It's a Booger

hi my friend

2011-02-22T09:43:00.001-08:00

how  are you friend ?  i tell you a good news  <dudu-co.com> best place for online shop  thousand of new original products  hope you like it take a look , and enjoy here

Z & E pilot up the Columbia

2010-09-05T19:00:00.000-07:00

February in Seattle

2010-02-20T11:53:00.001-08:00

Zoe's first podcast

2009-08-03T21:59:00.001-07:00

Live (barely) from Vancouver

2009-03-23T18:31:00.000-07:00

I'm at a conference in Vancouver, BC the first part of this week on redesigning the clinical office practice. There was a time in my life, not too long ago, when if you'd told me I'd be at this conference, I'd have responded unpleasantly. But this is actually really fun for me.

Brooke and I had planned a fun weekend in Vancouver with the girls in advance of the conference. Brooke got a great deal on a one-bedroom suite at the Sutton Inn in busy downtown Vancouver, and we made plans to play outside in Stanley Park and visit the aquarium. Brooke got sick with a very painful sinus infection, and was pretty miserable, but we figured she might feel better, and if she didn't she could sleep while the girls and I played.

She did not feel better.

And then Zoe did not feel well. The poor child came down with a 103-degree fever on Saturday and was knocked out. She had about as much energy as a wet noodle. She was only a little low in the morning, so we (minus Brooke) made it to the park to ride the train and visit the petting zoo, but she clearly was just going through the motions. By afternoon (tipoff time for the Huskies second round loss), she was noodle-like, flat out on the couch. Brooke pretended to feel better and took Elliott out for a while, because she was neither ill nor lacking in energy.

By Saturday evening, we were kind of down (not Elliott), feeling like the weekend was a bust, and worried about Zoe.

Sunday rolled around and Zoe's fever broke, and we rejoiced briefly until she began puking. After some debate, we decided that I would accompany us all back to Seattle and drive back up to Vancouver later in the day, in time for the conference. This was fine with me, because I love road trips. By the time we got home, Brooke was better, Zoe was improving, and Elliott was still Elliott, but slightly unstable due to lack of nap--so, high energy, stroppy, and unpredictable.

And I had a little cough, but I deemed it a sympathy cough, so I drove back to Vancouver. At the border, I wondered if they had any way of knowing that I'd crossed three times in four days and how would I explain that without a long story. Knowing what I think I know about complex systems, it seemed unlikely they would know or care. It wasn't a problem.

But my car developed a sympathy cough. As I sat in line, the engine began to sputter and lurch. I don't know the first thing about cars, but I decided this must be some simple obstruction, like a kidney stone, and that it would pass. But I am stupid and prone to denial about things I don't understand, and my Honda pointed this out to me with a flashing "check engine" light.

And I wondered, as I sputtered forward in line ten feet at at time, if your car dies in that limbo between countries at the Peace Arch border crossing, what happens? Is there some intergovernmental towing authority to rescue you? Do they take visa or honor my AAA card? And how would I alert anyone without making a seemingly hostile pedestrian approach on the Canadian border?

Fortunately, this did not come to pass. I sputtered through customs uneventfully, and decided I would just drive until something bad happened. The check engine light became un-illuminated, and the sputtering became less pronounced, but did not stop. I arrived at my hotel in downtown Vancouver, left the shuddering hunk of metal with the valet to be parked and rest and overcome it's affliction.

Sometimes denial gets you where you need to go.

So the car has been convalescing in the garage and I have been walking in the rain between my hotel and the conference center and the pharmacy, where I've stocked up on NyQuil and DayQuil to aid in my own convalescence. I spent last night with fevers and chills and a painful cough, and today pretending I was fine while learning about LEAN approaches to primary care clinic transformation. And enjoying it. Really.

Though I did forget my coat. And it is both cold and wet.

And windy.

Tomorrow I will attemp to drive from Vancouver to Seattle in a car in need of service, in some stage of viral suffering, under the unpredictable influence of sinus decongestants and caffeine, and without much reliable cell phone coverage.

And I'm just certain it will be fine.

Leading like a child

2009-03-12T05:51:00.001-07:00

I had the opportunity recently to attend a three day class in facilitative leadership, and it has re-shaped the way I think about almost everything I do. And really what it was...was...kind of a review of kindergarden, but with grown up examples from work. Very cool.

The basic idea was that we get things done--our work--through other people, and so it's probably a good idea if we all have some shared understanding of our work, even better if we all feel like we got to say how we think we should do it, and we would all like to hear that we did a great job.

In my daughter Zoe's pre-kindergarden class, the curriculum is the same. But Zoe comes home with art, and rocks in her pockets.

In the past few weeks, I have re-approached my responsibilities in at work with my new AP-kindergarden skills. In clinic, we created a vision--together--of what makes a good day. A really good list of about twenty things. Share, help each other, smile...a lot of these things are very basic, but in the chaos of a primary care clinic, they can get lost.

We also have identified things that get in the way of having a good day every day, and I've made it my job to guide us through ways to overcome those obstacles.

For every problem, we look at everyone who is affected (the stakeholders) and might want a say in creating a solution. We consider what a good solution would look like for them (a win). And we create the simplest possible plan we can all agree on.

So far, so good. I've been going for the easy "wins" first. There are bigger obstacles to having a good day every day, but we'll find our way. Together. Kindergarden-style.

Rambling Ambition

2009-03-10T05:59:00.000-07:00

It's six o'clock in the morning. I've spent my morning "quiet time" working on a meeting agenda and not writing, as I'd hoped. I'm going to try to squeeze this in, though when Brooke's hairdryer goes on, that's my signal to sign off and move upstairs. Squeezing things in is how things have been, lately. Everything is manageable, but there is never quite enough time to do EVERYTHING I'd like to do. I've been learning a lot in most areas of my life: medicine, family, leading others, being efficient. But I think I trip over my ambitions. I want to be an excellent doctor, a competent leader, a thoughtful, patient, and present father and partner, and I want to do it all effortlessly.

Ha.

And I'd like to be in better physical shape at 40 than I was at 30.

The hairdryer is going.

I've been working a lot recently with methods for clarifying just what all those ambitions actually mean to me. What would it look like if I achieved all those goals? How can I plot a course from here to there? Am I already there in some respects? Is it really important to fret about it?

Am I trying to hard? As Yoda says: "There is no try, only do."

Is it wrong to look to a muppet for guidance?

I like my doctor, but the tart was a little dry

2009-02-18T05:49:00.000-08:00

This morning's New York Times has a nice opinion piece about publishing patient ratings of doctors. The editorial board likes it. I like it. Patients like it. Who doesn't like it?

Doctors with low ratings, I suppose. (Note, that could be me; I've never seen patient ratings of me or my clinic.)

Note that the questions used in the Zagat/WellPoint ratings (yes, Zagat) appear to be built, at least in part, around validated patient experience questions from Gordon Moore's research. From the NYT:

Who knows better than patients whether they have confidence in a doctor? Whether they like his or her bedside manner? Or find it easy or hard to make appointments? Or are dealt with on time or kept waiting for hours? Or find the staff helpful? These are the kinds of items covered in the Zagat/WellPoint survey, not anything to do with the quality of medical care provided.

