Intermittent fasting

As physicians always on the run, zipping and darting between patient visits, procedures, meetings, and more, too often we don't get the time we need to have a healthy lunch.

For me, I found a plant-based protein powder smoothie that is easy to make and transport, tastes great and is a complete meal replacement (usually my lunch).

I make the smoothie the night before I am going to take it to work.

I use this smoothie recipe as an essential part of my Mediterranean diet with a primary goal to help me achieve a heart-healthy diet that is lower in carbohydrate intake, mostly plant-based and has enough protein.

The smoothie may seem like a lot of calories, about 400 calories, but you need to consider this smoothie is a meal replacement for me. It's not a snack. It is my lunch (or dinner).

I have shifted to intermittent fasting three-four days a week and this smoothie is really satisfying to drink - it hits the spot perfectly when I drink it around 2 PM.  The protein does offer me the satiety I need after a long fast and if I drink plenty of water and have a handful of cashews or nuts late afternoon, I can make it to dinner at 6-7 PM without feeling like I want to devout a kitchen cabinet door.

The recipe 1-10 grams fat/ 30-40 grams of protein/ 400 ish calories)

The foundation for the smoothie is all plant-based.

  • 10 oz nut-based milk: To reduce carbs, I use unsweetened nut-based milk. My favorite with higher protein content is Silk Original Protein (Almond milk, Cashew milk, and Pea Protein) - 10 grams of protein
  • 2 scoops protein powder: From Costco, I buy  Orgain™ Organic Plant-Based Protein Powder 21-30 grams of protein. My favorite flavors are vanilla and peanut butter powder.  Three flavors are available.
  • Prepped frozen fruit and veggie 1-1/2 packet: From Costco, I buy Clovis Farms Organic Super Smoothie, Fruits & Vegetables. It has kale, spinach, fruit and it's, chopped, frozen, and in individual serving bags.
  • If the fruit in your fridge is too ripe to eat, freeze it and save it for your smoothie
  • Ice

The optional stuff

That's it.  Put your ingredients in your favorite device to pulverize and mix to the texture you love.  I use the Nutribullet. It's small and fits in a drawer.

Serve, store and transport in a Hydroflask (perfect temperature)

There are a gazillion smoothie recipes out there.  This one has been just great for me.

Have fun and keep experimenting to see what you love.

Cheers,

Rafat Rizk, MD

Peer Teaching on Rounds

Project

This project is in an exploratory phase (Q2 2021).

Goal: Understand peer teaching during inpatient rounds.

Links and Resources 

How to log in to U-M Google

User name = uniquename@umich.edu (do not use @med.umich.edu)
Password = level 1
Use Chrome

Inexpensive USB microphones that work well with 3M Fluency Direct speech recognition with Epic EHR

[2 min read]

Figure 1. Two alternative corded USB options to the Phillips SpeechMike that worked well using University of Michigan (UM) Michigan Medicine Core Imaged Windows computers 

 

The beginning: Michigan Medicine launches Fluency

Michigan Medicine is retiring phone-based dictation and Dragon and transitioning to Cloud-based 3M™ Fluency Direct in February 2021.

In this post, I list the two mics that I tried. Both worked well on my work Windows computer with our EHR, Epic. I observed comparable speech accuracy to the Phillips SpeechMike Premium Dictation Microphone.

With the switch to Fluency, I tried the Phillips SpeechMike Premium Dictation Microphone. It works fine. But it is expensive ($300+). 

Because I do not need the array of programmable buttons on this expensive mic, and most importantly, because I wanted to dictate hands-free, I searched for other mic options.

For Mac users, please note Fluency is not available for you and me, so that is a bummer. 

USB Microphone alternatives to the Phillips SpeechMike

Disclosures: I am not endorsing, selling, or have any financial relationships to disclose for these products. If a link to Amazon is not available, please try searching for a similar product. 

NOTE: UM Michigan Medicine HITS (our IT team) does not officially support alternatives to the Phillips SpeechMike™.

Sennheiser Headset Mic 

$65 Sennheiser is a well-known microphone company. 

