loveliness in presence

Happy New Year! I hope you are enjoying a bit of time to reflect on 2013 and dream about 2014. And staying warm. I think resolutions are a beautiful thing, especially when they go beyond the typical list of do's and don'ts. 2014 is going to be a very exciting year for me. But first, a bit of reflecting.

I happily have been able to read a lot more than usual over the past 6 weeks, especially during the 2 weeks around Christmas & New Year's.  Growing up, I almost always had 2 novels going at once, but it's been quite a while since I've had enough leisure to do that. It was a great joy to read through Marilynne Robinson's Gilead in just 3 days. This is undoubtedly one of the most beautiful books I've ever read. The entire book is a letter written by an elderly pastor in the small town of Gilead, Iowa to his young son. He tells of abolitionists and pacifists, devout friends, deviant sons, and the old man's attempt to find peace and reconciliation in his final days. The language is simple and cuts clean to the reader's heart. Pristine.

Here is a passage that immediately had me writing in the margin:

By “life” I mean something like “energy” (as the scientists use the word) or “vitality”, and also something very different. When people come to speak to me, whatever they say, I am struck by a kind of incandescence in them, the “I” whose predicate can be “love” or “fear” or “want,” and whose object can be “someone” or “nothing” and it won’t really matter, because the loveliness is just in that presence, shaped around “I’ like a flame on a wick, emanating itself in grief and guilt and joy and whatever else. But quick, and avid, and resourceful. To see this aspect of life is a privilege of the ministry which is seldom mentioned.

I think this describes the way I feel about having difficult discussions with patients in the medical setting. Conversations about death and dying, scary diagnoses, psychological turmoil. During my month-long rotation in the ICU this happened pretty regularly, and I found myself feeling better on those days compared to others. I hate to use the word "better" here. Perhaps what I mean is something like more fulfilled, more alive. It's something I tried to explain to my husband, cringing as I used such positive words to describe such a negative situation, failing to explain it even to myself and wondering fearfully if it were just some sort of morbid fascination. But reading these words cleared it up for me. Like a confession these conversations highlighted the presence, the I, of those patients and their families. And what I felt was privileged to be part of such a lovely thing.

stealing joy

Wow, it's been a while since I've posted anything here. The longest yet. I've been thinking a lot about writing lately - writing or reading poetry and short stories, writing as a means of understanding medicine and human interactions. I want to delve into the newly-discovered world of narrative medicine. I should have some time to do so in the coming months, so we will see how far that goes.

In the meantime summer ended. The farmer's market made it's transition from strawberries and asparagus, to every green thing imaginable and berries, to squash and apples, and now it's gone. A chilly August was followed by a warm September and October (relatively speaking), but November  was ushered in with a freeze and I harvested all our potted herbs. The rosebush remains, two buds debating whether or not to bloom. My cooking followed the market trend. Transitioning from salads and things like these noodles to roasted squash, bean stews and all kinds of things with miso. The leaves turned and have almost all fallen, sweaters have migrated to the front of the closet, and I've initiated a daily ten minutes of sitting beside my SAD lamp. Autumn is verging on winter and I am determined to enjoy it by relishing in coziness as much as possible. I'm talking double socks, fun hats and scarves, casseroles and cookies, bubble baths, steam room at the gym, hot tea, poems like "November Night" by Adelaide Crapsey:

Listen. . 
With faint dry sound,
Like steps of passing ghosts,
The leaves, frost-crisp'd, break from the trees
And fall.

We already had our first snowfall, just a few days ago, it collected and stayed on the ground the whole next day, despite the brightly shining sun, deceptively not warming things up.

Actually, the first snowfall I saw was in October, but most people were asleep and it barely touched the ground before melting. I saw this beautiful snow - barely a fall at all, really a light drifting down, like a feather or crepe paper confetti - because I was up in the middle of the night on the labor and delivery floor of a community hospital, helping/learning how to deliver babies. Delivering a baby is one of the most magical experience I've ever had, and I struggle to describe it adequately. One doctor said it was like "stealing joy". There is something accurate about this, as it indicates that the doctor is still somewhat removed from this new family being formed. An integral part of the experience but ready to transform into bystander as soon as the whole visceral process is over. If you think of joy as something that is not diminished by being shared, but rather increases, then it sounds even more fitting.

