We Must Speak Up; We Must Speak OUT

I add my voice to the growing number of health care professionals and medical societies condemning the newest human rights violation by the Trump administration against our transgender community. The urgency of this issue is paramount! To deny health care rights during a global pandemic is both inhumane and absurd. Our trans patients and colleagues are already vulnerable due to the health disparities inherent in our system and biases from healthcare practitioners. Not only are out trans patients affected but all patients who fall under any part of our QUEER community in the past, present or future are at risk, making it even more difficult to be open and honest wit our health care providers.

Gender based and transphobic violence includes racism, murder and hate crime. It disproportionately affects black trans lives, especially black trans women. In the midst of the Black Lives Matter uprising and Covid19 the reversal of transgender health protections puts an immediate threat to black trans patients, and all trans BIPOC patients who identify as gender neutral or non-binary.

This recent action should be met with a call to arms from all medical professionals, including attending physicians, resident, medical students, nurses, APPs and staff. We must to do our best to provide trauma-based compassionate medicine and NEVER deny care for transgender patients nor any LGBTQ patients. The personal views of providers in any setting (outpatient, clinic, hospital or otherwise) must not be allowed to interfere with the right to health care. The recent COVID pop-up hospital in a Brooklyn park that denied transgender and LGBT care is an atrocious example of what the Trump administration is suggesting here.

There is a dearth of education for healthcare professionals from the earliest academic levels. Health disparities, intersectional oppression, and implicit biases of language, systems and structures have to be called out and addressed to stop this cycle of ignorance. Silence is clearly violence, and we cannot in good faith stay silent and allow conservative politicians to sacrifice health protection in the names of transphobia and racism – not now or ever again.

  • Kaiser Kabir OMS4 Lincoln Memorial University
  • Masina Wright, DO PGY1 University of New Mexico Hospital, Internal Medicine
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A Pandemic Wasn’t The Plan: Part 3 – Hormones 05/11/2020

Well, I bled for 16/30 days in April plus 5 in May. This is not my normal. This is pandemic menses. I don’t remember the relationships between cortisol, ovarian function and the reproductive cycle and frankly I haven’t had the energy to look it up again. I am also 46, so my ovarian reserves are low and having anovulatory/ short cycles could be the new normal until I get fully into bioidentical hormone replacement land. Still: Why such extended Abnormal Uterine Bleeding (AUB) ? And why this extended pain, expense and moodiness when I am already working long hours, alternating day and night shifts, and having to accept the global panic of COVID?

I have not changed much of my regular hormone regime. I have been taking bioidentical progesterone the second half of my cycle for the past 10ish years. Ovaries start decreasing progesterone production around 35yo often causing worsening PMS, cramps, and shorter lighter cycles. Taking progesterone lengthens my cycle from 21 to 26ish days and really helps with cyclic breast pain, bloating, cravings, PMDD and cramps. I had been on vacation when all this started and had not been taking it consistently 🙁

I also take testosterone as a subQ injection intermittently. It is prescribed as a weekly shot, but I tend to take it only every 2-3 weeks, mostly because I forget. Sometimes I forget to take it for months at a time. Cis female ovaries and adrenals produce small amounts of testosterone throughout the lifetime, and testosterone is the dominant cisfemale hormone of menopause! Endogenous production tends to decrease around age 40 as an average.

When I was working at Age Management Center, I tested dozens of women’s testosterone levels between ages 25-75 and it was extremely common to have very low levels: more common than normal levels! Optimization of this all-gender hormone brings a sense of vitality, physical and mental strength, increased muscle mass, heightened endurance, and improved orgasm strength (or orgasms, maybe for the first time!) It helps me have the energy to get to the gym and enjoy workouts. I also had an improvement in libido and sexual satisfaction. I have been taking this rx more frequently these days as internal medicine is *exhausting* so low T is not at the root of my hormonal shifts.

That leaves estrogen as the possible culprit, and this could certainly be the case.There are 3 different estrogens in the body that can be measured. Estradiol is the major circulating hormone that has all the beneficial effects – elasticizing bone, brain, blood vessels, and skin. Estrone is a metabolite of both testosterone and estradiol through aromatization and is theorized to have more inflammatory and proliferative effects. The ideal Estradiol: Estrone ratio is 2:1in the body. Estriol is the weakest estrogen and is localized to the uterus and vagina. This enhances vaginal lubrication and tissue health. It is also what is typically used for vaginal replacement in menopause or transmasculine health because it has less systemic effects. I am due to go get my hormone levels tested to see of I have had a big shift in estrogen levels. Lab work is ideal when done between days 19-21 of a cycle to catch all 3 hormone levels. I have not had any side effects of low estrogen yet, but as a 46yo, the decrease is coming.

I will likely transition to bioidentical hormone replacement when my ovaries retire fully. Humans used to go into menopause around 50-55 then die around 65. I do not think we were made to live an extra 40-50 years (90 yo) without any gonadal hormones. And as someone who will be in high productivity for many years head working in medicine, I will need these juicy, foundational, resilient, life giving hormones! Plus, I love the feeling of being strong physically, mentally, sexually and emotionally!

What about Breast Cancer you ask? Well, fortunately I do not have the gene that puts me at higher risk. I also eat lots of foods full of plant nutrients, antioxidants, fibers, and phytochemicals and good quality meats and fats. I exercise occasionally, especially out in nature where I can fill my lungs with fresh oxygen. I have a lot of stress in my life, but I do my best to counteract that with affection, loving kindness towards myself, sleep, mindfullness meditation, therapy, strong friendships and sunshine/water/flowers. Estradiol does increase proliferation of breast tissue; bioidentical progesterone counteracts that maintaining a balance of growth and suppression. Testosterone itself is also apoptotic meaning it is anti-cancer/ pro cellular health in nature. For me, in this body, having a well of hormones to draw from as I continue to function in the world is a source of inner vitality that I can give myself, even when my ovaries stop being able to produce it themselves. And, I will probably stop full bHRT after around 15 years, which is what evidence has shown is the time when long term hormone replacement therapy in ciswomen stops being as effective and starts to drift towards harmful. I may even just continue testosterone in those years which has less negative evidence as well as less links to breast pathology.

