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.

I love my Meatlover

According to my fiancé there are four food groups—meat, spicy, cheese and dessert.  If a vegetable or salad happened to land on his plate, he would eat it? Sure.  Would he go out of his way to find greenery for consumption?  Absolutely not.  If during the winter I make a warm and satisfying vegetable curry rich with potatoes, carrots and cauliflower, he’ll leaf through it and ask where the meat is.   When I go out of town, his idea of vegetable consumption is slipping a cucumber (don't ask) into his sausage-laden spaghetti sauce. 

Do men like meat more than women?  It’s not that I don’t love a juicy steak, a braised pork shoulder or a lamb chop less than the rest.  I thoroughly enjoy a well-cooked piece of flesh.  However, I don’t feel meat is necessary at every meal or even every day. 

I am surely not the only woman who feels that their guy is meat obsessed.  A survey of 14,000 men and women in the US between May 2006 and April 2007 illustrates this very phenomenon.  They found that “men were significantly more likely to eat meat and poultry products.  Women were more likely to eat vegetables, especially carrots and tomatoes.” [1] There were exceptions to the rules however.  Men, for example, were more likely to eat brussels sprouts or asparagus. 

Considering it was Andy’s birthday on Sunday, I felt it necessary to honor his four food groups.  For all he’s done for me, it’s the least I could do to give back.  I’m absolutely so lucky to have such a great partner to come home to everyday.  For breakfast, I made waffles, bacon AND sausage.  For lunch, we had authentic Texan BBQ.  And for dinner, he swore he wasn’t hungry, but I made him a Szechwan inspired spicy steak stir fry anyway.  And lets not forget the cake, red velvet with cream cheese frosting, that crumbled into a million bazillion pieces and foiled a beautiful birthday food pyramid.

Szechwan inspired steak stir-fry

2 tbsp veggie oil

1 tbsp Szechwan peppercorns ground

1 onion diced

2 cloves garlic

4 thai chilis chopped (leave seeds)

1 carrot finely diced

1 cup salted peanuts

1.5 lbs NY strip steak (or any other tender well marbled piece of meat) cut into thin strips

½ cup brocolli

3 tbsp soy sauce

3 tbsp Chinese cooking wine (or Sherry)

1 tbsp sugar

splash of rice wine vinegar

1 tbsp corn starch

Mix soy, wine, sugar, vinegar and corn starch in bowl.

In wok or cast-iron pan on high heat, preheat oil until smoking.  Add peppercorns, cook until fragrant then add onion, garlic, chili and carrot.  Cook until veggies are starting to soften, add peanuts, cook another 2 minutes, add steak and brocolli.   Cook until steak is not pink on outside, add sauce and allow to thicken.  Serve with rice.

1. http://www.eurekalert.org/pub_releases/2008-03/asfm-tdi031408.php

The end of bliss--with blissful white wine sangria

The end of bliss.  The fizzle of time with friends, relaxation, swimming pools.  No more absence of alarms, afternoon naps, 2am chats.  It’s time to WORK!  I know, I’ve been a doctor for a month now, but I feel as much of a doctor as Antarctica is tropical.  Besides freaking out on planes, or getting really worried about massive neurological injury from the keg stands and back flips witnessed at the pool as a paranoid, Advanced Cardiac Life Support certified physician, I’ve become a stumbling, blubbering idiot.

Well no longer! Sure, I’m going to be just as big a know-nothing as ever, but with my long, beautifully buttoned, clean white coat with my name with MD emblazoned on the breast, hopefully I can fool somebody.  I am in complete denial about the changes that are about to happen in my life; I have no true understanding about how my internship will shape the way I practice medicine and dictate my hobbies and habits. 

Orientation starts tomorrow morning.  I feel like my intern class is at the beginning of a car race.  Our engines are roaring.  We aren’t moving yet, but we are about to take off, deliberately hovering our feet over the gas pedal ready to fly the second we’re told to.  We’re hoping that after each lap we haven’t spun out, flipped over, or caught on fire. 

The program director muffles into the bullhorn “Ladies and gentlemen…gear up your specula” and we’re off, taking care of the women of Dallas county, one pelvic exam, C-section and ultrasound at a time.   You’ll see the track marks of my sneakers as I bolt down the hall.   The onlookers--the nurses, older residents and attendings watch and anticipate with a mixture of excitement and complete horror.

The finish line is far away.  All I know is that whatever happens in the next four years, it will be an experience I won’t soon forget.  Thanks to everybody for getting me this far, and I’m sorry for my grumpiness that will surely come.   To celebrate my last day of freedom, I made a large pitcher of white wine sangria.   It’s sweet and refreshing with a bit of a punch to dull the pain and anxiety I’m about to endure…and cools you off even in the hottest of days.

