#MedGradWishList

Every year about this time, I try to put together a list for people trying to find the right gift for someone they know who is graduating from medical school.

This year’s list is a special one.

If you haven’t heard of #medgradwishlist, it’s an amazing grassroots effort to create Amazon wish lists for URM students matching this week. This is a brilliant “pay it forward” initiative. I’ve been a Program Director and a Dean of Student Affairs and I know how many new grads finish medical school with enormous debt and empty bank accounts. The ~17,000 students graduating from medical school this year are about to start on the exciting – but stressful – path of becoming a physician. Not being able to afford the things that make that journey possible just isn’t acceptable.

If you want to support these soon to be MDs, here is the spreadsheet with the names of the residents who have registered.  (You can also search #medgradwishlist on Twitter). You can buy things on their list anonymously (or not). When you find the right thing for the right person, don’t forget to include some memories of your internship, advice, and words of encouragement!

If you are a student (or even a struggling resident) in need, please join this effort to get what you need. We are sure you will pay it forward to extend this support to next year’s class!

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I spent quite a bit of time looking at all the #medgradwishlists on Amazon, and I’m happy to share what I learned. In addition to their great ideas, I have some suggestions to add…

@drmlb‘s Top Ten #medgradwishlist suggestions

Instant Pot. This was on a lot of the Amazon lists, and I agree!!! II had to suggest one item to make life as a resident easier, it would be this. Several people asked for air fryers on their Amazon lists. Just as an FYI, you already (sort of) own an air fryer since your oven set on convection does close to the same thing!

Someone to help clean and do laundry. I know you can’t put this on an Amazon wish list, but if you have a family member who either can do this for you, or pay someone to do this for you, it’s one of the best gifts you will ever receive.

Digital gifts to make communicating and studying easier. The single most important tool for an intern is their phone. If they don’t have a new phone that can reliably work with WIFi and cellular, this should be at the top of your gift list. A computer that works, has the ability to do streaming well, and is reliable is also key since it’s how they will study, write, and watch educational videos. They’ll want the flexibility of studying in a coffee shop (once we get COVID19 under control) or on their couch so make sure it’s a laptop and not a desktop computer.

There were some great ideas on the Amazon lists for items that aren’t quite as expensive as computers that you might consider as well: ring light for Zoom meetings, LED study light, lap top desk for your lap, iPad Pro, Apple pencil.I should add that buying a large quantity of pens to be “borrowed” by attendings would be a big win, too.

The kitchen (other than the Instant Pot). It’s so important to eat well when you work as hard as interns work (and to stay well caffeinated). There were some great ideas from my new colleagues on their Amazon lists including single serve coffee makers, pot and pan sets, nonstick bakeware set (if they are a baker!), wine opener :-),  and food storage bags and containers. A box or two of Kind Bars (my favorite) or other meal replacement bars is a great gift, too. And for the times cooking is just one task too many – Door Dash, Uber Eats, and/or Grub Hub gift cards are a great gift. One other must have… a Yeti mug to keep coffee hot during rounds!

Clocks and watches. We all have phones that can serve as alarm clocks, but an alarm clock that gently lights up the room is a much better way to wake up than sudden noise. I wouldn’t say an Apple watch is essential (and if you do a lot of procedures it might be easy to lose) but it is worn by a good percentage of folx in the hospital. A new watch might be in order, even if it’s not an expensive digital watch.

USMLE3 study book. If you are a family member who is thinking about getting this as a present, you might also want to include a check for $895 as a “bookmark” to cover the cost of registering for this exam.

Make your home a stress-free zone. If you are setting up a new home, this list can be really extensive. You’ll need to go home to a clean, happy space, so whatever you can do to make that happen is important. There were a lot of good ideas in the Amazon wish lists including self-cleaning cat boxes, pet hair removal brushes, furniture, shower curtains, towels, and a video doorbell. I’d add a Roomba vacuum cleaner to this list, too! BTW, a good TV is important, too. We all need to binge watch the Great British Baking Show as therapy sometimes.

Sleep. In this category I would include good quality pillows, a new mattress, light blocking curtains, white noise machines, and electric or weighted blankets.

Music. Most people fill their space at home with sound as well as light, so think about good WiFi speakers like Sonos and/or gift certificates for ad-free music services  like Apple Music, Spotify, Pandora.

Health. Last but not least! The most important thing on this list in my opinion is a great water bottle since, particularly with masks on all day, none of us drink enough water. A new Sonicare toothbrush or WaterPik for dental health will be appreciated. Foot care is another important part of being a healthy resident, so consider gifting compression socks, good shoes, work insoles and/or a foot massager. Anything that promotes or makes fitness easier is also a good gift – a new bicycle for commuting, new shoes for the hospital, workout gloves, free weights, resistance bands. You might also consider a meditation app like Headspace, or subscription to yoga classes on line. And… lest I fail to jump on this wonderful bandwagon, if you can afford the Peloton, it’s a favorite among physicians!

