How weight-loss surgery affects the body; an expert's clues to solving and creating crossword puzzles: Upstate Medical University's HealthLink on Air for Sunday, Jan. 9, 2022

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a surgeon explains what it's like to recover from weight-loss surgery.

Timothy Shope, MD: Most of our patients are only in the hospital for a day or two. Uh, the overall physical recovery, uh, you know, we tell them to take probably a few weeks off of work. Um, but honestly they're up and moving around on the same day of surgery.

Host Amber Smith: And the crossword puzzle constructor who happens to work at Upstate provides some clues about clue writing and tell us about her side gig, writing the "Wordplay" column for The New York Times.

Rachel Fabi, PhD: I like to start every day with at least one crossword puzzle. It sort of gets me into a working space. Um, I don't know if that's true for everyone, but it's absolutely true for me.

Host Amber Smith: All that, some expert advice and a visit from The Healing Muse, coming up after the news.

This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith. On this week's show, we'll explore the allure of crossword puzzles with a bioethics professor. But first, a surgeon tells us what to expect after weight-loss surgery.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

If you or someone you care about has made the decision to have weight-loss surgery, today, I'm talking with a surgeon about what you can expect afterward. Dr. Timothy Shope is chief of bariatric surgery at Upstate. Thank you for making time for this interview, Dr. Shope.

Timothy Shope, MD: Thank you, Amber, for the opportunity.

Host Amber Smith: What is the most common reaction your patients have when you see them after surgery, after they've awoken from anesthesia?

Timothy Shope, MD: Well, they're usually just glad to be awake and have this fresh start for themselves. Many of them have spent months and months in a program working through a process to get the surgery. And now it's finally the day of surgery. And now they've finally got this opportunity to really get this new lease on life.

Host Amber Smith: Well, I know many bariatric surgeries, maybe all of them, are done laparoscopically now, through small incisions. So what impact does that have on how long a person recovers and how soon they go home from the hospital?

Timothy Shope, MD: We do the overwhelming majority of our procedures through what's called a minimally invasive approach, which includes standard laparoscopy and robotic approaches. An open operation is still done sometimes. Usually those are more for revisional type surgeries, where patients have had surgery before, maybe they've had other kinds of surgery in their upper abdomen. So the majority of our surgeries are done through these small incisions. And what that means for the patients is that basically recovery is dramatically accelerated. Most of our patients are only in the hospital for a day or two. The overall physical recovery, you know, we tell them to take probably a few weeks off of work. But honestly, they're up and moving around the same day of surgery.

Host Amber Smith: What determines when they're OK to go home?

Timothy Shope, MD: So there's a fair amount of medical things that we have to consider: Is their heart OK? Is their breathing OK? But those things are generally not really a big issue. And honestly, the biggest hurdle for the patient is whether or not they're able to hydrate themselves, whether or not they're able to drink enough, essentially, so that we can take them off of the IV (intravenous line) and, allow them to do it on their own.

Host Amber Smith: OK. And I was going to ask, how soon can they drink? How soon can they get eat?

Timothy Shope, MD: The drinking starts again as soon as they're awake enough from surgery. We encourage them to get about an ounce or so of fluid. So that's around 30 milliliters or 30 cc, which is basically one of those little cups that you'll see on the top of the cough medicine dispensers, for example. If they can get one of those down every 15 to 20 minutes, then they should be able to hydrate themselves. Sounds pretty easy. But after these operations, you really have a lot of difficulty getting any volume in at any one time. So we're not doing shots. We're talking about sips of those 15- to 30 milliliters of fluid, which can actually take a good 10, 15 minutes if they're pacing themselves well.

Host Amber Smith: And you say "fluid." Is it water, or is there a particular drink or beverage that you advocate?

Timothy Shope, MD: Initially, it's just water or clear liquid, something very low calorie and noncarbonated, something like Crystal Light or a no-sugar-containing Gatorade or something like that. Within a few days, they're usually on protein shakes, which are a little bit heavier, a little bit more difficult to get to go down. But again, if they commit to it, they can certainly do it.

Host Amber Smith: Now, once someone goes home on their own, do you have instructions for how they should eat in the first days after surgery and how soon they'll kind of get into a new type of eating?

Timothy Shope, MD: Absolutely, Amber. Realistically, those months before surgery that I was mentioning before are largely meant to help educate the patients and help them reframe how they approach the eating process after surgery. They work extensively with our registered dietitian staff. And so they know what to expect afterwards. Again, knowing what to expect and actually experiencing it is two different things. But they certainly are well prepared for it.

Timothy Shope, MD: So the process really is roughly two weeks' worth of those liquids that we were talking about. And then again, about two weeks more of softer foods. And then after about a month or so, they can be back on normal types of foods, usually just significantly reduced portions. We ask them to concentrate on proteins first and fluids, a close second. And as they advance that diet, they will come back to us, they'll be coached about what to eat next, what things to try, what things to avoid. So the process is really, again, we set them up ahead of time for success in the preoperative program, and we give them full support postoperatively to make sure that they have that success.

Host Amber Smith: So it sounds like it's a transition process.

