain on top of fruit, refrigerate overnight.

1. Lijinsky, W. “N-Nitroso compounds in the diet.” Mutation Research/Fundamental and Molecular Mechanisms of Mutagenesis, v. 443 issue 1-2, 1999, p. 129-38.
2. Viuda-Martos, M., et al. “Citrus co-products as technological strategy to reduce residual nitrite content in meat products.” Journal of Food Science, v. 74 issue 8, 2009, p. R93-R100.

To Corn Beef--Part 1

I’m not a St. Patrick’s Day person. I love the color green, I like beer, and I love parades and festivities, but why do they all have to come together on this drunken, boisterous “holiday”? My good friend and next door neighbor is freshly imported from Ireland. He says they don’t even truly celebrate St. Patty’s over there, and he tells me that the British, not the Irish, eat corned beef. I know I’m being a cynical party pooper sitting at my laptop griping while many friends and classmates are out having a raucous time. Hey, I’m happy right here!

Fortunately, my fiancé feels the same way about these shamrock laden festivities. He probably abhors the holiday even more than I do. In fact we met three years ago exactly, on St. Patrick’s Day, in a loud bar. We were out celebrating with mutual friends. He was even less happy to be there than I was, as the drunk girls in mini-skirts poured beer down the back of our necks. The first thing he ever said to me was “I’m grumpy and I don’t want to be here.” We fell in love. Now we’re getting married, and I think I saved the relationship on its first day with corned beef.

Three years ago, I bought the beef pre-corned from the market and braised it on top of the stove with some cabbage and potatoes. Just as my relationship has progressed, I think my cooking skills have as well. This year I decided to make the corned beef myself. Luckily I have local guidance. I live in the same zip code as the wonderfully inspiring Michael Ruhlman. Ruhlman is a writer by trade but also an expert on food and chefs. He wrote the book Charcuterie on how to salt and cure meat, including corned beef. I put myself up to the Charcuterie challenge.

The secret ingredient to corned beef, it turns out, is sodium nitrite. For food preparation purposes, sodium nitrite is packaged as pink salt, curing salt or Prague Powder #1. Sodium nitrite is not easy to come by, and I spent two whole days in my car tracking it down. Even Michael Ruhlman himself didn’t know where to find it locally and suggested I buy it online. When I did find the illustrious pink crystals, the woman selling the salt to me told me not to touch it. How could I put something in my mouth that wasn’t safe to touch?!

Why is sodium nitrite crucial to the composure of corned beef? And is it really toxic?

Sodium nitrite has been used in food preparations for hundreds of years. Nitrites serve multiple purposes: they add to flavor, they both preserve meat and maintain the red color of the meat. Multiple studies show the effective bactericidal (bacteria-killing, just like homicidal is people killing) properties of nitrites when preserving meat.

In 1972, the Swift Company along with the FDA contaminated canned ham with various concentrations of Clostridium botulinum (botulism) and various concentrations of nitrites [1]. They showed that with higher levels of nitrites, botulism was completely inhibited. Although ridding food of botulism seems benign now, botulism used to be a serious threat.

Nitrites are also known to destroy other bacteria as well, although the effect is more complex. The effect of nitrites on the highly pathogenic and sometimes deadly bacteria, listeria monocytogenes, is heavily debated. Listeria has been isolated from nitrite cured meats such as hot dogs. The current theory is that nitrites damage the bacteria, but do not kill it. Once the bacteria consume the nitrogenous compounds, they can rebound and grow rapidly after the shelf life of the meat has expired [2].

To make your own nitrated meat, Ruhlman was kind enough to publish the exact corned beef recipe on his blog this week. While I normally write my own recipes or adapt them significantly, I followed the corned beef recipe point by point. I had no idea how to make it! For the recipe, go here. Just make sure to have a lot of patience, and that you plan at least five days ahead of time.  And to find out if corned beef is toxic…stay tuned for “To Corn Beef—Part 2”.


1. Christiansen, LN., et al. “Effect of nitrite and nitrate on toxin production by Clostridium botulinum and on nitrosamine formation in perishable canned comminuted cured meat.” Applied Microbiology, v. 25 issue 3, 1973, p. 357-62.


2. Nyachuba, DG.; Donnelly, CW.; Howard, AB. “Impact of nitrite on detection of Listeria monocytogenes in selected ready-to-eat (RTE) meat and seafood products.” Journal of Food Science, v. 72 issue 7, 2007, p. M267-75.

