To parts (mid)west

End of the three-day

Shadowing

Yesterday, I spent the morning shadowing my colleague while he saw patients in our clinic. The goal was for me to learn how one doctor manages the flow of a busy clinic while still providing good care to patients and addresses all their issues.

I love shadowing. In residency, we rarely shadowed our colleagues or faculty. Life was too busy, too scheduled, too chaotic. We de facto shadowed specialists in their clinics on some rotations, but I had no personal investment in their practices, I didn't have to do their jobs.

Shadowing colleagues in my own clinic is different. Watching doctors with strong medical and communication skills, working efficiently with complex cases, is inspiring. In my post yesterday, I hinted at how a visit can get bogged down in chart review, and that there appears to be a better way to use the electronic record, on a screen, to engage with patients.

What I observed in shadowing this week was a great demonstration about how to use the screen as a visual aid in addressing concerns. There seem to be a few guiding principles I should follow:

1. Turn the screen toward the patient! What I can see, my patient should see. It's their health record, no secrets.

2. Exhaust the patient's list of concerns ("What's on your mind today? What else? And what else?" Until the answer is "that's it.") This I learned in medical school and residency. But now I'm learning to make sure I note it in the chart when the patient brings it up. I put their list on the screen for us both to see: our agenda.

3. Ask permission to go through their problem list (these are the things the patient is currently dealing with, things we should check in about frequently) to make sure it looks right. Patients who use our online service can view their problem lists at home. I also ask if we can look at the medication list on the screen, make sure patients know exactly what they're taking and what the meds are for.

4. Update lists and important information in the room, with the patient. It would be easy to think that this is a waste of time, especially when visits a stacked every 20 minutes or so, but I think patients appreciate it, and as we tend this clinical data, we're talking about a lot of health issues. The list work just gets us started and help us cover a lot of important ground.

5. Get it done now. I had a patient ask if he should take an antibiotic before his upcoming surgery. I told him I didn't know, but we should ask his surgeon. So we did, right away. I sent an email to his surgeon and the task was done. Or started, at least (we'll need an answer).

6. Summarize! Doctors review plans with patients all the time. Then both doctors and patients forget. Our electronic record has a very nice after-visit summary function into which I can type patient instructions, which I do in the form of a brief letter, noting what we agreed to during our visit. Again, I write this while the patient watches (I type fast), then review it with the patient to make sure I got it right. I print it and give it to them as I walk with them down the hall.

I'm sure there are more principles I can generate, but I'll stop there. It's getting late.

But before I go, one more word about shadowing. I learn so much from watching others do what I do. This was true when I was an actor, and it's true in medicine (also a performance of sorts). I think healthy medical practices should all encourage regular shadowing of colleagues so docs can pick up (and demonstrate) good habits and not get stuck in their settled inclinations.

Like Chauncey Gardner, I like to watch. I think we all should.

Work: A New Job

This is tardy. Apologies.

I have this new job. I've had it since last December, actually, but I just started last week, after several wonderful weeks of summer. My job is with Group Health Cooperative, as a family doctor in the Burien clinic.

"Burien," most people say, "why on earth would you go to Burien to work?"

It's my dream job. That's what I thought when I took it, that's what I think now. What's happening there is what should be happening all over the nation. We're practicing a new model of primary care, the "Medical Home," with a goal to be the model clinic on which others build their own practices.

But I can't really help my colleagues spark a health care renaissance until I learn where the bathrooms are, so I'm taking it slow, and I'm grateful that others are dedicated to transitioning me to my job in a humane, rational way. It's a complicated system.

I started last week with several days of orientation: benefits for a day, the electronic medical record (EMR) for two days, and a day of finding the bathrooms and learning how things work in my clinic. On day five, last Friday, I saw my first post-residency patient. Practicing on my very own license.

Yikes.

The support is wonderful, though. The co-op has a great consultation process, using secure email, through which I can ask specialists to comment on the care I'm giving. A quick question with the chart "attached" (we all use the same medical record), and within a day I have recommendations to help guide the care I'm giving. It's great, and helps me to continue learning at a rapid pace.

I've been seeing patients at a slower rate than my much more experienced colleagues, and for this I am grateful. I use the extra time I have to get used to the logistics of delivering care in a new place that is part of a big, complicated, but effective network of resources. It's not always intuitive how to get something done. I use every minute I've got learning how to be more thorough and more efficient.

One of my big challenges--one I'm thrilled to take on--is to integrate technology (our EMR) into visits in a way that engages patients and doesn't shut them out. Often, even with paper charts, the visit can become a kind of one-on-one between doctor and chart, with patients pushed aside while doctors dig for old notes, labs, and results to try to make sense of the patient sitting in front of them. In residency, I had many moments like this, me looking for a mammogram result while the patient looked at me looking down into a mess of paper.

I could easily make the same mistake, though at least it would be a paperless offense. What I've learned though shadowing one of my partners is to use the EMR with the patient to be more thorough, cover every concern the patient brings, and finish the work of coordinating and documenting care before seeing the next patient.

For those readers who don't have to chart for a living, I'll just say that's a huge accomplishment. The norm in primary care is "batch and cue," meaning a doctor finishes seeing a patient and puts the work generated by that visit into a cue--or a pile--to complete at the end of the morning, the day, or even later.