Timothy Shope, MD: It is. And again, it takes at least a month, if not six weeks, until they're back on those "regular" foods. But again, those are much smaller portions, and hopefully they make a substantial change in the types of foods that they're choosing.

Host Amber Smith: Now, do patients feel hunger since they're going to be eating so much less than they did before surgery?

Timothy Shope, MD: Actually, they don't. In addition to not being able to eat very much at any one particular time after these operations, the procedures themselves actually change around how our GI tract hormones are available to us and how they function basically. So, one of the operations in particular, called the sleeve gastrectomy, we remove about three quarters or so of the stomach, the organ, the stomach. And in that part of the stomach that's removed is where the vast majority of a hormone called ghrelin is produced. And it's not exactly correct, but the way to think about this is that that hormone basically does one thing. It tells our bodies it's time to go find some food. And so if that signal isn't there, most of those patients experienced a dramatic reduction in their hunger. And we see similar improvements in hunger, also in the gastric bypass, even though we're not actually removing that part of the stomach.

Host Amber Smith: This is Upstate's "HealthLink on AIr." I'm your host, Amber Smith talking with Dr. Timothy Shope, the chief of bariatric surgery. And we're talking about what things are like after someone completes the operation. Now, how soon would you advise people, typically, to get back to work and school, and how soon can they resume an exercise routine?

Timothy Shope, MD: Well, it really depends what kind of work they do. I've had people go back if they own their own small business and their kids won't eat if they don't go back to work, I've had folks back as early as a week. That's pushing it a little bit. But I think most people can probably do OK on that. If you're in manual labor, construction work, that kind of thing, you're going to want to take at least several weeks off. These incisions will need to heal even though they're small and generally heal very well. And physically, your body's going through a lot of changes with these operations and the change in the caloric intake and the types of calories and such. And so people will feel a little bit fatigued. That's pretty normal. But again, it's something that they can certainly overcome. My advice to patients usually is when you come back for your post-op visit, which is sometime around 10 days to two weeks after they leave the hospital, let's decide together if it's time for you to go back to work. And look, if they call me five days after they leave the hospital and say that they have to get back to work because the walls are closing in on them at home, I don't have any problem with them going back. As long as again, it's not sort of a physical labor type job.

Host Amber Smith: And if someone has an exercise routine or wants to start one, what would your advice be?

Timothy Shope, MD: Well, again, it really depends on the type of exercise that they'd like to do. We really do encourage activity of all kinds, even very early on. As I mentioned, they're going to be up and moving around the same day of surgery. When they go home, they can go up and down stairs. They can go out for short walks and as they recover over that first week or two, they can certainly increase that as much as their body tolerates and as much as they're able to keep themselves hydrated. If they want to get back to true aerobic-type activity or maybe even weightlifting-type activities that should probably wait for at least a few weeks. And it's another one where I would encourage them to have that conversation with their provider at their initial post-op follow-up visit.

Host Amber Smith: How soon will patients notice weight loss?

Timothy Shope, MD: Well, it's not immediate. But the majority of people will notice a substantial amount of weight coming off within that first month or so. When we talk about the weight loss for these operations, it's generally a year to a year and a half is the time frame that we talk about for maximum weight loss.

Timothy Shope, MD: But that is pretty well front-loaded, meaning that the first six or eight months is where are they going to experience the majority of that weight loss, and then the next eight months or so, a little bit here and there will come off. It really depends on the starting weight as far as how much weight they will lose in that first month. But I think on average, somewhere around 20 to 30 pounds in the first month is pretty typical.

Host Amber Smith: So in the surgery that you do, you're not removing any tissue or anything that would put weight on a person.

Timothy Shope, MD: Well, again, in the sleeve gastrectomy operation, we remove a portion of the stomach, but the weight of that is, yeah, it's way less than a pound. So no, we don't actually remove weight. They don't wake up lighter from surgery. In fact, because of the fluid that we give during surgery and during the hospital stay, some patients will go home up a pound or two. That's not not unusual, but realistically within those first couple of weeks, they are really starting to drop that weight.

Host Amber Smith: Now if a patient had diabetes, how quickly after surgery does that resolve?

Timothy Shope, MD: So that really depends on the type of procedure that they have. And I'm not trying to convince anybody to have any particular operation here. That's a conversation you should have individually with your surgeon. But with the gastric bypass operation, there's good data from decades ago that show that the patient's sugars, that level when we check their sugars, and also their insulin use or their medication use drops dramatically even within the first couple of days. And all of us across the country have had patients that are diabetic when they come to the hospital and are off of medication when they leave the hospital within a couple of days. And what that really tells you is that, with regard to the gastric bypass operations specifically, the improvement in your diabetes isn't just about the loss of weight. We just talked about how that doesn't happen immediately, yet, and you could possibly go home -- not everybody -- but some patients can go home off of their medications. So it's really about the rearrangement of the GI (gastrointestinal) tract that comes with the gastric bypass. And again, the modulation of those hormones that we were talking about earlier. The other operations that we offer, the sleeve gastrectomy, lap bands other operations that are available, also will improve in most patients, the diabetic profiles, but they don't happen as quickly, and they're really basically dependent on the amount of weight that's lost. So as you continue to lose weight, your diabetic profile should improve as well.