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p.s. What NOT to buy or ask for

  • Scrubs. I noticed a lot of folx asking for scrubs. Nope – don’t do it! You will be required to wear the scrubs from the hospital since there are rules about them being washed in the hospital laundry.
  • Textbooks. You are pretty much guaranteed to have access to a library where these books will be in digital format and free. These books are heavy! You aren’t going to take them to work and when you get home, you may have other things to read that take priority.
  • Printers. This is expensive and you just won’t use them. You are going to have to stay digital to really learn what you need to learn as a resident. Besides, if you do need to print out the return slip for Amazon, there will always be a printer at the hospital you can use!
  • Black bag. If you are a family member thinking of getting one of these… don’t.

And finally…

For my new colleagues matching this week and starting your internship in June …

May your journey through this liminal time be as stress free and as joyful as possible. May every day as an intern bring you hearts to heal and hands to hold, new learning, and a sense of wonder and awe.

We are so happy you are joining us in this noble and sacred work!

Studying for the In-Training Exam

Every year every resident in the United States takes an exam (called the In-Service or In-Training exam) that covers all of their specialty. It’s meant to be a formative exam for residents and their programs, which means it’s supposed to let everyone know which areas need more focus. Unfortunately, because there are numbers associated with this test it has become a higher stress exam than it should be, especially for residents who are applying to competitive sub-specialties.

First a word to Program Directors. When you think about this test there are only three categories for the results

1) Possibly at risk to pass the boards (< 10th% ile?)

2) Going to do fine (11-79th %ile)

3) Extraordinary test takers who really know the info (>80%ile)

This is a comprehensive (and long) exam that often has a VERY narrow bell-shaped curve. What that means is an incorrect answer on 2 questions (some years) can drop a resident up to 10%ile points. Doesn’t it seem silly to think that 70th%ile is somehow “better” than 60th% or 50th%ile? (I’m looking at you, subspecialty PDs)

Now for my colleagues in training. You stressed about this exam, you “crammed” (yes, we all did it – even those of us who know it’s stupid) and now you are breathing a sigh of relief that it’s over…

Take a good break from studying. For the next two weeks, use all the time you would have been using to study to binge watch something on Netflix, read a few novels you’ve been meaning to read, or do whatever gives you rest and joy. Then….

Put this in perspective. At the end of your residency, you will be launched into the wonderful, scary, amazing world of practice. You want to know that you know enough to do this, right? So back away from the idea of the In-Service exam as a pain in the gluteus, and see if you can think about it as a formative exam. Which leads me to…

Learn About Deliberate Practice. The best way I’ve found to think about deliberate practice is to understand how musicians practice. I wish I could remember where I read this so I could properly attribute it (please let me know if you know!), but here’s the best example I’ve found to understand deliberate practice – Serious amateur musicians and professional musicians practice a similar amount of time… say 2 hours a day (for the sake of this discussion). But how they practice differs. The amateur will play the piece from beginning to end multiple times, occasionally stopping to repeat the stanza that trips them up. The professional will play it once or twice, spend an hour on a stanza that trips them up, then start over. That’s deliberate practice. Taking the things that are hard (or you don’t like) and repeating them until they aren’t hard.

So, putting this all together, here is what I suggest you do to get ready for the In-Training Exam:

Step 1: Make notes.  

Take one of the major textbooks in your field and make a spreadsheet of every chapter, topic, and subtopic in the book. Your goal is to make notes on every topic in the book from March 1st to December 1st.  Start with some simple math… March 1st to December 1st is 39 weeks, so take the total number of topics in your text book and divide by 39 to set your weekly goal.

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But you won’t start with page 1 and work sequentially to page 846. (Yes, for those not in medicine, the books are usually that long). When you are on call, and you admit a patient with pneumonia, read the chapter about pneumonia and make notes to store in Google Drive? EverNote? OneNote? It doesn’t matter as long as they are in the cloud and searchable. If you hand write notes that’s ok, too, just use an app like Scannable to turn them into PDFs and store them on the web (don’t forget the keywords and/or tags so you can search for them when you are reviewing). What should the notes look like? You graduated from college and medical school, so I’m betting you have a system that works for you. But, if you’ve never heard of it, take a look at the SQ3R system for studying. (Spoiler, it really works.)