These are similar to Moore's patient experience questions:

I have one person I think of as my personal doctor or nurse
It is very easy for me to get medical care when I need it
Most of the time, when I visit my doctor’s office, it is well-organized, efficient, and does not waste my time
The information given to me about health problems is very good
I am confident that I can manage and control most of my health problems
I feel able to give meaningful feedback to my doctor’s office about ways things could be improved

Wouldn't you feel like you were being well-served as a patient if you could answer yes (enthusiastically) to these questions?

As a physician, I have an obligation to provide the highest-quality medical advice, supported by science. I also have to be a good practicing colleage to other physicians and staff who need my work to be thorough, clear, and timely.

But I also have to keep in mind the perspective of my patients, what they want and need. Doing a good job for them also means responding to the issues surfaced in the Zagat/WellPoint and Moore patient experience items.

It doesn't mean patients will always agree with my recommendations, or that I'll agree with their assessments and requests, if science and common sense suggest otherwise. But the experience ought to be efficient, respectful, and thorough.

I'm glad someone is measuring. Maybe I could be, like, the Nobu of family doctors one day.

Twittering the Future of Family Medicine?

2009-02-13T06:18:00.001-08:00

I had the chance last night to meet with some amazing family doctors to discuss ways to use social media to open and sustain a discussion about the current state of primary care and where we're going. And where we should be going. And how.

There will be room for every voice and perspective about how to get from where where we are now to someplace (or places) better for patients, public health, and the well-being of those who deliver primary care.

Primary care is stressed:

Access is poor: the uninsured don't have access, and if everyone did have insurance, we wouldn't have enough primary care doctors to care for them;
Costs are out of control, and we don't get much health for our health care dollars;
Reform at the federal level isn't as near as maybe we'd all thought. The white knight of bipartisan reform, Tom Daschle, got knocked out with an IRS body blow. And getting a big deal done on health care seems unlikely, even if it is even more important now than ever.

So what to do? There is tremendous support, in spirit, for better primary care, and it seems now that everyone wants a "Medical Home," though no one can agree on what that means, and the average primary care private practice can't afford to build one.

At out discussion last night, we agreed that there are things family doctors can do right now to move primary care forward at the front lines of practice. And we'll talk about those things in the online forum we're building. We'll blog, podcast, photograph, and discuss the path from here to somewhere better. And we'll make it practical. There's enough rhetoric already.

My assignment: name the project. Eep.

I'm on it.

Stress-free primary care?

2009-02-12T05:35:00.000-08:00

When I graduated from medical school in 2005, my friend Liz gave me a label maker and a book called Getting Things Done (GTD). I assumed it was a gag gift, though I knew Liz to be a fan of GTD and its author, David Allen, a productivity swami. I thought it was interesting, so I read it.

And then I labeled everything.

Over the last few years, I have practiced a watered-down version of the GTD process, which advocates "stress free productivity" through effective management of the information that comes to us faster and faster. When the mind is unburdened of the task of remembering all the things there are to do, it is possible to be present for whatever task is at hand.

Through residency, this was tough. The task at hand generally involved some high-stakes activity performed in the setting of sleep deprivation and incompetence-by-design. Delivering babies, for example: you become competent by doing it, they come in the middle of the night, and it's a big deal if you screw it up. There was little about residency that allowed for stress free productivity. I did what I could, but there were limits. Mostly, I just crashed through.

I've been out of residency less than a year, and have been a full time family doctor for a little over six months. I work five full days in clinic, seeing about eighteen patients a day for multiple concerns, acute and chronic. I also manage dozens of lab and study results every day, and respond to patient phone calls and email.

My goal: go in every morning relaxed and prepared for whatever comes my way and leave at the end of the day having acted on every piece of information that came my way. That doesn't meet I've cured everybody, cure is pretty rare in medicine.

But hope that by day's end I will have responded to every item that demanded my attention in a appropriate way:

Every patient visit ends with a mutually agreed plan;
Every patient call that came in got an answer, a plan;
I reviewed every lab or study result and made a plan;
I updated patient charts to clearly describe the plan to everyone who might need to know.
I set up reminders to myself so I don't worry that I'll forget about important parts of the plan.

When I accomplish all those things, there is an empty in-box in front of me, ready to receive whatever might arrive next.

More importantly, my head is not cluttered with all the things I "should" be doing or trying to remember all the things that might be coming in. Unburdened, I feel much more able to be fully present for patients during the twenty minutes I get with them. We have a lot to do in those brief visits and they expect my full attention. When I'm on my game, they get it.

Maybe I'll write more about this later. It seems like a good topic to explore further (running a visit, how the day flows, setting reminders, updating care plans, teamwork and communication, cross-covering for colleagues...)

But it's time to get started with the day, so off I go.

A path of endless bickering

2009-02-05T05:40:00.000-08:00

The health care reform effort won't get far if doctors whine like toddlers instead of being realistic about the need for payment change. An article in the recent American Academy of Family Physicians NewsNow newsletter online began like this:

A recent editorial by AMA Board of Trustees Chair Joseph Heyman, M.D., has led AAFP President Ted Epperly, M.D., of Boise, Idaho, to emphasize the importance of the AMA working with primary care physicians to ensure they are fairly and adequately paid for the services they provide to patients with Medicare coverage.

Heyman's editorial, which was posted Jan. 26 to American Medical News online and published in the Feb. 2 print version of the publication, urges payment increases for primary care physicians, but he emphasizes that the AMA would not support such increases if it means there would be corresponding reductions in subspecialists' payments.

"Payments to primary care physicians must increase," said Heyman, an OB-Gyn. However, he added, the AMA "absolutely opposes applying budget-neutrality rules that confine offsets to the physician payment pool."

"Congress should not rob Dr. Peter, the surgeon, to pay Dr. Paul, the primary care physician," said Heyman.

So, if primary care doctors earn more (encouraging more medical students go into primary care to fill the gap), and the specialists still get paid a lot to do procedures that may or may not be helpful to patients' health, then were does the savings come from?

We know that a good primary care system saves money by decreasing complications of chronic disease, so there's an argument to be made there, but I think we should act less like children fighting over who gets more M&Ms (or BMWs), and frame the debate around questions that matter.

Doctors should get paid for delivering care that works. The payment system we have rewards procedures and discourages talking to patients. Not everyone needs a colonoscopy to look for colon cancer (very few people do, actually), but we put a lot of cameras into a lot of bottoms for a lot of money when a $10 screening study you can do at home is equally effective at preventing colon cancer mortality.

As the Dartmouth Atlas of Health Care points out, where there are specialists, there are is more specialty care. Live in a town with lots of gastroenterologists? Predict lots of colonoscopies. It has nothing to do with evidence or effectiveness. Doctors have to pay the bills like everyone else, so you do what you're trained to do and bill accordingly.

I agree that physicians should be paid fairly for the work they do, procedure or not. But we should only be paid for care that works (i.e. has a measurably positive effect in patients' lives). Elective colonoscopy for colon cancer screening? Medicare shouldn't pay for that (or should pay $10, which is what it costs to screen for colon cancer). Eventually the payments to specialists would be driven down using good outcomes-oriented science, fewer medical students choose lucrative lifestyle specialities.