I have effectively convinced myself this was probably an estradiol dip in ovarian production resulting in a very short cycle partially due to low progesterone followed by an ovulatory but still low estrogen short cycle. Fingers crossed that this is not my new normal. I have also re-upped my commitment to taking my daily thyroid medication as well as adrenal herb supports, because the hormone systems all work in tandem and when one part is dysfunctional, others need to work extra hard. But the adrenal and thyroid systems are a whole other conversation for another day. And maybe I will read up more on the links between stress and hormones between now and then.

http://resources.ama.uk.com.s3-eu-west-1.amazonaws.com/glowm_www/graphics/figures/v5/0060/014f.jpg

Meanwhile, This Gal needs to get ready for her night shift in the COVID ICU. Stress. Yup. Exhausting emotionally and physically. Yup. My ovaries can probably read the cortisol and adrenaline levels in my blood and there may be another month of AUB ahead as my body instinctively tries to preserve its resources for essential functioning only in these pandemic times. At least I know what to do for it! I also did book an appointment with a new gynecologist to have an expert on board in case I need something like imaging or a more extensive workup. A Doctor cant always heal herself!


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Intermittent Starving vs Fasting

My IG and twitter feeds keep sending me promoted ads for intermittent fasting and young thin women in my Internal Medicine residency program keep telling me they are doing it. As someone with a hair trigger red flag signal for anorexia and eating disorders, I am triggered. As someone with a 20 year nutrition degree and as a gal raised with a spiritual practice of fasting, I do understand the value behind the concept. The problems start when restriction/binging/restriction patterns are overlayed on the foundational evidence.

This is the best nutritional protocol and evidence I found to implement intermittent fasting into a food plan for weight loss or for longevity. There is good reasoning and practice behind the idea that the liver stores glycogen for storage, and that this “immediate use” supply needs to be used up before the body creates new glucose from adipose cells and muscle. This is reasonable: fasting uses up the supplies . Then fasting decreases fat or muscle from stores.

Some fasting articles I’ve read suggest 16 hours between eating every day. This sounds anlot like the “don’t eat food after 7” rule that has quite a few generations of folks sleep binging and waking up covered in cookies.

Some articles suggest 16 hours between meals twice a week. This seems more reasonable to me as it allows for some pre-planning to have restful, quiet time during the fasting period. Our human bodies are not designed to “run on empty.” I grew up in a spiritual yoga community where fasting was part of the practice towards enlightenment, but work was not done during the fast. One’s time in the fasting state is to be spent meditating, reflecting, and processing (like while we sleep.) Yoga is also an acceptable practice during this time as it stimulates glands and organs as well as the musculoskeletal body to return to homeostasis. Fasting is designed as a parasympathetic state to rebalance cyp liver enzymes and clear the intestines. Pushing through fasting into sympathetic, highly motivated activity like mental or physical labor requires the adrenal glands to overachieve and drive metabolism through adrenaline and sheer will aka cortisol.

The one place where hard work on a fasting belly IS indicated is for anyone looking to lower insulin resistance by using the biochemistry of exercise. This could be someone requiring huge doses of insulin for only moderate blood glucose control, or someone trying to beat type 2 diabetes in the pre-diabetic state. Exercising on an empty stomach is one of the few ways to upregulate the special cellular receptors called GLUT_4 for insulin to bring blood sugar into cells. I have tried this and its oddly satisfying. Nerd out on biochemistry and GLUT-4 here.

I don’t intermittent fast intentionally myself. Some weekend days I wont eat food until 2-3 in the afternoon, just based on my natural appetite; however, I do have black coffee and water and sometimes juice during that time. To be my best self, I need frequent and regular fuel to keep this brain and body going for the intense work weeks I do. Not allowing myself to eat when I am hungry in not helpful for my mental health either – not only do I get edgy or feel anxious, my own disordered eating and body dysmorphia can easily be motivated by restrictive eating patterns.

Aside from mental health, some people also have genetic metabolic imbalances if their lineage experienced a traumatic food restriction. This has been researched in Irish descendants as well as Jewish folks. Caloric restriction can actually trigger a survival metabolism where minimal resources are burned and every morsel of fat possible is stored. This is ancestral trauma that has caused permanent alterations in your genome that get triggered by environmental circumstances.

The science is compelling though: improved metabolism, destruction of cancer cells, immune regulation, cortisol balancing, cellular rejuvenation…. benefits are numerous!

Here is what I would do if I was either doing a period of cleansing/detox and intentionally working on restoring health or if I was committed to a defined period of intentional weight loss (8 months from this algorithm.)

  1. Style 1: two mornings a week, fast until 12-1pm depending on your 16 hour window. On these mornings drink warm water, organic green tea or herbal tea, stretch and do yoga or go for a gentle walk, get into nature, rest/ meditate, write or reflect. Eat a Mediterranean style diet the remainder of the time.
  2. Style 2: For a more intensive weight loss experience, follow the algorithm for 2 days a week of restricted caloric intake from the JAMA article referenced at the beginning of this post. I would not also follow the time restricted feeding patterns myself as I find this too rigid for modern life and overrides the natural appetite instincts which are essential. Eat a Mediterranean type diet or Paleo. Consider pairing this with the Whole 30 protocol or an elimination diet for true restorative food as medicine. Follow the above guidelines for your calorie restricted days with rest, nature, reflection, massage, acupuncture or other healing practices, whole organic foods, teas and water. Once you have completed month 4, return back up the protocol until you are back at full weekly caloric intake and reassess.
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A Habit is Harder to Break than a Heart

Ugh. New Years Resolutions. Worst idea ever! And yet – I had a tough end of 2018 personally so I decided to make some resolutions in an effort to bring structure and more wellness to my life.

Well, it is 13 days in and I have already failed all of my official resolutions. In fact I failed my first one in the first two days of the year:

1. spend less time on my phone, especially in the company of people I love

Excuses are bountiful. However, If you are in the same boat as me with lofty goals and a complex life, I encourage you to think about resolutions as a year long goal, not something to be abandonded by week 3. It could take even 3 years to build the structure that you need to support the foundation of your bigger dreams/resolutions like an art or writing studio and time to produce new work.

The Winter Solstice (12/21/18) is when we annually rekindle the spark of the year ahead. This tiny flame grows to a raging bonfire at Summer Solstice with our culling and tending and then dwindles down to the blue flames of Halloween and Nov-Embers. Then the cycle begins anew with the next Winter Solstice.

If you looked at your resolutions as a fire you were to tend for a 12-36 month duration, would that change your approach? Your commitment to your Self or Visions?

I have things about my lifestyle I need to adjust, and those are built on deeply entrenched habits that function as crutches that allow me to perform in my hugely challenging day to day life. I cannot just pull the supports from my foundational Activities of Daily Living; I CAN build new supports/habits to relieve the not-so-functional structures.