It's About Time

Today I received the beloved email “Congratulations, you have matched.”  Phew.  And YEEHAW!  Somebody wants me, I’m going to have a job, and best of all, I’m going to be a doctor at an academic institution.  The killer part of this whole process is that I don’t find out until Thursday WHERE I matched.  While there are only 72 hours until I will know, I am positive that these three days will feel like an eternity.  Every second my watch seems stuck, with barely enough inertia to move forward, and then, if by force and luck, it ticks again. 

How can these three days, when they have the exact same amount of hours and minutes, feel so different than an average three days during a regular week?  The perception of time is so dependendent on the anticipation of things to come and awareness of the clock.  Think about when you put a stick of butter in the microwave for 30 seconds and watch the fat molecules liquefy while the digital clock ticks down second by second.  The 30 seconds feel like a year.  You want melted butter, and you will have to wait.

Time is a crucial variable in medicine.  Because perception of time is so tinged by emotion and adrenaline, this explains why parents when witnessing a seizure of their child will say it lasted for five minutes, when truly the event was probably much shorter (you know, I really can’t find a source for this.  I looked and looked for a study but I heard an ER doc say it once.  This might not be true, but I like to think it is.  Evidence based medicine, I’m sorry).  This is also why it is important to time contractions of labor with a clock.  We experience time constantly, but we are almost incapable of understanding and interpreting it without the aid of the sun or technology. 

To have the clock be your friend, this is a dinner that you can whip up fast.  I know a lot of the recipes I’ve been posting lately have been complicated and pretty unhealthy.  I think it’s the moment to leave you with something quick and light.  That way, you can enjoy your time with your food in front of you, and not watch it slowly roasting in the oven.  It will give you a few more minutes to obsess about your future and to worry about your past.  No regrets!  You did the best you could, and if you didn’t, then you have a lifetime to do better.

In a jiffy-springtime pasta (sorry the picture is really boring and horrible today.  I was honestly in a hurry to get to the bar and celebrate and I let it slide.  I will do better next time)

½ lb whole wheat linguine

2 tbsp olive oil

1 shallot diced finely

2 cloves garlic diced

1 bunch asparagus with tips trimmed, cut into ½ inch pieces

¼ cup pine nuts

¼ chopped parsley

1 tsp fresh rosemary

1/3 cup grated parmesan

Zest from 1 lemon

Juice from lemon

1 cup grape tomatoes

Boil pasta in salted water as directed.  Reserve 1 cup of pasta water when cooked.  In skillet, heat 2 tbsp olive oil and sauté shallot until transluscent.  Add garlic, asparagus, and rosemary until asparagus becomes bright and tender, about 5 minutes.  Add parsley, pine nuts, lemon zest and let parsley wilt about 1 minute.  Add grape tomatoes and cook for one more minute.  Add pasta with reserved water, parmesan cheese and lemon juice, mix to combine and serve. 

Torte Reform

Unfailingly, each time I tell somebody that I’m doing OB/GYN, the first thing that they tell me is either, “Ooh babies” or “You’re brave--the malpractice insurance.” I’m naïve. I chose OB/GYN because I am passionate about the field, and because of my love, I feel willing to pay the high insurance and face the threat of lawsuits. Because the only obstetricians I know are part of an academic practice that covers malpractice insurance, they don’t openly discuss, at least with me, their fear of lawsuits. Even so, I think the dread of bad obstetrical outcomes is palpable in each decision that is made on a labor and delivery unit.

I know next to nothing about the legal system. However, I think as a physician I should learn some basics as lawsuits will most likely, unfortunately, be part of my life. Many healthcare practitioners have told me “tort reform is the answer” and I just nodded my head. I have no clue what tort reform is. According to the Agency for Healthcare Research and Quality, “torts are civil wrongs where the injured person asks for monetary damages from an individual in a situation where there is no contractual relationship.” Thus, tort reform includes legislation that caps payments for non-economic damages when a patient sues a doctor and wins.

As of 2003, 23 states had some tort reform legislated into their government. There is evidence to suggest that tort reform is effective at curbing malpractice fees. For example, in California, legislation was passed in 1975 to lower malpractice costs; by 2000 their insurance premiums increased by 167% whereas in the rest of the nation, fees increased tremendously by 505% [1]. It has also been shown that in California, defensive medicine is less employed and that health care costs are 5-9% lower without significant change in patient outcomes [2].

