What I Am Reading: Timely Edition

(by whizbang) Aug 25 2015

Work-life "balance" has become a big issue in the circles of professional women. Can we have meaningful careers and families? Never mind that men do this all the time; society still expects us to run the household and nurture the children, even when we make six-figures. In various career circles, a couple of strategies have been suggested, including "Lean In" (build a career that lets you have the resources to do stuff) and lean out (making part-time work a safer career option).

IKnowHowLaura Vanderkam now presents her work with women making it work. She obtained extensive weekly time tracking sheets from 143 women earning at least $100,000 per year with young children in the home, showing their lives for 1,001 days. She included single mothers as well as those with partners. Some were self-employed while others were in hierarchical companies. What she found will surprise most readers:

  • Most of these women worked less and slept more than they thought
  • Family time approximated or exceeded that reported by more traditional mothers
  • Creative approaches to family time made this possible
  • Housework suffered most, either by accepting "good enough" or outsourcing as much as possible

By looking at a week's worth of tracking data, these women were juggling all the pieces of a complete life while averaging more than 7 hours a sleep each night. They were achieving in their careers and their families were not suffering.

The only criticism I can make is that this work definitely favors the "Lean In" school of life, although she includes women who took the other approach as well. Myself, I am a "Lean In" kind of gal.

I recommend that everyone read this book when they feel overwhelmed by their lives. I especially recommend it for male partners who expect their "women" to take care of the household. If you sign up at Laura Vanderkam's website, you can get her tracking tool and examine your own week. You may realize your life is not as gloomy as you think.


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Angry Birds

(by whizbang) Aug 20 2015

This week a wonderful article about hummingbirds appears on Slate.  For those of you unable to concentrate long enough to read this excellent piece, I will summarize:

Aztec origin myths aside, hummingbirds really are badasses. And there’s a biological reason why: Their lives depend on it.

The information in the piece only confirmed my patio observations. Last Sunday, I noticed that my feeder was empty aside from some dead ants. I noticed because a hummingbird hovered at it, then swooped by me. I know he wanted to tell me to get off my ass and get nectar out there.

So I did.

We then had at least 5 birds trying to make our feeder their territory. There may be more; they do not stay still to make counting (or photographing) easy, and several of them are the same type of bird.

King of the Feeder

King of the Feeder

I have identified the dominant bird of the past 4 days, shown to the right.

He is not the largest bird in the group, but he has successfully defended his quart of nectar. He spends much time perched on the feeder, sipping leisurely. If another bird approaches the spouts, he chases them off vigorously. At other times, he sits in a rosebush (just out of the photo frame to the left) and then ambushes the intruder.

Sneaky bird!

Despite his success thus far, he is not my favorite hummer in the yard, That title goes to the clever bird shown in the next photo.

Clever Bird!

Clever Bird!

Clever bird (to the left of the support pole) waits until King of the Feeder chases off an interloper. He then swoops in and feeds while the King is occupied. He gets chased off eventually, but only after a meal.

Of course, there are a couple of hummers that look like this guy, so they could be taking turns.

By yesterday, the King seemed to be tiring. He waited until intruders tried to drink, rather than attacking them as they approached the feeder. He also has done less defending from the rose bush, spending most time perched on the feeder itself.

These little guys are beautiful and fierce. Unless unicorns or dragons show up in the backyard, these little dudes will be the main show.

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My New Obsession: @ShoesOfPrey

(by whizbang) Aug 12 2015

Hot weather, blazing sun, a backyard pool, and cold beverages do not promote blogging. You will, therefore, understand how amazing this new site is since it got me to write about it immediately.

Have you ever imagined a perfect pair of shoes? The heels of one but the color of another, perhaps with an accent of reptile leather or leopard calf hair? What you imagine probably does not exist in stores, even if you have the money to purchase any designer out there.

Enter Shoes of Prey. This site lets you start with one of twelve basic shoe types, from ballet flats to stiletto platforms. You then choose from hundreds of materials to make exactly the shoes you want. In addition to varying the uppers, you can change the lining as well. You can add insets and accents and straps. Every single piece on the shoe can be a different material. The base prices vary with model, but they start at $129 for the ballet flats. With enough bells and whistles you could probably get a pair up to $300, but I have not gone there yet.