Building a new wellness foundation takes a team or at the very least a multifaceted approach. I failed my New Years Resolutions the first week because I did not have my new structures in place to support them. I now see who and what I could rely on to make this reality functional, and this second week of the year I was 50% more successful in my goals.

What are your NYR? What changes do you need to make this happen?

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Notes from the Road: Buenos Aires WPATH

I am in beautiful Buenos Aires at my second World Professional Association for Transgender Health. My first was held in Amsterdam in 2016 when I was a fresh faced, just-finished first year medical student. Now, as a mid-fourth year student I am significantly more exhausted and disillusioned; I also have so much more doubt about choosing this field of medicine as my calling.

I like to tell the story that I returned to medical school to practice transgender health. Specifically, to be able to prescribe transitional hormones and participate in the insurance racket to reach more people. And that is part of the story. The root truth is I have been compelled to be a full scope physician for many reasons and transgender medicine gave me a focus because it was something I could not attain as the Naturopathic Doctor that I was before.

The last session I attended at the WPATH ARGENTINA conference was an incredible and inspired panel of Brazilian intellectuals speaking on depathologizing the transfeminine and deconstructing cisheteronormativity. Fran Demetrio, a transfeminine Brazilian professor was so passionate and eloquent in her discussion of injustice, oppression, systemic violence and the colonization of knowledge imported by biomedicine. She was being translated which made some of the discourse hard to fully comprehend and I wished WPATH had provided a professional translator for her because what she had to say was so profound and important and well thought out. She framed a paradigm that took the personal out of the conversation and raised it to a social construct and human justice level. In rough translation, she explained that not including the existential experience of trans voices in episystemic medical knowledge creates symbolic violence and perpetrates the colonialism of transgender relationships. This generates mental health violence and tramples the [transgender] patients knowledge. Considering and understanding this is essential to depatholgize the trans experience.

Despite the  multiple disparities that this population faces world wide, there is a slowly increasing body of trans identified physicians and health leaders in the field. However, to date  many of the people making the decisions about gender medicine are not differently-gendered themselves. Surely, this is problematic. The numbers of trans identified health care leaders is increasing by the year, and with groups like the Transgender Professional Association for Transgender Health, they are seeking greater control around the discourse of gender medicine and claiming their place as necessary voices in the didactic.  

The tensions between cis and trans leadership has created a simmering anger within this medical community. A socialist friend of mine shared that in activism in general there is a current trend towards challenging aggressions towards advocacy leaders in many different fields with a similar theme of  – who has the power to speak and represent the cause?

I was personally attacked in this rising conflict this year when I created a transgender health elective as a third year medical student for global medical students to supplement core medical school curriculum. A variety of trans and nonbinary people on social media threatened to create a petition against the course as it does not have a transgender identified course leader and there were multiple flamings on Facebook. I personally received several vitriolic emails from different people about the course, its content, and my leadership. I was privileged to have a team of (cis and transgender) people who have been in the field for a long time holding leadership positions to assist me in creating online and email responses that were balanced, appealed to reason, and illustrated the many ways the course seeks to uphold and respect the “nothing about us without us” principle while promoting evidence based foundational medicine.

I brought up this conflict between cis and trans leadership in the didactic of transgender medicine again at one of the ethics seminars at WPATH, where leadership and authority privilege was being discussed. Unfortunately, I was emotional in my questioning of the ethics behind attacking ally’s and advocates, as I am still deeply shaken by this experience. The response from one of the panelists was that when working as a non trans person with the gender diverse community there is so much anger one must simply expect to be attacked and be ok with that.

I am a person who has been excavating emotional violence in my personal life and creating real boundaries to protect myself for the first time. I don’t think I can intentionally choose a career were the population I am exhausting myself to serve reserves the right to be emotionally violent towards me indiscriminately because of their experience of violence. That is like saying that my mother has the right to be violent towards me in any way she sees fit because of the abuse she and her mother suffered. No.

Again.

not  including the existential experience of trans voices in episystemic medical knowledge creates symbolic violence and perpetrates the colonialism of transgender relationships. This generates mental health violence and tramples the patients knowledge. Considering and understanding this is essential to  depatholgize the trans experience. “

Dr. Demetrio’s message ultimately lifted my perspective of the conflict to a healing systems approach. With this in mind, I am still recalibrating my commitment to trans health as a specialized field of medicine, while intentionally making room for the many trans identified health care leaders. As a nontrans woman and a white queer/lesbian, I devote the next phase of my medical education to the foundations of internal medicine as well as lesbian health, vaginal happiness, fertility, community health, and queer health issues like addiction and mental health. My view of women’s health includes trans and cis women, as does my passion for community wellness. I am confident that these past 11 years of studying transgender medicine and advocacy work will continue to inform the communities I serve, if in a less direct way.

I see now that when I claim my leadership vision within a paradigm that matches my own identity I can be stronger and more authentic.

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I Always Bring My Lunch

I was in NYC in August this summer, doing a short 4th year medical elective at the Center for Transgender Medicine and Surgery. I did some couch surfing, and stayed at an Air BnB in Williamsburg my last week. Medically it was an outstanding experience, and in my dream future, I will get to be a physician working at this clinic in Manhatten. Being away from home, I realized how much I rely on having my own kitchen! Making my lunch is I keep my body feeling good despite spending most of my time working in a hospital or relaxing in bed.

What do you do for lunch every day?  By lunchtime every day, I will eat basically anything. I sometimes eats my lunch at 10:30 AM I am so hungry. The more glucose my brain is burning, the more I need that hit of fat, phytonutrients and fiber.

Therefore, my cunning plan is to eat super healthy sometimes boring basics for lunch – lots of veggies, good quality fats, high fiber fruits, raw vegetables and very few processed carbs. Then,  I dont have to think as hard about what’s for dinner and still maintain a good nutrient balance.

So, what do I actually eat? Greens and grains, with cheese, avocado or nuts/seeds and random chopped veggies like carrots, cucumber, tomato, radish. In summer I love to put flowers in my food. A grain free diet is popular with the keto crowd, but I advocate to have at least a few cups of whole grains in the diet per week. The fiber, magnesium, B vitamins and serotonin release metabolically help keep the mind-gut axis regulated. We rotate our grains between short grain brown rice, wild rice, quinoa, and millet to maintain variety of flavor and nutrient profiles.

