The chronicle of a lonely do-gooder family doctor who survived.

Wednesday, December 31, 2008

New Year's Eve, My Last Day in B-town

I have a family I have been taking care of since 2001. They are from Iraq and I have seen them through so much. They were basically brand new refugees that came through Jordan when I first started seeing them. There are six in the family, including a child who was a newborn in 2001. The mother had *severe* PTSD, to the point of mental status changes and total incapacity. I had never seen real, acute post traumatic stress outside of psych rotations in med school and it was scary seeing it on my own. At my current practice, DSHS wasn't able to provide an interpreter and, although the community mental health system exists as a theoretical safety net, in practice it was just impossible to get her in. Multiple times, through the father and son who spoke a little English, I told them outright that they needed to get into a community health clinic, that I didn't think I had the resources I needed to treat them. I even called and made appointments, printed out information on refugee support services, but they kept coming back to me. For some reason, wisely or unwisely, they decided I was their best chance at getting help.

So I basically shot from the hip and did what I thought was best, started SSRIs and alpha blockers, treated insomnia, saw them frequently for longer visits and talked to them about their experiences. Treated the childhood illnesses, diagnosed an appy, helped the dad through a herniated disk, got the mother some surgery to repair a chronic eardrum rupture.

Now, slowly, over eight years, everyone is doing great. PTSD is totally in control on sertraline. Two of the kids are over 18 and lost medicaid coverage and so I've just been treating them on the side whenever I could for minor things. The mother who spoke no English and had a GAF of 20 eight years ago, now speaks near perfect English and seems totally normal to anyone she meets.

Every time I see them, their eyes brighten, they grab my hand warmly, and they are so grateful. This was a family I was so sad about having to say goodbye to after leaving this practice.

Today, my last day seeing patients here, they just came in for a scheduled visit. They are going back to Iraq for a visit for the first time and needed prescriptions refilled and a travel medicine consult.

The first thing they said to me when I walked in the room was "We heard you are leaving. We're coming with you. Tell us where you'll be and how we can go there." It turns out the father works at a barber shop not far from the community health center I'll be working at and it's actually totally convenient for them. Because they are listed as Arabic speakers in the DSHS system they will automatically have an interpreter show up for their visits (not that they need it anymore). They will get to see the mental health workers at the clinic. They will get much needed dental care for the first time. *And* I will get to see the two uninsured kids.

After the visit, they congratulated me profusely on the coming birth of my son and insisted on taking pictures of me to take back to Iraq to show the family there.

Wow. I swear to god, this is why I got into medicine.

Tuesday, December 23, 2008

Busy busy

It's been more than a month since I blogged?!

Life has been pretty damn hectic since I dropped the bomb that I'm leaving my job. I mean, there was all the credentialing and paperwork for my new clinic at the 45th Street Clinic, but tying up loose ends at my current practice has been unreal. I started there eight years ago as just a temporary gig while Shiree finished her training (thinking we would probably end up moving where she could find a job) but things have snowballed. I currently have so many other (mostly uncompensated) responsibilities (medical director, electronic health record champion, running the Highline Urgent Care Clinic, chair of the Director's committee, quality committee) that handing these things off to other people has probably taken 40 hours a week by itself and underscores some of the reasons why I was feeling pretty overwhelmed and ineffective.

Then there's the patients. I'm touched, mostly, that so many of them have expressed so much regret that I'm leaving. Within 3 days of mailing the letter explaining my decision, the remaining 6 weeks of my schedule were completely booked. People have brought me presents and cards, and some cried. I ran into a few at the airport (where many of my patients work) and one lady, a TSA employee, ran up to me, grabbed me and gave me a big bear hug, totally freaking out my wife. Almost everyone said some form of "I'm so happy for you, and I'm really going to miss you" and they seemed pretty genuine about it. I probably will miss 75% of them but there's a sizeable minority whose lives are so chaotic, whose problems run so deep, that I have this enormous sense of relief at finally extracting myself from their misery. We did find a replacement doc who will start working the day after I leave. I sure hope he's comfortable with chronic pain, self-inflicted disease, and mental illness. How did I attract so many of these people?

Yes, I'm pretty exasperated with this place. I've been trying not to let it show, you know, not burn any bridges. My medical group is mostly filled with good people who serve a really difficult population within a health care system that is totally failing. But it's been hard.