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A few other words of advice. It is VERY helpful to link your notes to a specific patient. You’ll remember everything much better; I promise. So, mention the patient with COVID pneumonia who always wore their yellow baseball hat… but don’t put any PHI in your notes so you don’t get in HIPPA trouble.  Also, don’t limit yourself to notes from the textbook. This system allows you to make and store notes when you read an article, learn a pearl on rounds, create a mind map, use questions banks, or do a presentation…

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Step 2: Deliberate practice. There will be sections of your textbook that thrill you. Parasites? For some reason we are all fascinated by them. Coagulation cascade? Not so much. Recognize that it will always be easier to learn about parasites than the intrinsic and extrinsic pathways. (Unless you are going into blood banking, in which case I apologize). Which means you need to spend more time on the coagulation cascade. Darn. #DeliberatePractice

The fundamental thing that differentiates learning (for your patients) from memorizing (for the test) is repetition. Your goal is to see everything you need to learn at least 5 times, spaced over at least 3 months. If it’s a topic that is difficult for you, it will probably be more times over a longer period of time. #DeliberatePractice

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One of the best ways to learn specific pieces of information you need to know (like the coagulation cascade) is to use an app like Anki or other flashcard apps. The advantage of these apps is they force you into spaced repetition (remember the minimum of 5 times over 3 months?), but if you are more comfortable with the old-fashioned (but effective) analogue system of actual flash cards, go for it!

But – write this down and put it over your desk – You can’t learn to practice medicine from Anki. You may be able to learn the coagulation cascade and the ratios for Massive Transfusion Protocols… but you won’t learn how to care for a patient who is bleeding out. That’s why you read and that’s why you are in residency.

Another great way to learn something is to teach it. Put together a brief presentation and handout for your medical students on the coagulation cascade… and make notes about their questions, who was there (maybe even a team photo?) before storing your handout with your other notes.

Step 3: Review. This system builds in review of everything you learned over the year (by reviewing it at least 5 times over at least 3 months, remember?) but for next year’s In-Training Exam, plan to take a full month before the exam to stop making notes. Spend this month before the exam to go through question banks, review your notes, and memorize the coagulation cascade. 🙂

A Visit From Dr. Fauci

‘Twas the tenth month of COVID, outside the med school,
The virus was surging, making us look the fool;
Our screeners took temps and filled out our checklists,
In hopes Dr. Fauci would soon pay us a visit.

Our masks were in place over both mouth and nose,
In full PPE from our heads to our toes;
And I in my N95 – quite well fit –
Had just settled down to rest just a bit.

When suddenly I started to get texts non-stop,
I jumped on a Zoom call to see what could be up;
And who should I see in the box, upper right,
Than a crack immunologist, oh what a sight.

Bespectacled, bemused and a tiny bit grouchy,
I knew in a moment this was Dr. Fauci;
At first he was “on mute,” the mic icon all red;
But once that was solved, I recall what he said:

Now Baylor, now UPenn, now Duke and now Vandy,
On Hopkins, on Harvard, on Mayo and Emory.
Learning Health Systems – this is your finest hour,
In our battle with COVID, you hold all the power.

When we had zero testing, no testing at all,
You spooled up research labs to answer the call.
From lab bench to bedside treatments poured out tout suite,
A remarkable feat that was really quite neat.

Need a vaccine? You gave us three, four or five,
That promise did so much to keep hope alive.
New treatments emerged in a chaotic stew,
Phase three clinical trials helped us know what was true.

Young doctors in training, PAs, nurses, et al,
Learned in a pandemic, an order quite tall.
With a passion for learning that must be life-long,
CME helped all doctors discern right from wrong.

And finally, a nod to providers front-line:
This truly has been your moment to shine.
Your safety, your families, and your own burdened hearts,
All took backseat to your blest healing arts.

You battled at onset, you battle on still,
You’ll battle to the end, and please know that it will.
The challenge is not ended, it continues today,
And we owe you a debt that we never can pay.

His eyes were quite moistened, and his voice all aquiver,
He said, “thank you, thank you” for the care you deliver.
And just before clicking on “End Meeting for All,”
Added “Academic Medicine, we’re proud you’ve got this ball.”


From James T. McDeavitt, M.D.
Senior Vice President and Dean of Clinical Affairs, Baylor College of Medicine

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Top 10 Holiday Presents for Medical Students, Residents and Physicians: #COVID19 edition

Every year about this time, I create a list of presents I think busy healers (and healers in training) would appreciate. I don’t have to tell you that this has been a year that for all of us, but especially for everyone in medicine, has brought a new level of stress and sadness. The healers need healing… and in that spirit, here are some ideas of what you can send your friends in medicine for Hanukkah, Kwanza, Christmas, the Winter Solstice… or to celebrate the end of 2020 and beginning of a new year of hope.