One of my favorite blogs, Academic OB/GYN, written by Dr. Nicholas Fogelson, recently discussed the importance of change within the country’s legal system in order to produce better obstetrical outcomes over the long term. This is in response to the recent National Institute of Health’s Vaginal Birth After Caesarian (VBAC) Consensus that convened this week. VBAC is a highly contended subject; having a vaginal delivery after a previous caesarian puts a woman at a low but existing risk of the uterus rupturing from the C-section scar being stressed during labor.

Many obstetricians refuse to do VBAC because of fear of litigation due to the risk of uterine rupture. The consensus concluded that VBAC trial was shown to be a safe option for most women [3]. Dr. Fogelson suggests that the apprehension to perform VBAC might be assuaged by “mini-tort reform” in which patients sign a release that in case of a uterine rupture during VBAC, they waive their right to sue. While this is a provocative idea, requiring unlikely consensus and collaboration among a highly divided obstetrical profession, I am not informed or experienced enough to have my own personal convictions on the topic.

I am so protected and coddled as a medical student. I have no concept of what it feels like to be the final decision maker in stressful or liable situations. It is easy to be idealistically devoted to vaginal delivery for every woman who desires it, but to take a stance on the complex and heavily weighted decisions that obstetricians make would be unfair. I do feel with full fervor, however, that it is important to do what is safest and best for our patients. Letting the terror of litigation overrun an entire field of medicine is expensive and can potentially produce worse patient outcomes.

What I am certain about and can propose however, is TORTE reform. As a rich intermediary between a pie and a cookie, this is one topic that there is only one right answer: YES! Tortes are traditionally made with eggs, sugar and nuts. In this recipe, which I very loosely based on a linzertorte, I’ve reformed the composition to have a Southern tinge as a dedication to the pecan pie. The dough is made from chopped pecans and almonds, as is the filling in a pecan pie with mixed nuts spiked with brandy, and it is topped with a gooey chocolate ganache. This is one torte reform we can all agree on (unless you don’t like nuts or chocolate; nobody will ever completely agree).

Nutty Torte Reform with Chocolate on Top

For the crust
½ cup blanched almonds
½ cup pecans
6 tbsp butter cut into cubes, kept cold
1/8 tsp salt
¾ cup cake flour
½ cup powdered sugar
1 egg yolk

For the filling
2 eggs
¼ cup walnuts
¼ cup pecans
¼ cup blanched almonds
(or you could do ¾ cup pecans or use other nuts such as macadamia nuts or hazelnuts)
1/3 cup brown sugar
1/3 cup corn syrup
2 tbsp brandy
2 tsp vanilla
Pinch of salt
Pinch of cinnamon
1 tbsp heavy cream

10 inch tart pan

For the chocolate ganache
1 cup chocolate chips
¾ cup heavy cream
Splash of brandy

Preheat oven to 400 degrees. Toast almonds and pecans for crust in oven for 7 minutes or until golden and fragrant. Toast the nuts for the filling on a separate baking sheet. Allow to cool. Blend in food processor for 30 seconds or until mealy but don’t overwork or it will start to look more like nut butter. Add flour, sugar and salt, pulse a couple of times to blend. Add egg and butter, pulse until blended. With hands, gently bring dough into ball and press into disc, don’t overwork, refrigerate for at least an hour.

Preheat the oven to 300 degrees. On a floured surface with parchment paper, roll out dough. If the dough becomes too sticky, you can press it into the tart pan with your fingers. Prick dough with fork and bake for about 15 minutes. While baking, whisk together filling ingredients. Once crust has started to brown, remove from oven, add filling and bake for another 25 minutes until filling has solidified and crust is brown. Allow to cool.

Over simmering double boiler, whisk together chocolate and cream until blended, add splash of brandy and pour over top of torte while cooling. Refrigerate for a few hours and eat!









1. Hellinger F et al. Malpractice Awards on the Geographic Distribution of Physicians. 2003. US Department of Health and Human Services Agency for Healthcare Research and Qualtiy. http://www.ahrq.gov/research/tortcaps/tortcaps.pdf
2. Kessler, David and McClellan, Mark “Do Doctors Practice Defensive Medicine?” The
Quarterly Journal of Economics, vol. 111, Issue 2, May 1996, pp. 353-390.
3. http://consensus.nih.gov/2010/vbacstatement.htm

Oda a la papa/Ode to the potato

Chile was devastated last week.  The trembling earth ripped through towns large and small, tearing down buildings, separating roads, and crumbling bridges.  Many lives were taken, and infrastructure was destroyed.