I heard once in a conference lecture that nutritional studies were done evaluating T4 –> T3 conversion activation (active thyroid hormone.) Subjects were fed fat based diets, protein based diets or carbohydrate (CHO) based diets. Only the diets with carbohydrates evidenced thyroid hormone conversion. Since I am a huge fan of having optimized T3 production for an effective metabolic mileau, I advocate for having a moderate amount of whole grains in ones basic nutritional foundation.I wish I had the study in-hand to back this up but I dont; maybe once I am out of medical school I will have time to research these things more fully. The bottom line is that whole grains are good for health and tasty and I like them in my lunch. They are filling and delicious and beneficial.

I like to layer the grains on the bottom, then a huge handful of greens – whatever has the latest expiry date when I am shopping! We rotate spring mix with herbs, arugula, baby spinach, crispy green leaf lettuce, and occasional kale salad (leftover.) I need fat with my lunch to feel satisfied, so I douse the whole thing with yummy olive oil and a delicious vinegar like balsamic or umeboshi or fire cider vinegar. Then, I add some protein: cheese is the easiest and I love cheese.  Tuna, egg or chicken salads are always a win too.

I also love toasted walnuts, pecans, pumpkin seeds or sunflower seeds. I buy them raw, and toast them in a dry cast iron pan until they are warm and smell nutty but not burnt. Make sure to stir! I store these in glass jars in the cupboard. The pumpkin seeds are best toasted with some Chalula hot sauce and cumin! Yum. These add a crunch, some richness, protein, and delicious essential fats. Finish the lunch with 2 chopped veggies for color, fiber, and variety: an organic carrot, cucumber spears with pepper, pepper slices, whatever floats your boat.

If you are a hard paleo and refuse grains, or if you are like me and sometimes need a second lunch or a hearty snack then organic nitrite free salami is a good addition. It is filling, savory, and works well with olives, carrot rounds and other veggies for finger snacks. Just veggies is not enough for me.

Lunch Plan B: huge leftovers fan here. If I go out to dinner, I almost always save half for lunch the next day. This is a win-win, because I stop eating when I am full (or save room for dessert) AND I have a pre-made meal to go. I hate waking up extra early to deal with lunch, so I usually get lunch ready the night before. We generally also cook for more than two, planning a lunch or two and maybe even a supper into every meal we co-create. Leftovers are exciting to me because these are usually rich yummy comfort foods like pasta, steak, curries and other “real meals”.

Finally, making lunch saves me money. The first day of my August rotation I went to the nearby Whole Foods for lunch. I wasted 15 minutes wandering around the hot and cold bars, trying to figure out what to eat. My $15 salad ended up being an awkward mish-mash of flavors that did not blend well. That day after work I went and bought $40 worth of groceries (almond flour crackers, apples, greens, cheese, nuts, yogurts and paleo granola for breakfast)  and brought my lunch to work every day for the next week, supplementing with enchilada leftovers.

Bringing your lunch ensures you know exactly what you are eating. It keeps you committed to your intentions with food, and lines up the healthy choices for you in moments of  “Im Starving” brain meltdowns that would otherwise allow for easy Trash. It is also a great way to plan your daily insulin for diabetics! Finally, it frees up dinner for more social food activities that may be less greens and grainy.

Oh, and bring a snack, maybe two. For Fall and Winter I find an apple is the hardiest fruit. Combined with nuts and raisins, it’s a great choice. Someone once said, if you dont want to eat an apple, you are not actually hungry. This holds true as long as your teeth are in good shape.  In winter and summer, cut up fruit like citrus or stone fruits an berries are refreshing and delightful. I also love dried mango slices from Trader Joe’s. If you crave yogurt and aren’t having it for breakfast, it’s a good option too. I love the dairy-free yogurts too like soy, almond and coconut singles, which are far better choices than anything a vending machine or a cafeteria might offer.

My basic formula is eating good quality food 65% of the time. Then I can easily process about 35% cheeseburgers, nachos, pizza, sweets, and other junk. To change your body composition this may need to become more like 75:25 and exercise has to be added in. I eat at least 60% of my daily food at work between 9-5pm. If I make sure these foods are healthy, wholesome and invigorating to my brain and bowels, my nutritional work is done for the day. Yay!

 

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Embedding Resilience in Medicine

      Half an inch from the first four thoracic vertebrae lie the central nervous system transistors (stellate ganglion) for your fight and flight nervous system. Needless to say, my upper back is constantly aching. I am metabolizing the unique stress of being a brand new doctor/medical student in hospital life. It’s a different kind of stress than the first two academic years: those were crushing content & exams, but they were ivory tower academia. This is the very real medicine that is literally birth, life and death stuff. More visceral than literal, I find myself often crying,  sometimes gagging, and occasionally elated.

The purpose of third year clerkship aka #MS3 is to get a sampling of each major specialty to help us decide on a residency. Its a generic med school formula consisting of: Pediatrics, Surgery, OB/GYN, Internal Medicine Inpatient & Outpatient, Family Medicine, Psychiatry, Community Health. Inpatient, we legally cannot write patient notes. While we can actively participate in patient care,  everything we do needs to be seconded by a licensed doc; therefore, we are mostly shadows, errand runners, and absorbent sponges.

Unfortunately, some throwbacks to fraternal physician hazing rituals are still in place even for third year medical students. For example, my Internal Medicine inpatient rotation, which is already a 6am – 6pm shift 5 days a week (with a 1 hr drive on each side) also requires 6 -24 hour shifts in the 6 weeks. I asked a friend who is a year ahead of me and attended a different hospital clerkship if her rotation was scheduled as such, and she said she had to follow hospitalist hours for that same rotation – roughly 730am – 330pm. If the point is to learn each of the specialty’s roles, it makes sense to follow the professional hours. If the goal is to teach us that Internal Medicine requires an exhausting slog of hospital life, and how to forsake all other aspects of our personal and academic life for our career, then this approach in third year makes sense. Slate Magazine said it best: Third Year Kills Humanity of Medicine.

I haven’t done the above inpatient IM rotation yet and yes, I’m actively worried about my health, my marriage, and my coping skills during that onslaught. I did one 86 hour “sneak peek” week with our Family Medicine inpatient service last Fall.  I did enjoy the steep learning curve and patient contact; however,  I often felt lost and useless as my resident dictated her many notes and ran around the hospital following up on pages and other details. I did get some good studying done and learned some basic inpatient skills but there were hours, especially after the first 8,  that I wished I had something more productive I could be doing in.