Trouble is, how do we remember everything that happened in the visit? We don't. We start forgetting things the moment the visit ends, and if we don't get to the work (making notes, writing orders, reviewing results) quickly, important things fall out of our heads, and things get left undone. Not good for patient care. Not good for clinic employees. Not good for families of clinic employees.

"Today's work today" is the buzz I've heard among the new model folks. What I'm learning at Group Health is even more immediate: something like "this moment's work this moment." Whatever our patients bring to discuss, we can work on it now.

We have powerful tools available to help us accomplish this, and I hope to write more about these tools and my experience as I learn (I'll bundle these under the label "work").

For now I'll say this. I am happy.

News flash. Naked bicyclists...in Seward Park!

Gun salesman?

I've been getting a lot of wrong number calls on my cell phone these days. One voice mail last week was from the billing office of a local clinic, responding to a call about overdue medical bills (I'm current, wasn't for me). No biggie.

This morning I found my phone, lost for the last couple of days, and retrieved a message from someone wanting to pick up the "military 38" he had bid on over the weekend.

That's a gun, right?

I don't make a habit of calling back wrong numbers (as some have done to me: "Who's this? Why did you call me? What do you want? Don't call again."), and I think I'm going to hang on to that policy.

Cancer in the South End?

I posted this to my neighborhood blog this morning, and thought I'd put it here, too, mostly so my mom can see how I'm spending my vacation.

There has been some buzz in the press and local blogs this week about the recently-released Agency for Toxic Substances and Disease Registry study, which finds, according to the P-I article published in this morning's print edition, that:

Residents of a broad swath of South Seattle from Seward Park to West Seattle face elevated cancer risks because of air pollution, according to a soon-to-be released government study.

The risks are significantly elevated in pockets of industrial pollution – and skyrocket within about 200 yards of highways, says the long-awaited study by state and federal scientists.

The affected areas are shown in the map I've grabbed from the P-I article, and risks appear highest, theoretically, in the industrial areas around Georgetown, which get pollution from factories, roads, and airplanes.

I decided to bring the study to the Colman Triangle blog because of the red, high-risk areas on the map at the north end of the Triangle (at I-90). I read the P-I article, and was curious, so I dove into the ATSDR report for more information, which I think is worth sharing.

Non-Cancer Risks

The press has focused on cancer, which I'll get to below, but the freeway at the north end of our neighborhood offers more hazards to our health. The bulk of non-cancer risks come from a chemical called acrolein, with exposure coming from car exhaust and cigarette smoke (note, are you still shopping for reasons to quit smoking?). From the report (bold type by me):

Similar to cancer risk, non-cancer hazards are highest near major roadways. Hazard indices decrease with distance from the center of highways, but exceed one (meaning risk is greater than baseline) up to a few hundred meters on either side of major highways. Acrolein is the primary contaminant associated with non-cancer hazards from road sources. The following four pollutants are the main contributors to non-cancer hazards from mobile sources in descending order.

• Acrolein
• Formaldehyde
• Diesel Engine Exhaust, Particulate Matter
• Nitrogen Dioxide

I've linked three of the agents above to the ATSDR info sheets about them. There aren't any well-defined cancer risks to these pollutants, but they do make breathing unpleasant and can affect folks with lung disease (asthma, COPD...) and children more than the rest of us.

Cancer Risks

There are a few things floating around the Colman Triangle that bring an increased cancer risk. From the report:

Diesel particulate matter, benzene, and 1,3-butadiene are the chemicals that contribute to the bulk of risk.

What kinds of cancer, you ask? Benzene is associated with leukemia (and anemia; benzene suppresses bone marrow production of red blood cells), while 1,3 butadiene appears to be associated with a "variety of tumor types."

Keep in mind that cancer results from long-term exposure, and that there are many other, non-cancer but unpleasant effects from shorter-term exposures (follow the links to read about these).

What to make of this?

I'm not a toxicologist or epidemiologist, so my ability to interpret the ATSDR study is limited to my training as a regular old physician (family doctor) and concerned citizen with two kids whose well-being I cherish more than my own. From what I've read, here's what I take away:

1. Our little neighborhood sits just south of a major interstate with tons of diesel traffic passing through, leaving us with a variety of pollutants in our air, water, and soil. The risk of toxic exposure drops with distance from the freeway (it's about 200 meters from the center of I-90 to Massachusetts), but risks still exist beyond the "red zone." We're also bounded to our west and east by Rainier and MLK, which carry plenty of pollutant-spewing trucks and cars.
2. Most of I-90 is covered in our neighborhood, which is nice. But...what happens to the pollution in the tunnel? Where does it go? The risk map is red even in the lidded areas.
   
3. Kids and the chronically ill, as usual, have it worse than the rest of us.
4. Cancer is bad, for sure, but anemia, birth defects, and lung disease are also significant effects of the pollutants found in the ATSDR study, and are likely to ruin your good time before cancer creeps in.
   