I lived in Santiago, Chile for a year.  I originally went for a semester in college and then returned for six months on my own before I started medical school.   My friends tease me for obsessing over my experiences there, but there is a reason that I am in love. 

When I went for the first time, I made a pact to myself to meet Chilean people and assimilate.  I decided to take music classes. There, in the facultad de artes at the University of Chile, did I meet some of the most energetic, spontaneous, creative, life-loving people I have ever known. 

We would go to the beach and sing Chilean, Cuban, Argentine, and Brazilian folk music with a band of accordions, flutes, guitars, charangas, drums and voices until the sun came up.  We went to soccer games together, where I employed the most vulgar and colloquial of Chilean Spanish vocabularies taught only by the best of friends, swearing my head off, avoiding the riot control police that paced the area with batons, and screaming for the U to win.  I even learned how to make sushi there from my crazy, 80s loving, left-handed, mullet embracing, sweaty, guitar swinging, rockstar pal Alvaro, who was also a culinary buff in his own right.

When I woke up last Saturday to find that this place that had been my home, my playground, and my safety net had been shook up so significantly, I felt panicked.  I spent all day trying to call my best friend to make sure she was safe.  I finally reached her and my other friends; they are fine.  They said though that when the quake hit, it felt as though the ground was a ship in a storm, rocking and jerking heavily.  It was terrifying.

I think the best way for me to cope with this tragedy is to honor what is truly Chilean.  There is nothing more Chilean than the potato.  This nourishing, simple, rudimentary vegetable has supported the world’s hunger for hundreds of years.  The origin of the European potato, however, has been a widely disputed topic, especially between rival countries Peru and Chile. 

The two major potato strains originate from the Andean regions of Peru and Bolivia, and from southern Chile, from the island of Chiloe.  The potato was discovered by Europeans in these regions in the 1550s and was exported widely.  Genetic analysis of potatoes on the Canary Islands, which were some of the original export sites of potatoes from South America, gives some clues [1].  This research suggests that potatoes were exported from both the Andes and Chile, however, the Chilean potato was better adapted to the climate of Europe and became the dominant species, long before the potato blight of the 1800s.  (I am unbiased in this research, as it is highly contended.  I like Peru and Chile; they can both be the birthplace of the potato!)

The recipe today is for a pastel de papa, or a potato pie.  Pastel de papa is the ultimate Chilean comfort food, made of pino topped with mashed potatoes and baked.  Pino is a staple of many Chilean dishes made of ground beef, olives, raisins, onions and hard-boiled eggs.  Although pino might seem a bit strange, it is complex and rewarding to the tongue.  To me this dish tastes like home.  And, in this recipe, you only need ONE pot and ONE pan to make the whole thing!

Pastel de Papa

5 medium potatoes
3 eggs
¾ cups half and half
1 ¼ lbs ground beef
1 medium onion chopped
½ cup raisins soaked in ½ cup white wine
½ cup kalamata or nicoise olives rinsed and roughly chopped
½ tbsp oregano
½ tbsp ground cumin
1/2 tbsp salt (plus more to taste)
Sprinkle red pepper flakes

For topping
¼ cup (1/2 stick) unsalted butter melted
1 tsp paprika
1 tsp salt
1 tsp sugar
Pinch of cinnamon

Preheat oven to 375.  Combine topping ingredients.  Peel and quarter potatoes.  Boil until fork tender about 15-20 minutes.  When potatoes have about 7 minutes left, add eggs to pot to boil.  In cast iron skillet or other oven safe pan, over medium-high heat, heat a splash of olive oil and brown ground beef.  Drain beef on paper towels, leaving a bit of fat to sauté onions.  Saute onions until soft, add oregano, cumin, red pepper.  Add raisins and wine, add olives, add beef, stir together.  Remove eggs and peel, they should be soft-boiled.  Cut into wedges and place on top of beef mixture.  In pot with potatoes, mash potatoes and add half and half.  Salt to taste.  Gently cover beef mixture with mashed potatoes.