Reframe the debate around what matters, what works, instead of bickering about cost neutrality. Health care costs too much. Some of us have to get less in order to make it work. And we'll all do just fine. Maybe our patients will, too.

Plan B?

2009-02-04T05:55:00.000-08:00

"There was no Plan B." So said David Axelrod yesterday following the abrupt end of Tom Daschle's bid to be the white knight of our failing health care system.

I think Daschle did the right thing in bowing out. It was the first right and non-stupid thing he did in a little while. I'm not sure how on earth someone avoids more in taxes than most people earn in in salary and thinks it won't get in the way of a senate confirmation. I also don't understand why taking $5 million in fees from the health care industry (my people, admitted) and thinks that won't come up as a legitimate conflict.

But we're all in agreement now, right? Daschle acknowledges the problem and dropped out. Obama acknowledges the mistake in allowing it to go this far, which created what even the most love-struck Obamanite would agree is an inconsistent rule: no lobbyists or murky ethics in the new administration, except when it suits the administration's needs. I feel better knowing that people in DC can do the right thing, even when it screws up the plan.

And as for the plan--meaningful improvement of how we deliver health care in America? Well, according to David Axelrod, Daschle was it. "There was no plan B."

Super. I'll be Congress will have a plan B, and it won't include universal coverage, guaranteed primary care services (prevention and chronic disease management), nor any kind of incentives for more students to enter primary care.

We've arrived at the time we've been talking about, when our health care system is unsustainable. Companies can't afford to keep the lights on, much less pay huge health care premiums for employees. Employees lose benefits or just lose their jobs. Patients come to me asking for six months of medications because they're losing coverage, and ask for hard copies of their scripts to take to WalMart for the $4 medication plan instead of filling for a few dollars more at our clinic pharmacy.

And there is no plan.

Having the federal government cover 30% of COBRA costs for out of work families is kind of like giving them a buck to help with the rent. Not enough. Out of work is out of work, zero income doesn't cover 70% of a health care premium.

That's not a plan.

There will be some kind of change, but I worry it won't actually help anyone. Those who spend a good part of the year shelling out cash while they wander around in the Medicare Part D donut hole understand meaningless change.

Let's hope for a good, solid plan B, and fast.

And by the way, Mr. President, good for you for admitting your mistake. I expect the learning curve in your job is steep. If you learn from the mistakes, we'll all benefit.

Hope lives on.

To parts (mid)west

2008-09-04T08:07:00.000-07:00

End of the three-day

2008-09-01T17:28:00.001-07:00

Shadowing

2008-08-21T21:42:00.000-07:00

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

2008-08-20T21:34:00.000-07:00

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.

2008-08-17T14:13:00.001-07:00

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

Gun salesman?

2008-08-13T07:37:00.000-07:00

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?

2008-08-08T10:45:00.000-07:00

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:

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.
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.
Kids and the chronically ill, as usual, have it worse than the rest of us.
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.
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.
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

2008-08-05T11:43:00.000-07:00

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

2008-08-01T13:47:00.001-07:00

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

2008-08-01T13:45:00.001-07:00

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.

2008-07-25T10:55:00.001-07:00

VW bus. Phil. John. Oregon wilderness.

Inspired by Simon?

2008-07-24T17:22:00.001-07:00

Introducing the Colman Triangle

2008-07-24T13:15:00.000-07:00

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.

View Larger Map

Advice I didn't need

2008-07-24T12:26:00.000-07:00

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

2008-07-22T14:07:00.001-07:00

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

2008-07-11T20:53:00.000-07:00

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!

2008-07-11T09:00:00.000-07:00

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

2008-07-10T08:56:00.000-07:00

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

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

2008-07-09T10:09:00.000-07:00

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

2008-07-08T13:10:00.000-07:00

Top of Mt. Si. Forgot sunscreen.

Jimi Hendrix Gets A New Doo

2008-07-07T12:49:00.000-07:00

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

2008-07-03T16:20:00.000-07:00

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

2008-07-02T09:51:00.000-07:00

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.

View Larger Map

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

2008-07-02T09:29:00.000-07:00

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

2008-07-01T09:13:00.000-07:00

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

2008-06-30T16:36:00.000-07:00

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

2008-06-29T20:18:00.000-07:00

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

2008-06-28T17:06:00.000-07:00

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

2008-06-28T14:38:00.000-07:00

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

2008-06-27T23:35:00.000-07:00

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?

2008-06-27T06:47:00.001-07:00

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

2008-06-27T06:34:00.000-07:00

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

2008-06-25T16:39:00.000-07:00

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

2008-06-25T08:41:00.001-07:00

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

2008-06-24T16:17:00.000-07:00

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

2008-06-24T15:48:00.000-07:00

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.

2008-06-15T15:55:00.000-07:00

Lunacy...sunacy?

2008-06-15T15:50:00.000-07:00

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

2008-05-25T12:54:00.001-07:00

The West Seattle farmers market is in full swing now.

2008-05-24T17:05:00.001-07:00

They're building the overlook park.

Saturday at the Aquarium

2008-05-03T10:11:00.001-07:00

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!

2008-05-01T15:52:00.001-07:00

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

2008-04-27T11:13:00.001-07:00

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

2008-04-25T07:27:00.001-07:00

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

How i spent my sunday afternoon

2008-04-20T14:55:00.001-07:00

What did you do for fun today?

Officers Quarters, Fort Worden

2008-03-14T17:04:00.001-07:00

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

Tim O'Shea is an absentee slumlord!

2008-02-21T11:30:00.000-08:00

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.

2008-02-18T16:19:00.001-08:00

the sun brings out the ballerina in everyone.

2008-02-09T13:52:00.001-08:00

My caucus.

2008-01-12T15:56:00.000-08:00

2008-01-06T15:47:00.001-08:00

Playground, between rains.

2008-01-01T11:44:00.000-08:00

New year bus trip

2007-12-31T13:19:00.000-08:00

I got a jump on my resolution for 2008 today and went for a lunchtime run between morning and afternoon clinics. It is stunningly sunny and lovely out today: 40-degrees and bright. I ran from DFM straight down to the waterfront near Peir 66, headed north along the water toward the Olympic Sculpture Park, which I bypassed to avoid the temptation of touching the art. I ran through Myrtle Edwards park along the pedestrian path to a little spot with parallel bars and a sit up platform. A little of this and that on the bars, then back south toward the sculptures again, facing into the bright December sun, which at best seems to rise halfway above the horizon and so far to the south that I was running right into it. Nice though. I wonder how many lux you get on a day like today?

Getting back to clinic took a little more uphill energy, and I started to fade a bit. But reminded myself that lunch awaited, and managed to press on.

Again, I did not touch any sculptures.

Thirty minutes remain now between me and my afternoon clinic.

Today it was easy to keep my resolution. We'll see what happens when the rain comes back.

2007-12-30T16:23:00.000-08:00

Who knew rei would be busy today?

What Are the Odds?