But it's more than just the joy of new life (what a presumptive thing to say, just). It's the entirety of this most ancient ritual, born of complete necessity, drenched in blood and vernix (lit. 'fragrant resin'). The hours of the mother contracting, dilating, effacing, breathing. Teaching your gloved fingers to feel blindly for cervix and station, like digging through a bag  of cotton balls trying to find the one that is slightly softer. The absolute miracle of a newborn maneuvering through the cardinal movements of birth, filling his water-clogged lungs with air, remodeling his entire vascular system. A fish becoming a bird. When things go perfectly smoothly, it's seems the baby would have slithered out whether your hands were there guiding him or not (which does occasionally happen even in a hospital!).

That night, minutes after the baby was born, the nurse looked out the window and remarked, we had a little snow angel on our hands. I've delivered four babies so far. And yes, I am most definitely keeping count.

bottle that feeling up

I recently read Cutting for Stone by Abraham Verghese. This novel did not receive very high reviews amongst the literary community, but it was strongly recommended to me by several medical students and physicians. Like them, I loved it. I suppose it stems from a love for the intertwining of medicine and art. Verghese is a physician who displays passion for pure, simple, hands-on medicine. He lauds the skilled physician who considers the whole of the patient and is able to diagnose with only his hands. Reference: "A doctor's touch" TED talk.

Throughout the novel he describes anatomy and disease processes in a clear and beautiful manner. Well, beautiful compared to a textbook. Apparently it's gibberish to the non-medical ear. Either way, I soaked it up and felt inspired to continue along this path to becoming a doctor. It made me want to really know my stuff - well enough to write about it without having to reference Netter's, well enough to feel minute but essential differences between radial pulses. (Shoot, I still get excited when I feel a liver edge.)What I'm about to say may sound crazy, but it was enough to make me think that studying for boards might not be that bad. Synthesizing all that I have learned the last 2 years, putting the pieces together and seeing the bigger picture of what all this time and discipline has really been about.

Wow. I wish I could bottle that feeling up and carry it around with me for the next 5 months.

Maybe a little Ethiopian food will help as a reminder. You see, most of the novel is set in Ethiopia and descriptions of the food sneak in every now and then. Of course, I became curious about sour injeera and garlicky wat. Finally, this weekend, we went to the Ethiopian Diamond with one of our favorite food-loving couples. To be honest, the experience itself was worth a lot more than the food. Don't get me wrong, it was tasty, but I don't think I would get excited about leftovers. The dinner itself was fabulous. The restaurant was filled with groups of people from every ethnic background imaginable, all eating with their hands, smiling. I love eating with my hands, like adding in that additional sense makes the food that much better. Ian had a bit of a cold, but medical students are pretty proud of their immune systems and nobody minded his hands in the mix. The sour injeera, salty meats, sweet honey wine, and friends to share it with all combined to make a beautiful evening.

creativity

I suppose I've always liked to think of myself as a creative person. One of my favorite things to do as a child was arts & crafts. My mother kept a room of the house well-stocked with things to keep me and my sister occupied during the many summer months that were filled with the plea, "let's make something!" Unfortunately, that room is still quite full of half-completed friendship bracelets, scraps of material and tear-off instruction sheets from fabric stores.

Now-a-days cooking is my main consistent creative outlet, along with a bit of writing and the occasional re-arrangement of something in the apartment. It's really not much and I have found that when I go a few weeks without much time in the kitchen I begin to crave creativity. A few weeks ago I found myself in this situation. I wasn't sure what it was at first but little by little I began to concretize it and pin it down: I wanted to burst out in a rainbow of colors - I questioned the point of this blog - I wanted to publish a poem - I wanted a channel for expressing creativity - not just expressing but also disseminating it. It was a strange feeling and I was glad when it subsided. I was surprised by what did it, too.

It was a conference on clinical hypnosis. First of all, I think it's really unfortunate that the word hypnosis stuck, which immediately conjures up images of yo-yos, swirling cartoon eyes and clucking like a chicken. The history goes back at least as far as Franz Mesmer, from whom we get the term mesmerize, so I guess there was a lot to work with/against. I would rather call it something like enhanced-relaxation-through-guided-imagery, but even that is somewhat limiting. If you've ever done yoga, it feels a lot like the final relaxation, Shavasana.

