Are We Using The Wrong Tools To Mold Doctors?

Readers of the revitalized Meditations on Medicine blog will know that I'm alternating between articles about medicine and recipes for my favorite foods. This week, will be more of an editorial, a softer article, rather than an explanation of recent developments in the world of hard science.

Some of you may remember an article I wrote some time ago about the three most important non-science courses a doctor should take - in it, I argued that social sciences, languages, and the arts had an important role to play in a doctor's education. This week, I'm going to follow up on that theme and ask whether the way we test and select doctors isn't having some unintended consequences.

A few years ago, the School of Medicine at Mount Sinai opened a program that send aside places for students who had not merely focused on the liberal arts in college, they had even been allowed to skip organic chemistry, physics and the MCAT (Medical College Admission Test). The goal was to produce clinicians who were not merely scientists, but compassionate healers. This article was the background of my interest, although my inquisitive mind has taken things a bit further.

I'm not going to question that doctors should be educated in the basic sciences. I'd even argue that skipping over organic chemistry and physics isn't necessarily a good idea. Organic chemistry, often derided as a 'weeder class,' in fact plays an important role as a 'weeder class.' A medical education takes a lot of work, and organic chemistry is nothing if not a lot of work, so it's a good measure of an applicant's ability to be up to the task. And physics, well, physics... You know, actually, physics may not be that important for most clinicians.

However, I do think that the way we elect students through standardized testing, and specifically multiple-choice questions, has had some unintended consequences.

Standardized testing and multiple-choice questions are the gate-keepers to a medical education. With the exception of the program listed above (and a few others like it), you cannot get an education in a healthcare field without demonstrating your ability to succeed at answering multiple-choice questions. Additionally, your advancement within the field is also governed by your ability to excel at this type of test. As a result, the medical field has selected for people who can succeed at this task, and have been trained since at least high school that the best way to assess a situation is through a multiple-choice format.

I'll just quickly outline what I mean. As anyone who's taken a multiple choice test can answer, in a given question, there is typically only one piece of information that enables you to answer the question - the majority of what's written is chaff, and it's your job to ignore it, cut to the chase, retrieve that piece of information, select your answer, and move on to the next question. For example: "A woman blah blah blah blah was visiting a friend's farm blah blah blah." The answer: She's got leptospirosis, which she caught from a cow. Another example: "A male Egyptian patient blah blah blah..." You don't even need to keep reading. Eastern Mediterranean = he's got beta thalassemia. On to the next question.

Why does this matter? The American public are frustrated with their doctors. Many patients are tired of short visits, brusque clinicians, and prescriptions with no explanation. Unfortunately, I think this at least partly stems from multiple choice questions. Visits are short and doctors are harried because they're trying to cut through the chatter and get the one nugget of information that will give them the diagnosis. When they've gotten that piece of info, it's on to the next bit, where they again make a multiple choice selection of a drug. We're frustrated with our medical system yes, but unfortunately, we have set our system up to select the people who are the very best at doing this. We've trained them to think this way, and shouldn't be surprised when they treat us this way.

This is a big problem, one that will resist easy fixes. However, though we may have difficulties in solving the problem on a large scale, we can still take steps to solve the problem in our personal lives. There are healthcare providers out there who do treat their patients like complex systems that deserve adequate assessments. Some are primary care providers, some are naturopathic doctors, some are other health professionals. Whether you have a problem that requires an essay to respond, or can be written in a short paragraph, seeking out a provider who listens to what you're saying and responds in kind is well worth your while. What you say isn't just a distraction getting in the way of the answer - it has value. You deserve to have your whole story heard.

Peasant Food For Fall

Growing up, I was regularly subjected to bowls of borscht throughout the winter. My Latvian mother, raised on hearty food like this, assumed that we would drink it up on cold, crisp days in New England.

Boy, was she wrong. The tangy/beety aroma of the soup and it's practically neon-red/purple color were a bit much for me and my brother, as were the dollops of sour cream she'd drop on top. I was never a good Latvian growing up, and the standards of Eastern European peasant food - dill, caraway, sour cream, pickles - never interested me. I can admit to being a picky eater when I was young, but as I've grown up, my tastes have expanded and I now crave the stuff.

Recently, the CSA I belong to delivered us cabbage, beets, carrots, dill and onions, and as I was already feeling in the mood for some soup, I made a pot of borscht. Here's my recipe:

1 lb beef (stew meat or other inexpensive cut, chopped into bite-size pieces)
1 onion, chopped
1 tbsp salt
1 bay leaf
4 peppercorns
1 bunch beets, peeled and chopped (approx 6 medium beets)
2 tbsp red wine vinegar
1 small head cabbage, shredded
3 carrots, peeled and diced
1 tbsp fresh dill, chopped

Add the beef, onion, salt, bay leaf and peppercorns to a stew pot, and cover with 6-8 cups of water. Bring to a boil, and then simmer for 45 minutes. As the scum (from the fat) accumulates on the surface of the water, spoon it off.
When the timer goes off, add the rest of the ingredients (beets, vinegar, cabbage, carrots, dill), and continue to simmer for 30-40 minutes. The vinegar will help the veggies maintain their color, and add a little tang to the flavor as well.
You can add water if it's necessary, but it shouldn't be.