2007-12-29T10:07:00.001-08:00

I went to the Seattle Aquarium this morning with my girls. A hundred-thousand or so marine animals. I managed one crappy picture of a person.

Seattle Snow

2007-12-01T14:24:00.001-08:00

Day off today.

Zoë wouldn't nap this afternoon and it was snowing, so we headed out for a run. There were huge snowflakes falling, covering the connected parks on our usual route but sparing the paths. Nice. Zoë fell asleep in the jogger after about twenty minutes--she needed it. As we dropped from the hilly stuff down to the lake, the snow turned into rain, which was unpleasant. I was dressed for snow, not rain, so I got soaked but pressed on, feeling like I had a lot of stress to get out. We ran along the lake for a couple of miles then headed back up through Mt. Baker Park. Near the top of the hill, the flakes got big again and there was more snow sticking to the grass. Zoë woke as I stopped to take a picture of the snowman (some industrious kid made the best of almost nothing).

We dropped back into our little valley, got home, wrung ourselves out and waited for Brooke and Elliott to wake up from their naps, finished making peanut butter cookies, and drove in the slush--becoming ice--to see Sachi and Travis, who just had baby boy five days ago. I got to see them in the hospital, a benefit of working there, but Brooke and the girls hadn't seen him yet. We took them some black bean soup, cookies, and satsumas. Zoë made a total mess of their place for an hour, and we headed back home for the slow, chaotic descent into kid bedtimes and now my own.

I'm on tomorrow morning early and need some sleep, so off I go.

Tomorrow it'll be fifty degrees and the snowy world of today will be gone. Maybe that snowman will see Monday.

Can't Touch This?

2007-11-25T11:45:00.001-08:00

Welcome to the Olympic Sculpture Park. Whatever you do, don't touch the art. Even though you're three years old. And you're outside. And the art is outside, where things touch it all the time. And don't run. Running is fun. So don't do it. Even if you're three, and run at an adult's walking pace. For the love of art, just walk. Just do what the security man in the blue jumpsuit says. No touching. No running. No lip.

And the art that looks like a bench? Yes, the one called "Bench." Can we touch that, Mr. Blue Jumpsuit? How about just with our butts?

I know this is old news, but it's still incredibly annoying. My first impulse was to set Zoë loose and let her run snotty fingers over "Eagle," maybe give "Split" a big hug, or see what "Wake" tastes like. But it was somehow more satisfying, culturally, to grumble in waspy indignance and walk on. I'm glad others have found creative ways to comment.

It is a cool park, though.

Macy's Parade

2007-11-24T12:20:00.000-08:00

Yesterday we all went down to the Seattle Macy's Parade. We found a moderately-crowded spot at the end of the parade route and edged in so we could see the floats, marching bands, and assorted oddities that passed by.

I loved the marching bands, especially (though I hate to admit it) the Washington State University band, in town for today's Apple Cup. I've attached a slide show with the few in-focus pictures.

Unlike last summer's disastrous pirate outing, this was actually fun for all of us and we'd do it again. We'll also go back and let Zoë stare at the Macy's windows, which are pretty good this year.

Buyer's Remorse

2007-11-24T06:15:00.000-08:00

"Let's go on a cruise! I hear Antarctica is great in November, and I got us a deal aboard a classic ship."

Fast-forward to November 23, 2007, and that slightly newer, larger craft in the background looks like it may have been worth the added expense, no?

But who doesn't like an adventure?

Hairball

2007-11-22T11:35:00.000-08:00

I guess this little ditty from this Week's New England Journal of Medicine explains the sudden internet frenzy for giant hairballs I noted earlier today. Again, yuck.

The Inevitable Thanksgiving How-To

2007-11-22T06:58:00.000-08:00

This mornings New York Times online features a six-minute instructional video on Turkey carving. Good stuff for the perfectionist looking for "maximum yield" from the holiday fowl. This is the first T-Day how-to I've encountered this year, perhaps because we don't have a television, I spend most of my time trying to read all the stuff on my feed-reader, and reading medical journals. But I do listen to NPR, and those guys always do some cutesy bit, like the Mama Stamberg's nasty cranberry stuff made with soap residue and cat litter. I didn't hear any NPR odes to Thanksgiving food, but that's just because I missed them.

And I missed Martha, and Rachel, and Ellen...

Are people looking for instructions for a better Thanksgiving bird? Yes. A search on my new favorite toy, Google Trends, produced a nice graphic description of turkey cooking searches (seen at right, in real time), spiking on Thursday morning. Most of the "hottest" searches this morning have something to do with Thanksgiving (with the bizarre exception of #11, trichophagia...yuck).

So now I'm off, with Zoë, to do my own last-minute Thanksgiving shopping for stuff I could have bought yesterday if I'd thought it through. I'm making a spinach madeleine to take to my sister's house.

Dry

2007-11-13T21:42:00.000-08:00

Thanks to all those who have offered sympathy for our water damage. We were proclaimed dry yesterday by the Wizard of Household Dessication. So we're back in our kitchen (sans floor, just particle board sub-floor).

We did enjoy touring some fun restaurants over the weekend, including Vio's on 19th: total kid chaos, by design.

Well, if he means all this, then I'm in

2007-11-13T21:39:00.000-08:00

Another Gated Community

2007-11-10T19:01:00.000-08:00

Here's another nice old house opting out of the neighborhood. Enjoy your isolation.

Screwed

2007-11-09T19:48:00.001-08:00

Five days after finding a small leak dripping into our kitchen, this is what we've got. We've had plumbers and "leak finders" (think CSI, but better paid), insurance adjusters, and now "water mitigation" specialists. Three silent, serious guys showed up yesterday and started destroying my kitchen walls and floors. There was water places I could not have imagined. They left these droids to dry things out. Noisy droids. Like jet engine noisy. They'll be with us through the weekend, eating our electricity and heating our house to a balmy 85-degrees.

Meanwhile, we're exploring kid-friendly restaurants.

Water

2007-11-04T12:43:00.000-08:00

I woke up this morning to the kind of noise that signaled something was not quite right. It was a clack-rattle...rattle-rattle...thwack. It repeated every ten seconds or so and was not associated with squealing, screaming, or crying. It seemed to be coming from the first floor, and was loud enough that I could hear it clearly from the third floor--and it woke me up. At 6:15am, which now was 5:15am, thanks to Ben Franklin and his daylight savings scheme.

There are a lot recognizable early morning sounds. This wasn't one of them. I got up to investigate.

I came downstairs to find Brooke putting bowls under drips and mopping water from the stove top (this was the noise that woke me), while Elliott, now about ten months old, made smaller clacking sounds with wooden blocks. Brooke introduced the scenario by saying "I know you're going to see dollar signs here," and she was right about that, but the first thing I saw was water pooled in the place I intended to make my morning coffee.

Boring story short, there is water leaking from someplace in the walls of our kitchen. All night it dripped through a ventilation hole into a kitchen cabinet, through the microwave, onto the stove, pilot lights, floor...and the wall behind the microwave and oven.