I went to this conference because clinical hypnosis is a fantastic tool for doctors. It can be used to help people with bladder control, chronic pain, addictive behaviors, and anxiety. It has many more uses also, especially in clinical psychology. I was encouraged to go as a student because of the way it would change the way I speak to patients even now. I definitely learned a lot but, to stay on topic here, I was also pleasantly surprised to find that it quenched my thirst for creativity.

The one thing you should know is that all hypnosis is self-hypnosis. Nobody can make you feel anything or control your mind. That being said, a big part of the basic level workshop was practicing self-hypnosis on oneself. I found this to be nothing more than tapping into my own imagination and letting my mind rest there for some time. This allows for all kinds of creativity and self-expression. Most importantly, it allowed me to enjoy and appreciate my own imagination in a way that I can tap into it on a regular basis without feeling like I needed to do something outrageous, like become a painter or a poet alongside medical school. (That would be a stretch of the imagination.) Once again, I was presented with exactly what I needed. It may not have been a great need, but what grace!

Do you ever feel the need for a creative outlet? Have you found it in an unexpected place?

right brain

Have you seen the TED talk called "Stroke of Insight" by Jill Bolte Taylor? First of all, I think TED is an idea worth spreading in and of itself. Secondly, I absolutely love this video. It depicts the brain in a way that completely dispels the idea that neuroscience is nothing more than cold hard facts. Our world is full of beautiful mysteries. Mysteries that science can help to explain, yet also further confound. I couldn't figure out how to embed it, but please do check out the link. I could definitely benefit from tapping into more right brain.

thanks to Ashley for discovering this picture.

anatomy and art

This summer has been a whirlwind. I feel like I have been not just in multiple countries or continents, but in multiple worlds. Now I'm back in Texas, visiting my family and trying to soak up enough heat and humidity to get me through  my next Chicago winter. I'm also trying to mentally prepare myself for second year, about which I have only gotten scary warnings. Actually, I should probably say prepare myself emotionally because I am not planning on doing any studying during these last 2 weeks of summer. I heard one friend mention his plans to review anatomy and physiology this month, while another one spoke of getting a head-start on studying for the Boards. I wish I had never heard them say these things - every time it crosses my mind I feel a tinge of both guilt and panic. Nevertheless, I refuse to pull out any textbooks or old powerpoints until at least the day before classes start.

Okay, now that I'm through with that, here's an attempt to push my mind back towards medicine. A vacation in Italy is actually a great place for this when you think of the earliest anatomists like Leonardo da Vinci. I even got to visit the church where Michelangelo studied cadavers, hiding himself from the rule of the Catholic church with the help of a priest. It is obvious that Michelangelo's anatomical knowledge allowed him to master the human form in sculpture and painting, but that wasn't enough for him. He wanted to show off a bit, so he snuck some neuroanatomy into the ceiling of the Cistine chapel. The amazing thing is that this was not noticed until the end of the 20th century. In 1990 a paper was published, noting that the cloth around God in the image of God Creating Adam is shaped like a sagittal cross-section of the right brain. More recently, it has been noticed that God's neck in The Separation of Light from Darkness is an uncanny depiction of the brain stem. For pictures and more, read this.

I love it when art and anatomy collide, and it's funny how medicine has changed the things I notice in art. For example, the veins of David's arm are much more interesting than I'm sure they would have been a year ago, and I was really excited when I noticed that this statue had a traumatic auricular hematoma, also known as "cauliflower" or "boxer's" ear.

In fact, it's something you can find all over the place. I came across a fun blog called Street Anatomy when I attended the opening of an art gallery that they hosted at the Museum of Surgeons last year. (I especially enjoyed this post.)

Here's another fun one that I noticed a few years ago on Gaudi's Sagrada Familia in Barcelona.

the anatomy lesson

This is Rembrandt's Anatomy Lesson of Dr. Tulp:

It pictures many of the things we expect to see in such a painting: men with beards, exquisitely dressed, huddling around a dead body in a dark room, intently listening to Dr. Tulp. The instructor is demonstrating how when he pulls on the flexor digitorum muscles it will cause the fingers to curl, and he is mimicking this action with his own hand at the same time. This is something I found myself doing repeatedly as a student of anatomy. Moving my own body that is, in order to picture how the inanimate muscles would function. Sometimes I even tried to imagine staring down at myself lying on that table,  in order to keep right and left in their appropriate places. So, are we using ourselves to understand that body and science, or are we using science to understand ourselves?