5. Smoking is still stupid. This study reminds me that smoking tobacco is similar to wrapping your mouth around the exhaust pipe of a running diesel engine.
6. The "fixes" to the problem are mostly to be found in rational public policy. Pollution standards for automobiles and factories should be designed to prevent disease and should be vigorously enforced. In our neighborhood, we can advocate for safe practices from our industrial neighbors (most of the Triangle is zoned for commercial and residential, creating a potential mini-Georgetown effect).

Those are my reflections. I look forward to comments and face-to-face discussions around the neighborhood.

Crossposted

Zero across the board

Here's a screen shot of the King County West Nile Virus surveillance report that landed in my mailbox this morning. It's like a no-hitter going into the seventh inning.

Washington state has been pretty lucky with West Nile thus far. We've presumed the virus would arrive here, in humans, sooner or later. Look at the 2007 CDC reporting map:


We totally lucked out (unless you're among the bird or animal cases noted), an island of gray in a sea of orange. Gray is my favorite color. So far this year we're free even of animal, bird, or mosquito cases (in King County, the state has animal/bird/insect cases).

But check out Oregon. Nothing across the state. Good year to be a bird there.

So I guess the next fever I see in clinic (once this luxurious six weeks of vacation is over--next week) is just a fever, or at least not West Nile.

Not a Blue Angels fan

But he tolerated today's show pretty well. Yagi's biggest concern was the curious chihuahua and some Cheerios some kid dropped while watching the planes.

Blue Angels fans

Here's a portion of the crowd that gathered atop the ridge over I-90 to watch the Blue Angels practice show. They got to see several direct flyovers from this viewpoint.

VW bus. Phil. John. Oregon wilderness.

Inspired by Simon?

Introducing the Colman Triangle

My local polygon has joined the much-hyped neighborhood blogosphere.

At a recent community meeting called to discuss arson, vandalism, and other feel-good subjects, we took some time to talk about how we might connect better. We planned to come together, again, for Seattle's Night Out event, and also to create a team blog for the neighborhood. I am thoroughly addicted to several of Seattle's neighborhood blogs: the Central District News, Rainier Valley Post, Miller Park, Capitol Hill, B-Town (Burien) Blog, West Seattle Blog, and Mid-Beacon Hill...for starters. There are more.

Neighborhood blogs have become a great source of local information, sharing news other local media don't cover (and I don't watch television or listen to commercial radio, so I'm limited to newspapers, electronic and echt, and public radio.

Our new local blog is called the Colman Triangle News. I'm not sure yet how we'll use it. Hopefully we'll follow the good lessons of other successful, local efforts. Whatever happens, I'm sure it will be fun.



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Advice I didn't need

The following arrived in my email box this morning from Public Health. Steer clear of bats. Okay. Gotcha. They carry rabies...but I avoid them anyway. The press release mentions a couple who found a bat in their home, where I'm sure they thought they were steering clear rodents with wings.

Reciprocal advice to bats: steer clear of people--they will kill you and send you and send your carcass for testing. Stay in your bat place. Please.

Yuck.

Steer clear of bats – they can carry rabies

KING COUNTY, WASHINGTON - Bats in King County can have rabies, as a local couple found out recently when a bat they found in their house tested positive for rabies. Because they weren’t sure whether the bat had scratched or bitten them while they were sleeping, they received post-exposure treatment, which is 100% effective if given promptly. Without treatment, rabies is almost always fatal once symptoms begin. Since the beginning of 2008 in King County, 22 people have been treated for exposure to potentially rabid bats and two of the bats that were tested were found to be rabid.

» View full press release.

Image: http://wdfw.wa.gov/wlm/living/graphics/t_bat.jpg

Action at 26th and Massachusetts today

I was on a walk to the dog park this afternoon, when a single cop car (the one in the center), pulled in behind me and picked a young woman out of a group of kids. I let the dogs into the park and lingered, though out of earshot. The first officer asked her a lot of questions and took a lot of notes. The cop car number quickly rose to three, and there was a lot of cop-consultation while the young woman sat on the front bumper of the car. No arrests, and I have no idea what this was all about.

Pretty Good

Pretty good day, today. The morning was lazy and lazed into the afternoon. I was in danger of not leaving the house at all, which would have been a tremendous mistake; 75-degrees, sunny, nice breeze, not a weekend. I rallied after lunch and headed out on my bicycle.

Through the tunnel and down to the lake. I'd intended to sit at Colman Beach with a book, but took a detour down to Seward Park, round the point and back up to Colman. There, I watch two dopey guys lope out of the water with turtles they'd found--or turtle-napped--from a the shady spot nearby where several turtles live. They declared their intention to race the stolen testudines on the lawn. Shockingly, the critters didn't respond to their trainers' verbal prompts, and sat totally still. A good move for the turtles: the dopes got bored put them back in the water.

You'd think that was the end, but at that point a woman in a yellow duck inner-tube floated by and scolded the dopes for not returning the turtles to the shady shore where they'd found them. Something about shade and goose poop and death--I didn't totally get it, but giving your spurned, pet turtle a ride home seemed like a reasonable gesture. The dopes didn't get it either: they apologized to duck woman, but didn't re-enter the water to retrieve the turtles. So duck woman exited her craft and dove for the reptiles. Good work, duck woman.