Needless to say, this can be a very deep rabbit hole to explore.

Designed by Pascale

Designed by Pascale

As a public service, I decided to try out the service. I had a pair of red ballet flats with some raggedy edges. I started with a basic flat and then chose a d'Orsay cutout on the instep. I added a pieced toe but kept it all in the same soft red leather. These beauties came today, and they are lovely works of art.

The site works in European sizes, and they recommended a slightly larger size than other conversion sites. The shoes fit perfectly, so I recommend taking their advice. However, if something does not come out right, the shoes are guaranteed with a 365-day return or remake agreement.

How can you go wrong?

Below is a video explaining more about Shoes of Prey:

Better yet, click on over and start designing your new dream shoes.


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On Further Consideration: What I May Be Reading

(by whizbang) Jul 17 2015

GoSetWatchmanThis week Harper Lee's novel, Go Set A Watchman, hit the shelves of booksellers. The internet gave a collective gasp when early reviews revealed that Atticus Finch has racist views in this sequel, set in the 1950s. I know, because I gave one of those digital huffs. I could not believe that Atticus would be this way! I had no desire to read this book.

With further thought, I am reconsidering.

Racism does not have an on/off switch; it resides on more of a dimmer, with a variety of levels in between the extremes. I know* a lot of people who would agree that Tom Robinson got treated unfairly in To Kill a Mockingbird. They would agree that people of African descent should not be abused by others just because of the color of their skin. They also would not want "those people" living next door to them. They would express dismay when a professional sports team fielded an all-black starting line-up. They are racists, but not as extreme as the white jury of Mockingbird.

As I considered the bits included in reviews about "the new Atticus," I realized that he never professed to be a civil rights pioneer in Mockingbird. Readers really have no idea how he feels about African Americans, other than recognizing that Tom Robinson cannot have raped Mayella Ewell. Providing Tom's constitutionally-guaranteed defense does not mean that Atticus wants black people living next door or attending school or voting.

I will likely download and read Watchman in the near future. With current discussions of race, the "new Atticus" may provide more important lessons than our more heroic version.


*I may be related to some of these people.

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A Doctor Deals: Metformin

(by whizbang) Jul 14 2015

Structure of Metformin

Structure of Metformin

The first-line treatment for type 2 diabetes (DM2) is Metformin. First synthesized in the early 1920s, the discovery of insulin a few years later eclipsed these agents, at least for a time. In the latter part of the 20th century medicine rediscovered these drugs, and they entered clinical use. Despite becoming the standard of care for DM2, it took 30 years to figure out how Metformin works!

Human studies show that its major action is reduction of glucose production in the liver. When we eat, nutrients of all types enter the bloodstream and make a first stop in the liver for metabolism. The liver can convert these other molecules to glucose, our circulating fuel for cells, via a process called gluconeogenesis (literally new glucose).  Patients with DM2 have twice the rate of gluconeogenesis in the liver as nondiabetic people. Metformin for 3 months can normalize this process.

Metformin also has beneficial effects on levels of fats in the bloodstream and uptake of glucose by muscles. Unlike many therapies for DM2, patients usually do not gain weight with Metformin; indeed, many experience weight loss.

AMPK-regulated enzymes circled

AMPK-regulated enzymes circled

One documented cellular mechanism involves AMP-activated protein kinase (AMPK), a protein that functions in a number of metabolic processes. These include lipid (fat) synthesis, muscle glucose uptake, and control of a number of enzymes in the gluconeogenesis process (diagram to the right).

Zhou et al showed that Metformin activated AMPK in liver cells, leading to decreased fatty acid and lipid production (which in turn increases the sensitivity of the liver cell to insulin). Inhibition of AMPK blocks Metformin's beneficial effects on gluconeogenesis, so activation of AMPK also provides an explanation for this beneficial effect.

So have we answered the mystery of Metformin? Of course not!