I recently posted at Metafilter about the sorry state of primary care in the U.S. and I personally don't know how much longer I will hold out. I mean, I'm pretty excited about my new job and feel like it will definitely be a more effective organization, and I love practicing medicine, but I am skeptical I will last more than five more years practicing full time unless, by some miracle, there really is sweeping change in health care that is strongly favorable to primary care.

Which makes it really important that I pay off my loans in the next five years. I am currently writing applications for government loan repayment in exchange for a commitment to work with the poor and underserved. If any of that comes through, and with some frugal living, I will hopefully be rid of that ball and chain. And not having to make that $2100 payment every month for the next 20 years will really open up my career possibilities.

Although I am making contingency plans to get out of medicine, I wouldn't say that going to medical school was a mistake. I mean, I have skills that will render me a useful, employable member of society just about anywhere in the world. But things have gotten so bad in primary care that I'm simply not willing to shoulder the ever increasing burden of an inadequate system on my back indefinitely. And that realization has actually been very liberating.

Tuesday, November 18, 2008

I am out of here...

Well, I did it.

I told everyone I'd wait until the election to make a decision about my future career plans, but in the end it didn't matter. Every day as I drive in to the hospital that sense of dread starts to fill up my stomach and grows stronger until I pull in to my parking space and trudge up the stairs confident I am about to spend another 12 hours doing mostly unpaid work as the agent of a system that utterly fails everyone involved.

I expect headaches in my job. I mean, it's the doctor who is supposed to be the lone hero in the middle of the bureaucratic insurance mess, who is desperately trying to make the system work for the patients, and even once in a while trying to save a life. And it's important work. There are times when families genuinely appreciate the work I do, moments when I feel actual satisfaction.

But those moments are becoming less frequent and the personal cost to me is becoming too difficult to bear. When I approach the end of each year and take stock of what it is I'm doing with my life, I can't ignore the fact that I am working longer and longer hours, doing less and less good for my patients, for a salary that still causes me to sweat the end of the month, hoping I won't have to use credit cards to pick up the short fall of the mortgage and student loan payments.

I love my patients. I mean, I really pour my heart into my practice and try to see the joy I used to know playing an active role in the most intimate, powerful moments in the lives of those I serve. Saying goodbye to them has been truly wrenching.

Despite the hope that the Obama election has given me, I am getting out of the private medical insurance game. The system is totally corrupt, likely unsalvagable. I hope to never go back. I have taken a job at a small community health center, much closer to home, at a reduced schedule, seeing mostly homeless and uninsured patients.

The doctors who work here still have some of that joy that led them to answer the call of medicine. They are dynamic and have an energy about what they do that I have only rarely seen in 8 years of private practice. They are true family physicians who see their patients in the hospital, who deliver their babies, and who help those babies grow up as healthy as they can. That's what I want.

Sure they have bureaucracy and headaches to deal with, but it's not from a system that is financially gouging their patients, it's not from a system that is supposed to be working. There's no illusion that this here is the safety net, the clinic of last resort and no one feels unappreciated.

Going back to The Suitcase Clinic at Berkeley, where I was first exposed to the difference that access to health care could make in someone's life, and extending through my residency at the county hospital here in Seattle, this is the work I have wanted to do for a long time. I just never thought I could do it, and still have a family, and a house, and pay off my loans, and who knows maybe every once in a while pay for a ski holiday. But with a baby on the way, I see myself coming home later and later every day with less and less job satisfaction and I now realize that I can't afford to *not* work in a place that preserves the integrity, the soul of medicine. The paycheck doesn't matter, the work does.

Monday, November 17, 2008


Yep, that's right. In this optimistic time of change, the Mrs. and I decided to go and make ourselves a kid. The little Sour Kitten is due in April. Things are going pretty well, Shireesha seems mostly over the morning sickness but is starting to feel the weight of the baby.

It's been a weird experience. Neither of us are what you would call baby-crazy and we hadn't even discussed it much prior to this year. There is so much uncertainty in the world, and with two careers in medicine specifically, that it seems fool hardy to throw a huge variable into the equation. But I do have more hope lately than I have had in years and with that hope comes a sense of freedom and possibility. Shireesha's career is finally in a somewhat state of stability and with my options wide open, this seems like a good time to bring a child into our lives. I mean, we aren't committed to the idea of being childless forever, so if not now, then when?