I was again--for the second time this week--without sunscreen on a sunny day...in the sun. I feared returning home, while an effective sun-screen, would mean sitting at the computer reading blogs and flying to Puka Puka and the like with Google Earth, so I decided instead to check out Medgar Evers Pool for some lap swimming (first choice was Colman Pool in West Seattle, but there's a masters swim meet there and the pool is closed to the public for three days).

Now, one might wonder why (risk of sunburn notwithstanding) I might choose to leave a perfectly good lake on a warm day and pay to swim indoors. Brooke, in fact, asked just this question. My reply: milfoil. Nasty, nasty stuff. According to Cornell's Department of Ecology and Evolutionary Biology:

Eurasian watermilfoil is a long, slender plant that grows underwater. It has a round, light colored stem with flat, feather-like leaves. In water less than 30-35 feet deep, watermilfoil can form dense stands that often reach to the surface.

And it's gross, and monsters live in it. If there's a monster in the pool, I'll see it and leave. Milfoil-dwelling monsters just reach right up and grab you from their creepy, slimy houses in the weeds. You never know until it's too late, and you're caught, like some dumb turtle, and made to race.

So I went to the pool, and had a very nice time, and wasn't killed by monsters. I wasn't even scared, thank you.

The hour of chaos was near, so I returned home, made dinner for Zoe & Elliott to ignore (though Elliott did eat Zoe's edamame, and didn't choke, and wasn't killed by monsters either). Played outside with the girls and neighbors, Zoe to bed sans hassle, dinner, and an episode of Weeds (season three, too good).

Et voila. Man of leisure. Journal entry complete.

Maybe tomorrow, sea monster.

The end of drug rep schwag!

According to the NYT's "Well" blog, drug companies will voluntarily back off dumping buckets of pens, post-it pads, clocks, and other cheapo-pharm-schwag into the hands of doctor-advertisers:

Clipboards, pens and mugs emblazoned with drug company logos are about to become collectors’ items. The pharmaceutical industry’s trade association, the Pharmaceutical Research and Manufacturers of America, has issued a new voluntary code of conduct that prohibits distributing the brand-adorned freebies to the nation’s doctors.

Glory be. I feel fortunate to have spent the last three years in a pharma-free residency program, and I regularly toss drug-logoed crap directly into the trash whenever I find it lying around (in doctors lounges, waiting rooms, etc). The clinical years of medical school featured daily lunches from drug reps (I ate them) and as much junk as you could grab: pens, stethoscope covers, measuring tapes, hand sanitizer, flashlights, scissors, stress balls, reflex hammers, mouse pads. So much clutter. My absolute favorite, while it lasted, was the Viagra pen: hefty, firm, metal shaft. Alas, it didn't measure up to a simple Bic Ultra or Uniball Deluxe Micro. The mighty stylo phallique cracked after just a couple of admission H&P write-ups. Junk.

By the middle of my fourth year, my fascination with free stuff and bad lunches was pretty much over, and I started to read the medical literature on the effect of drug reps on prescribing practices: turns out they do all this stuff because it works! It wasn't hard to remove reps from my life, especially after joining a non-rep-friendly residency.

As Tara Parker-Pope points out in her blog, getting rid of cheap tchochkie's printed with expensive brand name drug names isn't the same thing as cutting out speaking fees to physicians and informational dinners at El Gaucho, but it might un-clutter health care a little.

Burglarpalooza

According to the Central District News and CHS Capitol Hill, we're awash in crime lately. Is it the usual summertime increase? Climate change? The cost of gas? Corn? Starbucks employees anticipating unemployment?

Our South Precinct Crime Prevention Coordinator, Mark Solomon, sends out this regular newsletter to help with strategies to avoid getting your stuff stolen. Enjoy.

South Precinct Email Community Newsletter

July 7, 2008

Dear Community Friends,

Burglaries

I had been gone about four hours and when I returned home one day following an appointment. As I entered and looked at how my dining room table was out of place and the cabinet drawers were open, I thought, “I didn’t leave it like this, did I?” As I looked in my office area and found things off the shelves and on the floor, I thought, “How did this happen?” It wasn’t until I went in the bedroom and found that the jewelry boxes had been upended on the bed that I realized I had been burglarized. Forced entry through a locked rear door inside a locked fenced in yard. They stole jewelry, a laptop, my digital cable box, digital camera, cash, DVDs… and they took food out of my freezer.

It Can Happen To Anybody: Don’t Blame Yourself

I understand that queasy feeling that surfaces when you realize that your space has been violated, that someone came into your home, rifled through your dresser drawers and took your stuff. I know first hand the second-guessing, the questioning and the self-blaming. “If only I had done _____.” “Why didn’t I ______?” You have to admit, it is ironic that the crime prevention guy, the one that hammers you with home security tips, gets his place broken in to. It does go to show that; 1) it could happen to anyone, 2) If you have already taken precautions to improve home security, there may be some things you haven’t considered (the BB gun used to break the double-pane glass of the rear door was a new one for me; one that I’ve seen a few times since my burglary), and 3) further improvements could be made.

And since I know you’re wondering, I also waited 3 ½ hours for an officer to respond. The crime was not in progress, there were no witnesses, and there was no suspect information. With other things going on in the Precinct, my non-emergency call could wait.