Host Amber Smith: Does the new way that people digest food after this surgery affect medications that they take?

Timothy Shope, MD: It might. The biggest change is basically their ability to get those medications in in the early time period or whether or not they actually need them. So again, if patients are working hard to get enough hydration in and they're on medications, for example, that cause them to urinate more, a diuretic or water pill maybe, they need to back off on some of those medications. The gastric bypass operation, where we actually change anatomy, we reroute intestine that one potentially could, for some medications, change how they're absorbed. And so, we've got to be very careful with that, that those patients that have that operation make sure that they're working with their other medical docs, as far as how those medications are absorbed. And it doesn't mean that they can't have those operations. It just may mean that they need either a different medication or, ideally, let's do this operation to help you lose weight, so you get healthier and don't need those medications at all.

Host Amber Smith: I was going to ask, because I've heard that vitamin B12 and folate and iron, those levels are tracked in someone who's had bariatric surgery, but you just explained, sort of, the reason, right?

Timothy Shope, MD: Well, yeah, so the biggest issue with that is, again, the ability to absorb things, and actually we track multiple vitamins and micronutrients for patients. The ones you mentioned, but also thiamine, which is vitamin B1, vitamin D, zinc. There's a whole host of vitamins that we check for patients on a regular basis. All of our patients are encouraged to be on a standard multivitamin. If we identify that there is a deficiency of some kind, either based on our clinical evaluation or the laboratory studies that we get on at least a yearly basis, we're going to supplement those as well.

Host Amber Smith: Now, a certain percentage of patients will have the surgery and lose the weight, but then they regain. So I wanted to ask you to talk about where they go, where they went, wrong, and whether you have some advice that will help someone avoid making the same mistakes.

Timothy Shope, MD: Sure. So the first thing is I wouldn't say that they went wrong. I'd never blame it on the patient. In fact, when I have a patient that has that situation, I'm going to look at myself first. You want to make sure that the anatomy that you've created for them is proper and that is that they still have a quality tool, if you will, at their disposal to use. And if they use it properly then they should be able to get some of that weight regain back off. Most times the patient you're talking about there is maybe a couple of years out from surgery, and maybe they haven't been following up as frequently. They've slipped back into some old patterns of behavior, and they're just not making the proper food choices. Those kinds of things are things that, if they come back into the fold, essentially, and get back with their providers, get back with their dietitians again, usually -- again, assuming the anatomy is fine -- they can usually get back on track and lose some of that weight again. And so really that's the advice, is come back and see us, come back, go back to your provider, make sure that we have an opportunity to make sure that we've done everything we can do for you, and that we provide you with all of the support structure that you need to have success. You know, especially if somebody did it before, if they lost a hundred pounds and regained 25 of it, they should be able to get a decent portion of that back off, if we can get them back into those behavioral patterns that they had early after surgery.

Host Amber Smith: Well, this has been very informative, and I appreciate your time, Dr. Shope.

Timothy Shope, MD: Well, thank you very much again for the opportunity, Amber.

Host Amber Smith: My guest has been Dr. Timothy Shope, the director of bariatric surgery at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."

Some clues about how crossword clues are written, next on Upstate's "HealthLink on Air."

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." Today, we're tackling crossword puzzles with Dr. Rachel Fabi. She's an assistant professor of bioethics and humanities at Upstate who teaches about ethics and public health policy. And she also writes for the "Wordplay" column in The New York Times.

Welcome back to "HealthLink on Air," Dr. Fabi.

Rachel Fabi, PhD: Hi, Amber. Thanks so much for having me.

Host Amber Smith: Now, last time I spoke with you, you told us all about your experience as a contestant on "Jeopardy!." Your episode aired in February 2019. And I love the photo that you have with ("Jeopardy!" host) Alex Trebek.

Do you think that people who are good at "Jeopardy!" have a natural ability to solve crossword puzzles?

Rachel Fabi, PhD: Yeah, I think that's an interesting question. I think there's a lot of crossover between trivia people and crossword people. And especially with "Jeopardy!," where you have to answer quickly, if you want to be a speed solver on a crossword puzzle, having those neurons firing quickly, it helps you in both, but I think there's also this belief about crossword puzzles that it's just one big trivia contest, which obviously "Jeopardy!" is, one big trivia contest. But I think there's more to crosswords than just trivia. And so you don't have to be good at trivia to be good at crosswords in the same way that you need to be good at trivia to be good at "Jeopardy!."

Host Amber Smith: Yeah. Interesting. And you mentioned the timing of it, and I hadn't even thought of that. With "Jeopardy!," you know, the speed counts, but people can spend hours, days on crosswords, right? So when did you start solving crossword puzzles?

Rachel Fabi, PhD: It's interesting. It's actually very closely tied to my "Jeopardy!" story. So I started solving crossword puzzles when I was 13 or 14, and I was trying out for the "Jeopardy!" teen tournament, so I convinced myself that if I got really good at crossword puzzles, I would be good at "Jeopardy!." And that was how I was going to get on the teen tournament. It turned out that was wrong.