It is interesting to note that the men are not looking at the cadaver, but just beyond his feet, perhaps at an anatomical atlas. Rembrandt alone is focused on the body of the dead man and the shadow of death cast over his eyes. A little bit of research will reveal that the cadaver is a criminal that has been recently executed for multiple charges of theft. This may explain why it is his hand that has been dissected first. In those days the guts were usually removed first to get the gross part over with before it really started to decay. Today we start with the back, where amateur medical students are less likely to slice through arteries, nerves, and tendons that must be preserved and studied.

The dissected hand also appears to be quite out of proportion, larger than the right hand. And there is an anatomical mistake - the muscles in the painting originate on the lateral epicondyle, but they should originate on the medial (the side of the elbow nearest the torso). We certainly don't want to assume that this was actually a mistake. Rembrandt was a meticulous artist and he was likely in that room himself.  In his lecture "Observing Reason: Critique of Scientific Stance", J.M. Bernstein of the New School for Social Research suggests that Rembrandt purposely drew the faulty anatomical details based on the illustration of the opposite hand in the atlas these other men are looking at. He further proposes that this illustrates how science attempts to understand our world and, therefore, ourselves. I must admit that at some point I find it difficult to follow what Bernstein is saying because I am not familiar with Hegel's Phenomenology of Spirit. Nonetheless, he raises a point that we can all think about. Perhaps the fact that we get caught up in this anatomical error further emphasizes what Rembrandt wanted to show us. The men in the painting see the atlas, the instructor sees the mechanics behind the movement, we see the dissected right arm, but nobody sees a man who has just died.

thought feeling itself

The English Surgeon is a documentary about a neurosurgeon from England and his attempts to help a neurosurgeon in Kyiv, Ukraine. The Ukrainian is running a private practice and he's doing it in a way that the government does not like very much - performing risky operations, recycling equipment from England. The film depicts a faulty medical system that is controlled by a government bent on saving money. It's focus on a few individual patients and the general conditions of this clinic paints these two neurosurgeons as heroes. I would definitely recommend watching this film, but here is an interesting article if you are uncertain about committing the necessary two hours.

I'd like to share a few lines that really caught my attention.

• The film begins with the English surgeon saying this: "It is difficult to know when one is being reckless and when one is being wise, when one is being brave and one is being a coward." He said this in the context of the risks a surgeon chooses to take as well as the risks they were taking by battling the Ukrainian system, but it certainly applies to many areas of life.

• Here is another thought-provoker: "Everyone is equal. Everyone will get a consultation. The crowd should decide who gets to go first." This is what the surgeon said to quiet the mob of people waiting for a second opinion after being told their tumors were inoperable. But here, in the land of the equality and freedom, I have never seen such a system in place. It seems that we do not have enough confidence in our fellows, nor in ourselves, to handle such situations in a calm and polite manner.

• Recently I've been trying to pay more attention to subtle techniques used in film, journalism, and literature. I hope to offer you more examples in the future. These two neurosurgeons are not ones that people are inclined to criticize and the film does, appropriately I believe, show them in a very positive yet human light. But if you watch this film, look for what I am about to describe while they are in the marketplace. The two surgeons have gone to buy common drill bits, which they will be sterilizing and using to drill through a man's skull. It is crowded as many people shuffle from one booth to the next, carrying their goods and bartering. The camera pans through the crowd and stops on a ragged-looking woman picking through a few coins in the palm of her hand. A minute later, as the doctors purchase the drill bits, the camera zooms in on the Ukrainian physician's well-endowed wallet. I am slightly puzzled by this because in every other sense he is shown as a modest, self-sacrificing man. Perhaps the director's aim was to show that this man is still comparable to the doctors of Europe and America in some ways, or maybe he wanted to ensure the viewer that this is not a saint, just another man with personal interests as well as good intentions and good acts.

             How do you interpret it?