What You Should Do: Lessons Learned And Reinforced From Me To You

1. Always lock doors and windows when away from the home.

2. Have a home security assessment to see what you can do to improve your home security. This is a free service. Learn from my professional and (recent) personal experience.

3. Take inventory of your valuable items. Make a list of the items, model number, serial number and approximate value. For items that can be engraved, put your driver’s license or state ID number.

4. For those items that cannot be engraved, take a picture of them and have a written description of the item. Do the same with jewelry and include appraisals of the items.

5. Communicate with neighbors. There had been recent burglaries in the neighborhood, so alerting neighbors when an incident occurs makes everyone aware so neighbors can be more watchful.

Night Out Against Crime 2008

Speaking of communicating with neighbors, we encourage you to participate in “Night Out Against Crime 2008” on Tuesday, August 5, 2008. Night Out is a national crime prevention event designed to heighten neighborhood awareness, increase neighborhood anti-crime efforts, and unite our communities. It is a great chance to connect neighbors and share information with each other while learning more about crime prevention.

To register your block for Night Out Against Crime 2008 on line, please use the following link: http://www.seattle.gov/police/Nightout/default.htm.

The 2008 event theme is partnership with the Emergency Management Office to promote the SNAP (Seattle Neighborhoods Actively Prepare) program: More information about SNAP can be found at http://www.seattle.gov/emergency/programs/snap/.

Until next time, Take Care and Stay Safe!

Mark Solomon, South Precinct Crime Prevention Coordinator

Injury Test: failed

I posted yesterday from the sunny peak of Mt. Si, which I climbed as a test of how my painful heel would hold up on a steep trail with the support of a rigid sole. Overall assessment: ouch. At baseline these days, I've got a pain level of 2-3 (my reference points are zero=no pain, ten=can't bear weight on it), with periods of 6-7 pain. I'm happy to walk with a 5, and would hike with 6, if there were a compelling reason.

After an evaluation last week, I had decided to put off full-time "boot rest" for a few weeks while I readied myself for a hike up Mt. Adams. Once that ascent (and descent, hopefully) was complete, I'd go into the boot for a few weeks, get some new orthotics made, and work toward recovery, with the ultimate goal of a return to running.

I would also like to be pain free, but I don't know how likely that is. This pain has become chronic, and chronic pain doesn't usually go away.

But yesterday's experiment has changed things a little. At the trailhead, pain was minimal (about a 2), and I felt comfortable in my old Vasque boots. I climbed well, covering the four miles and 3,200 vertical feet in just over an hour. The last mile of ascent is steeper than the first three, and steep has been the thing that aggravates my pain the most (putting strain at the insertion point of my plantar fascia). My pain quickly rose from a three to a five to an eight, and by the time I was sitting, sans suncreen, at the sunny base of Haystack peak, I was worrying about how the trip down would be.

Justifiably worried, it turns out. The trip down, usually quicker than the walk up, took about two hours due to heel pain that caused me to alter my gait, putting strain on other parts of my foot and ankle. Pain was solidly at eight most of the descent, and was a nine by the time I got back to the parking lot.

At the trailhead, I sat with my foot in the icy creek for twenty minutes (a ten for pain until the numbness set in), then hobbled to my car. More ice last night.

This morning, nine. Ice. Still nine.

So, new plan. I fear I'm not fit to walk up and down Mt. Adams in two weeks time. I'll still go, but hang with the trailhead crew: Amy, Jen, and kiddos. Starting now (yesterday, actually), I'm in the boot most of the time, icing and resting. Until I'm doing better, I'm not a runner or a hiker. I bike, I swim, I act sensibly.

Podiatry follow-up next week.

Sunny...must flee

Top of Mt. Si. Forgot sunscreen.

Jimi Hendrix Gets A New Doo

Zoo doo, that is. The park adjacent to the Northweat African American Museum has recieved a giant load of topsoil. Over the last couple of weeks, workers were finishing up the insallation of a sprinkler system, and are now covering the park with manure--and covering the neighborhood in sweet aromas of rhinocerous, elephant, hippo...

This is a welcome development for the Jimi Hendrix Park, long in planning, development, and even longer in execution. The former parking lot may now, finally, become a place where people go to do park kinds of things rather than simply pass through.

Now, when will that Jimi Hendrix statue from Broadway delivered?

Guitar: chords and strums

I spent some quality time hurting myself with my new guitar today. I was glad for it, too, since yesterday proved an exercise in frustration and excruciating tone deafness.

Somehow, yesterday, I managed to get completely out of tune. Efforts to tune were comic and embarrassing. With no reference point for a note--any note--other than plastic horns in my kids' toy bins, I had no way of knowing where to begin. Naturally, I went to the internet. There are many online how-to-tune-your guitar tutorials, many of them handy You-Tube videos. One I watched was very straight forward, but required that I be sitting at a piano. Another wanted me to use a tuning fork (I have one for neurological exams, but wasn't sure that would work out). But...the guy in the video was sitting at a piano...right? And if he could summon an E for me, then it would be like I was at the piano.

I had a piano!

