Friday, 1 May 2020

Taking Action

I recall an incident in math class in seventh grade when the teacher grilled me in front of my classmates, triggering confusion and panic to the point where I had to admit I couldn�t say whether 70 or 80 came first. Hoping for some positive attention, I intentionally fell out of my chair. No cop-out philosophy will ever take the weight of existence off you. Since you are here, you might as well be here in your totality. COURAGE AS FINALLY GETTING FED UP People don't change when they feel good. They change when they're fed up. When things are going all right, you tend to do what you've been doing all along. Pain pushes you to those crucial turning points: finally to stand up for yourself, finally to allow intimacy, finally to feel love for yourself, finally to throw away the bottle and mean it. You hurt, hurt, hurt. Then, finally, you choose. It's that adverb finally. There is a wide range of vegetables available to you when following the Ketogenic Mediterranean Diet. In fact, all vegetables can fit into this plan in moderation. However, starchy vegetables like potatoes, sweet potatoes, peas, carrots, corn, and most beans will use up your carbohydrate allotment for the day rather quickly, so they need to be omitted or highly restricted. Nearly all other vegetables can and should be enjoyed liberally. The United States Department of Agriculture (USDA) maintains a list of nutrient values of a huge variety of foods, which is very useful when evaluating what to eat. Of course, you will be preparing these vegetables in a way that makes them much more palatable�with fat! Covering with extra virgin olive oil�based salad dressings, saut�ing in butter, covering in cream sauces, and stuffing with cheese are all encouraged methods for preparing vegetables included in the Ketogenic Mediterranean Diet. There is also an abundance of ways to incorporate vegetables so they do not feel like a grocery store produce section on your plate.

For example, cauliflower can be used to make pizza crust, bread, and sushi. Most fruits are too carbohydrate rich to be included in the Ketogenic Mediterranean Diet. Instead, I was kicked out of class. Over the subsequent years, however, as my desire to become a physician became a single-minded focus, I learned how to adapt to situations where my learning disability put me or others at risk. For instance, during internship I realized that after 35 hours without sleep I couldn�t catch prescription errors, so I showed all my scripts to a colleague before signing them. Frankly, I wondered if anyone should be writing prescriptions on no sleep, but knew I was not in a position to challenge the status quo. In short, I learned that the first order of business is survival, not rebellion. Perhaps worse than screwing up prescriptions because of fatigue is attempting procedures unsupervised before you are ready, out of a fear of looking look bad if you ask for help. See one, do one, teach one is a dangerous old saying among house staff. For instance, we learned to put large catheters into patients� necks, often late at night with on-the-job training from residents who had recently been trained themselves. We each carried around logarticles that indicated the number of times one had to complete a procedure supervised before one could do it independently or teach others. There was no gold standard assessment about whether any of us were doing it correctly. Enough is enough! Anger can be a loving and encouraging force. If coeur or of the heart, is part of courage, then perhaps the other part is rage. Some obstacles are so high, or so thick, that you can't surmount them by calm choice. It takes determination, dedication or perhaps an internal war of morals. It's as though a vital part of courage is the act of drawing the line. If you give in and give in and give in and 177 never say, No, that's enough! then you are a slave.

Free people draw the line. There has to be some limit somewhere, some point of no return. Apples, oranges, bananas, mangos, peaches, plums, and the like must all be excluded or heavily limited. However, there are fruits that we do not often think of as fruits that are wonderful additions to and can even be included as staples of this diet. Olives, for one, are actually a fruit, and because of their excellent monounsaturated fat and fiber content, should be eaten often and with gusto (though I suppose you don�t actually need to eat with gusto, if you don�t want to; that won�t affect the nutrition content of your meal). Avocados are also a fruit and have a fantastic amount of fat and fiber. Another category of fruits that is good to include are berries. Almost all berries can be included in small quantities. One ounce (28 grams) of just about any common variety of berry has less than four net grams of carbohydrate. They make excellent desserts, too�when combined with fresh, unsweetened whipped cream or plopped on top of some Greek yogurt, berries are divine. Because it is based on the ketogenic diet, the Ketogenic Mediterranean Diet necessarily is mostly fat. But there was pressure to get the job done without needing help. As a result, patients were sometimes subjected to numerous large-bore needle sticks in the neck by an inexperienced trainee who didn�t want to look bad, with potentially lifelong complications. I made a decision on the first day of internship that I would never cover up my inexperience at a cost to a patient. Hence I asked questions or called for assistance often. It did come with a price. I recall a supervising resident saying to me, Saul, you know you are not where you should be at this stage in your training. Hearing that didn�t feel good, but the alternative would have felt worse. I will take a lot of crap -

And finally, third, complying with expectations does not mean buying into the system or idealizing the people who perpetuate it. Beware the Stockholm syndrome, in which the kidnapped adopt the ideology of their captors, lest you become part of the dysfunctional status quo yourself. If you capitulate forever, you ultimately lose everything that's important in life. The American Revolution is an excellent example of people getting fed up. If only a disgruntled few are fed up, it is impossible to push a country to rebellion. But if substantial numbers are dissatisfied, one more insult will trigger the explosion. People will do the same within themselves. If small parts of you are fed up, no revolution ensues. But if enough of you is bothered, you can lead yourself to change. By developing self-compassion, you are in essence learning how to take public opinion polls within yourself. You can check the consensus to determine when action is needed. To be sure, there are times where slow, peaceful change works the best. Of course, as covered earlier in the article, fat is complicated and there are several different kinds. There should also be an emphasis on the consumption of omega-3 polyunsaturated fats. However, the body has the ability to differentiate between fats and appears to have fuel preferences when fat adapted. Not only does total fat oxidation increase when you are in ketosis, but the rate of saturated fat oxidation increases to a greater extent than that of the other fats. Because of this, your prioritization of fats looks different on the Ketogenic Mediterranean Diet. Monounsaturated fats are still in the top spot and artificial trans fats should still be avoided altogether, but the middle two spots switch. The easiest way to tell the type of fat is by how it behaves and appears when cooled. At lower temperatures, saturated fat will solidify, monounsaturated fat will become cloudy and thicken but remain a liquid, and polyunsaturated fat will remain liquid and clear when cooled.

Unfortunately, you will not always be dealing with something that is made up of just one kind of fat. In fact, there is no pure source of any one type of fat in the world. A few years after I finished my residency there was a national movement to regulate training work hours. It didn�t come from within the profession, which lacked the good sense to reform itself, but from the federal government. In fact, quite a few medical education leaders resisted change. Even some residents complained that reducing the hours they worked per week would compromise their education. This despite an avalanche of evidence that sleep deprivation diminishes learning and performance. The organization that accredits residency programs finally took reform seriously after Congress threatened to intervene if it didn�t. I was a residency director at that point. To me the need for reform was clear, but to many others it was not. Having bought into a pernicious culture, they were apologists for it. That attitude is neither good for patients nor the trainees who follow in their teachers� footsteps. But at other times, movement can only be accomplished by revolt. Learning responsibility is not learning how to get a pat on the head - that's learning servility. For many, the habit of looking outside for guidance combines with the natural human desire for attention. They become obedience junkies. Rather than take responsibility for everything they think, feel and do, people often look for something else to run their lives. Patterns may seem varied, but are actually equivalent. Adherence to a cult, passive dependence on a spouse, reflexive adherence to social fads, or even surrender to the guaranteed routine of drug addiction are some examples. In each of these ways, people give up self-ownership.

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