Rotini with Summer Garden Vegetables

No, I'm not giving up medicine for a career as a chef, but one of my New Year's Resolutions was to learn how to cook. So, here I will show you what I've learned. Blake started me off with The Best 30-Minute Recipe cookbook, and at this point I've probably learned about 30-35 new dishes. Earlier this year I started you off with one of my favorite recipes, and now I will close November with another one of my new "go-to" dinners. I like this one because it is one of the few veggie plates that I really enjoy. There's no substitute for sausage, but if you need meat that bad, I'm sure it can be added. Below are my additions to this excellent summer dish (or spring, or fall, or winter)...

Ingredients

• 4 tablespoons extra-virgin olive oil
• 2 zucchini, halved lengthwise and sliced crosswise 1/2 inch thick
• 2 yellow squash, halved lengthwise and sliced crosswise 1/2 inch thick (the recipe calls for carrots, but I like squash better!)
• 1 pint cherry (or grape) tomatoes, halved
• 1 onion, minced
• 3 tablespoons tomato paste
• 3 garlic cloves, minced
• 1/2 teaspoon red pepper flakes
• 1 1/2 cups low-sodium chicken broth
• 1/2 pound rotini
• 1/4 cup minced fresh basil
• Copious amounts of freshly grated parmesan cheese (just to make sure it's not a vegan dish)
• Salt and pepper

First, boil water for pasta, then heat 1 tablespoon of oil in 12-inch skillet over high heat until shimmering. Add zucchini, squash, and 1/4 teaspoon of salt, and cook until browned, about 5 minutes. Stir in tomatoes and heat through, about 1 minute. Transfer mixture to bowl and set aside.

Add rotini and 1 tablespoon of salt to boiling water and cook until al dente.

Add 2 more tablespoons of oil to skillet and return to medium heat. Add onion and 1/4 teaspoon of salt,  cook until softened, about 5-6 minutes. Stir in tomato paste for 30 seconds to coat. Add garlic and red pepper flakes, stirring for an additional 30 seconds. Stir in broth, scraping up any browned bits, and simmer until slightly thickened, about 1 minute. Remove skillet from heat, cover, and set aside.

Toss pasta with vegetables and sauce, adding basil and remaining 1 tablespoon of oil. Season with salt and pepper. Serve hot, add grated parmesan cheese as desired.

A feast for three!

Stop Supersizing, Massachusetts

In the second edition of our "Guest Blogger" series, one of my colleagues, Dhruv Khullar, continues the conversation concerning the New York Soda Ban. While I tried to address the moral implications of such a law and its inherent paternalism, Dhruv highlights the science behind the legislation. Dhruv is a fourth year medical student at Yale University, and an MPP candidate at the Kennedy School. He is also a Zuckerman Fellow at the Center of Public Leadership here at Harvard.

When you train to become a doctor at a time when more than 50 percent of the population is overweight, your eyes start playing tricks on you. You compare your clinic notes with the appearance of your patients, and words like “severely overweight” and “moderately obese” just don’t seem to fit. These words imply some deviation from a norm – but these states are the norm. You accept historic rates of obesity as the default – because for this generation, they are.

The passage of New York City’s controversial soda ban last month has reignited debates about how to address the nation’s obesity epidemic. The New York City law restricts the sale of sugary beverages in containers larger than 16 ounces in movie theaters, fast-food restaurants, sporting arenas, and other food establishments regulated by the city. Exempt from the ban are beverages sold in convenience and grocery stores, as well as fruit juices, diet sodas, and dairy-based drinks. Massachusetts would do well to consider a similar proposal.

Massachusetts has a history of trend-setting health initiatives that have resulted in a well-insured and (relatively) healthy populace, but even here obesity has taken a disturbing toll. The obesity rate in Massachusetts has doubled in the past 15 years, leading to large increases in associated conditions like diabetes, heart disease, and hypertension. Rates of childhood obesity have nearly tripled in the past three decades. And a recent study by Trust for America's Health and the Robert Wood Johnson Foundation estimates that by 2030, half of all adults in Massachusetts will be obese.