In reality, the residents are much more forgiving than the administration and often let us leave early (6am – 10/11pm) saying “there is nothing we could learn at 2am that cant be learned at 2pm.” I am eternally grateful for this ray of grace. And I do understand that night shifts and on-call hours are foundational for many physician careers and practicing them could be relevant.  But why, when 55% of Internal Medicine and Family Doctors report burnout, are we being subjected to these mind numbing hours as third years? How will medicine ever change if the hazing continues to be perpetrated generation after generation?

I accept that being a doctor requires selflessness & sacrifice. I accept that long hours are often required and I like to work – for an income, for a team, and for a good reason. I’m a second career medical student, I study and practice clinical skills because this is what I love! I accept that as a resident I will bear the brunt of hours spent watchdogging and admitting in part because we are the cheap labor force of institutionalized medicine. But, I have 1.5 years of med school left, and 3-6 years of residency/fellowship ahead. What is the purpose of having me work 86 hour weeks now,  and how is it going to benefit my relationship towards medicine?

To embed resilience in doctors, we as a profession and as an academic incubator need to provide time & space for rest, relaxation, and quietude. Only in parasympathetics can we metabolize the soul-rattling experience that comes from facing death and sickness and the burden of chronic disease in North America. Not only are we facing grief/loss/mortality, we are taking on the enormous responsibility of decision maker. A backlog of unprocessed emotion leads to substance abuse, chronic pain, sleep disorders, lack of compassion, and who knows what other organic & chemical dysregulation. We need regular daily time to cook good food, sleep with our loves, be intimate and vulnerable, Netflick and chill, get to the gym or get outside. Only in that space can we emotionally integrate this transformation.

Our clerkship Dean Dr. Taylor sent out this  reaffirming blogpost last month in which an experienced physician Dr. Youngson writes to his younger self. He says:

     “As a medical student or junior doctor, it’s easy to feel powerless especially in a hierarchical medical system that too often teaches by humiliation, punishes those who question the status quo, and grinds people down through overwork and inhuman working conditions…”

Change medical education so that we as medical students (and residents and attendings and all doctors actually) are seen as people who are more than life-saving, problem fixing, chart dictating, disease curing machines. A more gentle, humane practice of time & space for medicine while living life alongside the role of physician has to start at the beginning of the clerkship year when we integrate it’s practice with our academic foundations, or it wont be ingrained as part of the way we approach medicine.

Once I started thinking about time, resilience and integration as the cure of medical burnout, I began seeing evidence everywhere. I heard a NEJM Interview from 01/03/18 with Dr. Armstrong from Massachusettes General Hospital’s new Pathways program where residents are given time and a scientific team to investigate complex patient-based cases. The 12/26/17 issue of JAMA has an article by Jack Coulehan, MD MPH from the Center for Medical Humanities, Compassionate Care and Bioethics on Negative Capability and the Art of Medicine that speaks to “sustaining the physician through the ‘humdrum routine’ of professional life… [Using]… the power to recognize the ‘true poetry of life'” and of medicine. This is a reflective practice. He says:

In pursuing the steadiness and detachment required to master clinical practice, it is tempting to neglect the more difficult project of nourishing engagement and tenderness in our relationships with patients – and with ourselves.”

The future of medical education is not only about competencies met and clinical acumen. The true scholars of the next generations of physicians will be those who can achieve their best in patient care and scientific fulfillment, while also living a satisfying, integrated and joyful life.

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Gender Affirming Health Care: Top Ten Tips

This article was written for the American Medical Student Association journal The New Physician October 2017. The original can be found at this link: http://mydigitalpublication.com/publication/?i=445109&utm_source=webtoc&utm_medium=referral&utm_campaign=O17#{“issue_id”:445109,”page”:1}. Volume 66, Number 5.

Picture this: it’s your second day of practice. You graduated medical school, made it into a residency, and now it’s time to be a doctor …. In walks your third patient of the day – medium height, medium build, medium length black hair, charming but shy face and awkward smile and – your quick-fire practiced analysis stops there – frozen, you can’t tell if this person is a girl or a boy. You glance at your paperwork. First Name: Robin. Last Name: Also Unhelpful. The person is talking in a midrange tone, and you aren’t listening because you are frantically scanning their body to figure out what lies underneath the black tee-shirt and dark Levis. You look up at the persons face and see it start to close as they observe you floundering to see past their gender.

Transgender Medicine is a newly emerging subspecialty, but every health care professional is already seeing transgender patients. Trans people have always been a part of every culture worldwide; in the last ten years there has been a public blossoming of gender expression in social media, television, and probably your personal family or friend circle as well. Transgender people have come out as part of our modern society, and as physicians we need to be culturally and medically competent enough to provide good medicine for this community.

As of 2017, there are several epicenters of transgender medicine, research and scholarship worldwide. The Dutch are famous for their longitudinal body of evidence on transgender health, as they have been collecting research and academic scholarship on transition medicine within their socialized health care system for over 30 years. As such, they have a tried and true so-called “Dutch protocol” for male to female (MTF) and female to male (FTM) transitions that has been used as a template for most international Standards of Care.

The US has several gender specialty clinics that conduct research and offer high quality trans health care. These clinics and hospitals are also key players in this rapidly evolving area of medicine, surgery and research. The best known of these include:

  • Fenway Health Center in Boston
  • The Center for Transgender Medicine and Surgery at Mount Sinai in NYC
  • The Mazzoni Center in Philadelphia (which puts on the free Philadelphia Trans Health Conference annually)
  • The Center of Excellence for Transgender Health at UC San Francisco

For future and current physicians interested in Transgender Medicine as a specialty, the key areas for concentrated trans care are Family Medicine, Endocrinology, Psychiatry, Surgery/Urology and Pediatric Endocrinology. There is not yet a fellowship available in Transgender Adult or Pediatric Endocrinology (Coming Soon!) but the first fellowship in Transgender Surgery has been piloted this year at Mount Sinai in New York City.

Whether you want to dive into the depths of the transgender community and learn the intricacy of this rich and diverse community or not, as it was said before every physician will see trans people in their career. Take the time now to become familiar with the basics of transgender health literacy, for your professional integrity and your patients.

TOP 10 TIPS FOR BEING A TRANS FRIENDLY PHYSICIAN

DON’T GET HUNG UP ON IDENTIFYING GENDER IN THE FIRST 3 MINUTES. Gender and Sexuality Identity begin to develop at 2-3 years of age. Your patient has probably been trying to figure out their gender for a whole lot of years before they showed up in your office, so chances are their gender is more complicated than your 10 second evaluation. Once you notice you can’t confirm male or female specifically (spoiler alert: you may be wrong in your assessment) MOVE on with your objective assessment and Listen to what the person is saying.