• One last, marvelous, captivating line. The two surgeons perform brain surgery on a young man, removing a large tumor from a completely exposed brain while the man is awake. As we see the brain pulsating, slimy, like a living organism in and of itself, the English surgeon says, "That is thought feeling itself." And that, my friends, is one of the great puzzles of life!

the heart of the matter

When I took Organic Chemistry I was fascinated by the fact that so many reactions were in fact poorly understood or controversial. This weak grounding was only subtly noted and quickly skimmed over. I noticed a similar thing while reading about how to perform the cardiovascular physical exam in Bates' Guide to Physical Examination and History Taking:

"An extensive literature deals with the exact causes of heart sounds. Possible explanations include actual closure of valve leaflets, tensing of related structures, leaflet positions and pressure gradients at the time of atrial and ventricular systole, and the effects of columns of blood."

Netter's Atlas of Human Anatomy

Then Bates goes on to offer a simplified explanation, which is perfectly fine for the purposes of this textbook. It would have been so easy to pass right over this little bit, and under other different circumstances I might have done so. Fortunately, I picked up on it and gave myself a moment to be struck by wonder. I never knew there was still such mystery surrounding the heart. We can make mechanical replacement heart valves and recognize their clicking in chests. I am quite sure we know exactly what causes that clicking and the precise moment at which it occurs. But we cannot completely account for the natural heart sounds? The very same heart sounds that we can hear when we lay our head on the chest of our lover? The very same heart sounds that have been heard for millennia?

Leonardo da Vinci: The Anatomy of Man

We could certainly take this in all kinds of mystical and romantic directions. The human heart is more than it appears to be... man is an unfathomable creation... maybe the answers to our questions about love lie in those heart sounds.... But without going that far, we can simply appreciate the wonder. It may not hold as many questions for the world as it did before da Vinci drew it, or before Netter drew it - or for me before I held one in my very own hands - but there still is some mystery in the human heart. And a little mystery is a beautiful thing.

Auguste Rodin. The Kiss

"The most beautiful thing we can experience is the mysterious. It is the source of all true art and science." - Albert Einstein

community can fill the gap

I recently visited Chicago in search of an apartment, and some of the things I observed really got me thinking. I was in the suburbs rather than downtown, but many areas had a very urban feel. What surprised me was the great contrasts that existed from one block to the next. One moment I would be in a very nice residential area, full of rather idyllic-looking homes with gardens and happy families. Then, just a few blocks away, I would see a homeless man talking to himself, somebody eating out of a garbage can, or a woman who had clearly had a very rough night. I began questioning how this could be. Not, "why doesn't somebody keep these two groups of people more neatly separated?", but rather, "why do these extreme differences coexist? how can we see this every day and do nothing about it?" Now, I am by no means suggesting any kind of martyrism or asceticism. There are so many reasons that we should be able to have happy, comfortable lives without constantly feeling guilty. What I would like to discuss is the socioeconomic gap.

More specifically, I am interested in the socio- part, and in its effect on health. Socioeconomic status (SES) is the highest behavioral predictor of almost every health-related condition, including cardiovascular disease, respiratory disease, ulcers, psychiatric diseases, and stroke. By behavioral predictor I mean that it is the most accurate way to guess whether somebody will get one of these diseases once things like gender, age and ethnicity are ruled out. It's even more important than smoking cigarettes. And this is no minor prediction. A study done across Europe found SES to account for 68% of the variance as to who has a stroke. In some cases, the prevalence of a specific disease is ten times higher among those with the lowest SES than those with the highest. In some countries there is up to a ten-year difference in life expectancy when comparing the poorest and the wealthiest.

Why are SES and health so tightly linked? The first thought that came to my mind: lifestyle. Poorer people are more likely to drink, smoke, eat unhealthy foods, and engage in high-risk activities. Somewhat surprisingly, even when one controls for all these factors (i.e., compare poor smokers to rich smokers, etc.), lower SES is still linked to more disease. (As an aside, there are many fascinating studies linking stress to a broad range of diseases. Living in poverty certainly has its own unique set of stressors, such as long working hours, multiple dependent family members, and the unpredictability of keeping a job or having enough money for the next month's rent.) One extraordinary study looked at a single group of elderly nuns, all of whom took their vows as young adults and spent the rest of their lives in the same monastery with the same diet, etc. The patterns of disease, dementia and longevity were still predicted by the SES status they had before they became nuns 50+ years ago.