I think it's fitting that we don't have any expectations. I want to greet the new little one with an open heart, confident only of the idea that Shireesha will be a fantastic mother and that this experience will bring out the best in both of us.

Wednesday, November 5, 2008

Obama like me

There has never been a president who looked more like me.

Monday, November 3, 2008

Washington State Proposition 1000

Washington State Proposition 1000, the Right-to-Die initiative. Modeled after Oregon's generally successful Physician-Assisted-Suicide law.

Initiative Measure No. 1000 concerns allowing certain terminally ill competent adults to obtain lethal prescriptions.

This measure would permit terminally ill, competent, adult Washington residents, who are medically predicted to have six months or less to live, to request and self-administer lethal medication prescribed by a physician.

Should this measure be enacted into law?

Yes [ ] No [ ]

I voted no.

Yes, I am a bad liberal. Yes, I am another fascist physician trying to foist my personal ethical beliefs on my patients.

Actually, I am neither and I have really mixed feelings about this, something that is rare in this age of divided politics. I won't be heartbroken if it passes and I am pretty sure I signed a petition to get this on the ballot.

Here is my thinking. My day is divided into 15 minute blocks of time that I spend with patients. 2 minutes is spent with the nurse, checking in the patient and taking vital signs. 6 minutes is spent on documentation and insurance paperwork. 2 minutes is spent on the acute medical issue that I insist we deal with, which the patient could care less about: the blood pressure of 235/115 or the psychosis or the 50 pounds of weight loss since I last saw them. That leaves about 5 minutes, on a good day where I'm not behind from the previous 10 visits that looked like this.

Pain and suffering during a terminal illness is a Really Important Thing to discuss, certainly one of the most important conversations you could have with your physician. I absolutely believe that a rationally thinking person might choose to end their life, on their own terms as a logical and even morally correct thing to do. I just don't see how the current health care system is set up to do this the right way, granting enough time for consideration and safeguards that actively ending life deserves.

To be clear, the current system is so broken that we cut corners on hundreds of other important conversations: the new diagnosis of cancer, the decision to begin hospice care, whether grandma should be moved into a nursing home. Proposition 1000 is just where I have finally decided to draw my own personal line.

Friday, October 24, 2008

Early Voting

DAMN that felt good!

Hell *yes*, the King County Charter shall be amended to make the offices of King county executive, King county assessor, and King county council nonpartisan, and establish the nonpartisan selection of districting committee members! Take that Elite Media!

Wednesday, October 22, 2008

Dengue Fever

Tony, Xian, CJ, and I caught Dengue Fever last night at Neumo's in Seattle. These people are the hippest, funnest band I have seen in a very long time. Ch’hom Nimol's stage presence was incredible and such a voice! The band members were having such a great time and were so gracious, politely shaking hands and talking with fans after the show. There were several Cambodians in the audience and Nimol twice invited them on stage to sing with her in Khmer. A large portion of the audience was actually dancing, not just head bobbing, but dancing with arms waving in the air, totally unheard of in our cold, rainy, reserved city. Just amazing.

Wednesday, October 15, 2008

Batman vs. The Penguin: The Debate

The role of the presidential debate as a factor in the election is probably over, and even Batman knew it. When campaigns go on for years and both sides insist on total control of the message, what use is this? Who really thinks this is an exchange of ideas between two learned men? And who the hell are these people who haven't made up their minds yet?


It has come to my attention that everyone in the world who has a blog posted this video this week. I, for one, am proud to be a member of the blogosphere and never have I felt such unity as this. Rock on, bloggers.

Thursday, October 9, 2008

Michelle Obama: Be not afraid

Now this is leadership.

I was getting all bothered and ready to post about the Palin Mob video when someone in a heated discussion thread linked to this speech by Michelle Obama about the role of fear plays in American politics. I was going to write about how reckless, unpatriotic, and plain stupid it is to insinuate that a major party candidate for president fraternizes with terrorists, how such speech is just asking for a crazy redneck with a gun to take drastic action, how inciting such fear is almost the very definition of terrorism. I was going to write about how maybe someone with no experience, who's spent time as a radical secessionist is a wee bit riskier than Obama for electing to high office. I was going to write about how terribly indecent it is for McCain to not loudly denounce this kind of speech.