$147 Sennheiser Headset Noise-Cancelling Microphone (sounds, better if you need to listen to audio)

Sennheiser Consumer Audio SC 660 USB ML (504553) - Double-Sided Business Headset  

Gooseneck Mic 

This table-top gooseneck is very nice. But be mindful of security issues in open settings. It would work well in an office or staff room or any other secure location. 

$45.00 Sound Tech GN-USB-2 18 Inch Professional Uni-Direction Noise Canceling Gooseneck Stereo Microphone 

For Michigan Medicine colleagues, if you have the Dragon Nuance microphone, this will still work. You can program some of the buttons. If you are a button minimalist, just program one button for F2.  

Installation, Training, and Calibration on a Windows Machine

In my experience, installing the microphones listed here was simple. It was a plug 'n play process and worked without any hitches. I did not have to download any drivers.

  1. Launch the Fluency program
  2. Plugin the mic and wait for the installation of the drivers, which should happen automatically.
  3. After Windows installs the drivers, calibrate the mic.

In my experience, this entire process took 4-5 minutes.

Meet Tilde on your keyboard

Using Fluency, I turn on/off recording, using the keyboard Tilde key on the keyboard (it's located below the ESC button on a Windows keyboard)

Voice command "Go to sleep" and "Wake up" is also an option to tell Hal (2001 Space Odyssey) when you want him to wake up and transcribe your every utterance.

Tilde key

Tilde Key (image at https://www.computerhope.com/jargon/t/tilde.htm)

If you have a Mac, you are out of luck.  

If you have a Core-imaged Windows computer, the microphones discussed here should work for you.

Suppose you have a Mac, like me. None of the microphones will work for you to dictate notes on a Mac.

Even if the Mac is CoreImaged, Fluency will not be available for you (as of this writing). Even more of a bummer, the Mobile app on my iPhone does not sync with Epic (MiChart), so I can't use that.  

Summary

If you are not going to use the suggested Phillips SpeechMike handheld microphone's programmable key functions, you don't need to commit to that mic. You have options for less expensive mics. 

Remember, HITS will not support these other mics.

Thanks for visiting.

Raf Rizk, MD

Comments: Twitter

How to switch from a personal Google account to a UM Google account

Michigan Medicine users who use Google documents and sites should know how to switch from a personal Google account to a UM Google account.

It's easy to switch accounts.

It can be frustrating the first time you see the 'you need access' message. And if you are in a hurry, you might abandon the UM Google Document/site which you wanted to use because you think you don't have access.

If the target site/document you want has sharing permissions set to allow any UM user access, then all you have to do is to switch accounts and use your UM level-1 login to gain access (Figure 1).

I hope this blurb helps you overcome technology speed bumps.

Raf Rizk, MD

Figure 1

Easy to make low carb and high-protein (and tasty) smoothie for busy doctors

Busy, busy, busy

As physicians always on the run, too often we don't get the time we need to have a healthy lunch. We spend our day from early morning to late night zipping and darting between patient visits, procedures, meetings, then hop on the computer at night to do more work.

We often don't have time do what is good for our own health and that includes making a health lunch that we can finish in  five minutes during our 'lunch break' (what's a lunch break?)

The smoothie as a meal replacement

So I have started using plant-based protein smoothies which are easy to make and which taste great (at least for me).

A smoothie can be a complete meal replacement (usually my lunch but it can work for dinner, if I add a snack).

I use smoothies as an essential part of my Mediterranean diet with a primary goal to help me achieve a heart-healthy diet that is lower is low carb and high protein.

A well built smoothie might look like it has a lot of calories, about 400, but you need to consider that a smoothie is a meal replacement. It's not a snack.

I have also shifted to intermittent fasting three-four days a week (more on that later) and a smoothie is really satisfying way to break my fast at work when I have seem to only have time for a three minute lunch on a day when I full schedule of patients.

Anatomy (ingredients) of a smoothie

Protein: 10 grams in nut milk

  • I use unsweetened nut-based milk.
  • My favorite with higher protein content is Silk Original Protein  which contains a blend of almond, cashew and pea protein.

If you are allergic to nuts or don't care for dairy, nut free and nondairy  milk options are available listed in a nice pro/con review at thekitchn.