The size of American waistlines has grown in concert with the size of American sodas. In the 1950s, the largest soda sold at McDonald’s was 7 ounces. Today, a “child size” is 12. The default “small” at most fast-food restaurants is now 16 ounces, and health-conscious Subway offers only 21-, 32-, and 44-ounce options. Regal Cinemas boasts a 54-ounce large with a whopping 175 grams of sugar. That’s more than 40 teaspoons. Free refills. All in all, the average soda in the United States is 6 times larger than it was 50 years ago, and the average American is 26 pounds heavier.

So is a soda ban the cure for our obesity epidemic? Of course not.

Our current epidemic is a complex, multifaceted problem that developed over the course of decades. There is no silver bullet. But there is good reason to believe that bans such as New York City’s are a bold step in the right direction. Soda is the single greatest source of added sugar in the American diet and consumption has tripled since the 1970s. Adolescents today consume up to 15 percent of their calories everyday from sugary beverages and fruit juices. And liquid calories seem to be processed differently from those in solid foods so people don’t feel as full after drinking calories as they do after eating them.

But the true value of a large soda ban is not in limiting the number of nutrition-less calories Americans gulp down at movie theaters and fast-food joints. After all, people are not restricted to buying just one soda – if you want to buy two (or three or four) sodas, that’s your prerogative. Heck, stick a straw in a 2-Liter and be on your merry way. No, the ban’s true significance comes from thrusting the issue of portion sizes squarely into the public consciousness. It comes from forcing individuals to make active choices to consume more, rather than reflexively accepting stealthily and steadily swelling dimensions of food and drink. It comes from taking the first step toward resetting our cultural defaults.

The portion size of almost everything has increased over the past several decades. With profit margins of up to 90% on products like sugary beverages, it’s not hard to see why. The result is that we find ourselves in a food environment that strongly encourages vast overconsumption of unhealthy foods.

This overconsumption has serious consequences – both for the health of our population and the health of our medical system. Obesity-related diseases cost the healthcare system an estimated $147 billion every year, and account for about 10 percent of all medical costs. Obese individuals spend 42% more on healthcare than do people in a normal weight range. Massachusetts recently sent a strong message about controlling medical costs with its first-in-the-nation health-spending cap, which seeks to limit overall health spending so it grows no faster than the state economy. But this cap must be accompanied by a larger conversation about obesity and disease prevention if it’s going to be effective. We can’t cap our massive spending until we start capping our massive sodas.

Psychological Safety - Why "Asheville" Works

Over the last few months, I have reflected at length about my experience as a medical student in the "integrated clerkship" or "Asheville" model. For those of you new to this concept, the idea is that medical students in their 3rd year learn the basics of clinical medicine in a radically different format from the norm. In the "traditional" model, student-doctors rotate through different fields of medicine in "blocks." For example, they may spend 8 full weeks in Internal Medicine, 8 weeks in Surgery, 4 weeks in Neurology, 4 weeks in Family Medicine, etc. Students get a taste of each of these core clerkships to help them decide which specialty they will pursue. In this curriculum, students often work with many different "attending" physicians (docs at the top of the hierarchy), fellows, residents, interns, and other medical students as they rotate through their clerkships.

The Asheville model transforms the way medicine is taught to budding clinicians. Instead of block scheduling, students do all their clerkships at the same time. They generally work in the outpatient (out-of-hospital) setting, one-on-one with the same attending physicians for an entire year. This may mean working half-days in each clinic; for example, Monday mornings in Family Medicine, Monday afternoons in Neurology, Tuesday mornings in Pediatrics, etc. Space is blocked off to see certain "longitudinal" patients in the hospital and in other clinics. These patients are seen many times throughout the year, and provide an opportunity for the student to become truly invested in the health care of other human beings over an entire year. Students generally begin their year with a few weeks in the hospital in order to garner "inpatient" experience.