I went through the steps of tuning low E, then tuning the rest of the strings by ear. Quite proud of myself, I thought I'd celebrate with a big, happy G chord. Well, it sounded like shit. Really. Awful. Not G. Not anything. I was sure that I'd heard the E correctly and the rest of the tuning went well, so clearly that means I'm tone deaf. So be it.

I had some errands to do, one of which took me right past the Guitar Center (where I'd bought my guitar the night before). I willfully violated Joe's clear advice and bought a tuner. Not only that, an electronic tuner. Clips on to the end of the guitar and tells me it doesn't care if I'm tone deaf.

I also bought some picks. Sorry, Joe.

So today, once I got off my chair long enough to pick up my guitar and put myself back in the chair, I was in tune, or so my new friend told me. My chords sounded good to me, but what do I know.

I spent some time working on the five chords in chapter one of my Fretboard Logic book, working on finding them and playing them without awkward rattles or muted string sounds. I spent about an hour with that, then jumped into one of the free online lessons at Next Level Guitar. I chose "How To Strum," because I don't know how to strum. I watched the short video several times (had to learn a new chord participate--now I know six) and learned a couple of strum patterns and a chord progression. Next I'll learn what those terms mean.

So now my fingers are, well, injured. I would have loved to keep on playing, but couldn't put my fingers on the strings, they hurt so much. So I read about fixed gear bikes for a while and headed out for some errands.

I'm sitting now at Stumptown Coffee, across from the girls daycare, and it's time to pick them up. So off I go, bloody fingers and six chords in my head.

Unemployment is good.

Park close to home to shut down for July 4

Reported yesterday in the Rainier Valley News, one of my favorite neighborhood blogs, Sam Smith Park (the I-90 lid park) will close mid-afternoon of July 4 for safety reasons. To quote the Post:

The same goes for Sam Smith Park - the largest and most central part of the I-90 lid, which ironically enough, is home to the Urban Peace Circle, a sculpture by Seattle sculptor Gerard Tsutakawa that was dedicated to children killed by gun violence in Seattle’s inner city.

I guess that's a good--if sad--thing: the park is regularly a mess after July 4, with fireworks strewn everywhere. But will the fireworks--and the people who light them--just disappear? Where will they go? Other parks. Parking lots. Streets.


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I guess we should be happy the city is looking out for our safety. We'll see what kind of impact it has on the neighborhood. There's a lot of good discussion on the park closures on the RVP's site.

Guitar

Many thanks to Joe, my friend and mentor, who took me out to the Guitar Center last night to help me buy...a guitar (I was tempted by a few drums, though). I am a total novice with the guitar: I know three chords and my fingertips are soft and callus-less. For now. Joe and I sat with several guitars, playing "Little Boxes" using the chords I can play, and eventually settled on a Yamaha, reasonable price.



I stayed up last night playing my three chords, watching videos of people playing guitar, and wondering when my fingers might start to bleed. I also spent some time reading Fretboard Logic, the book recommended to me by Guitar Center dude for learning the "reasoning behind the guitar's unique tuning." The book is good...logical. I'll work on the first chapter, learning the basic open chords, until my fingers can't take it anymore.

I don't anticipate posting any videos of me playing guitar. Nobody wants that.

Foot

I had a visit to the podiatrist this morning to talk about heel pain. Six months, two steroid injections, buckets of ice, tubs of ibuprofen, one loud "pop," and ongoing nagging pain that gets worse, not better.

It was a good visit: an informative discussion about short-term plans (summit Mt. Adams in three weeks) and long-term goals (return to running, pain-free). Dr. Huppin says both should be fine, and that the healing begins with a week in a charming rocker-bottom boot to let my plantar fascia--presumed to be partially-torn, that was the "pop"--rest.

The idea of training for a climb to twelve-thousand feet while resting in a foot immobilizer is a little hard to get my head around, but I'm okay with paradox. I'll just wear the boot when I can (like when I'm not riding, swimming, driving...).

In a week, I'll ditch the boot and do some more serious training: stairs, hills, mountains, along with ice, ibuprofen, and lots of tape.

In three weeks, I'll do the climb, put myself back in the boot (for one, two...three weeks?), and get fitted for new orthotics that I can use for running. My current orthotics are, it seems, not overcoming my tendency to pronate.

And it will take a long time, I thin, to return to running. My partially-torn plantar fascia will get better, and I'll get back to running (so I can mess with my knees and back), but I may need to exercise something like patience.

Funny concept.

Monday

Today was my first day--weekday--of not having any kind of work responsibilities. That said, I did get paged about work, which was fine. Sort of. Well...

I run the risk of sitting inside reading blogs all day, so I made a plan to get out of the house and go grocery shopping. Twist: no car, only bike and trailer. I figured I can get two kids and their stuff in there, so I should be able to get groceries in, too. The grocery store is only three miles south, with some good hills along the way. And it went well. The groceries weigh about what Zoe & Elliott weigh, but they move around less and the milk does not accost the pasta the way Zoe does to her sister. So it's relatively safe.

Lots of people ready to smile at kids in the Burley, only to see two gallons of milk staring back at them. Not so cute.

I did a bunch of stuff at home, then headed out in the other direction to get blood drawn for my new job; must prove I'm immune to measles, mumps, rubella, etc, and documenting that I've been immunized isn't adequate. So I got another ride in. Sticky hot, by that time, though.