On top of beef mixture, add butter/paprika mixture.  Bake pastel until golden brown and bubbly, about 30 minutes.  

Rios D et al.  2007.  What is the origin of the European Potato? Crop Science.  47.  May-June.  1271-1280

It isn’t always as it looks—the case of the savory cheesecake

In medical school we are always taught the classic presentation, the triad of symptoms, and the pentad of problems when we try and diagnose a disease. To uncover pathology is simply pattern recognition. For example when a patient presents with appendicitis, we expect to find pain in the lower right part of the abdomen, a fever, no appetite, nausea, and vomiting.

Unfortunately, medicine is not so simple. As it turns out, the classic presentation is probably less common than the atypical presentation. Many of the physical exam signs that we rely on to make a diagnosis are not reliable. In the excellent series “The Rational Clinical Exam” published in the 90’s and early 2000’s by JAMA, the authors reviewed literature focusing on the utility of different physical exam signs.

When a patient thinks they have strep throat, for example, the only signs or symptoms that help rule in strep throat are presence of exudates in the throat and recent exposure to somebody with strep throat [1]. Having a sore throat or fevers, the “classic presentation” is not predictive of strep infection, although fever can help secondarily guide the diagnosis in the absence of other signs.

Conversely, oftentimes what appears to be a classic presentation of one disease turns out to be something else, or is labeled idiopathic (another way of saying that “We have no idea!”) One of the hardest things I had to cope with in the clinical years of medical school was how many times there was simply no explanation for why somebody was sick. After watching so many episodes of House, I had assumed that everything would culminate in the diagnostic climax of a happenstance realization: “Did you say cheese? Hmmmm, as the resident pensively braces her chin. It must be Kawasaki’s disease!”

What’s true in the hospital can also be true in the kitchen. Things are not always as they seem. This recipe is for a savory cheesecake. Perhaps upon initial examination it appears to be dessert. But look closer. That green layer isn’t pistachios or mint. It’s spinach and chard. On top is a layer of red peppers and tomato, on top of that a layer of roasted yellow pepper, carrot and saffron. It isn’t dessert, but dinner! The beauty of the savory cheesecake is that it can be eaten for breakfast, lunch or dinner, hot or cold. It can be served as an appetizer or a main course. To warn you though, this is not light on calories, time, or dishes. It is however, rich, filling, and extremely appealing.

It isn't always as it looks--the three layer savory cheesecake (recipe cont...)

BRAINFREEZE!

The first appliance that I bought when I got my own kitchen 4 years ago was an ice cream maker.  I already and a microwave and toaster; an ice cream maker was the next logical purchase.  Every time that I waltzed down the Costco appliances aisle, it was screaming my name.

While purchasing an ice cream maker might seem like an excessive, unnecessary purchase, I think it is not.  Chocolate peanut butter ice cream cakes?  Chocolate chip cookie ice cream sandwiches, homemade?  People love this stuff.  If you make ice cream at home, you will make friends.

The hardest part about making ice cream is remembering to put the maker in the freezer at least a day ahead of time.  Good ice cream is made of so few ingredients that the assembly is simple.  So, you make the ice cream (or frozen yogurt in this case), you freeze it for a few more hours for it to harden up, and you take a spoon directly to the container and BAM!  As you ravenously destroy your homemade delicacy you get a chilling headache running from your eyes to the back of your head.  BRAINFREEZE!

What causes brain freeze or ice cream headache anyway?  Current neurologic models suggest that vascular constriction and referred pain are to blame [1].  A life-saving randomized trial performed at Dalewood Middle School showed that ice cream headaches were more prevalent in the group that ate the ice cream in less than 5 seconds versus the group that savored every last spoonful [2]. 

A survey of over 8000 Taiwanese adolescents showed the prevalence of ice cream headache is about 40% [3].  Boys were more likely to have brain freeze than girls, and older children were more likely to have brain freeze than younger ones.  Those that had chronic migraines were much more likely to have ice cream headache.  The association between ice cream headache and migraine has been shown in the past, however is still disputed considering one study showed that people with brain freeze were less likely to have migraines [4,5]. 

The best brain freeze is self induced.  Therefore, I recommend making this creamy chocolate malt frozen yogurt.  It is very tangy from the yogurt, not like the chemically altered, gooey sugary stuff from the mall, so if you don’t like yogurt, you probably won’t like this either.  The yogurt is strained for about 4 hours beforehand to remove excess water so the result is very creamy with a lot less calories than regular ice cream, although I do add some cream to give a good texture and flavor.