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#10.  White coat, jacket and/or scrub “bling”.  Everyone who works in a hospital has a badge that must be worn all the time. And we all need pens (except for the attendings… we just “borrow” pens that students and residents keep in their pockets for us … just kidding … mostly). Here are some suggestions: Find a lanyard or badge holder from their favorite sports team or that will otherwise have meaning for them. Buy a box of cheap pens (that can be given away to needy attendings)  + a great pen that will remind them of you every time they write with it. For white coats, find a meaningful or humorous pin that could be worn on other clothes as well.

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#9 Happy Feet.  Think about putting together a “happy feet” box – include things like warm slippers, good socks, a certificate for a pair of shoes to wear in the hospital, compression socks, toenail clippers, and any other foot care products that sounds right. 

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#8 Better sleep. Sleep can be hard if you have had a really hard stretch at work. It’s especially hard if you’ve worked all night and have to sleep during the day. You can put together a combination of gifts like new high-count sheets, eye covers and ear plugs for sleeping after a night shift, a certificate for a new mattress, a white noise machine or a weighted blanket.

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#7 Work food. Busy students and residents frequently miss meals. Think about creating home made “snack packs” for the hospital by combining options like nuts, dried fruits, and high quality candy into small zip lock bags. Or buy healthy meal replacement bars in bulk. Make sure they are high quality, real food bars. My favorites are Kind bars but there are many other bars that are healthy and delicious.

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#6 Gift cards. When you ask students and residents which gift cards would be most appreciated it’s pretty consistently these three:  Amazon, Trader’s Joes, Whole Foods or other grocery stores, and Starbucks.

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#5 Digital upgrades. A high-quality phone is a critically important tool in the hospital. Everyone in medicine spends a good part of the day texting each other, looking up patients on Haiku (the Epic phone app), checking UpToDate for the latest treatments, finding other medical information in many other places and – of course – staying in touch with our teams, friends and families. Up to date computers, iPads, and AirPods (or equivalent) are also great gift options for any student or resident.

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#4 A cleaner house. Pre pandemic, I recommended someone to help clean as the number one gift for medical folks. But, even with the limitations imposed by COVID, there are still gifts that can help! Number one on this list would be a Roomba so they don’t have to vacuum.

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#3 Healthy meals at home that don’t take time. The Instant Pot has been my top recommendation as a gift for students, residents and busy healers for several years. Another wonderful gift I’ve recommended before is How to Cook Everything Fast: A Better Way to Cook Great Food by Mark Bittman. This year, I would add a certificate to meal delivery plans. The one I use is Clean Creations (because I like to have vegetarian options), but many of my friends swear by Freshly. Every city has companies that are similar, so do some homework and you’ll find several to compare. If you are a good cook, you might consider creating your own “meal deliveryservice” for your loved one, especially if you live in the same city.

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#2 Caffeine. This comes in different forms for different people, but unless they avoid caffeine for religious reasons, almost every healer and healer in training I know has a go to form of caffeine they love. For most people, it’s coffee. The number one gift on the list (my opinion) for coffee lovers is a Nespresso machine (and some pods to go with it). You can also get them a metal “pod” for their own coffee rather than the Nespresso pods which will save some money. There are other options for pod coffee machines, so you might want to read about them all before deciding. Having tried coffee from a variety of machines, I personal think Nespresso makes the best cup of coffee, but I am partial to espresso. Another great gift option for serious coffee drinkers is programmable coffeemaker so their coffee is ready when they get up at “dark thirty” to get to work. For tea drinkers, there are many options for teas, brewing systems, and pots. For all healers, regardless whether they are coffee or tea drinkers, a gift at the top of the list would have to be a Yeti or Contigo tumbler. These tumblers keep coffee or tea hot for hours… so your drink is still there and still hot when you get pulled away from that first sip.

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#1 Money. Students and residents, with rare exceptions, don’t have money for special things. Some don’t have enough money after rent and loans for things most of us would consider essentials. Giving money may seem a bit impersonal, but you can make it personal with a letter, a card, or creative packaging.

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p.s. If you want to check out my pre-quarantine lists for other ideas here are the links to last year’s list, and the year before.

p.p.s Thanks so much to my Twitter friends for helping me with ideas!

Compassion, #COVID19, and @Twitter

No one listens, learns, or changes their mind when they are being attacked. As healers, we know this. We deal with patients and families all the time who don’t understand or are so traumatized that the last thing we would think of doing is yelling at them as we try to help them on their journey to health.

We’ve all seen the videos of mobs of people without masks rushing to get to the front of a crowd to hear @realDonaldTrump. We’ve all seen the photos of people in crowds at bars, parties, and on college campuses with no one wearing masks. If you are tempted to think this is ok, I have two things I’d like to share…

It’s not about you.