So the drive report says:

• No trips, no miles

Hopefully lots more days like this ahead.

More Hot

Unbelievably hot here today. We sat around on the "terrace" (i.e. our driveway, where we've set up a kid pool, some furniture, and a big umbrella. We watched the thermometer like idiots as the numbers climbed into the upper 90s, 100s, then got smart and left for the lake, where it was easily twenty degrees cooler. It's 85 degrees outside our front door right now with a nice breeze.

Tim O'*&%ing-Shea didn't bring his sweaty arse to the 'hood today to tidy his slum: $750 and counting.

Drive report for the weekend:

• Saturday: no trips, so no miles. Walked up Beacon Hill to Galaxie with Elliott on my back and a tired, smelly dog beside me;
• Today: two trips, about 15 miles. West Seattle Farmers Market this morning (biggest haul of the summer, had to go back to the bank for more money after two laps around the market), combined that trip with a dog/cat supply run. This evening's impromptu trip to the lake (by way of the grocery for a picnic dinner) was short and worth it.

Tomorrow I will begin in earnest doing absolutely nothing. I'll try at least to be organized about it.

Hot

The "official" weather says that it's 84 degrees outside right now. Outside our house, though, it's warmer than that. I snapped this shot of our home thermometer--outside temp on top. Since I took that picture ten minutes ago, it's warmer still: now up to 104 degrees. Yikes.

Worser and worser

In the spirit of neighborhood blogging...

It appears that our local slumlord, Tim O'Shea, is in trouble with the city...again. Back in February I wrote that ol' Tim was in it with the DPD Compliance Division.

In the interim, his properties have been settled by squatters and become happy little crack-houses, one of them burned (inadequately, one might say), they were relieved of all their salvageable metal, and have nearly disappeared into the surrounding vegetation.

Two days ago, that little white sign re-appeared on the door, this time outlining a bunch of things that Timothy J.C. and Elizabeth O'Shea (of 2350 North 59th Street, Seattle, WA 98103, as it says on the public posting) must do in order to meet the minimum standards the City of Seattle requires. While he gets his lazy, crack house-owning act together, he'll pay $150 every day for ten days, then $500 daily until he acts like a responsible adult.

As of right now he's $600 in the hole. That's sixty hours of labor he's thrown away, and there are more than enough able bodies waiting every morning down the street at Lowe's for an opportunity to help Tim set things right with the City and his deeply disappointed neighbors.

I heard hammering this morning, but it was my neighbor, Gloria, working on her house. Tim's compound is quiet.

Meter's running, Tim. Fix your property.

Drive report

For Friday, June 27:

• Drove one trip
• 7.1 miles, round trip home-clinic-home, dropped some stuff at Goodwill and brought back all that heavy stuff from clinic (it'll sit in my car until I toss it)

Now what? Do I have to drive at all before August, when I start my job? Most certainly, yes. And when I start work in Burien, almost ten miles one way, I'll have to start thinking differently about driving. Drive 55 max on the highway? Get a hybrid?

We'll see. For now, it's just summer and I don't want to think about it.

Family Medicine Blogs?

There don't seem to be many Family Medicine blogs. Why is that? It's kind of an exciting time for primary care and Family Medicine. The sky is falling, the system imploding (slowly, slowly), patients and employers who provide insurance are fed up, and as a result there are some great new models of care being developed to improve care.

But nobody is writing about them. Well, nobody is blogging about them.

What to do about that?

Blue skies

It seems like the dreary cold weather that hung over the Northwest has finally left us. I woke up to another clear blue sky this morning.

Driving report for yesterday, June 26:

• No trips, no miles (all bike)

Today looks like it will require a little driving. I have a load of stuff to clear out from my desk at Downtown Family Medicine. I suppose I could plunk that stuff into the Burley, but it's a lot of weight to have bouncing around. I'll add in a Goodwill run to consolidate trips. Errands this afternoon will be on bike.

It's my last day of residency!

Out of my car report

Driving report for June 25:

• 21 miles driven (to SeaTac and back)
• One car trip
  

I said I was going to begin my get out of my car effort with a car trip, and fair things being fair, I'll own those miles. I drove my mom and Jim to SeaTac with a side trip to Burien for a drive by of the clinic I'll be working at starting in August. Drove straight home, parked, and did the rest of my commute on my bike.

I rode from home in the south Central District to Fremont, then to REI, then back home. Among the things I got at REI were a new helmet I got at REI Outlet and had sent there (free shipping) and a helmet-mounted mirror, which was awkward to use, but seems like it will be helpful in the busy Seattle streets.

The weather could not have been better for biking.

I'll keep reporting on my driving behavior for a while, since it seems like it will help me own driving as a conscious choice (I almost always have a choice). I think it's useful to track number of trips, too, since many of the impromptu trips I make (for groceries, cat food, children's tylenol...) are both annoying and avoidable. If I can consolidate trips, I will.

Tomorrow appears well-suited to bicycling. I can take the girls to daycare in the Burley and zip past downtown traffic on my way home from clinic in the afternoon.