Protein: 20-30 grams in plant based protein powder

There are a gazillion options when it comes to protein powders.  I have listed what I have tried.

  • Orgain™ Organic Plant-Based Protein Powder 21-30 grams of protein. My favorite flavors are vanilla and peanut butter powder.  Three flavors are available.  Shop around.  (I get it from Costco)
  • $$ Arbonne chocolate and vanilla are super yummy.  My sister told me about this one
  • More to list here as I try other options.

The fruit and veggie -- sooooooo many options

Seriously, there are infinite options for you to use when you create your glorious protein wonder drink.  I keep my path simple, perhaps boring to some, but I need to create my drink quickly and not have to worry about finding time to shop for ingredients. I am sure I will expand my repertoire for this component of my smoothies.

  • I really like Clovis Farms Organic Super Smoothie, Fruits & Vegetables. (You guessed it, I buy it from Costco)
  • It has kale, spinach, fruit and it's, chopped, frozen, and in individual serving bags.
  • Each serving is nicely packed into unit doses and I find that half a bag per smoothie (less carbs) tastes just right for me.

I have saved many of the fresh strawberries, berries, and bananas from going to fruit heaven by freezing them instead of discarding them. If you have fruit in your fridge or on the counter that is too ripe to eat or about to go bad, freeze it and save it for your smoothie.

The optional stuff to add to milk, protein powder, fruit/veggie

That's it.  Put your ingredients in your favorite device to pulverize and mix to the texture you love.  I use the NutriBullet. It's small and fits inside a drawer right next to the fridge.

Transporting your smoothie

Keep the smoothie cool to put smile on your face. No smoothie will taste good if it is warm or hot.

  • I use a Hydroflask (keeps it at a perfect temperature)

Summary

There are a gazillion smoothie recipes out there.  Have fun and keep experimenting to see what you love.

Cheers,

Rafat Rizk, MD | Twitter @rafrizk

 

 

Legal Ez: I have no financial relationship to any product, etc. etc., etc.  mentioned in this post.

Nephroptosis: Floating (mobile) kidney as a cause of unexplained abdominal and flank pain

Overview

Renal ptosis, nephroptosis or “floating kidney,” describes a phenomenon where the kidney descends within the retroperitoneal and causes a range of symptoms including episodic renal colic-like severe pain, flank pain, abdominal pain, testicular pain that can be accompanied by nausea and vomiting.

  • The distance of descent downward of the kidney is defined as >5cm or two vertebral bodies while moving from the supine to erect position.
  • Diagnostic studies to confirm this elusive diagnosis include a range of different imaging modalities combined with supporting history.

Below is a list of articles I read to help me understand how I will approach this enigmatic and controversial diagnosis for a patient I care for who has suggestive symptoms.

I have shared this list for colleagues that may need to consider this diagnosis in a patient.

If you want to get a sense of what patients report and how nephropexy can resolve symptoms, read a few of the case reports. This diagnosis will not be easy to make, but if you make the correct diagnosis and treat the patient, you may save him or her a lot of pain and suffering.

 

Selected Literature

Hoenig DM, Hemal AK, Shalhav AL, Clayman RV. Nephroptosis: a “disparaged” condition revisited. Urology. 1999 Oct;54(4):590–6.

Nanayakkara PWB, van Bunderen CC, Santerse B. A bumpy ride to a discarded diagnosis. Lancet. 2007 Feb 3;369(9559):436.

Yoshida S, Matsumura M, Maekawa K, Minaga K, Kamata K, Nozawa M, et al. Recurrent abdominal pain caused by nephroptosis. Clin J Gastroenterol [Internet]. 2020 Feb 28; Available from: http://dx.doi.org/10.1007/s12328-020-01110-x

Taylor J, Prasad K, Rohrer R. Dynamic Renal Ptosis Demonstrated on 18F-FDG PET/CT. Clin Nucl Med. 2019 Apr;44(4):303–4.

Mogorovich A, Selli C, De Maria M, Manassero F, Durante J, Urbani L. Clinical reappraisal and state of the art of nephropexy. Urologia. 2018 Nov;85(4):135–44.