Last week my friend Dan showed me how turn off the water at the street, so I did that, and the leak stopped. Predictably, so did all the other water in our house. Called the builder, who said call a plumber and if it's he's error (and not a nail I put into the pipes) he'll cover it. Called Dan to ask for a plumber recommendation (now starting to see those dollar signs). Got one. He can come "after Tuesday."

So the water is off. The leak has stopped. And we're waiting to hear what Big Jim the plumber has to say about things. We'll get creative with dining, bathing, and washing clothes this week. It'll be a Trader Joe's microwave experience. We'll shower at work. Elliott can have a bath at daycare. Who knows where Zoe will get her grubby toddler self clean. We could hose her off outside, I suppose.

Good times.

Pirates!

2007-07-07T14:55:00.000-07:00

We meant well. It's just that, well, we didn't know.

It's another beautiful July day in Seattle, blah, blah, and we ran out of things to do at home, so we decided to head out for a morning at the beach. Instead of the usual quick trip down to Lake Washington, I suggested that we head over to Alki in West Seattle. Better sand, salt water, marine air...and the pirates were coming ashore today.

Pirates?

Pirates. It sounded like fun. Summer around here means Seafair, a series of events, connected I-don't-know-how into a "fair" of sorts that seems to last most of the summer. We've experienced the events on nearby Lake Washington for several years--like it or not--since it's so close to home. Massive crowds gather for hydroplane races and the air show, featuring the Blue Angels and forcing the daily closure of the I-90 bridge (it's an interstate, and they close it) for about an hour to accommodate...something.

But then there are these pirates. I've read about them, seen them on TV (before we chucked it). They seem to be a group of fairly normal adults who dress up once a year as buccaneers and act like utter twats. We had something similar in St. Louis, where I grew up. The Veiled Prophet organization gave local businessmen a kind of annual costumed release from the bondage of their khakis and needlepointed belts. The big VP event was the debutante ball, at which the masked, heavily bejeweled (and presumably sodden) veiled prophet would welcome young, wealthy, white women into "his court of love and beauty." Not a joke. I went, several times. A willing participant. Filthy, sodden fun. Humiliating. Embarrassing.

These pirates seem less sad, somehow, and less evil. Drunk, yes, but they're pirates, so you expect that. And, to bring us back to the beach, they were scheduled to come ashore--raid the beach--this morning. We're early people these days, so when we arrived, there weren't that many folks around. Vendors seemed to be anticipating big crowds, though, offering ice cream, kettle corn, face painting, and pirate gear--tons of pirate gear. As we walked toward a sandy spot away from the band and the out-of-place pole vaulting competition (more medieval than pirate), Brooke asked "so what do these pirates do when they come ashore?" Good question. "Looks like they sell stuff."

I've heard the pirates used to be pretty out of control, and that they've reined it in a lot recently. A family event, and all that. I don't know how bad phony pirates can be--pretend pillaging?--but I'm kind of sorry to have missed out.

We found a spot in the sand with a view of the gathering "armada," several sleek sailboats flying the skull and crossbones, positioned about fifty meters offshore. The crowd on the beach was much more impressive--thousands of people with kids, dogs, coolers, umbrellas, blankets...and pirate gear. If it were pirates versus spectators, the pirates wouldn't stand a chance. Several of the more convincingly outfitted pirates milled around, making friends. I snapped a photo of Aussie-accented swashbuckler and a gregarious, hirsute Russian guy looking menacing a black hat-and-flag ensemble and Tony Soprano potbelly. In this photo I particularly like the disembodied hand flying the Motley Crüe sign--a gesture with inexplicable longevity.

At this point it was clear that we had made a gross miscalculation. It was a mistake to be here. We should leave. Zoë was behaving poorly and Elliott was tired, hungry, and poopy. We were unprepared. But the pirates were going to do this storming the beach thing and we've been in Seattle for seven years and not ever seen it. All these people were here to see it. It was going to be cool. Worth staying for. We would stay and witness this tradition.

The armada was growing, though it was unclear that these ersatz pirate ships would have the wherewithal to come ashore, much less storm anything. To the east, from Elliott Bay, came some cannon shots. The sloops moored before us had been firing rounds all morning, but these were louder. These explosions were coming from two mid-sized landing craft, steaming toward us loaded with pirates. Here it was. The attack! Everyone on the beach stood. Kids stopped misbehaving and ran toward the landing zone. Parents yelled at their kids to come the hell back, then ran off after them. Small-time thieves moved in to grab beach gear and wallets abandoned by parents chasing kids. The landing craft eased into the beach right in front of the giant inflatable pirate island cum kid playground. And I mean it eased in. Backed up. Re-approached. And the ramp...lowered...and...some...pirates...walked...ashore.

This was by far the worst pirate event I've ever attended.

Feeling duped and frustrated, we packed up our hungry kid and our misbehaving kid and walked down the busy boardwalk to our hot car. Along the way, I passed a sad-faced young woman with a bandana on her head and pirate makeup on. She was standing sullenly against a wall next to a similarly-costumed young man. She frowned and said to him: "I thought there would be cool stuff here. All I've seen is a bunch of angry parents."

Yup.

Happy Fifth of July

2007-07-05T16:49:00.001-07:00

I took today off as an extension of yesterday's holiday--a mini-weekend right in the middle of the week. I started with Zoë's swim lesson at Safe & Sound this morning. I'm so proud of how brave she is in the water, especially putting her head under and jumping in--fearless. The goodbye was predictably tearful for us both as I put her on the school bus back to daycare. I suppose I could have taken her home and spent the day with her, if parting was so difficult...

Instead, I spent a glorious day with no children and no responsibilities. I ran two loops around Seward Park, bought salmon for dinner, blueberries, and mangoes at PCC, dropped my groceries at home and rushed out for an afternoon under the sun at the lake. Magnificent. My book and I had a fantastic time. My feet were having a great time when I snapped this picture, but if you ask them now, they'd tell you the time would have been a little bit better with sunscreen.

What did YOU do this morning?

2007-07-03T21:38:00.001-07:00

So this was my morning. Two months ago I chipped my front tooth on a piece of mango and have been waiting ever since for the pleasure of an hour tilted back in a dentist's chair, blood pooling in my head, jaw cranked open and secured with a bite block, and a large rubber face condom attached I-don't-know-how to several of my teeth. I was like this for a while, looking out the skylight at...sky. I was sure my jaw had become unhinged and I'd have to spend the rest of the day waiting for an ER doc to give me enough ativan to manipulate it back into its proper place. I dodged that, but twelve hours later my jaw is still killing me.

The day got better. I went from the place of suffering to my clinic to work on a giant stack of charts that needed tending. For about two hours my face continued to be totally numb (I had some fillings replaced too), and I was sure that I was drooling like an idiot while I worked out care plans for patients from the day before.

I spent the early part of this Tuesday afternoon in a weekly lunch meeting, followed by a discussion with classmates outside by the Seattle U fountain. It was a bright, sunny, warm day and I could once again feel my face. Just when I thought things couldn't get any better, they did. Our afternoon didatic session go canceled due to who-cares-why and I was sprung. I took advantage of this found time by going for an hour-long run on Lake Washington.