My second guess at an explanation: access to health care. Interestingly, European countries that have recently switched over to universal health care systems have not seen any improvement. Of course, even in countries with universal health care systems the wealthy do still have access to better, more timely care. However, one study conducted at the University College of London indicates that this still does not explain everything . Workers in the British civil service system range from blue-collar workers to upper-class administrators, but they all have roughly equal health care access, are paid a living wage, and do not have much fear about losing their jobs. Despite these automatic controls the rate of death due to cardiac disease is four times higher amongst the poorest. Finally, what I find to be the best argument against the idea that this gradient is simply explained by health care access, is that the same is true for diseases like juvenile diabetes and rheumatoid arthritis, which have very little to do with lifestyle or preventative health care.

So, poorer people have more disease and die sooner simply because they are poor.  This actually has an even greater effect across society than you might expect. In countries with the greatest socioeconomic gap everybody has more disease and the overall mortality rate is higher. But, isn't wealth relative? Yes, it seems that considering yourself to be rich or poor is relative and the key here is the gap itself. Income inequality has a profound effect on the health of any group of people. The SES-health gradient is much stronger in societies with greater inequality, and more subtle in more egalitarian societies. This has been shown repeatedly and on many levels. For example, income inequality predicts higher infant mortality rates across many European countries, and higher mortality rates across all ages (except the elderly) in the United States. Louisiana, the least egalitarian state has about a 60% higher mortality rate than New Hampshire, the most egalitarian. Those are overall rates, not just rates for those on the bottom of the gap. 

We seem to have figured out why this gradient cannot be explained away by the previously discussed, more obvious, factors. Kawachi explains this phenomena with the sociological concept of "social capital." Higher social capital is found in communities with a large amount of volunteerism and organizations, where people feel like they are a part of something bigger than themselves.  This is definitely lacking in  American communities, where few people know their neighbors and the rights of mobility and anonymity are sacred. 

This all comes across as rather depressing information. It means that even if we successfully provide universal access to health care, this SES gap will still exist, the poor will still be unhealthy and even the rich, try as they might to build their castle on a hill and put up a wall around it, will not be able to remain untouched by the rest of their society. This is not just about not having money, it is about poverty, and it is complex. I could most grasp the difference when I read Robert Evans' statement that "most graduate students have had the experience of having very little money, but not of poverty. They are very different things." 

Now then, where is the beauty in this? I feel like I can actually do something about it. Universal health care and welfare programs are big and complicated. I do not even have the knowledge to really understand the long-term effect these kinds of things have on individuals or on society at large. The economics and politics are so convoluted that I just want to shy away from them. But I think I can help strengthen a community. And your community isn't confined your neighborhood. It seems to me that many people have coped with the psychological distance placed between American neighbors by creating less traditional communities, like a book club or church, even though they may meet several miles away from their home. I plan to use this knowledge for inspiration to participate in or create programs for community outreach programs to educate people about a healthy lifestyle, and to let them know what resources and activities are available in their own community. 

This information came from Robert M. Sapolsky's Why Zebras don't get Ulcers. It offers an accessible, entertaining overview of the link between psychological stress and disease, and I highly recommend it. Please reference the book or send me a message if you would like more specific citations to any of the studies mentioned.

stress and breathing

I have realized recently that I often have trouble relaxing. This week I completed my ultimate final as an undergraduate. That, I think, is a good reason to celebrate and to say, "Okay. I have accomplished something. I should now relax for a little while." But that is not how it happened. In fact, before I even took the last final I began feeling anxious about the next thing on my to-do list. I am now noticing that this is a recurring pattern. Maybe it is a pattern of yours also.

Before I finish one project I start thinking about the next one, so that by the time I finish the first I am so mentally involved in the second that the former doesn't even seem like much of an accomplishment. It was just something I had to do to get to where I am now. This is true even with major life events. Why do we have this tendency to let free-floating anxiety stop us from recognizing the value of our accomplishments? When you consider the pace of our lives, maybe this question is not so hard to answer.