I totally agree that, as an adult, if you want to not wear a seatbelt, you have that right. But you don’t have the right to drive drunk and kill or injure someone else. If you want to drive 80 miles an hour on your ranch and ignore safety, go for it! But if you want to speed and run stop signs on our shared roads, that’s not ok. Why? Because the person you hit with your car could be a family member or friend… and they will unquestionably be a neighbor (because we are all neighbors).

Masks are about compassion.

If you come down with COVID19, it’s also not just about you. If you do get sick with COVID19 (and I hope you don’t), it’s not about “getting over it” like a cold. You could have a lifetime of consequences… but if it was just about you, that would be your choice.  But that’s not how this works.  If you are COVID19 positive (with or without symptoms), you can infect your elderly family member, the kid next door who is on chemotherapy for cancer, the nurse who takes care of you when you go, frightened and alone (since no one will be allowed to stay with you), to the hospital.

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Since my new friend on Twitter asked me about the science, I’m happy to help with some of what we know:

  1. Masks decrease the spread of COVID19 in a community.
  2. Masks do not cause low oxygen levels.
  3. Masks do not cause an increase in carbon dioxide.
  4. COVID can be spread for up to 6 days before you develop symptoms.
  5. There are people who have the virus, can spread it to others, but never develop symptoms.
  6. The virus is small, but it travels on droplets (that’s how others get infected) – and that’s why masks work. (That’s also why it’s not cool to put on masks made of lace, gauze or other things with holes)
  7. We can’t rely on herd immunity, unless we think its ok to have up to 2 million dead Americans.
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p.s. I changed how I interact with folks on social media after I listened to Nadia Bolz Weber’s interview with Megan Phelps-Roper on her podcast, The Confessional. Megan Phelps-Roper was a member of the Westboro Baptist Church who became the voice of her family on Twitter, spreading their particularly venomous message. But a funny thing happened … there were people on Twitter who, instead of yelling at her, responded to her venom with compassion and curiosity… and it changed her life.

Lessons from the Pandemic: Richard Rohr, Walking, and Lawn Chairs

It’s almost impossible during times of stress to be motivated to do hard things. For all but the most hardcore exercisers, ice cream just seems more soothing than running when you are emotionally exhausted (Right?). I’m no different. But, as much as I would like to think “later” will be ok to regain what I have lost in these months of being more sedentary than usual, I have begun to realize that I needed to get moving again.

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Enter Richard Rohr

I’ve been a fan of Richard Rohr for years. He’s a gifted writer with the laugh and smiling eyes of someone who has tapped into something I want to know more about. I subscribe to his weekly email, which this week introduced Jonathan Stall’s practice of moving “as a way to invite brave creativity.”

There is a lot to unpack in that idea.

What exactly would “brave creativity” look like? I’m not sure, but it sounded like something I, and I suspect all of us, need more of right now.

“We invite you, as able, to take some time this weekend to move mindfully through your local area.”

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I set off on a different kind of walk.

I grabbed my mask and headed out for a walk in my neighborhood, trying to think about this not just as exercise, but as something more. I read Jonathan Stall’s advice again:

  1. Bring something to jot ideas down while you are out, but more importantly, invite your “goals/pains/dreams”  to join you on this walk.
  2. Walk for at least 30-40 minutes
  3. Wear a mask if you get within 6-10 feet of anyone (respect for your neighbor)
  4. Start the walk with a sense of being open. “As you begin to move, seek the realms of wonder, of space, and of reaching high into what’s possible…”

Where did all these lawn chairs come from?

I’ve walked many times before in my neighborhood, and I’m an observant person.  But today, as I walked, I began to notice all the chairs on people’s lawns and all the swings, and “tires” hanging from trees. 

Were they always here and I didn’t notice them?

Are more people sitting outside now than before – even though it’s outrageously hot here in August?

Is this because of how much we all need (safe) connection to each other during the time of pandemic?

Are there actually more chairs, swings and tires because of how much we all need to hear birds, see trees and listen to the cicadas in the summer evening right now?

Next steps?

Yes, there will be next steps. This experiment led me to more questions than answers, but I had a real a sense of being taught, too.  

Try it?

Let me know what you see.

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Don’t Eat the M&Ms

As a former Program Director, I couldn’t help but imagine the conversations that occurred after this event…

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After “WHAT WERE YOU THINKING?????” – which would have probably been my first sentence – I would have been upset, but I also would have realized that these residents were meeting in the way that residents and students have met forever. They were having a goodbye party for people who were leaving. Probably not outside, and probably not socially distanced, judging by the outcome, but I totally get it.

But the consequences of a casual party like this are real and it’s worth thinking about this by asking three questions…

1. What are the chances you’ll get infected at a party?

This one is easy. You have 100% chance of getting infected… unless it’s 0%… and there is no way to know which way it will go.

