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Chocolate cake: a medical metaphor

Chocolate cake has always been important to me. Well, in fact, chocolate in general has played a pretty central role in my life. When I was a child my mother, who was generally a terrible cook, had a yummy chocolate cake recipe that she modified from her friend Maytie’s, by swapping out the milk for orange juice. This had the advantage of making the cake non-dairy and thus servable after a meat meal in our kosher household. It also added a delicate orange flavor which I loved. When I met my husband and we started living together he was just learning to cook and bake. He set himself a challenge. He wanted to learn to bake the “Platonic Form” of chocolate chip cookies, chocolate cake, and chocolate brownies (you may notice a theme here). Our early married life was marked by numerous experiments to try and achieve that perfection. Chocolate cookies came first, the original Toll House cookie recipe on the back of the chocolate chip bag is just about perfect. The brownies were the hardest. It took years to find the perfect fudgy ones. The chocolate cake however quickly became a standard. Every birthday, every celebration was honored with a chocolate cake, usually with orange butter or ganache icing elaborately decorated by my daughter Erica with beautiful art. She once did a copy of Starry Night for our anniversary.

So what does this have to do with medicine?  When I was young and there were so few women in the field, all medicine was described with sports metaphors. My teachers would look pityingly on us “girls” and say things like “Well since you have never played team sports…” I swore then that if I ever became a teacher I would always use cooking and baking metaphors.

When we talk about the history of medicine, the development of medical specialties is very interesting. Originally there were physicians and surgeons. Physicians were gentlemen often the younger sons of the aristocracy. Surgeons on the other hand were tradesmen related to barbers and animal castrators. Most common people did not go to physicians but to apothecaries who would compound remedies. Of course there were always wise women and herbalists who informally cared for the population.

In the 19th century the General Practitioner was born. These were men who combined the skills of Physicians, Surgeons, and Apothecaries. Later, in the early 20th century there was the movement to professionalize medical education and move it to Universities rather than continue as an apprenticeship.

In 1910 Abraham Flexner was given a grant from the Carnegie foundation with the aim of standardizing and improving medical education. He chose the model of Johns Hopkins Medical School. The Flexner Report suggested the current model of organ system based specialities. Special populations, such as pediatricians and geriatricians were added later. One of the side effects of the Flexner Report is that it solidified the white male dominance of mainstream medicine, closing many of the traditionally Black Medical schools and those accepting women students in the United States.

It is important to realize that these specialities did not come on tablets from Mt Sinai. They are very human and relatively recent inventions in the history of healing.

So, if you think of medicine as a large iced chocolate layer cake, you can think of the icing as the signs and symptoms of illness and the names of all the diagnoses. The top layer of the cake is common disease. Think: Pneumonia, Hypertension, CAD, Hashimoto’s etc. The filling between the layers are the procedures, both diagnostic and therapeutic. The bottom layer is the uncommon disease: arrhythmias, sarcomas, rare infectious diseases. The lie about family doctors is that in order to be good docs they have to know everything about everything, which is obviously impossible. The lie about specialists is that they need to know everything about nothing, which is equally offensive. What is actually true is that there is a corpus of knowledge that family docs need to know. If we look at the cake, family docs take the top layer of cake. They are the specialists in common diseases across the body spectrum. Depending on where they live, and their access to specialist back-up, they may do more or less complex procedures and manage the illnesses that their community requires them to manage.  Specialists take a slice of cake. Their knowledge is deep, and detailed. They understand both the common and uncommon diseases of their area of expertise.

So this is my medicine cake teaching metaphor. Not as good as our actual chocolate cake but still a serviceable teaching tool.

Since my husband retired at the beginning of the pandemic he is spending more time in the kitchen. He has, with the passage of time, experience, and reading, deepened his knowledge of baking. He decided for example, that using almond flour in the brownies was not just for Passover, but in fact the best way to make them at any time of year. Reading our favorite cooking blog, Smitten Kitchen, he realized that the substitution of orange juice for milk necessitated a decrease in the amount of baking soda. This fixed the pesky cake collapsing problem we had dealt with for the past 30 odd years. His attention to detail and willingness to experiment and learn makes him a better baker now. I hope that following his example will make me a better doctor. Because, as you know, I love a good cake!