Then I was reminded what real leadership means.

10/9/08: Obama 364, McCain 174 with Pennsylvania, Virgina, Colorado, Ohio, and Florida nearly in the bag.

Saturday, September 20, 2008

New patients

I work 80% full time seeing patients, the rest being various administrative and teaching responsibilities. The average American goes to the doctor 2.3 times per year (yeah, lots of you never go to the doctor but there are a special few who go like 20 times a year, so it averages out). Doing some math, my practice should be full at about 1600 patients, a number I surpassed like 6 months into my career (you know, primary care shortage). However, thanks to the magic of cost sharing, under insurance, and general lack of concern for their health problems on the part of my patients, I can't keep my schedule full at 1600 patients; periodically I have to open the practice back up to new patients, agonizing over the decision each time. There are currently about 2300 people who consider me their primary care physician.

In July of this year, as we were looking at empty schedules and rising expenses, we had to bite the bullet and open up again. Though I like not losing money and laying off employees, I still protested hard. Not that I mind being busy, what I mind is being exposed to the circulating pool of crazies.

"What do you mean by 'circulating pool of crazies,' Dr. Sour Puss" my nurse asked.

"There's this population of patients, chronic patients with unfixable problems who burn out their doctors pretty quickly and once it's clear that doctor cannot help them, they jump to the next doctor-victim" I said. Because they go to the doctor a lot, and because they are always looking for a new doctor, they represent a disproportionate amount of the new patients calling to schedule an appointment. Just ask any doctor who just recently hung out his or her shingle.

"You're just being negative like always, you need to relax."

"Oh really, you don't believe me, eh?"

There's a white board in my office and we've been keeping a track. Here is the current tally as of today.

Since July 19, 2008

Number of new patients, establishing care: 44
Number of new patients with a pain complaint requiring narcotics of > 3 months' duration: 23
Number of new patients with very severe uncompensated mental illness: 9

Saturday, September 13, 2008

Obama talks like a fag

“Joe stated his case logically and passionately, but his perceived effeminate voice only drew big gales of stupid laughter.”

Marc Fisher wrote an interesting op-ed in the Washington Post this week.

For Working Moms, 'Flawed' Palin is the Perfect Choice

In it, he makes the typical argument that Palin resonates with people because she's one of the common people. But what I think is interesting is what it actually says about the other side. Here's the money quote:

"She's just as flawed as we are," Tweddle said. "It's not the fact that she's a woman but the way she does it all. And let me tell you: There're more American parents with unwed pregnant teenaged children than American parents with Harvard grads. She's real."

Things have gotten pretty twisted when going to Harvard and raising children who don't get pregnant has become a political liability.

There was another fantastic article linked to on Metafilter this week by Jonathan Haidt, a professor of psychology at University of Virginia who researches morality and emotion:

What Makes People Vote Republican?

It's a fairly dense essay, but one well worth reading. In it, one of the arguments he makes is that the moral structure that motivates Republicans can be divided into ingroup/loyalty, purity/sanctity, and authority/respect. He urges Democrats to understand how these themes motivate people to vote Republican and offers a prescription for how Democrats can turn them to their advantage.

The ingroup/loyalty foundation supports virtues of patriotism and self-sacrifice that can lead to dangerous nationalism, but in moderate doses a sense that "we are all one" is a recipe for high social capital and civic well-being. A recent study by Robert Putnam (titled E Pluribus Unum) found that ethnic diversity increases anomie and social isolation by decreasing people's sense of belonging to a shared community. Democrats should think carefully, therefore, about why they celebrate diversity. If the purpose of diversity programs is to fight racism and discrimination (worthy goals based on fairness concerns), then these goals might be better served by encouraging assimilation and a sense of shared identity.

The purity/sanctity foundation is used heavily by the Christian right to condemn hedonism and sexual "deviance," but it can also be harnessed for progressive causes. Sanctity does not have to come from God; the psychology of this system is about overcoming our lower, grasping, carnal selves in order to live in a way that is higher, nobler, and more spiritual. Many liberals criticize the crassness and ugliness that our unrestrained free-market society has created. There is a long tradition of liberal anti-materialism often linked to a reverence for nature. Environmental and animal welfare issues are easily promoted using the language of harm/care, but such appeals might be more effective when supplemented with hints of purity/sanctity.