White wine sangria

2 bottles sweet cheap white wine (we used Reisling)

1/3 cup sugar

3 stone fruit diced (peaches, nectarines, plums)

1 mango diced

1 orange diced with peel

½ lime diced with peel

soda water

ice cubes

Mix wine, sugar, fruit and allow to sit for a few hours.  Serve over ice with a splash of soda water. 

Shaping Up with Shrimp

I’m slowly sinking into Texas life.  Besides desperately trying to avoid the last few boxes to unpack, I’ve decided to get back into shape.  I’m going to need all the stamina I can muster for those long days on labor and delivery when I start residency in a week.  I know, IN A WEEK.  We are blessed to live within a block of an amazing bike/running trail so I’ve been sweating it out running and on the bike and in the gym lifting weights.

I got a new computer for graduation (thanks Dad!) and I was uploading all of my old pictures.  Besides feeling sentimental and nostalgic for the ridiculous adventures of times past, I came to the sad realization that I packed on a few more pounds than I appreciated in medical school.  I think this might be directly correlated with receiving a Kitchen Aid stand mixer for Christmas a few years ago, which made a batch of cookies nothing more than a few minutes away.  Perhaps living with a boy had something to do with it too.   

Research shows that married couples are much more likely to gain weight, but even cohabitation increases the risk significantly of weight gain.  A longitudinal study of 1293 couples shows that those who transition from single/dating to cohabiting were more likely to become obese than those who stayed dating [1].   I definitely increased my portion sizes when Andy and I started to have dinner together every day.  Unfortunately for my figure, he is definitely taller and runs a whole lot more than I do.

No matter!  I’m looking forward with a positive attitude.  I don’t really believe in dieting per se, but I am trying to eat more healthy foods.  This is especially easy because one, it is too damn hot to eat large portions of fatty food, and two, that the produce around here is awesome and it’s prime fruit and veggie season. 

This beautiful shrimp dish, which we discovered in an old issue of the sadly defunct Gourmet couldn’t be easier or more delicious.  It is a French/Mexican/Asian fusion of sorts, which I accompanied by a large salad of grilled vegetables (which ended up to be kind of gross so I’ll spare you that disaster of a recipe).   Healthy, light, and super yummy. 

Shrimp in Ginger Butter Sauce

Gourmet September 2008

           

6 ounces large shrimp in shell, peeled

1 tablespoon unsalted butter

2 teaspoons grated peeled ginger

2 tablespoons medium-dry Sherry

2 tablespoons coarsely chopped cilantro

Pat shrimp dry and season with salt

Heat butter in a heavy medium skillet over medium-high heat until foam subsides, then sauté ginger 30 seconds. Add shrimp and sauté 2 minutes. Add Sherry and sauté until shrimp are just cooked through, 1 to 2 minutes. Stir in cilantro and season with salt and pepper.

The, NS.; Gordon-Larsen, P. “Entry into romantic partnership is associated with obesity.” Obesity (Silver Spring, Md.), v. 17 issue 7, 2009, p. 1441-7.

In a Vermont state of Mind—maple walnut/ginger ice cream sandwiches

It’s incredible how one can be the same person and yet be so different.  Returning from my five-year college reunion last weekend has really given me a lot to think about.  It was truly an incredible weekend; people are the same fun they were before, but calmer and more self-assured.

It was amazing to re-encounter people who have continued life with equal passion to how they had approached school.  They still love books, ideas and the world.  They continue to write and travel, and continue to make me feel like a whole person, complimenting my scientific life.  I miss days when my less scientifically inclined friends would turn to me and say “oh Liz would know, she’s in science,” whether the discussion was about physics, genetics, or something I probably had no real data about.  For whatever fraction of evidence I could muster, they broadened my horizons about much more—literature, history, art, politics and music.  

I returned to a venerable Utopia, a liberal arts college trapped in the hills and cornfields of Vermont, where professors share their beers, their offices and their families, the food in the dining hall is better than many restaurants, the mountains sing each time you walk outside, and there is endless amount of stimulus and encouragement for self-expression and personal cultivation.  I was reminded of what my dreams and hopes were by many that remember a snapshot of my former self from five years ago. 

I was also reminded by many how consumed I was with music—many were sad to hear that I was playing piano at an extreme fraction to my previous dedication, and composing really not at all.  As hard as it is to leave my musical passions hibernating, I am really proud of who I am and what I’ve done in the past five years.  I feel centered, balanced, and in love.  Medicine, for as abusive as it is, has made me a more whole person.  I have found writing and cooking, which are much more pleasurable companions than the tormenting angst of composing.  I feel safe in my friendships, and family life has stabilized just a little bit.