Chocolate Malt Frozen Yogurt
4 cups low fat plain yogurt
1 cup heavy cream
¾ cup sugar
½ cup cocoa powder
½ cup malt powder
Cheesecloth

Place a couple of layers of cheesecloth over a strainer over a bowl.  Add yogurt and cover.

Refrigerate for at least 4 hours until the yogurt has lost most of its moisture.  Sift chocolate powder into cream, add sugar and malt powder.  Stir to combine.  Whisk in strained yogurt and add to ice cream maker as directed.  Freeze until hardened. 


1. Kaczorowski, M., &  Kaczorowski, J. (2002). Ice cream evoked headaches (ICE-H) study: randomised trial of accelerated versus cautious ice cream eating regimen. BMJ: British Medical Journal, 325(7378), 1445-6.

2. Hulihan, J. (1997). Ice cream headache. BMJ: British Medical Journal, 314(7091), 1364.

3. Fuh, J., Wang, S., Lu, S.,  & Juang, K. (2003). Ice-cream headache--a large survey of 8359 adolescents. Cephalalgia, 23(10), 977-81.

4. Raskin NH, Kittle SC. Ice cream headache and orthostatic symptoms in patients with migraine. Headache 1976; 16:222–5.

5. Bird N, MacGregor A, Wilkinson MIP. Ice cream headache-site, duration, and relationship to migraine.  Headache 1992; 32:35–8.

Uncertainty Soup

The last couple of weeks have been wrought with anxiety.  Match day is only two weeks away.  I have full intellectual capacity to understand that my chances of matching are extremely high and that wherever I end up I will get excellent training. 

Emotionally though, I’m a wreck from the uncertainty of it all.  Not only does my life depend on the match, but my fiance’s life completely weighs on it. He has an established career where we live, and he is willing to give it up to support me.  I’ve been constantly up at three in the morning strangled by my down comforter from turning around it forty times, I’m highly dependent on carbohydrates, and I appreciate a cold beer like never before. 

I’m certainly not alone in feeling nervous and frantic.  My guess is that 80% of senior medical students in the US feel exactly the same way that I do.  But we have to snap out of it!

Being a doctor is equivalent to uncertainty.  Every diagnosis, prognosis, and treatment decision that we make as physicians has the potential to be incorrect and can be extremely harmful. We have to counsel patients on the risks and benefits of procedures, and be able to handle the possibility of a disaster.  The ability to deal with this daily struggle and accept the chance of error is critical to becoming a successful, happy doctor. 

Studies show that when physicians that struggle with uncertainty they can provide substandard care [1,2].  A Swiss survey of about 1200 doctors in varying levels of medical experience showed that stress about uncertainty was highest in women, those with relatively few years of experience, and those in surgical sub-specialties.  Similar results were shown previously by Gerrity, an expert on uncertainty. The study illustrated that stress with uncertainty was directly related to lower job satisfaction and perceptions in abilities to make decisions.

Compared to the uncertainty that we will face on a daily basis, hopefully this puts the stress from match into perspective.  Good luck on getting through the next couple of weeks.  We’ll know soon enough.  No matter how stressed you are, one thing to be certain about is what to make for dinner.  This hearty, spicy, red soup is chock full of roasted red peppers and tomatoes.  It is easy, vegetarian, and is the perfect antidote to stress.  It’s topped with homemade garlicky croutons.  Simply delicious.

 