The authority/respect foundation will be the hardest for Democrats to use. But even as liberal bumper stickers urge us to "question authority" and assert that "dissent is patriotic," Democrats can ask what needs this foundation serves, and then look for other ways to meet them. The authority foundation is all about maintaining social order, so any candidate seen to be "soft on crime" has disqualified himself, for many Americans, from being entrusted with the ultimate authority. Democrats would do well to read Durkheim and think about the quasi-religious importance of the criminal justice system. The miracle of turning individuals into groups can only be performed by groups that impose costs on cheaters and slackers. You can do this the authoritarian way (with strict rules and harsh penalties) or you can do it using the fairness/reciprocity foundation by stressing personal responsibility and the beneficence of the nation towards those who "work hard and play by the rules." But if you don't do it at all—if you seem to tolerate or enable cheaters and slackers -- then you are committing a kind of sacrilege.

Unity is not the great need of the hour, it is the eternal struggle of our immigrant nation. The three Durkheimian foundations of ingroup, authority, and purity are powerful tools in that struggle. Until Democrats understand this point, they will be vulnerable to the seductive but false belief that Americans vote for Republicans primarily because they have been duped into doing so.

I would state it even more simply. For Republicans, morality is about what unifies us. It's about circling the wagons. For Democrats, morality is about what we aspire to. And actually, if you try and separate the historical context from each model of morality, neither way of thinking is necessarily superior. Haidt makes the point that Democrats aren't winning because, recently, they don't understand what's motivating people to vote Republican. I think Obama does it better than most Democrats (who do you relate better to, Obama or Pelosi?) but McCain and Palin (in the last couple weeks at least) are outdoing them. If the Democrats want to win, they need to play up the fact that they are basically normal people who have more in common with working stiffs than old "7 houses" McCain, while still trying to explain why it's okay to vote for the smarter candidate.

But how exactly do you show middle America that being smart is a good thing that makes you a better leader while not alienating those who don't self-identify as educated? As the right holds on to power by demonizing smart people with new ideas ("The Liberal Elite" I suppose), the more I believe this nation's survival depends on answering this question; Haidt offers a pretty good answer to this question.

The most dangerous element in American society today, more than the military buildup, the suspension of civil rights, the encroachment of religion into government, the failure of the mortgage industry, or the lack of affordable health care, is this disdain for intellectualism. Being a nationalistic flag waver doesn't lead to fascism nearly as fast as demonizing ideas does.

Thursday, September 4, 2008

Patriots and Nationalists

It's a fine line between patriotism and nationalism. According to Webster's dictionary, the only distinction between the two is degree, that nationalism is an "extreme" form of patriotism. In my mind, a patriot is someone who loves his or her country, someone who is willing to serve his or her country, and someone who sees his or her country for what it is, warts and all, and still wants to be here. A nationalist is someone whose love has become fanatic, contingent almost on being number one. Someone who believes that no matter what happens, fidelity to the motherland is more important than anything else. To a nationalist, it is more important to win than to be right.

If it weren't so bloody clear that McCain is going to get trounced in November, last night at the Republican convention would have given me an ulcer. While the Democratic party convention (to my surprise actually) was filled with speeches about what we, the patriots who love this country, can do to serve and make it better, last night the Republican convention was filled with statements that demonize anyone who dares point out the things that aren't going so well, and they're willing to lie outright to do it. I almost threw up when I heard Sarah Palin say "There's only one man in this campaign who has actually fought for this country," referring to McCain's military service and implying that dropping bombs on people is somehow more virtuous than any other public work.

It reminded me of the words of another great American, who hit the nail right on the head:

Tell me who's the real patriots
The Archie Bunker slobs waving flags?
Or the people with the guts to work
For some real change
Rednecks and bombs don't make us strong
We loot the world, yet we can't even feed ourselves
Our real test of strength is caring
Not the toys of war we sell the world
Just carry on, thankful to be farmed like worms
Old glory for a blanket
As you suck on your thumbs

Real freedom scares you
'Cos it means responsibility

So you chicken out and threaten me

Saying, "Love it or leave it"
I'll get beat up if I criticize it
You say you'll fight to the death
To save your worthless flag

If you want a banana republic that bad
Why don't
you go move to one?

