Thursday, May 21, 2015

A Son’s Sojourn to Commencement

Michigan State University College of Human Medicine Class of 2015 - where in the world is Ben?

Ben where are you?

A family affair - only physicians are allowed to hood new graduates.
Chris (Pediatrics), Aditi (Emergency), Dave (Pathology), Melodie (Pediatrics), Vinnie (Pathology), Ben (Emergency)
buddies on the threshold of many sleepless nights

Tricoastal: Pacific, L. MI, Atlantic - Theresa, dr. Ben, Dad, Rachel, napless Naomi, John, dapper cross-legged Jack

As I prepare to hood you, on your momentous day, emotions bathe, overflow, and clarify my perspective.  

When I mention your upcoming graduation to family, friends and colleagues, they imply that this happened predictably because I’m a physician, and yet this has been a singularly unique voyage that I couldn’t imagine 11 years ago.  Although when I took you on rounds at the age of 8 (the highlight being cafeteria fare), you stated that you wanted to have a desk facing mine when you grew up … how that warmed my heart.

It began four years ago with a white coat ceremony to denote the beginning of your life inside medicine.  Except that this did not occur at school as is customary but in our home, among friends and family, your mother dying of myriad complications of a unsuccessful bone marrow transplant for acute myeloid leukemia.  As physician friends offered advice and admonishment, your mother beamed through rivulets of fulfillment as she placed the white coat on your shoulders, hugged you, her bucket list nearly complete.  Mom … would not survive until you returned the following weekend to say goodbye.  

What a way to begin your first year.  Fortunately you found good friends, including one who had just lost her father.  You studied relentlessly.  You passed.  Your sister, nephew Jack and I visited for your birthday.  It couldn’t have been easy.  The acute loss swirled beneath waves upon waves of medical factoids, necessarily so.  You survived.  

But your growth really began after your BA in sociology, unclear as to what to do next.  Then began your two 2 year walkabout.  Taught college English in China close to Zhengzhou and traveled throughout.  Returned, found a restaurant job making pizza.  Traveled to Equador to volunteer in a cloud forest farm making physical and cerebral contributions, and traveled throughout. 

In Equador, a tragic fatal bus-truck accident in which you and Daniel were fortunately not seriously injured jarred you to life.  At close hand, a profound experience of the transience of life.  As you’ve told me, that single life-altering event galvanized you into action, maturity. 
And really it began in infancy.  At age one, you developed alopecia universalis.  If forced you to become prematurely self-conscious.  Some stared, others said things, some stole your hat, and we fretted.  Mom ferried you and I coached your basketball team, to shelter you, perhaps overly so.  Special dispensation for your cap in school, and your bandana in soccer.  And you made great friends that remain for you today.

I never urged you in a medical direction as I didn’t see the requisite self discipline or passionate purpose.  After the accident, you began the post-baccalaureate sciences, beginning at the starting block.  You did well, but quit the Chicago program to move nearer to friends in S.F.  You found a research job and completed the sciences one by one over 3 years.  You proved that you could do the work inspired by Paul Farmer’s Mountains beyond Mountains.  Mom remained steadfast in her belief that you would be successful.

And in S.F., you found your individual stroke.  You left the post-bac program against our advice to swim (or sink) on your own in S.F.  You chose not to take the MCAT prep course (and may have lost some points).  When your score was satisfactory, you decided to take your chances and not to retake it.  Deciding on the competitive field Emergency Medicine, you gained enough confidence to avoid having a back-up plan.  And in the last week there, you started a long-distance marathon with Theresa.

I may have opened the gates of opportunity but you swam through, maturing your stroke, perfecting your breathing, applying discipline to practice, and most of all finding what you are made of, the most important.  But it was Mom who imbued you with self worth, empathy towards the underserved, and who remained unwavering in her belief in your ability to triumph.

And so on this momentous milestone, the end of one incredible sojourn and beginning of another, I observe in amazement.  Taught so well by your mother, gates opened by your father, a village of Koslov’s to help, and spurred by traumatic experience, you have evolved into your own person with your own voice, a mature and disciplined learner, passionate for the underserved, carrying a calm, thoughtful and articulate demeanor.  How unimaginably far you have come.  I share this special moment with you, especially as a father, also as a physician.  Today, unrelenting joy is a watershed for those here, and especially your mother, also here, who so lovingly supported you and bore the bulk of the responsibility for who you have become and your achievements.  Who, in her last moments, was fulfilled by knowing that you would embark upon and succeed in this incredible journey … which has only begun.