THEY IS THE NEW SINGULAR PRONOUN: For some people, She doesn’t feel comfortable, but neither does He. Some people live in the space between male and female, and those definitive English pronouns can feel extremely uncomfortable. Being mis-gendered by pronouns is also surprisingly hurtful to trans people. “They” is a neutral pronoun that just feels more comfortable for some people. Why not use it? (Ps. Please don’t use the “it’s just not good grammar” argument because chances are your grammar isn’t perfect otherwise; and, while it may commonly be an English plural pronoun, Latin-based languages have pleural pronouns that can also be used in the formal You/singular.) Again, the use of “They” is really helpful to some people for communication purposes, so embrace it, try it on every day, and get used to it. In fact, it really comes in handy when referring to someone whose gender you can’t figure out, as in saying to your attending “I’m not sure what’s wrong, but they look really terrible, would you come take a look?”)

ACCEPT THAT SOME PEOPLE LIVE OUTSIDE THE LINES: Technically, the term is “non-binary” for people that don’t neatly fit into the sex-gender binary of male / female. This is a complex spectrum of identities that can be any shape or form and have any meaning for an individual. The non-binary space can be intentional with hormone use, or how people are born or mature. For people who have always fit within the binary, it can be hard to remember that other people LIKE THE WAY THEY ARE. It isn’t our job as physicians to try and get them to fit within a specific box. For other people, the non-binary identity may be a stepping point, a transitional space, or something they struggle with. As always it is simply our job as health care providers to create a safe place where people can talk about their health care needs, and help them get these needs met.

STATISTICS DON’T LIE: Not a lot is known about trans health care seeking behavior from an evidence based perspective, but from my community I know that many of my gender minority friends avoid health care due to bad medical experiences being misgendered, disrespected, or worse assaulted/insulted or denied care. From the research that does exist, the statistics are alarming. Dr. Angela Carter, a transgender physician from Portland, Oregon writes “One in 5 transgender people have been turned away from healthcare because of their gender, and an estimated 30% have avoided seeking care due to fear of discrimination. Reports suggest that 50% of transgender people have had to teach their physician how to care for them; 24% of trans people have been verbally harassed while seeking care; and, 2% report an actual physical assault while trying to get care.Read more of her great Trans Health 101 article here: http://ndnr.com/endocrinology/transgender-healthcare/.

PAPERWORK: What is named, exists. If you have a box for Transgender or better yet Male to Female, Female to Male, and Gender Nonbinary on your intake form or embedded in your EMR next to Male and Female, you can have that helpful self-identifying information at the first encounter. At the same time, this improves the patients visit experience, offering a named identity and acceptance from the first encounter. Make sure your staff are educated in trans cultural competency as well. Include training elements like being compassionate and respectful with patients who may have gender incongruent birth names, insurance navigation, and associated pronoun use.

EMRs – UN/NECESSARY EVILS: It will take a long time and many years of advocacy work before most hospitals EMRs are updated to contain alternate gender identities; however, having staff who are trained in ways to communicate about gender differences can soften the experience for the person who is in an acutely ill and vulnerable state needing medical care. For example, triage personnel (and med students!) could say “”So, I know this may be a difficult question right now but what is your preferred pronoun and what is your is gender designation on your health insurance?” This non-judgemental approach leaves space for the person to give an answer without an explanation and conveys compassion in a business-like open-ended manner.

DON’T JUDGE A BOOK BY ITS COVER: Many trans people “pass” for their chosen gender completely. We need to be mentally and medically prepared for providing effective and competent health care to people who physically inhabit bodies that are hormonally and anatomically complex. Doing this work AND exploring your own personal, moral, or religious complexities of feelings about trans gender and identity needs to be done BEFORE that patient walks in your door needing your professional skills as a doctor, not your human opinions.

KNOW YOUR RESOURCES: The World Professional Health Association (wpath.org) has been the guiding force and academic collective of transgender scholarship for the past 30+ years. WPATH has been at the heart of the conservation and documentation of the protocols used for transitional medicine. There is a published a Standards of Care (version 7.0) that is available online and in print. University of San Francisco also has a superior online learning center with everything you need to know to start basic primary trans care including evidence based protocols. http://transhealth.ucsf.edu/trans?page=guidelines-home. Fenway Health is the east coast online epicenter for trans health resources and reading and has great free training webinars http://fenwayhealth.org/care/medical/transgender-health/. Take an afternoon and familiarize yourself with these sites, bookmark them, and pass them on.

KNOW MORE RESOURCES: No one should have to travel beyond state lines to get competent medical care. As with most kinds of medicine, having a grasp of your local resources is essential, especially for primary care docs who just can’t do everything (contrary to popular belief.) Know who is providing competent transgender primary care and endocrinology for adults and for children in your area, who has experience with transition hormone therapy, where to refer for respectful electrolysis and other cosmetic procedures, and who is offering the basic surgeries like mastectomy in your part of the world is a great way to provide your gender minority patients with access and resources. If there isn’t anyone offering these services, consider taking a WPATH certification course and becoming that person.

DON’T BE AN ASSH**E: The best thing to do when you make a mistake is apologize. I have over 10 years of professional experience with trans health and gender non-conformity has been part of my social circle for 20+ years and I still unfortunately misgender people, use the wrong pronouns, and say awkward things. And then I apologize and learn from my mistakes. Doctor-patient relationships are built on an exchange that requires integrity and some transparency. You don’t have to be the expert in trans medicine- your patient is the expert in what their body (mind spirit) needs. Your job is to help them maintain a safe and consensual medical space where they can address health concerns and work towards their optimal self-expression. This may include transitional hormones and gender affirming surgery for some, or it may be flu shots and cholesterol testing for others. Or oncology. Or labor and delivery. Or sickle cell anemia. Who knows what the person will need, trans people are people and you have one in your office right now. What will you do?

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Balancing with Ayruvedic Medicine – from Womens Power to Heal

510fafgjdbl-_sx336_bo1204203200_I am doing an Integrative Medicine Scholars program through the AMSA and we have to do a project to explore some aspect of Integrative Health. Ayurveda is a practice of medicine I don’t know much about, so I decided to do a personal practice incorporating lifestyle, nutrition and herbal medicine principles for the month of January. My friend Cathleen Miller helped me to figure out what my Dosha is (constitutional type) and lent me this amazing book, and …. here we go! Below is an outline taken directly from this text for (my) Pitta-Vata type.