-Jello Biafra, The Stars and Stripes of Corruption, 1985

Monday, September 1, 2008

Obama, McCain, and health care.

With health care reform being such an obvious issue on the minds of American voters this year, it’s surprising to me that we don’t hear more from the candidates about it. I suspect it has to do with the fact that any real, durable solution is going to be controversial. It will be good for some, bad for others, and will involve a great deal of compromise. Not exactly the kind of issue you want to build your campaign around. And so the public debate is limited to the usual meaningless sound bites. “Affordable health care.” “Access to the highest quality medicine.” “Coverage you won’t lose when you change jobs.”

As a doctor, people do ask me about the candidates’ positions and sometimes they even want to know my opinion who has the better plan. Those who know me have heard me say over and over again that the best, most cost effective, comprehensive, highest quality system is a single payer plan. I am under no illusions about the chances of this coming to pass in the U.S. But I do see it as a starting point for the debate, a model that we will need to move towards eventually.


John McCain’s health care reform ideas are largely influenced by John Goodman, an economist and president of the conservative think tank The National Center for Policy Analysis (he's the father of the Health Savings Account! Which nobody uses!). He has an amusing, little blog over here where he just sort of rants about things he appears to know a tiny bit about. The National Center for Policy Analysis describes its mission as finding “private sector solutions to public policy problems.” In addition to solving the health care problem, the NCPA also manages to find time to have position statements on affirmative action, crime, the economy, education, social security, terrorism, and welfare (these guys must be Really Smart!) Mr. Goodman’s health care credentials seem limited to a book he wrote criticizing single payer health care and he apparently has no direct experience in actual government health policy. McCain's chief domestic policy advisor is Douglas Holtz-Eakin who is said to favor free market solutions to the health care problem. And for good measure, we also have Tom Miller, resident fellow of the American Enterprise Institute, the Bush Administration's cactus league where new "talent" is developed. What's astounding to me is I could find no evidence of any actual health care experts, physicians, or patient advocates informing McCain’s health care plan.

McCain’s plan depends on market forces and individually purchased insurance to drive down costs, with government setting policies that would reward care providers on outcomes. Currently, employers who buy health insurance for their employees get to deduct the premiums they pay from the their corporate tax bill. McCain wants to eliminate this tax deduction and then use that extra tax revenue to give money to individuals in the form of tax credits, which they can then use to buy their own insurance. He expects such a credit would be $2500 for an individual, or $5000 for families.

Now, everyone knows that health insurance on the open market costs way, way more than this, at least $6000 a year for an individual and about $12000 for a family. His solution? Deregulate the industry so that individuals are encouraged to purchase much less comprehensive insurance with high deductibles and allow them to purchase insurance from any company willing to insure them, anywhere in the country.

And what about the people with complex, expensive medical problems to whom insurance companies will simply refuse to sell? He plans to create a large government-run insurance pool for those that the health care industry calls “uninsurable.”

The plan also pays lip service to improving the speed with which generic drugs are brought to market (although, one presumes not by limiting the current patent laws that protect pharmaceutical companies), improved health care technology (whatever that means), and reform of medical malpractice.

As I see it, there are several problems with this that illustrate how poorly informed McCain really is about the health care system:

1. Companies that are already doing the right thing by providing health care for their workers will be forced to subsidize those companies that aren’t. It won’t take long for most smaller employers to simply stop providing health care altogether, which is what I suspect is the idea all along. But then what happens to the revenue that is supposed to fund these tax credits?

2. It doesn’t fully fund health care. As an individual, you will still, conservatively need to cough up $3500 and the bill will still go up 5 to 10 percent a year. And most people who are uninsured now will simply remain uninsured because the cost is still far too high for them. Many of those who use the tax credit will likely purchase inexpensive bare bones policies with super high deductibles, which is little better (from a primary care perspective) than no insurance. I can tell you, it is extremely difficult to treat something as simple as hypertension when your patient tells you “Doc, I can only afford to come see you once a year.”