Host Amber Smith: I didn't get on the teen tournament at all. But I did keep solving crossword puzzles, and then, 15 years later, I made it onto adult "Jeopardy!," and I'm still solving crossword puzzles, but as a 13-year-old, it was not the best way to prepare.

Host Amber Smith: So what did you like about crossword puzzles? What attracted you to them?

Rachel Fabi, PhD: Well, I started solving them regularly when I was preparing for "Jeopardy!," but even before that, my grandmother was very into crossword puzzles, so it was something that I could do with her, and then I think I stuck with it because I really liked the organization of a crossword puzzle.

It's a square. Usually there are 15 squares by 15 squares. It's a perfect grid, symmetrical in some way. And you're organizing concepts and ideas and names and wordplay and all of these things that you enjoy independent of putting them into a grid, right? If you like trivia, if you like wordplay or puns, all of those things can then be organized into this box.

Rachel Fabi, PhD: And I think (laughs), taking these really disparate ideas and putting them into a neat grid really appealed to me.

Host Amber Smith: Do you prefer paper, or do you like doing them online these days?

Rachel Fabi, PhD: I do both. I like doing it on the computer when I'm trying to solve very quickly. If I'm in a competition, and there are lots of crossword competitions out there, I find that I go faster when I'm typing.

But there's something really luxurious and kind of fun about bringing a crossword puzzle, like, to an airport bar, you know, and sitting there with an actual piece of paper and a pencil and pondering the questions, the clues, the grid, more slowly. So it really depends on how quickly I'm trying to go.

Host Amber Smith: Well, how did you begin constructing your own crossword puzzles?

Rachel Fabi, PhD: Yeah, so that's also tied to "Jeopardy!." That had been a goal of mine my entire life, was to make it onto that show. And then I had made it, and I was on the show, and my episode was about to air, and I was trying to figure out, OK, what is the next like hugely nerdy thing I can do?

And so, as an almost lifelong solver of crossword puzzles, I decided that the next nerdy thing to do would be to get a puzzle in The New York Times. So that was sort of my next major goal. And so I'm on Twitter, and there's sort of a whole crossword subculture on Twitter, and I saw someone say, "Hey, we're looking for new constructors for this charity pack that we're putting together. If people donate to charity, they can get this pack, and we want new people to help contribute to it. And if you don't know how to do it, we'll pair you up with a mentor who can teach you how to make crossword puzzles.

So I got paired with a really fabulous mentor who taught me how to build a puzzle, and once I started, I was hooked, I loved it so much, and I haven't stopped. So in the last two years, I think I've made something like 150 puzzles, total.

Host Amber Smith: How long does it take to make a crossword puzzle? One that would go in USA Today or The New York Times? Is that an all-day project, or what's involved?

Rachel Fabi, PhD: Yeah, it really depends on how complicated the puzzle itself is. So if you're making for the USA Today, they're generally very straightforward themes, and they're all themed puzzles. There are also themeless puzzles that run in The New York Times, but in the USA Today, it's a simple theme, and so coming up with that theme set, the entries that sort of are the theme ones, can take a long time if you decide on a title or what we call a revealer, which is where it describes what the theme is, and it's embedded in the puzzle, sort of latch onto a title or a revealer, and then you have to brainstorm the entries that can go along with that theme, and if it's really complicated, that can take a while. Or if it's really simple, like for the USA Today, it might come to you very quickly. And then you lay them out in that 15 by 15 square, using software. I use a software called CrossFire, which is for Mac. There is also software called Crossword Compiler, which is for Windows.

And you start filling the grid around your theme entries. So the software suggests words that can go into different spaces based on the letter patterns and the blocks. And so it's a lot of iteration because you'll find you put something in that you think will go nicely with your theme entries. And as you start building off of the things that you've put in, you'll realize I don't really like the options that I have over in that corner now, and so you have to sort of undo it, and it's a very iterative process, so that can take anywhere from an hour, if it's a really easy grid, to I have some that I've been putting down, putting away, coming back to, trying again for almost a year at this point, and I'm still not satisfied with.

Host Amber Smith: Now these grids, the 15 by 15, they have to have symmetry? They have to be like a mirror image? Is that one of the rules?

Rachel Fabi, PhD: That's one of the sort of unwritten rules, maybe they're written somewhere, but one of the unwritten rules of crossword puzzles is that they have to be symmetrical in some way. Now that's shifting; there are some puzzles, including the USA Today, that will take asymmetric puzzles.

I personally like the constraints that are imposed on a constructor when there is symmetry, but in general, the most common kind of symmetry in a crossword puzzle is rotational, which means if you took the grid, and you rotated it 180 degrees, upside down, the square pattern would be the same. But you also see some sort of mirror symmetry in some puzzles, and sometimes you'll even see diagonal symmetry, which is symmetrical across the diagonal axis.

Host Amber Smith: In the puzzles that you've constructed, do you ever get feedback or questions from people who are trying to answer it?