A recent report of 32,480 nursing home residents and staff showed that “Of the individuals who tested positive, 70.8% of residents and 92.4% of staff lacked symptoms at the time of testing.” The authors also showed that the viral load (which helps predict whether or not the individual is infectious) was the SAME in people who had symptoms and those who didn’t; “In a large cohort of individuals screened for SARS-CoV-2 by qRT-PCR, we found strikingly similar distributions of viral load in patients with or without symptoms at the time of testing.”

What this means in practice is that every single person we encounter has to be considered infectious.  And that means every event and every encounter has to be carried out in a way that will prevent transmission of the virus.

2. What are the chances you’ll get really sick or even die if you get COVID19?

Based on data from the CDC, for 20-40 year old people with no underlying medical conditions, here’s the answer to my hypothetical M&M question:

  • 700 of the M&Ms will give you fever, cough, and/or shortness of breath. Lots of patients describe it as having “lungs on fire.”
  • 440 of the M&Ms will give you some pretty awful muscle cramps and aches.
  • 120 of the M&Ms will make you lose you sense of smell and taste. It usually comes back, but not always
  • 3 or 4 of them will put you in the hospital (that goes up to around 20 M&Ms if you have an underlying medical condition)
  • 1 of them will put you in the ICU unless you have an underlying medical condition. In that case, 5 of them will put you in the ICU
  • It’s unlikely you’ll die unless you have an underlying medical condition, in which case 3 of the M&Ms will kill you. If you carry this home to your 70 year old grandparent with an underlying medical condition, they have a 20% chance of dying (the equivalent of 200 M&Ms for you).

3. If you are in health care, what effect will this have on your patients and your colleagues?

Whenever I struggle with a decision as a doctor, I go back to my “rules”, which serve as the reference point for my moral compass.

Rule 1: Do what’s right for the patient.

Rule 2: Look cool doing it.

Rule 3: Don’t hurt anything that has a name.

If, as a healer, you decide that “just this once” won’t be much of a risk and you end up with COVID19, you break all three rules. You will be infectious for a long time before you get symptoms… which means you will expose patients, friends and colleagues (who all have names) to this potentially deadly disease. And – there is nothing less “cool” than creating a avoidable situation that ends up with colleagues having to cover for you while you are in quarantine and/or recover from COVID19.

We all want this to end… and it will.

We have a special calling – and responsibility – as healers (which includes all healthcare workers since healing takes a team). It’s what makes our work so filled with awe, and so rewarding. It’s also a burden sometimes. But we all took an oath, we all made a promise, and when we are past this point in history and looking back, it will mean something that we held true to that promise.

“Do you think it would be ok if I…?”

“We had a graduation celebration, but it was smaller than usual… only 20 people… and the older people just stayed a little while.”

“We meant to stay socially distanced… but you know kids.”

“God will protect me… I don’t need a mask.”

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Oh, how I wish this were over. We all do.

And it will end.

It will end, but what we have to grapple with now is how many of us will die unnecessarily before it ends… because the rest of us “had to get our hair cut” or thought this was some kind of political “hoax”… or just couldn’t be bothered.  

Because I am a physician, I have a lot of friends and family who call to ask some version of “Do you think it would be safe if….” I usually respond by telling them what I’m doing and then answer questions as they try to figure out the changes they need to make to be safe.

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I am in awe of how much we have learned about how the virus spreads in aerosols, how it stays on surfaces and how very infectious it is. We owe a huge debt of gratitude to the scientists who have tackled this pandemic with heart, mind and soul. This knowledge is guiding us, protecting us, and is essential to save lives.  

So, with gratitude for the science that has helped us better understand #COVID19, here’s what I tell my friends and family we are doing when they ask….

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Stay Home. We stay home unless it’s for an essential need. For example – we would go to the dentist for a painful tooth (but not for a routine cleaning). We have supported our local restaurants with pick up or delivery, but we don’t go to restaurants yet. When we do, it will only be outside and only if we are sure CDC guidelines for restaurants are being followed. There is no way we would go inside for a movie, rally, worship or other public gathering. The data are more than clear… large gatherings inside are the highest risk activities right now.

I get our vegetables from Pierre at a Plant It Forward farmer’s market sponsored by Dandelion Cafe. (I’m mentioning them on purpose because having these just picked vegetables has been a true gift!) But I have the rest of my groceries delivered. I ask the delivery person to put them on the step (by text). I wear a mask, and don’t open the door until they are more than 6 feet away to thank them. (BTW, they are doing amazing work to keep our communities safe – please tip often and as much as you can).