3. For the most difficult, costly patients who have the greatest need, he’s basically proposing a government administered single payer program, which absolutely blows my mind. I mean, god forbid we have government involved in health care, unless of course you are actually sick and need health care, then it's fine. Now, a normal person might think if it’s good enough for the people who are going to use it the most, why not make it more cost effective by including more healthy people? Hell, you could even prevent some of those cheap healthy people from becoming expensive sick people by getting them steady access to primary care. I guess you'd have to be a normal person to think like that.

4. The “cost savings” of the plan relies on competition within the individual insurance market even though that is typically the most expensive segment of the health insurance market, one that involves individual underwriting and exclusion of pre-existing conditions.

5. The single biggest piece of most physicians’ overhead is that which is devoted to administering the insurance system. I contract with 15 different insurance plans and it requires almost 2 full time employees to send those bills, chase after bills that get denied, collect co-pays, change prescriptions every time one of those insurance companies gets a new formulary, and make sure my credentialing is current with each company. I shudder to think what would happen in a deregulated insurance market, where patients come to me with hundreds of different insurance plans, each with their own package of benefits. Certainly, many primary care physicians would choose to abandon insurance contracts at all and go to a strictly cash out of pocket business. Again, this may be the plan all along.


Obama’s top health care advisors include David Cutler, a professor of applied economics at Harvard who has years of health policy experience and who helped craft Bill Clinton’s health care reform plan, David Blumenthal, a practicing physician, professor of medicine at Harvard, former vice president of Brigham and Women's Hospital, former director of the Center for Health Policy at the Kennedy School of Government (his resume includes minor things like correspondant for the New England Journal of Medicine, sitting on the advisory committee for the National Academy of Sciences), a man who has more than 20 years’ experience writing about health policy and reform, and Stuart Altman, a health care economist who helped develop health policy for Richard Nixon, Bill Clinton, and John Kerry. 2 of the three are from Massachusetts, a state that has implemented its own, generally successful, universal health plan. Say what you want about Clinton's reform attempt or the Massachusetts plan, but these are people who are well known and respected in the health care field who have spent their careers researching and thinking about this stuff.

Obama’s plan is a standard “play or pay” plan. Employers would be required to provide health insurance or they would pay into a fund that would create a new national health plan, similar to Medicare. In addition, for those that would prefer private insurance to a government-run plan, he would establish a new national health exchange that would allow small businesses and individuals to purchase insurance as part of a large pool, similar to what several states are doing successfully now.

Under Obama’s plan, there would be a mandate that all parents must purchase insurance for their children but it stops short of mandating all adults participate for the time being (this was the key difference between Obama and Clinton’s proposal).

Obama also plans to increase regulation of the insurance industry to end risk rating based on health status and to create a new system of reinsurance whereby the federal government would subsidize employers for costs incurred by catastrophic medical cases, protecting the remaining pool of insured persons from these cases.

Like McCain, Obama’s plan also has statements about driving down costs but his proposals are much more specifically friendly to primary care. He would do this through the adoption of electronic records, promotion of chronic disease management, emphasis on prevention and public health, payment to providers on the basis of performance and outcomes, all ideas that bring us closer to achieving the Future of Family Medicine’s proposed medical home.

It is not entirely clear how Obama’s system is going to be funded. He proposes a combination of allowing certain tax cuts to expire, reduced administrative expenses, and savings from improved prevention and disease management. I think we are likely to get a system that costs as much as what we are currently paying, but one that is much more comprehensive, leaves fewer uninsured, and serves the needs of ordinary people much better that what we currently have. Employers want to get out of the business of providing health care and this proposal will give them a path to do exactly that. And this may move us all much closer to a single payer system. For the time being it preserves the health insurance industry and maximizes individual choice.

It would be na├»ve to think that either candidate is simply going to pass whatever reform plan they want in their first days in office; our political system simply doesn’t work like that. The president merely dictates the direction and tone of the debate. When you read the candidates’ health care proposals, it doesn’t tell you so much about what they really are going to do, rather it gives you insight into how the candidate and his advisors think about the problem and their vision for the future.