Metformin has one obvious, often troubling, side effect: diarrhea. For myself and a number of friends who take it, the first dose induced events not unlike the clean-out for a colonoscopy (ask your 50+ year-old friends about the joy of colonoscopy prep). Some folks have ongoing diarrhea that limits therapy with the drug; in most patients, like yours truly, the problem eventually resolves (or becomes less problematic).

Why does Metformin cause intestinal problems? We really do not know. Some have suggested that it reduces intestinal absorption of glucose which could contribute to changes in stool pattern. Its effects on the liver may also change stuff downstream in the gut. Some have suggested that these intestinal effects may be beneficial as well, through changes in the microbiome.

For a drug that's a century old, there is still a lot we do not know about Metformin. At least we know it works!


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Another Problem for Puerto Rico

(by whizbang) Jul 01 2015

My recent meeting included a session with the Deans of Puerto Rico's four medical colleges. As we discussed diversity and inclusion, they presented an unexpected issue. Because Puerto Rico is a US territory, its medical schools are accredited by the same groups as those on the mainland. Their students must take the MCAT, National Boards, and Specialty Boards that mainland students do.

These exams are only offered in English.

That means only truly bilingual students can hope to get into medical school and eventually qualify to practice. For the urban population and wealthier people, this is not a huge problem. For the bulk of the island, that level of English fluency is difficult. Medical school thus becomes primarily an upper-class option, perhaps even more so than on the mainland United States.

Then, if you have that sort of fluency, training on the continent provides more options than the island. Once you move to train, it becomes tempting to stay, leading to major brain drain for Puerto Rico.

My school's problems seem less weighty now.


By the way, San Juan is a lovely city. You can visit the Caribbean without a passport. All of your appliances, including your cell phone, will work. OK, some Verizon customers had issues with voice calls, but my AT&T phone worked just fine. No plug adapters required. There's history, tropical beauty, and the ocean. You will eat more rice, beans, and plantains that you imagined possible, but the food is delicious. So is the rum.

So go; you can thank me later.



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What I Am Reading: #GDIGFA Edition

(by whizbang) Jun 26 2015

One of the plenary sessions at this meeting demonstrated the utility of Whole Brain(R) thinking.

Now, I assumed that I tried to use my whole brain most of the time, so I got the book, The Whole Brain Business Book, and read it en route to Puerto Rico. This model overlaps with a lot of other approaches to how we humans perceive the world, but it can provide a useful new frame for the problem.



Four aspects of human pattern preference occupy each quadrant of the diagram. The upper left thrives on logic and facts. The bottom left craves order and process. The lower right focuses on the human-emotional facet of things. The upper right is creative and big-picture. Many, if not most, people have a dominant quadrant. This doesn’t mean that we cannot appreciate the other perspectives; they just come less easily to us.

Many people have more than one quadrant that is relatively strong. The two upper quadrants are often found in inventors, scientists, and other creative yet data-driven types. The bottom half of the diagram, with its order and emotion, often finds professions like nursing supervisors. Those who favor the left side rely on facts, logic,and order, while those on the right tend to be idealistic.

As I read this book, I thought about the pharma booths I saw at recent clinical meetings. Ad agencies certainly know how to pull all of these perspectives into the show. Each booth featured big images, most often people living good lives with their disease (because of this drug, naturally). If not a patient image, some other emotionally charged picture appeared; fish out of water seem to be favored by pulmonary products. A tag line also dominates the big stuff, often with a message appealing to those D (upper right) quadrant folks: “Imagine a world without disease X.” Less prominent, but still big enough to catch the eye, are diagrams and graphs showing study results about the drug to start pulling in the left side of the diagram; after all, you have to get them close enough to take the reprints and package inserts that have the details they need to change their practice!

Like all models, this one cannot solve every problem of interpersonal communications. It explains a lot, if you let it. And Ann Herrmann-Nehdi put on a rollicking work-shop this morning where we all learned a lot.


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(by whizbang) Jun 19 2015

logo-aamc.gif-dataI have finally dug into the latest AAMC dataset on the status of women in academic medicine. The website AWEnow (Academic Women for Equality Now) will be featuring these updates over the coming weeks. Today I posted the overall scores for the nation.