As much as I’d like to give in and go back, I need all the friends I’ve made in the five years since graduation.  Because in the end, as fun as it is to talk about books, ideas, and the New Yorker, I also have the compulsive need to talk about diarrhea, pus, blood and amniotic fluid freely, which only perverts such as med students and doctors can tolerate.  Alas, life keeps going, but it is fun to reflect—and dance, drink and sing, together.

To celebrate Middlebury College, I recreated my favorite cookies back in the day—maple walnut.  Even though when I brought them up to my friends, none of them remembered them.  Well I do, and those devilish cookies stole my slender figure!  I paired the cookies, which are brown and buttery with a cool ginger ice cream and piled them into luscious ice cream sandwiches.  I learned after I bought an ice cream maker (which is documented here) that frozen treats are great bribes for boyfriend’s roommates to let you hang out at their house and they are really just plain good.  The great thing about homemade ice cream sandwiches is that the ice cream is very soft when coming out of the ice cream maker which makes it very easy to stuff the sandwiches. 

Maple Walnut Cookies with Ginger Vanilla Ice Cream

2 sticks softened butter (unsalted)

½ cup maple syrup

¾ cup brown sugar packed

1 egg

2 cups flour

1 tsp baking soda

1 ¼ tsp salt

1 ½ cups chopped walnuts

Preheat the oven to 375.  Beat sugar, butter and syrup until fluffy.  In separate bowl, combine flour, soda and salt.  Add egg to butter mixture, stir to combine, and add flour mixture.  Add walnuts, drop spoonful sized cookies and bake 8-10 minutes or until set and golden brown.  Allow to cool on sheet and transfer to cooling rack.

Ginger Ice cream

Scant cup sugar

1 cup milk

3 cups heavy whipping cream

2 tbsp grated ginger (grates very easily frozen—freeze the night before with ice cream maker)

1 tsp vanilla

Combine sugar, milk, vanilla and ginger and whisk until sugar dissolved.  Add cream.  Add to ice cream maker and follow directions. 

To assemble cookies add soft ice cream (if it is too melt-y then freeze for one to two hours before applying), freeze on cookie sheet until ice cream is firm and wrap individually in foil.

In the Garden with Grandpa

I just got back from an amazing extended weekend at my five year Middlebury College reunion bookended by time with my young-acting grandfather in upstate New York.  By the way he behaves you wouldn’t know he’s 84 years old.  He’s jubilant and astoundingly healthy—he doesn’t even take any pills.

The most wonderful thing he’s done in the past five years with his partner, Gail, is plant a particularly large organic garden on the back lot of his old house.  Together, they have composted, seeded, tilled, planted, pruned and picked an incredible variety of fruits and vegetables.  Gail told me that although they had tomato blight last summer two years ago they donated over 300 pounds of tomatoes to the food bank.  That’s a lot of manual labor for two people expected by society to be blankly staring at a TV screen somewhere, frail and unable to productively contribute to the community.

I feel incredibly lucky to have such a great model of aging right in my family.  If I am blessed to make it that far in life, I can only hope I have half the energy and half of the good health that my grandfather does.  In fact, I think he might have more energy and be in better physical shape than I am at a ripe age of 26.   My grandfather proves that aging, although often categorized as a disease, might slow you down, but it can’t stop you just because you walk a bit slower, see a little worse, are deafer than a goldfish, or have weaker bones or sorer joints. 

Obviously, there is no fountain of youth, but five hours a day with a shovel can definitely slow down the clock.  One study of over 1200 aging Swedish men showed that intense gardening and other leisure activity is correlated with decreased mortality.  These findings positively support that intense physical activity is good at keeping us alive [1].

Yesterday, I was spoiled by a morning of planting, weeding and plucking up young beets, scapes and rhubarb that we crafted into a delicious feast including my favorite beet recipe.  I spent all weekend eating fresh kale from the garden which was sublime and quickly morphed into a delicious raw salad.   Even though I ate this salad two or three times, I couldn’t get enough, and made my own spin on it in my Dallas kitchen by crafting it into a pasta dish.  By simply adding a bit of hot pasta water and the hot pasta, the kale wilted just ever so slightly.  Dinner came together in 15 minutes and I ate it on the porch with a fascinating book, some bossa nova and a couple of glasses of white wine. 

Linguine with wilted kale

4-5 leaves kale chopped into edible pieces
2 cloves raw garlic minced
¼ cup lemon juice
½ tsp salt
¼ cup grated parmesan
¼ cup olive oil
¼ cup pasta water
½ lb whole wheat linguine

Mix all ingredients expect pasta in large bowl.  Cook pasta as directed.  When done add hot pasta water to kale and then add pasta.  Stir, add extra grated parmesan, salt and pepper to taste.  Enjoy!

Neda Agahi and Marti G. Parker.  Leisure Activities and Mortality: Does Gender Matter? J Aging Health 2008; 20; 855