Out of my car

NYC Bicycle Commuter, 5th Ave. @ 58th St.
Originally uploaded by bicyclesonly

The mayor of Seattle has asked nicely for Seattleites to get out of our cars this summer, and with gas at $4.40 a gallon, I'm happy to do so. To this end, I'll be looking for every opportunity to ride my bike, walk, or take the bus (though the annual bus pass my residency gave me expired, and I'm unemployed for the summer).

Also, because I'm a nerd and a slave to data, I'll keep track of the miles I've driven. Might inspire me to drive less, or at least to have to justify my driving habit.

I'll begin this effort by driving my mom and Jim to the airport (they won't fit in the Burley trailer), then I'll bring the car home, park it, and take my bike out for the rest of the day.

Safe & Sound

Zoe has been taking swimming lessons again this summer at Safe & Sound, the very cool kids-should-be-safe-and-comfortable-and-happy-in-the-water swimming school in the basement of the China Harbor restaurant on Lake Union.

Her pre-school does transport for all the kids who want to go, which is fantastic. I've been to see her lessons twice in the last week, and it is so much fun to watch her learning how to swim. When I was her age, my parents tossed me in the water with a styrofoam bubble strapped to my back...but it wasn't so organized...or in a Chinese restaurant basement.

Seattle pedestrian right of way

I recall having heard one morning on KEXP that pedestrians have the right of way at all Seattle intersections (I was driving down Pine to downtown, tons of pedestrians, few signals) . It was a brief, throw-away comment swallowed immediately by the rhythm of some John-in-the-morning tune, but it's been stuck in my head ever since and I've wanted to check it out.

This afternoon, while I was reading about bicycle rights in Seattle, I hopped over to the "Pedestrian" section and learned that it's true: pedestrians have the right of way at Seattle intersections, not just marked crosswalks. Specifically...

WAC 132E-16-040

Pedestrians -- Right of way.

(1) Stopping for pedestrian. The operator of an approaching vehicle shall stop and remain stopped to allow a pedestrian to cross the roadway within a crosswalk unmarked or marked when the pedestrian is upon or within one lane of the half of the roadway upon which the vehicle is traveling or onto which it is turning.

So cars, stop for pedestrians at crosswalks (unmarked or marked), and pedestrians, watch out for cars that haven't read WAC 123E-16-040 or the "Hang Up and Drive" legislation to become law on July first of this year.

Lunacy...sunacy?

The sun has finally come back to seattle. Will it stay?

The West Seattle farmers market is in full swing now.

They're building the overlook park.

Saturday at the Aquarium

After a rough Friday night of Elliott crying and Zoë waking up to share her thoughts at 3, 4, 5, and 6am, we stumbled downtown to the Seattle Aquarium at opening time. I like the early part of the day there: not too crowded, and the guys cleaning the giant fish tank put on a little show.
They talk to the kids with their cool underwater radios, they give high-fives through one foot of glass, and finish up with the "Underwater Somersault of Death." Today was migratory bird celebration day, so they had activities and face painting (Zoë got a pink, migratory [?] crab on her cheek). Elliott toddled around, unpainted. We saw everything once, then had lunch at the upstairs cafe. I just got coffee and ate everything the girls rejected, which was a lot.

It's amazing how half a day can disappear like that.

Grandmommy's Here!

Grandmommy Chapman arrived intact this morning from St. Louis. We had lunch, then picked up Zoë & Elliott for a trip to Galaxie for hot chocolate. Not pictured here is Elliott, who threw a FIT all the way home, followed by another FIT. A belly full of mac & cheese was the cure.

As I type, Zoë is throwing her very own FIT to avoid going up to bed. The big stall: water, cereal, helping make dinner...she is not a good negotiator. Unmotivated to compromise.

Sunday, West Seattle Farmers Market

This week was the celebration of market opening. Since West Seattle is open year-around, I suppose the celebration was for other markets opening soon (Columbia City is this week). Zoë met a fine young(er) man (pictured) who charmed her with dancing and kissing her hands. They followed one another around for quite some time, playing cat-and-mouse with their kid-size lawn chairs while the band played, people danced, and the alpacas did whatever they were doing.

Next week the market will be "joined" by the folks from Sustainable West Seattle, who will host their first festival across the street. Tons of good stuff going on.

Decisions, decisions

Spotted on the #48 bus this morning. What is one to do when given an impossible choice?

How i spent my sunday afternoon

What did you do for fun today?

Officers Quarters, Fort Worden

I haven't had a single room in I don't know how long.

Tim O'Shea is an absentee slumlord!

Timothy J.C. O'Shea, who's name appears in this public posting tacked to one of his properties, is the worst kind of absentee speculator slumlord. He has bought up most of a city block in our neighborhood for the intended purpose of building homes. What he's really done is ignore the properties and let them sit empty. Well, not empty, actually; there's a brisk crack cocaine trade going, so at least the houses get some attention. One burned, but not nearly enough. Another (formerly rented by our friends) was looted for scrap metal.

It's a disgrace. Tim O'Shea is a disgrace and an embarrassment. We live here while he presides over a drug-infested bunch of squalid squatters' shacks. Tim talks a good game, but doesn't have the goods to follow though.

Shame, Tim, shame.

Build it or sell it.

the sun brings out the ballerina in everyone.

My caucus.

Playground, between rains.

New year bus trip