Good news: The overall share of women in leadership has increased over 4 years (3 datasets).

Bad news: At this rate, I will be 94 when women hold half the leadership positions in academical centers.

Go see my pretty graph here!

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How To Fix Youth Hydration

(by whizbang) Jun 12 2015

This week a story about inadequate hydration in US youth has gotten a fair amount of press. As a pediatric kidney doctor, I end up seeing these kids in my clinic, most often for stones. Getting these kids to drink enough liquid to keep calcium from getting together with other stuff to form crystals and rocks is tough. The biggest barriers come from the schools!

The first problem is lack of access to fluid. There are water fountains in the halls, but kids often do not like to drink from them. Also, a mouthful of water every hour or two is far less than most of these children need. We have a stock letter we send to schools allowing our patients to carry water bottles to class.

ToiletLoveThe next issue involves bathrooms. Carmines' law of physiology states, "You drink, you pee, you don't, you die." Our stock school note also asks schools to let our patients use the bathroom when they need to go. Too many schools have really short transition times between classes that do not give students time to use the restroom. Teachers can also be reluctant to allow their pupils to wander about the school unsupervised, even when pursuing a noble activity like urination.

My final issue also involves bathrooms. Too many students tell me that they do not want to go to the bathroom at school. They are often dirty, unpleasant, and sometimes unsafe. If we want our kids to drink enough fluid, then we need facilities where they can "recycle" that liquid. These facilities should be ones we would use ourselves, and not just in an emergency situation.

We evolved on the savannah where access to liquid was often unpredictable, so our kidneys can conserve water well, without immediate damage. Long-term effects of concentrating urine may occur, but kidney stones are a clear, early result. This is more than a matter of telling our offspring to drink more. It's a matter of making them able and willing to pee more.

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Getting Loud and Angry

(by whizbang) Jun 10 2015

I remember when Acquired Immune Deficiency Syndrome (AIDS) first appeared as a case report in the 1970s. This mysterious illness shared epidemiological features with hepatitis B and some other disorders that made a virus the likely culprit. Eventually we discovered HIV and a number of drugs that have turned this former death sentence into a chronic manageable disease. Magic Johnson has been living with HIV for almost 25 years now! The cure is still out of reach, but what progress in 37 years, from “we have a syndrome” to a chronic disease.

How did this happen? We threw a ton of money at AIDS/HIV. Why did we designate so much funding to a disease that the mainstream had little to fear? At risk and affected people knew how to make some noise. Organizations like ACT UP lobbied and protested. Entertainers and politicians showed support with red ribbons.

Funds at the NIH got earmarked. Not all of that money led straight to scientific advances, but with that much moola driving things, things got done. It was almost like the space-shot of the 1980s.

Once upon a time, kidney disease had vocal advocates. When dialysis first became a practical treatment, it was performed on the floor of congress to get kidney failure treatment covered by the newly formed Medicare program.

Unfortunately, since those early days of yore, the focus for kidney disease has been on reducing costs, not improving treatments. Sure, we have incremental changes in equipment for dialysis and new ways to prevent transplant rejection, but really novel stuff? Not exactly.

We also have contracting funding for kidney disease research, Partly this is because chronic kidney disease disproportionately affects the poor, minorities, and other disenfranchised people. Even high profile patients like Alonzo Mourning and Sarah Hyland have failed to motivate congress.

We need more visibility for kidney disease. We need loud and even angry patients demanding research funding so that we can have cures. Dialysis works fairly well, but we can make it better with more research. Transplant is even better, but it is not a cure. We also do not have enough kidneys for every patient, and there are some diseases that repeatedly attack the new kidney, making dialysis the only option. While Medicare covers dialysis for most patients, it may not allow the optimal prescription for everyone. It also cuts off transplant immunosuppression coverage after a couple of years, making patients choose between their medications and other expenses.

In other words, despite our progress, we do not have kidney disease figured out by a long shot. Our patients, friends, and loved ones deserve better. We need to demand it, loudly and, perhaps, with some anger.

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