Certainly make this Roasted Red Pepper Tomato Soup

4 red peppers halved and seeded

2 medium/large shallots diced

2 medium carrots diced

1 sprig fresh thyme

1 sprig fresh rosemary taken off stalk and chopped

4 cloves garlic

2 tbsp olive oil

6 oz can tomato paste

1 ½ tbsp sriracha

1 cup dry vermouth or sherry

28 oz can diced/crushed tomatoes

2 tsp salt

1 tsp brown sugar

3 cups water

1 cup half and half

Juice from ½ lemon

For croutons

1 round loaf sourdough

¼ cup olive oil

½ tbs salt

¼ cup grated parmesan

1 tbsp paprika

4 cloves garlic smashed into paste

1 sprig fresh rosemary finely chopped

Preheat the broiler.  On a large broiling pan or cookie sheet place red pepper halves skin side up, and press down to evenly expose all parts. Broil peppers until completely charred on skin side, about 10-15 minutes.  When done, peel charred skin which should come off easily and dice.  Preheat large pot on medium heat and add olive oil.  Add shallots and garlic.  Salt and cook, stirring frequently until carrots are tender and shallots are translucent, about 10 minutes.  Increase heat, add sriracha and tomato paste and cook for 2-3 minutes.  Add vermouth, diced tomatoes, red peppers, salt, brown sugar and water.  Bring to a boil, and reduce heat to medium, simmer for about 10 minutes to meld flavors.  Turn off heat, add lemon juice and half and half.  With immersion blender or blender, blend until all large chunks are gone.  Serve with croutons.

To make croutons:

Preheat oven to 400.  Cube bread to about 1x1x1 inches.  In large bowl add olive oil, garlic, paprika, parmesan, salt and rosemary.  Stir to combine.  Add bread and stir to coat all pieces.  On large cookie sheet, spread bread cubes.  Bake until crispy and brown, about 15 minutes.  Serve on top of soup.

1. Bovier, P., &  Perneger, T. (2007). Stress from uncertainty from graduation to retirement--a population-based study of Swiss physicians. Journal of General Internal Medicine, 22(5), 632-8.
2. Gerrity, M., DeVellis, R.,  & Earp, J. (1990). Physicians' reactions to uncertainty in patient care. A new measure and new insights. Medical Care, 28(8), 724-36.

Maple syrup pork roulade--homage a Maillard

You could say that Camille Maillard got me into medical school. He also helped to get me through it. Disregard the fact that he was born over 100 years before me, in France, and died alone while on a jury in Paris in 1936. While I adore the other Frenchman of his time notably Debussy, Ravel and Saint-Saens who certainly provided sexier and more impassioned contributions to society, Camille Maillard’s work brought me to the laboratory and taught me the importance of diligence, mentorship and hard work.

Camille Maillard penned the Maillard reaction, the long chain of reactions between an amino acid or protein and a sugar. The chain reaction results in browning and formation of complex chemical compounds called advanced glycation end products. While this all seems drab and dreary, in fact the Maillard reaction is an important player in both food and medicine.

The Maillard reaction explains why a chicken turns brown and delicious when you slather it with maple syrup or honey and bake it (although this is also due to caramelization which is a different chemical process). The reaction also has important implications in diseases such as diabetes. When we measure the hemoglobin A1C to keep track of how well somebody controls their diabetes, we measure an end-product of the Maillard reaction. Much of the end organ damage in diabetes can be contributed to excess glucose reacting with proteins in the microvasculature.

My work with the Maillard reaction involved test tubes—lots of them. There were enough test tubes full of solutions in varying shades of brown, champagne and yellowish beige to swear off of test tubes for life after I finished college. The research was repetitive and I don’t think I was very good at it. The experience wasn’t apparently life-changing.

What made my research exceptional was my wonderful mentor. He treated me as a peer, worked with me in the lab, and even washed my test tubes (which is so SO embarrassing…I’m sorry Roger!) I felt encouraged to keep going, to keep track of my work, and I to write that damn thesis. Hey Rog, will you make me write my medical school one too? When I started slacking he gently suggested getting back on it, and when I was really lazy he got mad and I deserved it. When I wanted to play piano for a term instead of do lab work, he let me, and when it was time to give a 20 minute presentation on my research, he stayed late repeatedly and made me practice.

I always knew I was lucky to have such a dedicated teacher. While I’ve had plenty of guidance and support in medical school, there’s nothing that even broaches the level of professional companionship of my undergraduate education. As I soon find out where I will spend the next four years of intensive training, I can only hope to have mentors that care not only about the work that I do, but about the beliefs, values and interests I have. I wish for everybody reading to have somebody a few years ahead to pick you up, guide you through, and seriously hurt you if you start acting like an idiot.

The following recipe is more complicated and time consuming than the average one that I post, but the result is spectacularly beautiful and delicious. It embodies the maple syrupy spiciness of New England (where I went to college) and it utilizes Dr. Maillard’s work with an overnight sugary marinade to promote slow browning before the meat is baked. It is a meal unto itself, and should be used for a celebration of someone special. The recipe ideally takes two days, so plan ahead! If you don’t eat pork, you could always use chicken breasts, just make mini-rolls applying similar principles.