When I studied in Spain we took a siesta everyday. Everybody did. Really. There was a pause in the day to go see your family at home, to meet a friend in the park, to take a nap. The whole schedule is different to accommodate for this break from work and from the heat of the afternoon. It just means that the work day is pushed a couple hours later. The evening meal is also pushed a couple hours later. But the beautiful thing about that is that when you do finally sit down to the dinner table you know that it means you are done for the day. Since you don't eat until 10 p.m. there really is no question of getting back to studying or paying the bills or cleaning the house. It will be time for bed. So you can just enjoy your food and a glass of wine, and really have a conversation with your loved ones without feeling rushed to finish eating and get back to work. I know studies show that not eating late in the evening is better for your metabolism, but I think the relaxation encouraged by this schedule must have some serious benefits.

Although eating a very late dinner has not been a lasting habit for me I have tried to hold onto some of those things that I observed and experienced while in Spain. Both during the siesta and during dinner I felt like I was really taking a break from the day. I think we should take a daily break. It doesn't have to be long and it doesn't mean that you are not working hard enough. It just means taking a few minutes to stop what you are doing, take notice of your emotions and physical feelings - if you are tired, if you have been squinting your eyes at the computer all day, or if your body is aching from physical activity. Maybe you can take ten minutes to talk to a friend (without mentioning how busy you are). Maybe you can take thirty and enjoy every, single, simple, tasty bite of your lunch. 

Now, if you don't mind a quick little bit of biology, I would like to tell you why this is so important:

Our central nervous system has two main components, the sympathetic (fight or flight) and the parasympathetic (rest & digest).  These two are constantly in flux and when we get stressed because we are sick, get injured, are running away from danger, or are annoyed by the people around us or worried about getting everything done, the sympathetic system tends to overpower the parasympathetic. When the cause of this is psychological/social it's bad news for our heart because it starts beating faster, which wears on our blood vessels. Again, this is great when we have to fight infection or engage in strenuous physical activity - but when we don't it just causes our bodies to wear out more quickly.

Both the sympathetic and parasympathetic systems are always active and it just so happens that when we exhale the parasympathetic system automatically kicks it up a notch. One way that it does this is by lowering our heart rate. Your heart automatically beats more slowly when you exhale than when you inhale. Every time you do it. This is one reason prayer and meditation are so effective. So...

The next time you feel anxious and think your body might be working over-time, take 2 or 3 minutes just to sit quietly and breathe deeply. Inhale for a count of 4, exhale for a count of 6. Try to think only about your breath, not everything else going on around you. This should help to clear your mind and relax your heart.

health care

While preparing for medical school interviews last summer I made sure I was confident in my response to any questions about health care reform. I had no problem doing this, as it is something that interests me and it really helped me to process my thoughts about the issue. With the historic passing of the health care bill this weekend I think now is the perfect time to share my thoughts. I am fairly ignorant of all the politics and economics involved, but I certainly think the system is in need of repair. I am hopeful that this bill will begin to make that repair possible, but I also think it ignores some of the main problems.

I propose that we need a sort of social health care reform, a new cultural attitude toward health in general. As a society we have become so detached from our own whole well-being. We have dissected it into diets and statistics about exercise and visits to multiple physicians for pills and procedures to make us "better". Did you know that Texas high schools no longer require that students take a health class? And PE is only required until 6th grade? Although I never thought these classes did me a whole lot of good, I  think this is a problem, at least symbolically. It is essential that we educate our children about nutrition and encourage them to form habits of eating well and being physically active. One of my goals as a future physician is to educate my patients about having a healthy lifestyle. I also want to participate in programs that promote these things within my community (and I won't be waiting until I have an MD to do that!).

I think the second thing our country needs is an increased emphasis on preventative health care. We need to encourage all the people who will finally be able to have health insurance to see family doctors and OB/Gyn's on a yearly basis, rather than waiting until they get sick and going to the emergency room on a Friday night. If a 30-year-old man finds out that he has high blood pressure and can work with his physician to control that, he might not need a heart catheterization when he is 50. The benefits of this to the individual, the physician, the nation's health care system, and the health of America as a whole will go a long way.

After voicing these thoughts one interviewer said that I sounded like a passionate primary care physician-to-be. I'm not sure about the primary care part, but the passion is definitely there.