Tonight we had some friends over for dinner out on the driveway patio. I'm starting to embrace the driveway more as a legitimate outdoor pastime. We still need plants out there, but I like it.

I'm headed for bed and a gram of tylenol. Reveille at 0530, I'm sure.

Saturday in the Park

2007-07-01T09:23:00.001-07:00

Saturday was brilliant. The nicest day of the year, meteorologically speaking, and a day off for me. A predictably early morning--5:30a, I think. Zoë has learned that getting out of bed, opening her door, and coming upstairs to flail around in bed with her parents guarantees her the attention she wants. We've set a 6:00a alarm for her that plays beach surf sounds. Our agreement is that she can come upstairs when she hears the ocean. I'll have to check for conch shells in her bed, because she seems to be hearing the ocean earlier every day. Could be the 5:15a sunrise...

An early-morning trip to Seward Park for a quick walk around the point became more like an expedition. The parking lots were full of cars belonging to people training with the Leukemia Team in Training, so we found some nearby street parking. I forgot the front wheel of the stroller (a Burley bike trailer with stroller conversion--useful if you remember the parts), so we pushed it for three miles on two wheels. Not as bad as I thought, since neither Zoë nor Elliott would ride in it. Zoë was a very big girl and walked most of the way, first running, then walking, dawdling, and flat out refusing the move. Remember that weak, floppy feeling you got when your mom took you shopping? She had that. Eventually we got her back into the stroller with most of her clothes on backwards and made it around the loop in time to get home for lunch.

Just as we completed our walk my pager went off. I've got three moms-to-be due this month, so I've been anticipating the whenever page. A call to triage confirmed that one of my patients, a 24 year-old Vietnamese woman in her first pregnancy, had ruptured the night before (her water broke) and she was being admitted to labor & delivery. She wasn't particularly active in her contraction pattern and my on-call colleagues can handle anything, so I figured I could count on some more family time.

Home, lunch, book for Zoë, nap (for everyone), then that sleepy indecisiveness about what to do with the afternoon. We'd planned to go to Coleman Pool, the outdoor, heated, salt-water pool in West Seattle's Lincoln Park, but with a laboring patient it seemed like a bad idea to be that deep into an activity. We decided instead to explore the new wading pool on Capitol Hill (I could walk to the hospital if called in). That's where I took the picture of Zoë. It's an amazing place. A pyramid of cascading water feeds into a fast-moving chute, eventually spreading out into a lazy trickle down a cobblestone-studded slab. Adjacent is a huge, warm, wading pool, well-populated with kids and probably full of urine. But whatever, it was beautiful Saturday and every kid deserves to swim in a little pee on such a day. We hung out there for a couple of hours, playing in the pee, watching the capoeira dancers do their thing, the guys tying one another up in preparation for some performance, apparently, the parade of man-kilts, tattoos, piercings, musicians, lost children, and lost adults. Pretty great.

Home, dinner outside on the "patio" (our driveway) Brooke's newest bid for some outside space in our city townhouse. She has created a magical little world where we usually just park our car. I put Elliott to bed and then decided it was time, at about 7p, to head in to the hospital.

My patient had been making great progress all day, contracting and painfully dilating all day while I splashed around with my daughter in the pee-pee pool. By the time I arrived, it was just a waiting game. I worked on some admin stuff while I waited, chatted with the nurses, fellow residents, and Carroll, my attending. Eventually, we focussed on the birth event: ninety minutes of pushing resulted in a charming little baby boy. Some stitches, a lot of documentation and orders, then home. Asleep at about one o'clock.

My only regret is that I didn't get a beer on such a lovely day. I'll fix that today, unless the pager starts going again.

Resumption

2007-06-29T07:30:00.000-07:00

The cycle now moves back into writing. I've been reading an eye-opening blog by my friend and colleague, Mary Wierusz, about her experience doctoring in Kijabe, Kenya. She'll be there with her husband, Mike, for a month, and will, I hope, post frequently. It has inspired me to put my own thoughts down--though the experience doesn't compare.

It's 7:30 and I have lots to do to get myself out the door and on my bicycle to clinic for a morning of gynecologic procedures, so I'll leave this post as a marker and return for more later.

Not my best day

2007-05-10T21:26:00.000-07:00

It started out pretty well. Zoë was up before 5am crying nonspecifically, but I managed to get her back to sleep until 5:30, which is my typical wake up time these days. She re-woke sweetly with a "Daddy, I'm ready to get up now." So we did. She played while I readied myself, then we came downstairs for the usual routine: coffee, cereal, the drawn-out cereal-or-waffles decision, and feeding of the impatient animals.

Then, at about 6:15am, the pager. I figured it was an obstetric patient in labor, but that didn't make sense; I'd be there in a half-hour anyway, so why page? Bad news. The patient whose baby I had delivered last week was in the intensive care unit: unresponsive, intubated, unstable. Two minutes later I was in the car, fearing the worst.

Briefly, my patient delivered a lovely baby boy last Friday evening. The labor had been complicated by some high blood pressures and extremity swelling, causing us to evaluate her for pre-ecclampsia, but the tests were negative so we elected to press on with a normal delivery. I had to use a vacuum to get the baby out, in the end, but all went well...until yesterday.

At risk of blathering on, I'll just say that headache and leg swelling got worse, and by early this morning, she was also febrile and in severe respiratory distress. ER, intubation, ICU. My colleagues were just finishing up her orders when I arrived.

Moments like this make me wish I was doing almost every job I've ever been fired from. I had no words to comfort my patient's husband, and no idea what had gone wrong in the thirty-six hours since I'd last seen my patient. I'm again at the moment of blather, so I'll rein it in.

Her picture looks a lot like pre-ecclampsia AND some kind of infection--certainly something with a big respiratory hit. We don't much like AND kinds of pictures in medicine; they disturb our desire for parsimony. We would much prefer to say that one thing went kerflooey and spoiled a bunch of other things that were going well. In this case, it appears to be a couple of inciting events.

The good news is that she did well today, all things considered. She did not die. At 7am, that wasn't so certain. She's sick. I'm hoping tomorrow morning to see a little improvement.

I have rarely felt worse than I did this morning standing at my patient's bedside in the ICU, wondering what I could have done to keep this terrible thing from happening. I don't ever want to feel that way again.

I stopped on the way home for a bit of Irish whiskey (the Protestant variety, after some debate), perhaps as a way of escape, as my theatrical training would suggest, or maybe to commune with my father, who would know what to say to me now if he were here. Turns out Brooke knew what to say. So did Zoë: "Daddy!!"

It is approaching 10pm, and I'm to be up again early. I'm off to bed once I set up the coffee maker and put a pill in the stupid cat's throat, but I needed a moment to reflect on the day. I'll go read myself to sleep now with a review of the blood supply to the cerebellum in my old clinically-oriented anatomy book.

Tomorrow will be better, right?

2007-05-08T13:57:00.001-07:00

Lunchtime. Seventy degrees.