One of the questions I get asked about staying home is “but I’m young… isn’t it ok for me to go out?”. The answer is yes and no. Younger people are less likely to die or develop chronic lung disease from COVID19, but it’s not impossible. Here’s the real issue – If you end up infected with COVID19 you’ll infect people around you that are at high risk… and they could die or have horrible outcomes from the disease. Do you really want to risk hurting your grandparents or that nice guy at the store who always says “Hi” to you? Think about creating a “quarantine pod” as an alternative to going out to restaurants, bars and concerts… it’s not going to be the same, but it’s a good compromise to keep socially connected while being as safe as possible.

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Do it virtually if you can. If we are asked to run or be in a meeting, we do everything possible to make it virtual. If you are in charge of gatherings, this is an important responsibility. There is no reason to expose any of your colleagues or employees unnecessarily.

I’m an academic surgeon. I can’t do surgery virtually, but I can do a lot of clinic visits by video. I can do all my group teaching and committee meetings by Zoom. There is no moral justification to have meetings in person if they can be done online and I’m happy, as someone who can decide, to make sure my students and colleagues aren’t exposed to more risk than necessary.

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Socialize outside. If I am meeting a friend (or friends) I’ll only do it outside and only if we have discussed in advance how to manage the event. I’m excited that this weekend I’m going to an outside workshop that FAMHouston is facilitating to teach refugees how to grow vegetables in container gardens. These are my friends, so I really want to see them! We have established in advanced that we will meet CDC guidelines with everyone in masks and more than 6 feet apart.

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#WearYourMask. If I’m around anyone, I wear a mask, and I ask them to wear one – AND we stay at least 6 feet apart. The masks only come off if we are outside and more than 6 feet apart. It’s also really important to wear it properly! In particular, if your nose is hanging out, you might as well not have it on. Two other important things: 1) A face shield alone is better than nothing, but isn’t as protective as a mask and 2) the masks with the “breathing valve” aren’t worth wearing. Remember, my mask protects you. Your mask protects me. That’s why if we all wear masks we can stop the spread of COVID19!

Exercise with a mask available. When I’m outside exercising, I have a cooling mask (it is Houston, after all!) around my neck. As soon as I see someone coming towards me, I pull up my mask. I get a good 20-30 feet beyond them before it comes back down.

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Bring your own glass. I had a friend over for a glass of wine on the back porch not too long ago. They didn’t come through my house (and I would do the same for them). I opened the gate to the backyard, and they walked through my back yard to the back porch where I met them. They brought their own wine glass. We sat on opposite sides of the porch, 10 feet away from each other and had a wonderful, soul healing visit.

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Assume if someone else has touched it there is COVID19 on it. It’s a long shot, but what if… the UPS driver has COVID19 but is asymptomatic, coughs on their hands, picks up the package they are delivering … and now you pick it up. One inadvertent rub of the eyes at that point could easily mean an infection.

We put an old towel on a table and designated that table as “contaminated.” We put new packages on the table and immediately wash our hands. (If you work in an OR, you will understand this well… if you touch something contaminated you “rescrub” i.e. wash your hands before touching something else.) This sounds complicated but it’s not… if it’s just been handled by someone else, we assume it’s contaminated.

We have found that it’s easy to leave things on the table for 3 days before we open them (surprised us, too!). Obviously, groceries that need to be in the refrigerator are a little different (they get put in new plastic bags which go into the fridge). And, because three days may be long for some items…bottles of beverages get washed with soap and water before they go in the fridge.

Now, I have to be honest. A lot of new data are coming out that says we may be on the far end of safe with this. Some surfaces clearly are more at risk (like door handles), but things that get delivered are probably not really a problem. This is one to figure out your comfort level, stay up to date on the new info, and come up with a reasonable plan.

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I hope this helps.

Whenever I am tempted to say “just this once” … or fall into the trap of feeling like it can’t really be “that bad” to meet without masks, I think about how all my colleagues are putting their lives on the line to care for infected people… and how I would feel if I were the one responsible for their death, or the death of someone I know and love.

Be safe and take care of each other.

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Making Sourdough Bread as a Resident (or anyone with a crazy work schedule)

I just waved goodbye to a dear friend as she started the drive to her new residency – with a jar of “Tamar”, my sourdough starter* in her cooler. I was going to print some instructions to send with the starter, but decided it might be better to put those instructions here for her – and for all of you who have thought about making sourdough bread (but think you are too busy).

Why bother?

This is a legitimate question. What I’ve learned from making my own bread during the pandemic is that it’s more than just having delicious, warm bread to sustain you.  I won’t wax too poetic, but there are three reasons I think you should ponder baking your own bread:

  • A sourdough starter is a living thing who is there to help feed you
  • Making the bread is an act of self-care, a gift to yourself
  • This is a  profoundly slow and deliberate act. Mindfulness doesn’t get any better than this.