If desired, add a dollop of sour cream to the soup before serving. This does well when accompanied by rye bread, pickles, or other Eastern European fare.

More News About Wheat and Gluten Sensitivity

Some time ago, I wrote a post about celiac disease and gluten sensitivity. In that piece, I pointed out that celiac disease is several times more common than previously believed, and that an interesting study found that celiac disease is not more common merely due to increased awareness, but actually because of increased prevalence. The article also discussed non-celiac gluten sensitivity, also called gluten-sensitive enteropathy, but noted that diagnosis of this ailment was difficult, due to the absence of accurate blood tests.

Enter a recent article that's making the rounds. Authored by an international group of researchers, the article reviews the data on non-celiac gluten sensitivity. The article has gotten a lot of attention because it takes a serious approach to what has been a difficult area - many people have self-diagnosed and self-treated with gluten-free diets, and it's been hard to integrate this with current medical knowledge. The article offers a bridge to help clinicians understand this phenomenon, and brings them up to date with the latest information.

While gluten avoidance is likely to remain the gold standard for identifying the disease, at least until lab technology catches up, I for one am glad to see medical research working on this. It's not exactly clear as to why we are increasingly reactive to the food we eat, but we are, and hopefully we can get a handle on what is going on here.

Finally, it's worth noting that, while medical science is still catching up, it's important to rely on the experience and knowledge of a healthcare professional to help you understand your health. Many digestive disorders overlap in their symptoms and a healthcare provider like a naturopathic doctor, nutritionist, or holistic MD can help you understand your specific health situation and health needs. So if you've got tummy trouble, go get it figured out! You don't need to live with a pain in the butt, either literally or figuratively.

How To Make Really Good Hummus

Hummus is a great snack food. It's tasty and satisfying, which makes it palatable to a lot of people, and it's also much healthier than many other options. It's rich in fiber, protein and unsaturated fats, which carry their own benefits, in addition to promoting satiety when other sugary snacks cause people to crash and burn.

Making hummus is a remarkably simple, but technique matters. Do it wrong and it could end up dry and brittle, or thin and soupy. Additionally, flavor it wrong and you’ll rue the work you put in. With this few ingredients, the flavor is really dependent on things meshing well.

As I said, the ingredients themselves are fairly simple:

1 ¼ cups dried chickpeas

Salt

Juice of 2 lemons

2 cloves of garlic (or equivalent measure of garlic powder)

4 tbsp tahini

Step one of making good hummus is to start with dried chickpeas and soak them overnight in cool water (at least 12 hours, up to 24 hours is fine). The chickpeas should absorb most of the water and increase in size.

When the chickpeas are done soaking, boil them in fresh water for at least 90 minutes. Add about a teaspoon. When the beans are very soft, drain them and make sure to reserve the cooking water.

Combine chickpeas, lemon juice, tahini and a small amount of salt in a food processor. Regarding garlic: the flavor of raw garlic will overwhelm the flavor of the beans. You can lightly sautée the garlic to mollify the flavor before adding it, or you can do as I do and use garlic powder. Purists may shudder at garlic powder, but in this case it provides the flavor you want in an easy to use form (however, garlic powder soup is another matter..).

Add a small amount of the cooking water to the mixture and set food processor to puree. I generally recommend starting with ¼ of a cup, and adding at ¼ cup at a time until you reach the desired consistency. I look for a nice smooth, creamy consistency – signaled when the hummus is flowing smoothly through the food processor.

Using the cooking water is a crucial step that many skip – not only does the water provide for optimal consistency of the hummus, but much of the best flavor of the chickpeas is left behind in the cooking water, and leaving that out can result in bland, flavorless hummus.

A Long-Awaited Return

It has been a very long time since I last issued a blog posting, but I have been hard at work on a very exciting project which I hope to have news about in the upcoming weeks. In returning, I will be posting on a weekly basis, and will be alternating my favorite recipes and pieces on medical topics, which I hope will lend some balance to this endeavor.

To make a soft start, I'm including a picture of a correctly proportioned meal as this week's blog post. You'll note that in the picture below, the amount of vegetables and plant-sourced food outweighs the amount of meat by a pretty significant margin. Not only does this meet the suggestions put forward by the 'MyPlate' initiative, but it also meets the older criteria regarding per-day serving recommendations.

To review both briefly: The MyPlate initiative recommends a quarter of the plate be comprised of grains (in this case mashed potatoes and leeks substitutes), another quarter be protein (in this case, poached salmon), and half the plate be fruits and vegetables (in this case a mix of lettuces).

The older style 'Food Pyramid' recommends 6-11 servings of grains per day (we have 2 servings here), 3-5 servings of vegetables and 2-4 servings of fruit (we have 4 servings here), and 2-3 servings of meat or other protein (we have 1 serving here). This system has been largely discarded, because it's very difficult to use - 1/2 a cup of cooked grain equals one serving, 1 cup of veggies/salad is one serving, and 3 ounces of meat qualifies as a serving (the size of a deck of cards).

As you might imagine, I prefer the 'MyPlate' approach. It's simple and easy to follow, and unlike the food pyramid, it can be conveyed using enticing photos like the one below. Bon Appetit!