Some believe this model of teaching offers a better environment in which to learn, because it humanizes medicine with intimate patient contact. I certainly felt this was the case. My experience was very different from that of my colleagues in the traditional model. Instead of me watching the intern watch the residents watch the fellows watch the attending in action, I was partnered with my attending physician, not as an equal, but as someone who was expected to perform in tandem at a high level. Such a close relationship can be daunting at first, but over time the sense of team is palpable. Attending - Student - Patient. Published data now exists (as well as yet-to-be-published data) suggesting that this type of learning is extremely positive for both students and faculty.

But, why?

I have often pondered this question. Why did I feel so invested in my patients, and why did I feel like I was really part of a team? How did these close relationships with attendings affect how I learned? I am starting to find some answers whilst studying leadership. One idea that has caught my attention is Dr. Amy Edmonson's concept of "psychological safety," and how it affects learning environments in teams.

Roughly, psychological safety "describes individuals' perceptions regarding the consequences of interpersonal risks in their work environment." Team members often worry they will be thought of as ignorant or incompetent if they speak up or make mistakes (e.g., the medical student who asks a "dumb" question may get a lower grade). In a psychologically safe environment, however, asking for help is encouraged, and reporting mistakes is a way to learn, not a route to punishment. Here, mistakes lead to learning and speaking up leads to innovation. Institutions that have psychologically safe environments succeed. In hospitals, this can mean the difference between a nurse who thinks a medication dose is inappropriate, but administers it anyway for fear of being wrong, and one who double-checks with the physician to make sure the dose is correct. Medical errors are unfortunately all too common, and patients often find themselves at the mercy of these mistakes.

Dr. Edmonson breaks down work environments into four different "zones," each with different characteristics based on levels of psychological safety and accountability.

• Low Psychological Safety + Low Accountability = Apathy Zone
• High Psychological Safety + Low Accountability = Comfort Zone
• Low Psychological Safety + High Accountability = Anxiety Zone
• High Psychological Safety + High Accountability = Learning Zone

The second I saw this table in her book, Teaming: How Organizations Learn, Innovate, and Compete in the Knowledge Economy, a light bulb went on in my head. Third year medical students fit very well into these categories. Most medical students would undoubtedly perceive their environment as high accountability. Thus, they would find themselves either in the Anxiety Zone or Learning Zone (or some may find themselves in the Apathy Zone during a particularly awful rotation), depending upon whether their environment is one of high or low psychological safety. To maximize clinical education, one would hope that students find themselves in the Learning Zone environment with high psychological safety, as this should be the most effective teaching environment.

As a student of the integrated model, I cannot speak too much to traditional learning and its level of psychological safety; however, the hierarchical structure of the traditional medical team model has had some difficulties in this area (and its shortcomings are well-documented). I can, though, attest to why the integrated model helps students find themselves in the Learning Zone. I think there are three reasons why this model promotes a psychologically safe environment: 1) medical students work with the same attending throughout their clerkship, 2) students work with that attending for an entire year instead of just a few weeks, and 3) students often find themselves one-on-one with these attendings, providing numerous opportunities to build strong relationships and a sense of "team." This relationship for some may start out in Anxiety Zone, but it often quickly moves to a psychologically safe environment as the two parties become more comfortable with one another.

As an example, one of my favorite clerkships last year was Family Medicine. It was a clerkship I enjoyed, and in which I excelled. Every Monday morning I worked in this clinic from 8am to 12pm, first seeing a patient by myself, then again in conjunction with my attending. Right off the bat, every mistake became a learning opportunity or a "teaching point." Expectations were clear. I was a third year medical student so mistakes were anticipated. But, I was expected to learn from my mistakes and get better (high accountability). From a grading perspective, I didn't worry about "messing up." If I was unsure whether I heard a heart murmur or "crackles" in the lungs, I told my attending. I knew I would have many opportunities during the year to listen to hearts, and my grade wouldn't be affected by asking questions. I wasn't worried about being seen as "ignorant" or "incompetent" (high psychological safety). Looking back, I spent all my time in the Learning Zone.