So, if you are intrigued, I’ve thought about this for a while and here is how I think this could work for residents – even during a crazy 80 hour week.

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Step 1: Get or make a starter

There’s a decent chance that someone where you work bakes sourdough bread. If they do, they will be delighted to give you some starter. It’s not a bad way to make some new friends and/or expand your circle of friends.

If you don’t find someone with starter, make your own. Sourdough starter comes from the bacteria and yeast that are in our environment so it’s a matter of mixing flour, water and time. If you want to help out some scientists while you make your starter, check out the NC State Sourdough Project.

Step 2: Understand the big picture

  • Sourdough starter is a living thing. You need to feed it once a week by adding some water and flour. Period. If you want to stop here and just have the starter around “in case” you decide to bake, this is all you have to do.
  • You are going to love the science of this. I’ll even predict you’ll end up using a scale to make sure your grams of ingredients are exact… but remember, as much as this will feel like science, its also how our ancestors made bread thousands of years ago. Don’t lose that perspective.. or that connection… when you bake.
  • It’s a four-step process with variations depending on the recipe:
    • Mix the 4 ingredients (starter, flour, salt and water) to make dough
    • Rise – long and slow. Overnight in the fridge, 2-6 hours on the counter. It varies by the recipe.
    • 2nd rise – usually. for 1-3 hours and in a container to shape the dough
    • Bake

Step 3: Find an easy recipe to start with so you don’t get overwhelmed…

Here’s a really easy first recipe:

  • Mix the dough (1 cup starter, 1.75 cups lukewarm water, 5 cups of flour, 1 tablespoon of salt)
  • Let it rise for about an hour then stretch it out and fold it onto itself several times. The recipe says repeat this once an hour for a total of three times, but you can skip the 2nd and/or 3rd times if you need to.
  • Put it in the refrigerator overnight.
  • Flip it over, seam side up into a bowl or loaf pan (to shape it) and let it sit for 2.5-3 hours.
  • Flip it back over (seam side down) into your pan, slash the top to provide a controlled way to expand and bake.

Step 4: Map out a schedule

Let’s say it’s Thursday evening and you are off on Friday. Here’s how this recipe might work for you…

  • Thursday when you get home, mix the dough. If you don’t have time to let it rise on the counter for an hour and stretch it, just put it in the refrigerator. (Trust me, it will work). Take the starter that didn’t go into the recipe, feed it, and put it back in the refrigerator.
  • Friday when you wake up put the dough in a bowl or loaf pan and let it sit for 2-3 hours on the counter. This will mold it into whatever shape you want.
  • Heat up your cooking container (dutch oven, oven proof pot, tray) as you preheat the oven.
  • Put parchment paper on top of the bowel and flip the dough out of the bowl onto the parchment paper.
  • Use the parchment paper to lower the dough into your hot cooking container.
  • Score the top and bake!
  • (Don’t forget to let it sit for an “hour” before you slice it… no matter how good it smells)
When you overproof dough (too long with too vigorous a starter) is gets REALLY liquid and REALLY sour. It isn’t worth trying to salvage it.

It’s an art. Everyone has bread that bombs.

Don’t worry! Just keep the starter alive, regroup and try again!

If you find you are having issues with getting a good rise, it’s ok to put some dry yeast in as “insurance”.  Poilâne’s famous sourdough includes it as part of the recipe, so it can’t be a “failure” in the sourdough world!

Comparing stater activation between white flour (dotted line) and whole wheat (solid line)

What to study next

If you are reading this, there’s a good chance you are Type A. You’ll probably get a notebook and treat this like a science experiment … like I did. Go for it! It turns out that even though sourdough bread has only 4 ingredients (starter, flour, water, salt) there are lots of variables that can affect the loaf e.g. temperature of the water, humidity in the room, etc. There is real joy in paying this much attention while creating something that is so sustaining. On the other hand, if this doesn’t make you happy, just make the bread!

Did I mention?… it’s not just bread…foccacia, pizza dough, pancakes… just wait until you find all the cool things you can do with sourdough starter and discard!

Blogs and websites that have helped me a lot

King Arthur Flour – Sourdough Baking: The Complete Guide  (Check out their blog, too)

The Perfect Loaf

Here are some of my favorite books so far (all links are to independent bookstores)

Artisan Sourdough Made Simple, by Emilie Raffe

Do/Sourdough/Slow bread for busy lives by Andrew Whitley

The Tassajara Bread Book

Poilâne by Appolonia Pouilâne

Starter Sourdough: The Step-By-Step Guide to Sourdough Starters, Baking Loaves, Baguettes, Pancakes, and More 

I wish you mindful baking and joy from your sustaining and delicious bread!

*There is a tradition of naming sourdough starters.