2007-05-01T11:03:00.001-07:00

Sunday

2007-04-29T11:53:00.001-07:00

Sunday sucks. Unless it doesn't. This one--today--is shaping up pretty well. We turned the grocery chore into a fun trip for Zoë and me, then met with Hilary, Dan, and Felix at the Mt. Baker playground. The playground became packed, so we walked down the hill to the beach and sat for a while in the sun while Felix and Zoë wandered near the water. I've never really spent much time on this beach. When the weather is beach-warm this place is packed, and we usually seek a little more space and quiet, either at the adjacent Coleman Beach or under a big, shady tree at Seward Park. But today was just almost warm, so we had the place to ourselves.

Felix and Zoë contemplate a swim

It got close to lunch-and-nap time (for everyone--maybe Sunday doesn't suck), so we walked back up the hill and headed home. Three-quarters of the humans are now up from nap and contemplating next moves. I'll take Zoë for a run past the same places we spent the morning and Brooke will take Elliott and Yagi out for a long walk, IF Elliott ever wakes up from her nap.

It is sunny and 64 degrees out.

I used to fear Sunday. The last day of the weekend. School tomorrow. I was almost never prepared for Monday, academically or emotionally. Now I quite enjoy most things about Sunday, except the endlessly-expanding white board task list dogging me. If anything on the list of chores can me made fun (like the grocery this morning with Zoë), it goes a long way to keeping my mood happy.

I've also been experimenting with a new method of checking off tasks from the white board: I erase them. You'd think a chore undone would lead to an adverse consequence. Well, no. I haven't noticed a problem yet. I'll report again later on this experiment in doing less.

Well, Elliott may be stirring now. Yes, she is. Mewling, even, so here I go, back to the day.

And my white board is mostly blank.

One of us forgot his house key

2007-04-13T17:34:00.000-07:00

We may be stuck outside in the rain, but I can still post. If only someone with a key knew...

Look, no biting!

2007-04-12T17:36:00.001-07:00

Well, not for the moment, at least. But watch out.

I didn't have time to go for my camera before this moment disappeared, so I settled for this with my phone.

It'll haunt you, too

2007-04-07T22:18:00.000-07:00

In the nicest way.

Probably Free to a Good Home

2007-04-07T12:09:00.000-07:00

Probably free to a good home
(20th & College on Beacon Hill)

Paternity leave, Day number I'm not sure anymore. It's not such a lovely day today as it was the last two (70s-80s, sunny, mountains out...), but still the outside was inviting, so after two cups of strong drip coffee I strapped Elliott to my chest, put a leash on Yagi, and headed out for a walk around Beacon Hill. Our destination was, bien sur, Galaxie, but the route was to be improvised. I've not yet walked through that neighborhood, and was quite pleased with the sights. There are great views of the mountains and across the valley to the Mount Baker neighborhood. The housing in dense and old, mostly. Lots of old craftsman homes from the 1920s, many are well-maintained, but there are a few that need some love. There are also a bunch that qualify as tear-downs.

We wound our way up the hill, following interesting sights and quiet streets on our way to the coffee shop. I spoke with my mom for a while while we walked, and she told me of her afternoon yesterday with Zoë, who is visiting St. Louis with Brooke this week.

Galaxie was packed. I hooked up Yagi out back next to a woman eating her breakfast. He begged until she gave him a piece of sausage. I got coffee--it takes me two at home plus a double-shot latte to get to "normal" these days--and talked with Woody a little about the benefit they're having tonight--wheelchairs for someplace in South America. Galaxie would be a great place for a party (and has a liquor license, which helps), but I'm not looking for a place to host anything these days.

Coffee was to go today, and we set out down the hill by a new route, admiring the sights and looking for the worst houses on great blocks, a buying strategy I'm obsessed with lately, though it will be another fifteen months or so before we're looking for anything. And who knows where we'll be looking?

It rained lightly as we neared the bottom of Beacon and entered the roaring Rainier Valley. It felt nice, the rain, and I let the drops fall on Elliott's head so she could appreciate them too.

We were out about an hour and a half, home just in time to feed Elliott and beat the heavier rain. Now all the critters are asleep but me. I would be too if I were smart, but I'm glad I stole a few minutes to write about our morning.

I love spring in Seattle

2007-04-04T13:45:00.000-07:00

Snapped with my low-res phone and posted on the spot (this text added later) on a long walk through Madrona, along Lake Washington Blvd, and into the steep trails of Frink Park, then home via the ridge along 31st near our old home on Norman Street.

2007-03-18T15:39:00.001-07:00

Sunny sunday.

Movin' On Up

2007-03-16T20:57:00.000-07:00

Many thanks to Hammy over at Ham Salad, one of north shore Chicago's bestest strings, for adding this admittedly inelegant title to the Must Read list. You'll find the Salad on my own Read This list, too.

Algorithmanic episodes

2007-03-16T11:12:00.000-07:00

Jerome Groopman has been all over NPR the last few days giving interviews about his new book, How Doctors Think. This morning he landed a seven-minute session on Morning Edition, and recently spoke at length with Terry Gross on Fresh Air. The book sounds like a well-constructed inquiry into the algorithmic processes of doctor think. How do physicians make sense of patients' stories and arrive at a diagnosis?

Or a mis-diagnosis. Groopman discusses the experiences of physicians and patients--even his own experience as a patient, to point out where doctor think goes wrong. The diagnostic process, relies on information from the patient about symptoms, personal and family history, risk factors. Doctors then collect relevant "objective" data (physical exam, labs, studies), and assemble a list, or differential diagnosis we think might explain what the patient is experiencing. Ideally, it's an exhaustive list, and we narrow it with directed studies to rule things in or rule them out. We work hard at it, but for various reasons we don't always get it right, and the consequences can be severe. Dr. Groopman explains to Steve Inskeep on Morning Edition:

"Usually doctors are right, but conservatively about 15 percent of all people are misdiagnosed. Some experts think it's as high as 20 to 25 percent. And in half of those cases, there is serious injury or even death to the patient."

Why do you think that doctors would be wrong that often?

Well, you know, it's very hard to be a doctor. We're working under tremendous time pressure, especially in the current medical system. But the reasons we are wrong are not related to technical mistakes, like someone putting the wrong name on an X-ray or mixing up a blood specimen in the lab. Nor is it really ignorance about what the actual disease is. We make misdiagnoses because we make errors in thinking.

We use shortcuts. Most doctors, within the first 18 seconds of seeing a patient, will interrupt him telling his story and also generate an idea in his mind [of] what's wrong. And too often, we make what's called an anchoring mistake — we fix on that snap judgment.

An anchoring mistake? Sounds like what my people call early closure, a very common problem. Making big differentials is hard, and many things influence how quickly we decide we know the diagnosis. Often, it just seems to fit...mostly...more than other stuff. But is our list comprehensive? Did we consider only common diagnoses? Is is time to trot out the rare, eponymous syndromes we memorized in med school but have never seen? Deciding early to attach a diagnosis to a symptom feels good, especially when there are other patients with symptoms waiting to be seen.

There's something about categorization that appeals to me. Calling something anchoring mistake, when you could just as easily call it laziness, gives me a kind of hope. If I miss a diagnosis and because I'm lazy and the remedy is to "try harder," well, I'm screwed. The problem and the solution are both pretty vague, and my fear around messing up again takes over. Fear motivates, for sure, but I would argue the outcomes aren't so great.