Arnerlöv C, Söderström M, Öhberg L. Mobile kidney pain provocation ultrasonography before surgery for symptomatic mobile kidney: A prospective study of 43 consecutive patients. Scand J Urol. 2016;50(1):61–4.

Golab A, Slojewski M, Gliniewicz B, Sikorski A. Retroperitoneoscopic nephropexy in the treatment of symptomatic nephroptosis with 2-point renal fixation. Surg Laparosc Endosc Percutan Tech. 2009 Aug;19(4):356–9.

Barber NJ, Thompson PM. Nephroptosis and nephropexy--hung up on the past? Eur Urol. 2004 Oct;46(4):428–33.

Plas E, Daha K, Riedl CR, Hübner WA, Pflüger H. Long-term followup after laparoscopic nephropexy for symptomatic nephroptosis. J Urol. 2001 Aug;166(2):449–52.

Transition to Clerkship (TTC) Annual MiChart Bootcamp for UM Medial Students

Welcome

Dear M2 students,

Congratulations on many things, including getting into med school, getting into UM, and now moving one step closer to the very edge of the clinical waters.

You are about to move away from watching lectures at 2.5x and dive into clinical years -- the water will be 'refreshing' and most definitely invigorating.

On this page, I am listing resources aimed at helping you prepare for a smooth MiChart Boot Camp.

Since 2017, I have had the pleasure of teaching the MiChart Bootcamp to medical students in the annual Transition to Clerkship (TTC) course. I am looking forward to this year, 2020, the first time we conduct the entire course online using Zoom.  In previous years we met in groups of 40 students, four sessions, in one large computer lab.

Let's get started.

Epic trivia

We started using Epic (Epic Systems) for our electronic health record (EHR) in 2012 (summer roll-out, I remember it soooooo well). By now all of you know our EHR is called MiChart.

  • In 2012 there was a competition to name our new EHR and the name MiChart was coined. I think there was an iPad given to the person(s) who came up with the idea.
  • The previous EHR which was really visionary in design and is called CareWeb. You can still use it for the time being (it may be retired in late 2021).   Records dating back to 1991 are in CareWeb and I encourage you to read some of the golden oldies notes back when doctors used very nice prose and narratives to write about patients.

MiChart v.s. Mychart

You should distinguish 'our' MiChart from the worldwide Mychart, which is used by 100 million patients to connect to the Epic EHR patient portal. If you are a patient at UM Michigan Medicine, you can access the UM Mychart here

Important Stuff

Review the Pre-Boot Camp Checklist to ensure you have a happy Boot Camp experience

Highlights are in the bullets below; see details in Table 1.

  • A tablet will not suffice for the MiChart Boot Camp. Ensure you have a computer with the needed software installed.
  • Watch this video if you have not logged in before: How to log in to MiChart for Newbies
  • Watch this video How to check your security level from within MiChart. It's especially important to do this step if you previously used MiChart for research. If you don't have the correct security clearance as a student, then you will not have access to all the MiChart features.

The website MiChartFLY is our training ground for the Boot Camp

I created this site and you can use it for reference after the Boot Camp.  On MiChartFLY you will find 1-3 min How-To tutorials that will help you master MiChart.

Please login to MiChartFLY for our Zoom virtual class

Important links

Keep these handy

I look forward to meeting you all.

Thank you.

Raf Rizk, MD | Assistant Professor | Division of Gastroenterology and Hepatology

HEADS UP !

In the table below click on a cell to enlarge an image and view hidden text, please.

Table 1 Pre-Boot Camp Checklist

How to Deterimine What Your Security Level is in MiChart

To see if you have full  view and write privileges in MiChart. Please visit my training site for MiChart, MiChartFLY

My Short List of Favorite Apps and Websites for our Splendid Trip to Italy

In late September of 2019, Jackie, my wife, and I traveled through four regions of Italy and enjoyed a splendid vacation to celebrate our thirty-year wedding anniversary.

The thirteen days in Italy flew by way too quickly.

We met incredibly friendly people in all the regions and always got the help we needed when we needed directions or ideas where to eat. The choices were endless for savory and sweet Italian cuisine and we usually asked the local folks where to eat.