Rachel Fabi, PhD: Yeah. Sometimes mostly what I get is corrections (laughs) from overzealous solvers who say, "Oh, this minor detail about this thing that you put in this one clue was incorrect." I had a typo that editors missed in a USA Today puzzle about a month ago; they had put, it was something about, an Olympic city for 1988, and they had changed it to 1998. So the actual answer was Seoul, but in 1998 it was Nagano, so I got a lot of emails from people saying you have the year wrong for the city.

Host Amber Smith: This is Upstate's "HealthLink on Air." I'm your host, Amber Smith, talking with Dr. Rachel Fabi from Upstate's department of bioethics and humanities. We're talking about her side gig as a crossword puzzle constructor.

So I wanted to ask you about the characteristics of a good clue. What do you think makes a really good clue?

Rachel Fabi, PhD: Well, there are so many kinds of clues. So you'll have a fill-in-the-blank clue, which I think is usually one of the easier footholds for someone who's maybe new to solving crosswords is when you have a nice fill-in-the-blank, you know what goes in that blank, right? It's very easy, or you don't know, but you figure it out.

But my favorite kind of clue is a wordplay clue where there's some sort of pun going on, and in the rules of crossword puzzles, if you see a question mark at the end of the clue, that's the signal to the solver that this is a pun, there is some sort of wordplay happening here, and that's my favorite.

Host Amber Smith: How do you feel about people who look up the answers if they're struggling with something, looking back into your profession of ethics, is it ethical to consult a dictionary or Google?

Rachel Fabi, PhD: Absolutely. There are no stakes when you're solving a crossword puzzle. It is your puzzle to solve however you want. And it's really between you and that grid how you get to the end.

Now if you're in a tournament or a competition, then we get into some ethical issues, but I actually think that looking stuff up when you get stuck is the best way to get better, because you'll learn those crossword words that maybe you don't see in your daily life outside of the puzzle. And if you don't look them up, you'll never know what they mean, and you'll never get better.

So I'm all in favor of people looking stuff up when they get stuck.

Host Amber Smith: How do you feel about rebuses? This is something I had never heard of before I prepared for this interview. And it's cramming extra letters into the same box? When did that become a practice?

Rachel Fabi, PhD: Sure. I don't know when people started using rebuses, but I love them. I think that they are controversial. There are people who are very anti-rebus because they think there should be one letter per box and that's the only way it should be done. But I think it just adds a little extra wrinkle of difficulty.

So an example of a rebus might be, if the theme is something like "kitty corner," and then in the puzzle, you'll have the word "cat" crammed into one box. So you have the letters C, A and T, and then running through "cat" in both directions, across and down, you'll have some word that uses those letters in that order.

And so it's just been crammed into one little box. I just think they're fun. I think it makes it a little bit harder, but they don't deserve the hate that they get on the internet, for sure.

Host Amber Smith: Well, they're not used in all of the puzzles. I mean, I've never encountered them myself. It must be a unique thing.

Rachel Fabi, PhD: You're more likely to see a rebus on a Thursday, which is when The New York Times runs their tricky puzzles, and those are sort of the hardest themed puzzles that The New York Times offers. And so tricks like rebuses or something else funky happening in the grid you're most likely to find on a Thursday.

Host Amber Smith: Well, let me ask you about an ongoing controversy about clues and crossword puzzles: Whom are the puzzle makers making the puzzles for? Because I imagine that would influence the way you word the clues.

Rachel Fabi, PhD: Yeah, I think that that's right. So, crosswords is undergoing a bit of a revolution right now. Historically, I think that some editors have had in mind this idea of the typical solver who looks like your grandfather or looks like an older person who reads the encyclopedia for fun.

And I think that that is changing a lot. I think that younger people are getting interested in crossword puzzles, and I think a more diverse set of solvers is emerging, who isn't just like a stuffy New York Times paper-delivery subscription recipient. So I think crossword constructors are, it's sort of a feedback cycle where as constructors become more diverse and they put their worldview, the things they care about, into crossword puzzles, solvers who resonate with those things are going to be drawn into this hobby as well. And so it's a feedback cycle where crosswords are just getting more and more diverse, more diverse solvers with more diverse constructors. And I think that that is a really good thing for the field, for this space, because it's more inclusive.

Host Amber Smith: So do you, when you sit down and start a puzzle, and I guess you kind of start with a theme, do you have a solver in mind, or do you try to put together something that could appeal to (people in their) 20s to 70s, male, female, all, I mean, do you try to include everyone?

Rachel Fabi, PhD: I think it really depends on the venue where you would like to publish your crossword puzzle.

If you're writing a crossword puzzle for The New York Times, you want it to be as inclusive as possible. It should be accessible to anyone who has the skill of solving crossword puzzles or the desire to learn that skill. I think there's also sort of parallel to that this indie crossword scene, where there are fewer constraints on what people put in their grids.

You might get some more risqué content in indie crossword puzzles, or a very niche subculture could be packed into a crossword puzzle, and so, when you're trying to write something that is going to be published in a newspaper, you want it to be as wide reaching as possible, but there's a lot more room for creativity and putting yourself and your own voice into a puzzle and the things that you care about when you don't have editorial constraints to worry about.