Balancing Pitta-Vata Rhythms –

  • Rise with the sun and go to bed by 10 pm – maintain steady eating and sleeping routines
  • Ease yourself out of all stressful activities and maintain only those projects that create ease – allow adequate time to complete projects
  • Take ample rest
  • East wholesome, fresh, moderately warm, moist substantial and calming foods.
  • Avoid bitter, cold, raw, hot, spicy, oily, salty, fermented or stale foods and stimulants.
  • Shield against hot, wet, humid, cold, damp, or stressful environments.
  • Embrace serenity, love, warmth, healthy rituals and calmness.

Nutrition Principles

AVOID: caffeine, refined sweets, alcohol, saturated fats, excess salt, oily and spicy foods, and commercial dairy projects, as well as highly processed junk foods, meats, additives, frozen, canned, commercially grown, bioengineered, transgenic refined salts, sugars, flours and hydrogenated oils.

CHOOSE:

VEGETABLES Broccoli Brussel sprouts cabbage Cauliflower
Artichokes Asparagus Bamboo Bitter greens Black olives
Celery Cucumber Green beans Dark greens Parsnips
Peas Potatoes Sprouts Summer squash Sweet potato
Winter squash yams Watercress Bok choy Carrots
Daikon Beets Leeks

 

FRUITS Apples Apricots Coconuts Dates
Fresh figs Oranges Pears Pomegranate Tangerines
Mango Plums Raisins Quinces Limes
pineapple Avocado Banana Grapefruit Kiwi
Lemon Peaches Tamarind Rhubarb

 

LEGUMES Aduki beans Mung beans Kidney Lima
Lentil Navy Pinto Chickpeas Tofu
Black beans

 

NUTS Coconut Roasted sunflower seeds Roasted pumpkin seeds Poppy seeds
Water chestnuts Macadamia nuts Sesame seeds Pecans Walnuts
Pine nuts Pistachios

 

DAIRY Unsalted butter Cows milk Cottage cheese Sweetened yogurt
Buttermilk Whole cows milk cheese Cream Ghee Sour cream

 

OILS Sunflower Almond Olive Coconut
Dark sesame Light sesame

 

SWEETENERS Maple syrup Dates Sucanat

 

SPICES Coriander Cumin Cardamom Cilantro
Curry leaves Dill Fresh basil Fennel Turmeric
Saffron Peppermint Spearmint Ginger Anise
Mustard seeds Sage Nutmeg Thyme Ginger
Cloves Rosemary Tarragon Oregano parsely

 

Practices

  • New moon journalling with saraswati mantra – Aim Sarasvatyai Namaha
  • Ginger compress one week before the new moon (unless bleeding)

1 gallon water

1 handful grated fresh ginger

1 lg stainless steel pot with cover

2 stainless bowls

  Bring water to a boil, and add ginger secured in a ouch with a drawstring. Squeeze the  pouch to release the ginger juice and drop into the water. Simmer 30 minutes. Let sit 5 minutes before uncovering when taken off the heat. Create a compress towel and apply to lower back for 4-5 minutes or until lukewarm. For full instructions, see text p. 264.

  • Rose Oil Pichu – for headaches, hair loss, pain in the eyes, poor vision, mental fatigue and nose bleeds. Pichu: a powerful lubricating and loving therapy that helps maintain mental calm, emotional equanimity and helps balance the doshas. Best time: waxing moon phase. C/I bleeding. Best time: morning or early evening.

¼ cup dried roses

1 c sesame oil

Bring to boil over low heat and remove from heat, Add rose flower, cover and let steep 4-6 hours. Strain and use.

PICHU instructions: need pottery bowl, 12 “ clean cotton square and cotton hand towel.

  • Wash hair a few hours before
  • Release all stressful thoughts and details from the mind
  • Assemble the supplies on the floor close by
  • Soak the cloth in oil and lie down; place the cloth ear to ear. Press down on the cloth and wipe away excess oil
  • Rest quietly for 30 minutes and rise slowly, use hand towel to wipe away excess oil and maintain a peaceful attitude for the rest of the day.
  • Shakti Mudra – should be daily but 3 times per week seems doable – enhances sense of self, reinforces femininity, self esteem and restores vital energy to the womb.

Sit facing east

Bring palms together and separate slowly

Form the Shakti mudra hand position – see p. 192 text

Breathe deeply into pelvis and breathe out slowly, tracing the exhalation from the base 0f the perineum, circulating through the uterus and belly

Maintain for 15 minutes

Take a deep breath and make a commitment to a life of non-hurting

 

  • Yoni Mudra – 3 days before the new moon and full moon to revise Shakti prana.Not when bleeding.

Sit in meditative practice with palms facing up

Create the yoni mudra hand positions – see p. 155 text

Hold the hand gesture for 5 minutes

Allow breath to flow freely throughout the body, keeping the mind centered

HERBAL MEDICINE

Herbal Teas for PMS – Vata type predominant – take for 3 days of the new moon as well as the 5 days before menses

Helpful herbs: nutmeg, valerian, triphala, ashwaganda, shatavari, cinnamon, turmeric, fennel, dill and wild yam.

CINNAMON, CLOVE AND CARDAMOM DECOCTION (VATA) for PMS

2 c water

2 c organic milk

1 tbsp cloves

1 tsp cinnamon

1 tsp cardamom

½ tsp ginger

1 pinch saffron

 

LAVENDER FENNEL GINGER TEA DECOCTION (PITTA) for PMS

I c water

1 c organic cows milk

1 tso roasted fennel seeds

1 tbsp lavender petals

1 tbsp hops

½ tsp ginger powder

1 pinch saffron

bring water and milk to a boil. Toast the fennel seeds, then add all herbs and spices and simmer on medium for 15 minutes. Remove from heat, add saffron and stand 3-5 min before drinking.

 

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The Pitfall of Alcohol

I’ve been avoiding writing this post for at least a week, probably two. Mostly because it has personal meaning to me as alcoholism runs in my family on both sides – My mothers father was one of the “Mad Men” of the 50’s, worked in advertising and died of liver failure due to alcoholism. I guess he got pretty ugly in the end. My paternal grandparents didnt drink at all (which leads me to wonder if their parents were alcoholic) but all of their children have a penchant for the sauce.