Every day we walked for miles on hikes like on the trails in Cinque Terre, which are worth every step or through centuries of history in Rome and Florenzia (Florence).

Planning for a first trip to Italy takes time and there are a gazillion resources. Here, I have listed a few suggestions for apps for your phone and guides and a few websites that we found especially useful.  The list is short and doesn't list all the apps, YouTube videos and websites that we checked out before and during our trip.

Our 13- day itinerary included four regions

Detroit, Michigan > Rome > Florenzia > Cinque Terre > Positano > Rome > Detroit

Enjoy all the chapters of your journey from planning to doing.

Ciao!

When your US cell phone won't connect to the Internet

We have Sprint and we used Sprint Global Roaming and added unlimited data (optional) for $25.00 / week. We did a ton of walking averaging 7-8 miles/day and many times we wished we had a more reliable cell phone connection that would keep us connected to Google Maps.

I was not happy with the cell phone service and this poor connection often rendered our typical mapping apps irrelevant.

Connecting to Wifi is easy but not always available and Wifi doesn't help when you are hungry, have sore feet and lost and looking for the restaurant you located in your hotel or AirBnB where Wifi was great. Soooooo,  having a local map (paper) or downloading a map to your phone for offline use can be very helpful.

Suggestions

Consider buying a local SIM card in Italy.  It's not expensive. With a SIM card you may find your experience is much better when using map services... especially on hikes in national parks or cities where the cell signal is weak.

When you buy a SIM card for use in Italy (or Europe) you don't have to rely on WiFi to make calls locally in Italy and you don't incur per-minute charges from your US Carrier for roaming. This comes in handy when you need a map or want to call and tell the restaraunt where you made reservations that you are running late (or lost and need help).

TIPS

Ask your US phone mobile carrier if your phone is unlocked (it probably is).

Become familiar with TIM (Telecom Italia Mobile) in Italy - it's one of the easiest places to buy a local SIM card; there are other choices. Take your passport with you; they will ask for it and make a photo. Learn more on The Roman Guy blog.

Download local maps for offline use to your phone of the region you will visit when you have a strong data connection. It's not a perfect solution but it's better than nothing.  Learn more on Google Maps Help for navigating offline.

If you don't mind spending a little money, purchase an app for navigating offline.  I tried several apps in this category and my favorite IOS app is  Sygic GPS Navigation & Maps. This app is fantastic and I will also use it in the USA when I am not in an anemic cell phone connection.


 

Purchasing your train tickets: paper versus online

train

Our train Rome to Florenzia

We loved the trains in Italy. High speed and local trains both offer very different experiences.

Suggestions

Consider downloading apps for purchasing a paperless train ticket

Depending on where you are traveling you may use different companies and different apps or websites. Paperless train tickets are nice and easier to have handy (unless you lose your phone).

If you want to use a third party app here is my favorite: Omio. I liked this app (you pay a few Euros more per ticket) because it was easy to use, stored all our purchases and I could buy the ticket for my wife and I and then send her the link.

 

Omio is a third-party app for purchasing train tickets with a user-friendly interface. (Compare pricing to the train companies.)

 

TIP: Take a screenshot of the train ticket in case you can't open the app and view the ticket because of a poor cell or Wifi connection.

TIP: Remember you may need to validate your paper train ticket before you board the train.  Do a little Googling and see some stories of the why/how to validate and implications of not validating a ticket.

Pickpockets

We had no problems but I met one traveler in two weeks who was a victim of a pickpocketter.  Use your judgment and search for the defense options you like most.


 

Apps, websites and guides

There are a gazillion websites, apps and books to guide your travels in Italy.  Here is our short list of finalists.

Suggestions

Rick Steeves and Italy

Rick is well known as a guru of travel in Italy and much of Europe.  We used several of his resources.

  • The IOS app Rick Steves Audio Europe ™. This is nice for self guided audio tours that hit the high points.
  • Book, Best of Italy . It's heavy when you want to pack lightly, but worth it if you like to read and prep for a visit.
  • Website ricksteves.com is endless with resources and tours if you want to join them
  • Youtube videos are very informative