If I can categorize my apparent laziness with nifty terms like anchoring mistake (in which I make a snap judgement) or representativeness error (wherein I tell myself that common things occur commonly), my type-A doctor mind has something productive and familiar to do: memorize a list. In this case, knowing the ways my thinking might not serve me well helps me see potential pitfalls in diagnosing and treating--also known as helping--patients.

I haven't read the book yet, but I will. I did, however read Dr. Groopman's article from January 29, 2007 in the New Yorker. The writing is excellent and the examples compelling. If the book is anything like the article, I'll be reading all weekend.

Match Day

2007-03-16T09:06:00.000-07:00

The Seattle Post-Intelligencer got it together enough yesterday to show up at the UW School of Medicine Match Day event over in Montlake. The article is a reasonable account of how things work, but I was surprised at the severity of the language describing the experience of medical training, both in school and residency. Some examples:

"The Match" -- a high-anxiety cap to the end of a grueling four-year medical education -- will determine their professional futures, not just where they will live for the next three to seven years, but what specialty they will pursue.

There's a buzz going on, but the excitement has the tamped-down quality of people who have learned to manage anxiety to survive the rigors of clinical rotations, being called out for not knowing answers during rounds and monster exams.

There is recognition, too, that as hard as medical school was, residencies, renowned for their brutal on-call schedules, can be even harder.

Well, that all sounds quite difficult, doesn't it? True, medical training isn't easy, but it's not Darfur. There's a language tossed around in the press that creates this mystique of systematic torture by drill-sergeant faculty.

The UWSOM event is quite informal: lots of milling about, tamping down anxiety and eating dry pastries until the envelopes are distributed. You can open your envelope when you want and with whom you want. Some schools parade students in front of a crowd to read their "fate" for everyone. Check out this video from yesterday's University of Cincinnati Match Day event.

I would rather die than participate in that. Sorry, Shannah.

On the residency end, we go about our business on the morning of The Match and wait for a mid-morning page with the list. I got the page as I was strolling home from my massage through a sunny Seattle park. Quite a different scene than in Cincinnati or even at here at UW. I was thrilled with how we matched overall and especially at my beloved Downtown Public Health clinic.

Back to my brutal schedule--last legitimate day of vacation.

What the fe-mail-man brought

2007-03-15T15:18:00.000-07:00

Turns out Day Six of "24" is out on disk, the first four episodes, at least. Guess i have my evening planned. Please be wrong, Melanie, please be wrong.

March in Seattle

2007-03-15T13:36:00.001-07:00

Out walking this morning I tried to capture these brilliant yellow blooms with my low-res camera phone. Not too impressive, but also gives me an opportunity to figure out how to post directly from my phone.

More vacation

2007-03-15T08:02:00.001-07:00

Last week when we decided to chuck the travel plan for this week, I was warned to avoid letting a week at home--on vacation--become a week of chores. Yesterday got a little bit chore-heavy. I like getting things done, perhaps because I like checking things off lists. Actually, I like having things done and making lists, but that transitional period of doing the things on the list...well, not so much.

Yesterday there were a couple of things on the list that I felt I had to do. We got rid of Brooke's desk the other day--gave it to Hilary and Dan for their new house--to free some space for a crib, glider, and changing table Brooke picked up on craigslist. Those things go into the current guestroom, soon to be Elliott's room. The desk is gone, and all the stuff that had been in the desk was on the floor, waiting for me to sort through it. What a lot of junk: about 75% of it went straight out the door, either to the garbage or to Goodwill. There is still some stuff there that I couldn't part with (but should). I created a defer decision pile and made some lame excuse to Brooke for why I couldn't deal with it that moment. She didn't buy it, but she didn't call me on it, either. So there it sits. Overall, I did not enjoy that chore.

Next on the list was to return a bed to Ikea. Brand new and yet-unassembled (but out of the box), we slogged it down to Southcenter (big box retail hell) to get it out of Elliott's room. That was the second unused new bed we unloaded this week. Ikea gave us store credit, since we were beyond the return period and didn't have a receipt. We walked around the store for a while and found some more crap to bring home to replace the stuff we spent the morning purging. New crap, though; the other stuff was old crap.

On the way home the first thing we did was get lost. Happens every time we go to Big Box Hell. After a slow tour of the Valley Medical Center parking lot, we inched onto the freeway and eventually onto the I-405 HOV lane, which moved at about 60mph while the other three lanes literally sat still. Traffic was miserable all over due to accidents and a big police foo-faa over a stolen car.

I hate car life. I would prefer to walk or bike or bus or run everywhere I need to go. But...but...you know I'd like to say now "that's just not practical." But...it IS practical. As Bus Chick points out every day, we've got great public transit. I could easily take Zoë around town on my bike, and the trip from here to daycare and work is all on trails or wide, dedicated bike lanes. And I've demonstrated to myself that running is feasible, having commuted that way nearly all of last year. But then I got a car. Terrible idea! Immediately I started driving, taking advantage of the free parking I have at work and the ease of just getting in and going. I've paid the price with ten pounds gained and physical fitness lost. If I can park a car at work, I can also park a jogging stroller.

Just takes a little planning, which will be easier when I'm not so sleepy all the time. Any day now, I'm sure Elliott will just sleep right through the night. Any day.

Vacation

2007-03-13T14:12:00.000-07:00

I'm off work this week. It's good. We thought about going away for a few days, renting a cottage on Whidbey Island or Hood Canal. That would be good fun, if it weren't for Zoë and Elliott and their dueling sleep schedules...well, their awake schedules, I should say. It's bloody exhausting. Weekends turn out to be pretty hard, and three days in a cottage, even in a lovely setting and even with a hot tub, would have been less like a vacation than like work. The alternative was to stay in Seattle, send Zoë off to day care in the morning, and enjoy life with one very portable infant. We can take naps, write, go for walks, get massages, all thanks to the happy two-parent-to-one-child ratio we used to think was so hard. Yesterday we called Sam to babysit for the afternoon, then headed out for lunch at High Spot and a walk. No nap.

Last night, we gave Elliott a bath, which I videotaped and and might post if Brooke can get over thinking our children will end up like the Star Wars kid or that poor Numa Numa Dance fellow. I don't see it happening with the bath video, but maybe with Zoë's "Shake Your Booty" song.

Also last night we completed season five of 24. I love the series, and season five was great, especially Gregory Itzin and Jean Smart as the president and first lady. I've now seen the whole thing through last season, and haven't a clue what has happened this season. I'm pretty sad to read that Melanie McFarland, the most trusted hairdo in TV reviewing, isn't "feeling it anymore." It will be a while before I can start in on season six. What'll we watch next? Back to Entourage, perhaps, so I can dream of being a movie star.

This morning I got in a good long walk with Yagi. Through the I-90 walking tunnel, down to the lake, and along the water while Yagi swam and carried big sticks. I'm off now for a haircut, then to pick up Zoë. Again, no nap. What the hell is going on here?

It's a nice pace. Next time maybe we'll go for the cottage.