Before I was a medical student, I thought the damaging effects of alcohol could be traced directly by measuring liver enzymes – and as long as those harbingers of hepatic cell death stayed within a reasonable limit, one was “getting away” with whatever one was doing. Enter: neurology. Boy was I wrong. Oh and Ps. Dead liver cells cant release ALT or AST, so good liver enzymes in the face of chronic alcoholism is actually a pretty bad sign.

The blood brain barrier is an effective barrier to most things except: nonpolar and lipid soluble molecules. Enter: CO2, O2, and ETOH (alcohol.) This means that as soon as alcohol is in your blood, it is seeping into your brain. And brain cells/ neurons are permanent cells – they don’t have the ability to divide, so they don’t replicate. You get what you started with – some axons can be regenerated, but once the cell body dies, your numbers start to decrease.

gait-ataxiaThe cerebellum is one of the parts of the brain most affected by alcohol cell death; this is why people become unsteady and clumsy anterior-vermiswhen drunk – inhibition of cerebellar function! There are multiple and complex inputs to this lower brain region from almost every aspect of the nervous system, so it can compensate for loss of neurons (when sober) for a long time. Up to 80% of cell death can happen before symptoms become noticeable! Unfortunately, once this is happening in the sober state, the cells are dead and there is no ability to recover balance or coordination.

I didn’t know that memory loss is also a component of chronic alcoholism. There are two halves to the cognitive decline that will happen eventually called Wernicke-Korsakoff syndrome, and these are from alcohol related destruction to two more areas of the brain.

confusionThe first set of symptoms is reversible, and is related to a deficiency of vitamin B1 aka thiamine. The mammillary bodies are wee nubs on the underside of the brain that are part of the social and emotional brain. They take information from the hypothalamus and hippocampus, and run it to the anterior nucleus of the thalamus. nrhpth08

 

 

 

 

This is a critical loop in emotional and social behavior integration at a cognitive level. I guess this is partially where the numbing effect of alcohol on the emotions could occur? With a deficiency of B1, the mammillary bodies hemorrhage and cause Wernickes encephalopathy, characterized by confusion and your eyes not tracking properly, as well as the unsteadiness from the damaged cerebellum. This is why in hospital treatments, alcoholics are first given thiamine/ B1 to see if it can reverse the symptoms. From a prevention standpoint, taking a good quality capsule (not tablet) daily multivitamin seems like a good idea for anyone drinking on a regular basis.

This condition can progress to irreversible memory loss for the past, with an inability to make new memories, plus psychotic symptoms. This is called Korsakoff psychosis. As people lose their ability to remember, they start making things up to fill in the blanks called confabulation. This can be really depressing for friends and family members as it becomes clearly evident that the damage is permanent.

and THEN, there is the metabolic damage that is occurring below the neck. (This next section is biochemical mumbo jumbo, but since this is my review exercise, I’m going to include it for my medical interest:)

screen-shot-2016-09-26-at-12-32-00-pmEthanol/ your drinks/ are 80% broken down by cells (cytosol) of the liver. 15% of alcohol is broken down by microsomes in the brain and liver, and this pathway is upregulated in chronic alcoholism. The remaining 5% are converted to fatty acids and phospholipids that are thought to play a role in tissue damage. Both primary pathways break down ethanol to acetaldehyde, which is metabolized  down to acetate…..Acetate, where have you heard that before? yes, NAIL POLISH REMOVER, flooding your liver and brain.

The major metabolic consequence is from the elevation of NADH that occurs in the cell and in the mitochondria in steps one and two with excessive and continual amounts of alcohol intake, because this NADH will inhibit the TCA cycle from running. No TCA = no glucose metabolism = no fuel for the cells. The brain will still need fuel, so the liver cleverly shifts the glucose from the alcohol (which can no longer be metabolized) to ketone production + free fatty acid synthesis (aka fat storage.) This explains, in painful detail, why alcohol makes you gain weight and affects blood sugar levels.

screen-shot-2016-09-26-at-12-36-56-pmFinally, I wanted to add this last slide for an important prevention note. This is the process of the 15% microsomal pathway that is upregulated with chronic high alcohol intake. Note the second step produces ROS – this is reactive oxygen species aka free radicals which are known to cause cell damage and cell death. Higher levels of ROS are bad in general and associated with greater inflammation and cellular damage across the board. This points to another potential place for prevention – with use of high dose antioxidants like CoQ10 200-300mg, resveratrol (500mg), alpha lipoic acid (200mg) and vitamins C (1000mg) and mixed tocopherol E (400IU).

screen-shot-2016-10-08-at-4-29-14-pmWhen alcohol intake gets high enough to start causing brain damage, obviously the primary treatment goal is to reduce the intake. Our first case study had a 37 yo male drinking 12-16 beers PER DAY. How many drinks, realistically speaking, are you having per day? How many does that add up to per week? Does that seem reasonable to you?

I don’t know enough about addiction to know how to address real chronic alcoholism. I imagine it is incredibly hard to quit, and even to reduce daily intake without a pure and strong internal directive to do so – no one can be told to do it,  the drive Must Come from Within. Treating underlying depression, anxiety, or life stressors are surely part of the picture, but what if you just drink to have fun? Sometimes, the party needs to stop, or gets out of control. I guess we all need to grow up sometime and learn to tolerate whatever it is we harbor inside our minds (before they get destroyed.)

Alcohol is a depressant, so withdrawal symptoms are the opposite – agitation, irritation, worse case scenario people can have seizures. Benzodiazapines, some sleep drugs and alcohol all work on the GABA-A receptor in the brain. Chronic alcohol use downregulates the expression the neurotransmitter GABA, one of the “off switches.” Once high levels of alcohol start to lower, it takes time for the brain to start making enough GABA again, resulting in foul moods, irritability and general unpleasantness.

There are medications like naltrexone and acamprosate that can help reduce the cravings for alcohol, and medications to treat the side effects of withdrawal, mostly aimed at these same parts of the brain. These are definitely worth exploring with a psychiatrist or addiction specialist to figure out what approach will work best for you. Complete abstinence does not need to be the goal. GABA as a supplement is not absorbed well, but is readily available and might be worth a try for someone who is just cutting down on daily intake, and has addictive enough a personality that switching to benzos instead of alcohol could exacerbate rather than relieve the problems. However, it is unlikely GABA alone would be enough to support sobriety. Making the very personal and often terrifying choice to look at one’s habits and face trauma/addiction is the place to begin. A comprehensive medical assessment with an empathetic and respectful health professional who has experience in addiction is next step. (if you are in Maine, I highly recommend Dr. Merideth Norris!)

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