Host Amber Smith: Now do you personally prefer sort of the unchanging knowledge questions, the history, literature, geography, or do you like pop culture, slang terms, things like that?

Rachel Fabi, PhD: I mean, give me all of it. I think it's all great.

I think a puzzle that doesn't have any pop culture or any slang, I think it feels stuffy to solve. It's not very exciting, but I think when a puzzle is all pop culture and all slang, that becomes inaccessible to other solvers. And so I think having a good blend of those things is the mark of a really skilled crossword constructor, because they can bridge general knowledge and art, history, geography with colloquial phrases, maybe something that you would just say to your friend, and it's something that you encounter in real life. And I think that that's a lot more fun to solve.

Host Amber Smith: What about the use of commercial terms -- Pepsi, Samsung -- do you think it's OK to use names, words like that?

Rachel Fabi, PhD: Totally. I mean, I don't think that you could write a crossword puzzle in 2021 without the word "Oreo." (laughs) I mean, you could, but if we couldn't use these commercial terms, these things that you encounter in your daily life, first of all, it would be really constricting because I mean, really, "Oreo" --- it's three vowels in a four-letter word; it's great.

But also it gets, you know, back to that accessibility and inclusivity issue. If the only things that we think are worthy of being in crossword puzzles are the things that you need a college degree to know about, that's really exclusive. And so brand names, like everyone goes to the grocery store, encounters these brands in their daily lives, and I think that makes it more inclusive as well.

Host Amber Smith: Are you OK with these obscure words that no one ever heard of or sees except in crossword puzzles?

Rachel Fabi, PhD: (laughs) In small doses, yeah, I think they're fine. The prototypical "crosswordese" in crossword constructing, we call it "crossword glue" because they're the words that hold together the rest of the interesting stuff in the puzzle, but sometimes you need a little glue to make it work, is the word "etui," which is spelled E-T-U-I. Which is like an old-fashioned word for a needle case when you're doing needlepoint, and then you put your needle into your etui, and I've never in my life seen that word outside of a crossword puzzle, but it's kind of fun. Like it's interesting that there is a word for such a thing. So in small doses, I am here for the etuis.

Host Amber Smith: Now Will Shortz (The New York Times' crossword puzzle editor) has said that solving crosswords can make a person calmer and more focused. Do you find that to be true?

Rachel Fabi, PhD: Definitely. Yeah. I like to start every day with at least one crossword puzzle. It sort of gets me into a working space. I don't know if that's true for everyone, but it's absolutely true for me.

Host Amber Smith: I'd like to get your advice for people who want to be good at crossword puzzles. What tricks can we try? Is there anything that'll help make us better?

Rachel Fabi, PhD: I mean, I would recommend checking out The New York Times' "Wordplay" column, especially with the early week puzzles. So the Monday, Tuesday, Wednesday puzzles of The New York Times are the easiest ones of the week.

Those are also the columns that I write. I write the Monday, Tuesday and Wednesday columns. And so the goal of my column is to help new solvers get better and to learn to recognize patterns and the sorts of things that you'll see in clues, like what does it mean when there's a question mark or what does it mean when a clue is in quotation marks? Or what does it mean if it ends with "comma-say-question mark" ( , say?). You know what I mean? These are all markers that if you don't do a lot of puzzles, and you're just getting into it, you'll have no idea what that means. Um, and so we write the column for new solvers, with the idea of being: here's some tips to get into it, aside from plugging my own column.

Other things that I recommend to new solvers is to just keep solving, because the more exposure you get to these things that are just in crossword puzzles, these clues to what's going on with the clues, the more you see that the more you'll understand it quickly. And the third thing I recommend is to solve the USA Today puzzle. It is written at the easiest level of all of the daily puzzles that are published in newspapers.

It is consistently really high quality. It is consistently really inclusive. The constructor slate is really diverse. I think 75% of their puzzles are written by women, compared with other puzzles out there where it's closer to 25%. They've been really intentional about shifting that gender ratio, and so the USA Today is just my favorite beginner puzzle for new solvers to check out.

Host Amber Smith: Does, reading the dictionary help or is that sort of wasted time?

Rachel Fabi, PhD: I mean, I've never done it. I don't see how that could really help you solve a crossword puzzle because you'd have to memorize the whole thing, and that seems unlikely to happen. So I think that time is probably better spent just solving and getting used to it and looking stuff up when you get stuck.

Host Amber Smith: This is Upstate's "HealthLink on Air." I'm your host, Amber Smith, talking with Dr. Rachel Fabi from Upstate's department of bioethics and humanities. We're talking about her side gig as a crossword puzzle constructor.

Now you mentioned already what a question mark indicates in a clue, that it might be a pun or a play on words in some way. Can you tell us about some other common things that we might see in the clues?

You've probably written about them in the "Wordplay" column. What about ellipses -- ... (the "dot-dot-dot")?