[This was one of the highlights of my life.  Both Ben and I, separately, the night before thought a lot about Teri and her effect on this moment.  I barely held it together during the hooding, but when I read my thoughts to Ben, gentle torrents ran free...]

GI Blog #2 Why milk drinkers are mutants and lactose intolerance is the new normal

Years ago while doing my training in gastroenterology, I performed the very first lactose breath test in a 32-year-old volunteer who often drank milk and ate ice cream. After an uneventful first hour, the test confirmed his lactose intolerance in dramatic fashion – a rapid dash to the bathroom that resulted in watery expulsion, along with a rise in hydrogen gas in his sampled breath. This was my first confirmed diagnosis.
So why milk? (Disclosure, I am not paid by the National Dairy Council.)

Milk is an abundant source of calcium and vitamin D. Vitamin D promotes calcium absorption and bone health and prevents rickets and osteoporosis (thinning of bones). In Florida, ultraviolet light activates vitamin D in your skin, but in Wisconsin, higher calcium intakes compensate for the lack of sun exposure in winter. But milk is also full of lactose, the milk sugar. 

Lactose absorption
Your small intestine is lined by villi, which are small, finger-like projections that absorb nutrients. These villi are lined at the tips by lactase enzyme, which is the protein that splits lactose, a double sugar, into glucose and galactose for absorption by the intestine. In someone with lactose intolerance, the unabsorbed double sugar traps water and passes on to the colon where it causes gas, cramps and diarrhea.

Testing for lactase deficiency
The original test was to give lactose sugar in water and measure rising blood levels of glucose. This has been replaced by the noninvasive breath hydrogen tests, which are great for kids and adults. We also can measure lactase enzyme in biopsies taken from the small intestine during endoscopy, but it is too invasive and costly to do when trying to diagnose lactase deficiency alone. 

Who gets lactose intolerance and who doesn’t?
All babies have lactase enzyme during breastfeeding, but in most of the world once they are weaned, the enzyme is turned down, and they eventually become lactose intolerant. The same pattern applies to the animal kingdom: Dogs, cat, cows … all mammals, in fact, become lactase deficient when there is no further milk exposure after weaning. In Asia, Africa and the Middle East, lactose intolerance can affect 80-90 percent of the population. 

It’s the other way around for those of northern European descent as 90 percent or so have lactase persistence and can drink milk as adults. They deviate from the normal biological pattern due to a mutation that allows the lactase enzyme to persist beyond the point of weaning. Yes, a mutation leads to milk drinking!  

What is the advantage of lactase persistence?
When a trait is common, there is usually some biological advantage to it. And so it is with lactase persistence. Over the past 10,000 years, it allowed hunter-gatherers to become stable dairy herders. Because calcium for bones is so important, it also allowed people to live in such inhospitable locales such as sunless Sweden – and even Wisconsin! Having lactase enzyme beyond infancy may have even prevented pelvic rickets and allowed normal babies to be born.

What symptoms do you get?
We mentioned the typical symptoms – gas (topic of another blog), bloating, grumbling, crampy abdominal pain, and diarrhea. However, a number of studies in kids and adults show that giving lactose sugar to lactase-deficient patients doesn’t always cause symptoms. There is also evidence to suggest that you get symptoms from milk when lactase deficiency is combined with irritable bowel syndrome (IBS). That is, the lactose in the colon causes gas, triggers spasms and pain from IBS. Hmmm, so it is complicated, less clear than one would think.

So you are lactose intolerant, what to do?

The latest National Institutes of Health consensus panel (of which I was an early member) suggests continuing to drink/eat some milk/dairy due to its high nutritional value, rather than eliminating it. In fact, most lactase-deficient individuals can drink up to one-half to 1 glass of milk without symptoms – you have to find your tolerance level and stay below it. Cheese and yogurt (because it contains bacterial lactase) are better tolerated than milk or ice cream. And there are over-the-counter lactase enzyme pills you can take with dairy.

That volunteer subject with lactase deficiency? That was me. Now I know I am quite normal and don’t have a disease! Caucasians who are lactase persistent, on the other hand, are mutants. I had to spill the milk and speak the truth. See you at Culver’s.

Lactose (sugar) intolerance – you develop GI symptoms when drinking milk
Lactase (enzyme) deficiency – you have low lactase levels but may or may not get symptoms when drinking milk
Lactase (enzyme) persistence – you have normal lactase enzyme levels from a mutation

- B Li, MD, gastroenterologist, Children’s Hospital of Wisconsin