Migas

Literally, crumbs or scraps, migas are the genius breakfast of some Mexican brainiacs disguising chips and salsa into a delicious breakfast.  Migas are a great use of the bottom of the tortilla chip bag or some stale crumbs that you found in the back of your cupboard hidden behind the seven pound bag of chocolate chips. 

Migas are a Texas staple and one of the amazing foods that have become necessities since I became a resident of this great state almost a year ago.  Yep, it’s been a great year in Texas.  The weather, the food, the people—it’s all awesome.   So, here I share some of my joy with you.

Gooey cheese, tortilla chips and eggs.  Breakfast of champions.

Migas

Serves two hungry people

2 tbsp veggie oil

1 small onion diced

1 clove garlic

½ cup green salsa or small can green chiles

½ cup tortilla chips broken into small pieces

4 eggs

½ cup shredded cheese (cheddar, jack, whatever you got)

salsa, sour cream, cilantro to top

In a large skillet over medium-high heat, heat oil until ripples.  Add onion and garlic with pinch of salt and stir carefully until translucent.  Add green salsa and chips, stir until chips are slightly soggy.   Add eggs and stir until cook, add cheese until melted.  Serve with toppings and enjoy.

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.

Huevos a la Mexicana

Silence.  Well, it’s really the absence of silence.  The manmade noises, the churn of humanity are reduced to a hum.  We are left with sounds previously unnoticed.  The swish of the waves on the beach, the rustling of palms, and the creatures that activate at dusk are all that ring in our ears.

This week I unplugged from it all and spent a week in the Pacific region of Mexico with my best friend from high school.  We didn’t rough it, but we did play to local style by taking buses everywhere instead of taxis and planes and eating lots of delicious street food.  We flew to Puerto Vallarta for a night and then immediately departed to Guadalajara and then a small town on the beach near San Blas.

I unplugged from it all.  I checked my email twice and called my fiancé for five minutes.  The current Mexican telenovela buzzed in the background while I ate my pozole, but that was it for TV.  It was incredibly refreshing and mind clearing.

My friend found this magnificent bed and breakfast (although no breakfast for us) right on the beach.  I’ve been on a fair amount of beach vacations and stayed on the beach plenty of times.  But what I didn’t comprehend was that not only were we on the beach, but that we were on the beach alone.

Miles of smooth sand stretched out and the clear water extended shallowly out for hundreds of yards.  Other visitors, Mexican locals, frolicked a quarter of a mile away.  Vendors drove by in ATVs and pickups right on the sand selling ice cream and banana bread.  Otherwise, silence.

For breakfast, we adventured to the building adjacent to ours.  We pick up the menu and I start to ask questions in Spanish about the different food.  The cook for the small restaurant, an older lady named Maria Camanera astutely asked me if I like to cook.  I asked her how she knew. “Is it because soy gordita (I’m chubby?)” She chuckled.  “No" she says, "because you talk about food with passion.  Most people aren’t like that.”

I ask her to teach my how to make a simple Mexican breakfast “huevos a la Mexicana”.  She cuts up Serrano, onion, and tomato, which she proudly states are colors of the Mexican flag.  The gas to the grill glows in the underlit kitchen as she stirs her eggs and beans and presses freshly made corn tortillas right in front of us.  I contemplated staying forever, with the waves and the sand and the sun.  Silence can be very seductive.

Huevos a la Mexicana

½ onion finely diced
½ Serrano seeded and finely diced
1 ripe plum tomato finely diced
4 eggs
2 tbsp vegetable oil
Chile sauce
Refried beans
Corn Tortillas
Avocado slices
Mexican cook and beach

Over high heat, heat oil until smoking and cook vegetables until onions start to soften.  Salt to taste.  Add eggs and stir until cooked.  Serve with love.

Time for some Vitamin D (Part 1—with FLAN FAIL!)

Fiesta!  Time to celebrate!  I’m done with classes in medical school and just hanging out until graduation on May 16.  This includes some much needed sun in Mexico (we leave on Sunday) with my best friend from high school. 

When I went home last month to visit my mom, I had a skirt on to honor springtime.  She was aghast the pastiness of my white legs.  We went on a walk that night and my two stumps were aglow in the moonlight.  

While this complaint of lack of sun seems vain, it elucidates the negligible amount of time I’ve spent in the sun in the past three years.  Not only have I lived in Cleveland, voted by Forbes to have the worst winter weather in America, but seemingly, for the past two summers, I have done my absolutely hardest rotations during peak summer sun hours.  Going into the hospital before the sun’s up and catching only the twilight zone at the end of the day just does not help. 

Even though basking in the sun puts people at increased risk for deadly skin cancers, one benefit from our favorite burning ball of gas, besides sanity, is that the skin reacts with sunlight to produce vitamin D.  Vitamin D, if you haven’t noticed, is all the rage right now.   A quick literature search reveals research blaming vitamin D deficiency for everything from heart disease to diabetes, low birth weight babies, chronic pain, pelvic floor disorders and neurologic deficiencies. 

Obviously this is a rapidly growing area of interest, but is the hype real?  Even three years ago in my first year of medical school I was taught the vitamin D deficiency was quite rare and remember the lecturer saying that “only some old lady who doesn’t eat anything and is locked up in her bedroom all year” could lack this essential nutrient. 

Vitamin D deficiency is actually much more prevalent than once previously thought.  When I did an endocrinology rotation all of the fellows who are young and healthy tested their vitamin D blood levels.  They were all insufficient.  In the National Health and Nutrition Examination Survey from 2001-2004 of 6275 nationally represented children from ages 1-21, 9% were deficient and 61% were insufficient [1].  A study of 2500 mothers and infants in urban Boston showed that 58% of infants and 35.8% of mothers were severely deficient [2].  People of darker skin color and colder climates are at the highest risk.

In the next post, I’ll discuss the role of vitamin D in the body, and review some of the literature about the health effects of deficiency.  I’m sure you’re wondering how you can boost your own vitamin D levels.  Get outside and get some sun.  Supplemental tablets  (the Institute of Medicine is about to release new dosage guidelines) and foods with vitamin D such as fortified milk products, eggs and fish, are also good sources. 

To prepare for my Mexican adventures and to boost all of our vitamin levels with eggs and milk in a sweet way, I tried to make some cinnamon infused flan.  I just love anything custardy.  In fact, my very first memory wasn’t of my parents or our cats but of custard that our neighbor made.  And the donuts we ate at the beach.  I’ve been a life-long food lover, and now I want to share it with you. 

Well, you see, I wrote this post and had a FLAN FAIL!  It looked great until I tried to flip it and it turned into a puddle of soupy caramel egg mush.  So, for the next post, I’ll try a new recipe that is guaranteed to succeed.  For now, I give you my stages of flan grief. 

1.  Kumar, J., et al. “Prevalence and Associations of 25-Hydroxyvitamin D Deficiency in US Children: NHANES 2001-2004.” Pediatrics, 2009.
2. Merewood, A., et al. “Widespread vitamin D deficiency in urban Massachusetts newborns and their mothers.” Pediatrics, v. 125 issue 4, 2010, p. 640-7.