Rachel Fabi, PhD: Yeah. So when you have ellipses in the middle of a clue, it means that the first part of the clue before the ellipses is the clue to the entry. And so is the second part, but they're not necessarily related to each other, so it's basically giving you two clues to the same entry. And the "dot-dot-dot" is sort of a way of saying, "Isn't it funny that these two things are related (laughs) or that they can both mean the same thing, even though they seem different?" Another common thing that you'll see in crossword clues is an indication that the answer is going to be in a non-English language.

And so sometimes that will be at the end of the clue, we'll see (Fr), which just means "in French," right? But more commonly, in the clue itself, you'll have a word in that language, so you'll see a French word in this clue or a Spanish word or a German word in the clue. And that tells you that what you're looking for is going to be in French or Spanish or German or whatever language.

Host Amber Smith: If a question is written in past tense, what does that mean?

Rachel Fabi, PhD: That means that your answer is going to have to be in past tense, and if your clue is a noun and it's plural, then your entry is going to be plural. So the part of speech has to match, the tense has to match, that sort of thing.

Host Amber Smith: Is there any way to tell from a clue whether the answer is one or more words? Because I know some answers are more than one word.

Rachel Fabi, PhD: Yeah, it usually won't tell you. There is a whole other type of crossword puzzle called cryptic crossword puzzles, which are very popular in the U.K. and are becoming more popular here, where they'll tell you the enumeration at the end of the clue.

So for instance, if it's a two-word entry that is nine letters long, it'll tell you "3, 6," right? And you know it's a two-word entry, where the first one is three (letters) and the second one is six, but we don't do that in American crosswords. So that's really a very British thing, and it's a totally different style of wordplay, too.

I'm very bad at cryptic crosswords.

Host Amber Smith: Sometimes I'll see a question that's in quote marks, a clue that has quote marks around it. Is that trying to tell me something?

Rachel Fabi, PhD: It very much is. Yeah. So when you see a clue in quotations, it means that it is looking for an entry that is colloquial that means the same thing. So for instance, if the clue in quotes is "Hey, you," right, then the colloquial equivalent of that might be P-S-S-T, like, "Pssst!" you know, to get someone's attention. And so it just means: What is something that you might say that means the same thing as the thing in quotes?

Host Amber Smith: What about brackets? If I see brackets in the question?

Rachel Fabi, PhD: Brackets usually mean that the clue is not necessarily a word or that the entry isn't necessarily a word that you would say; it's more of an action. So for instance, in brackets, you might see, this is a clue that I wrote: [more tuna, please].

And the answer was "meow," right? You're not speaking the word "meow," it's just something that means the same thing. Well, that's a hard one to explain. I'm not sure I explained that very well.

Host Amber Smith: But I get what the cat's meow is saying: "more tuna, please." I guess once someone starts into the crossword world, will this all kind of become more second nature?

It's a little intimidating.

Rachel Fabi, PhD: (laughs) Yeah. I really think so. I think if getting deeper into crosswords more than just solving occasionally is something that you're interested in, again, starting with the USA Today is a good on-ramp. And I think people who really, this is meant for people who really love this and will find from that entry point a lot of different directions that you can go. You can get involved with sort of crossword Twitter, and that's a whole space where you can connect with other constructors and other solvers. There are tournaments that you can do. Many of them have been online over the last few years, for obvious reasons. but I think, you have opportunities to compete and connect with other people, either online or in real life, and yeah, it's a really welcoming, kind, generous community. People are always looking to mentor new constructors and people who want to learn how to make puzzles. People are generous with their time and happy to help new constructors.

And so it's a fun space to sort of explore.

Host Amber Smith: As a constructor, how do you archive all of the crosswords that you've made in the past? And do you have rules for yourself about whether you will reuse certain clues?

Rachel Fabi, PhD: My archive system is a mess. It is just a series of folders on my desktop. But I actually don't pay very close attention to the clues that I've used. I mean, I think if I come up with a really clever clue for something, I'm going to remember it and not use it again, but I have a bit of puzzle amnesia; like I can solve the same puzzle a few weeks apart and not remember solving it. So keeping track of what I've used in puzzles for sort of more mundane clues is not something I'm concerned about, but if it was a really good one, I'll try not to reuse it.

Host Amber Smith: Now that you've been on "Jeopardy!," And you've had a New York Times crossword puzzle published, what's next? What's your next challenge?

Rachel Fabi, PhD: Oh, man. Well, I mean, here at Upstate, trying to get tenure, that's my next sort of professional challenge. And then in terms of nerdy stuff, I mean, writing the "Wordplay" column, getting invited to do that, was really a dream.

It's really fun. I love talking about crossword puzzles. Obviously, I could talk about them all day, and so having a platform to engage with solvers about this thing that I love has been really cool. And I'm going to keep doing that, keep writing for The Times. I did audition for another game show recently.

I haven't heard back, but I think it went well. So I will keep you posted and maybe keep doing some of that on the side as well. But in general, I'm pretty satisfied with the level of nerd that I have reached.

Host Amber Smith: Well, thank you so much for taking the time to talk with me.

Rachel Fabi, PhD: Yeah. Thank you for the invitation. This was really fun.