I suspect there are many reasons why the integrated clerkship model is such a successful learning experience, and I don't believe creating an environment of psychological safety is a panacea for improving medical education across the board. I do have a sneaky suspicion, though, that fostering a Learning Zone environment would go a very long way toward that goal. I hope to study this concept further, both in medical education and in Surgery. I would be interested in your thoughts and comments.

References

• Ogur B, Hirsh D, Krupat E, Bor D. The Harvard Medical School-Cambridge integrated clerkship: an innovative model of clinical education. Acad Med. 2007;82(4):397-404.
• Edmonson, Amy. Teaming: How Organizations Learn, Innovate, and Compete in the Knowledge Economy. Jossey-Bass, 2012.

Really Really Missing Medicine

As the year has progressed, I am reminded daily why I went to medical school: I miss taking care of people. While I have enjoyed aspects of taking a year off to study public policy, there are many times when I agonize about not seeing patients and having all the knowledge I built up over the past three years slowly slip away. Some of my colleagues are starting to interview for residency slots, and all my closest friends stayed in North Carolina this year. With Thanksgiving around the corner, I have been trying to keep everything in perspective. Every time this "gap" year starts to get me down, I try to remind myself how fortunate I am to be in school, to be a future doctor, and be bestowed such wonderful opportunities. But in truth, it has been a difficult year.

The year has been much like my gap year after undergrad. There are many parallels. Although I was not writing about my journey via social media, I was journaling frequently. That "super-senior" year came with an identity crisis. I could no longer define myself as a swimmer or a student, but I didn't have a vocation either. I was working at Starbucks, while my friends had moved on to graduate schools and investment banking. I was questioning who I was and where was I going. I learned that what I thought was hard-work was going to be barely passing if I wanted to be a doctor, and I had to take a crash course in honesty. In reflection, I don't look fondly upon that year, but I do understand its importance for personal growth. I learned a lot about myself, and I realized I had a lot of growing up to do.

This year has been similar. I thought taking time off to study public policy and leadership would answer many of my questions; instead it has engendered even more. I am currently reading a book called True North by Bill George, former CEO of MedTronic and professor at the Harvard Business School. In the introduction, he lays out what he believes should be one of the most important questions any leader must ask himself or herself, "What is the purpose of my leadership?" It is this question that I have struggled with all year. There are many things I am passionate about, and numerous fields I could see myself delving deep into. I love the ethics of health care. I love leadership in medicine. I have found writing cathartic. I have relished my time in rural care, as well as pediatric surgery. I like certain types of research, but I can't stand the bureaucracy. As one of my friends in school recently quipped, "It sounds like you love academics, but hate academia." Perhaps there is some truth to that statement. I feel like I have so many passions that are pulling me in different directions, I just don't know where to begin.

And I feel like I'm ready to take the reigns on a passion and run with it.

The question of whether I see myself as part of the academic world is an interesting one. As one of my former mentors recently told me, "My dad's an academic, my mother's an academic, and my sister's an academic. Every time I question why I don't live in that world, I just spend an afternoon with them and I am easily reminded." Throughout my short medical career I have very much understood that sentiment. But at the same time I have realized that do some of the things I want to do in medicine, I may need that support structure. It is exhausting to think about sometimes, and I need to do a better job living in the present, not the future.

Later in True North, Bill George reminds the reader, "The hardest person you will ever have to lead is yourself." At all points in our careers, this remains true. However, I am finding that now this is particularly apt. Perhaps that path will become clearer in the next few years...

A Case for Rural Care

(this was a piece that I wrote that was accepted to the Bulletin of the American College of Surgeons; I will post a link here when it is published)