My guest has been Dr. Rachel Fabi. She's an assistant professor of bioethics and humanities at Upstate I'm. Amber Smith for Upstate's "HealthLink on Air

Here's some expert advice from Dr. Sharon Brangman from Upstate Medical University.

Is forgetfulness part of aging or a sign of dementia?

Sharon Brangman, MD: That's one of the most frequent questions I get asked, and people say, "I'm having 'senior moments,'" and they're terrified that they have Alzheimer's disease. And I think it's something that if you're concerned about, you should definitely pursue it.

Go to your health care provider and get an evaluation. But I can tell you that most people are on overload. They're multitasking. They have a lot of information to process, and they're trying to do too many things at once.

However, if your memory problem starts to interfere with your ability to get through the day, then I would be concerned. If your memory problem makes you start to have problems at work, so maybe you're late for meetings, or you're not prepared, or you forgot to make important calls, then I would be concerned if your behaviors change from what you used to do on a day-to-day basis. If maybe you're more withdrawn, and you don't want to participate in conversations with other people, or maybe you start to say things that come to your mind without filtering them and being appropriate, then I would be concerned if it starts to impact some of the day-to-day things that you do, like driving.

If you start to have problems figuring out how to get to a place that is normally familiar, then I would be concerned.

So what we're looking for is a memory problem that also impacts your day-to-day functioning. And that's how we start to tell the difference between a memory problem that might just be due to being overloaded, overtired, multitasking versus one that might be more serious and needs further evaluation.

However, what I want people to understand is that memory loss is not a normal part of aging. So there's always that thought that oh, old people always get forgetful. We may have changes in the way we process new information as we get older, but memory loss is not normal.

So if you have a memory problem, you should go and get it evaluated.

Host Amber Smith: You've been listening to chief of geriatrics Sharon Brangman from Upstate Medical University.

And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.

Deirdre Neilen, PhD: Eating disorders cause great suffering. Treatments vary in efficacy and can bring their own sets of problems.

Three of our writers gave us insight into how health care professionals and others sometimes cause more stress to the people they say they wish to help.

Sophia Valesca Görgens is a medical student at Emory University. Here's her poem, "On Obesity":

There is a weight to my body I fear

causes doctors to judge me

for my lack of control. Just stop

eating, they say. Your risk scores

for heart disease are too high.

Don't you know better

treatments are available

than your own will to exercise? (I admit I have no will to exercise.)

They list medical managements,

try to convince me of surgery

where they cut the stomach small.

I don't know how that can be better.

I had a friend who died on the table,

blood clot to the lungs. Or lost

too many vitamins. Called dumping syndrome --

as if giving it a name makes it worthwhile.

I live in this body and breathe. I am

worthwhile, but sometimes I forget

because of how, not what, how

they speak at me.

Jessica Mehta is a citizen of the Cherokee Nation and the author of several books.

She is currently a fellow at the Halcyon Arts Lab in Washington, DC. Here's her poem, "Great Grace and Sharp Wings":

37 years old and still starving myself -- how much

longer until I don't care anymore? You say,

Stop caring now, but I don't know

if I can be one of those old ladies

with limp hair and no lipstick.

(Not that this is old, it's just ...

when does old happen? How do we

simply slip into it like it fits? I'm not sure

I have the capacity to grow old

with grace or by any other means.)

Do we call fat 60-year-old women

fat-fat, or is that when plump begins?

How about 70? Or 80? When

does it all end and how do I stop

running hands over stomach

to see if today's a skinny day? My plan

is to die at 66, right before the life

insurance expires and maybe

(if I do it right) they'll say it was a slender

old woman who fell

with great grace and sharp wings

in front of that rumblin train.

There'll be no open casket and guilt-

laden memories are kind to the dead.

(Please, if you remember, call me beautiful

in the obits and choose a photo

where my collarbones protrude like plumage.)

And finally, Sarah Kuhlman, a retired neonatologist from Springfield, Missouri, gives us a hint of the story behind one woman's weight in her poem, "Rage":

Compulsive Eating

to keep

what you would take from me

I consume and assimilate

voraciously

without hunger

to hide

what you can't see in me

I add layers

immobilizing

dressing in armor

to silence

what you refuse to hear me say

I pad and stuff myself

stealthily

muting my screams

I grow large

into significance

Female Insignificance

a doctor

changing into scrubs

in nurses' locker rooms

she surrenders her thoughts

for a man's presentation

so others will listen

securing the mortgage

her name on the deed

her husband is listed as owner

delivered from her body

her children bear

their father's name

and so she

ate and ate

and no one dared to notice

Weight Loss

I burn my banner

I squelch my rebellion.

I shrink

Not to walk the runway

or joined the olympics of lust

not to be

what I am told I should be

small, boyish, passive

quiet

I am a woman warrior

exhausted by the weight

of insignificance

Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York. Next week on "HealthLink on Air," meet a paramedic who provides medical care on movie sets. If you missed any of today's show or for more consumer health podcasts, visit our website ( at healthlinkonair.org ).

Upstate's "HealthLink on Air "is produced by Jim Howe with sound engineering by Stephen Shaw. This is your host, Amber Smith, thanking you for listening. .