With that in mind, I’m throwing my lot in with Obama’s team. His plan prioritizes the needs of patients and primary care over that of insurance companies and employers. He’s listening to the right people, and his plan builds on previous successes. McCain recklessly proposes that the entire country adopt an untested insurance paradigm, one that seems guided by conservative economic ideology and not actual real-world experience. I am convinced that there will be another real attempt at health care reform during an Obama presidency, hopefully this time with real results.

Reagan speaks out against health care reform and the fact that it will inevitably lead to a communist takeover of America.

Sunday, August 17, 2008


The people in the town where I work are not the brightest in the world, especially when it comes to their health. This is a source of both unending frustration and endless amusement. As an example of the former, yesterday I was awoken by the consulting nurse at 430 AM.

"Your patient is calling. She says she was hit hard on the head yesterday. She had a severe headache all day and then in the afternoon she passed out and didn't wake up until just now. I told her she needed to get to the emergency room right away but she says she hates the hospital and refuses to go."

"Ok, my first question, when she decided to call me, what did she expect I would do?"

A much more amusing but no less tragic situation arose the other day when Mr. X, a short, extremely round middle aged man, came in to see my friend Chris.

"Mr. X, I noticed my nurse forgot to get your weight, do you know how much you weigh?"

"Sure, I weigh exactly 350 pounds, my weight hasn't changed in years."

A little skeptical, Chris asks "How do you know that?"

"Well, they have this scale at work, I check every day. I step on the scale and I slide the little thing all the way to the end until it stops. 350 pounds."

"Maybe we better check on our scale."

The guy steps up to the digital scale and the numbers roll way past 350 and stop at 546.

Mr. X is flabbergasted. "546?! That's really bad, isn't it?"

Saturday, August 16, 2008

P-p-p-pick up a Knighthood - Penguin at Edinburgh Zoo

This is the most awesome thing I've ever seen. I look forward to the day when the armies of the world have nothing better to do than bestow honors on zoo animals and parade them around.

Sunday, August 3, 2008


Finally got around to figuring out how to host files. Here's 2 extremely amateurish recordings Xian and I did. I assure you, there was almost no effort put into these.

Llamas in Pajamas

Loopy Loop 1

Saturday, July 26, 2008

205 miles, Seattle to Portland, July 12-13, 2008

I keep telling people it was the most fun I'd had in months. 9500 riders on a 2 day tour to Portland supported by the Cascade Bicycle Club. I'd never done any long rides like this before, but I've always wanted to. There is no better way to see a place than on a bike. And there are no friendlier people than a bicyclists on a tour.

Matt, Greg, Fil and I did the ride over 2 days, stopping to camp in Centralia. Fil had done it last year and I when I was driving him back up and was impressed by how much fun everyone seemed to have. This year, I remember thinking about 2 hours into the ride how incredible it was and that there was no question I'd be back next year.

It's too bad the photos turned out like crap. My camera died just before the ride and no one else brought one so I just got a couple disposables. $40 for about 40 crappy pictures. Awesome.

Parents, please talk to your kids about Chamois Butter before it's too late.

Crossing the Columbia River...

(Did I mention it was 90 degrees?)

Wednesday, July 23, 2008

Letters of Medical Necessity

People, this is what it has come to:

July 23, 2008

To Whom It May Concern:

I am the primary care physician for Mr. X. He has a history of intracranial hemorrhage (“bleeding in the brain”). This is usually a bad thing for patients and in Mr. X's case it has resulted in permanent paralysis (“inability to move”) on the left side of his body as well as cognitive deficits (“he doesn’t remember things well or have good judgment about things”). This occurred 2 and half years ago and his status has not improved since your company began insuring Mr. X, nor is it expected to change. His previous equipment was given to him in the hospital and has deteriorated from daily use over these years and is no longer safe for him to use. In fact, he has been living in bed since your company denied my previous prescription for new equipment.

As you might imagine, with a paralyzed half of the body, it is quite difficult and unsafe for someone like Mr. X to be walking around town. He would be prone to falling over and hurting himself almost immediately after support is taken away. Nevertheless, we generally recommend that these patients try to get out of the house, as laying around in bed all day carries a number of other medical risks and does not help one’s general state of well being.

So you can see the conundrum we in the medical community face when approaching these patients. Fortunately, there is a relatively new technology that allows these patients to be easily and safely moved around their homes and in fact outside in the community. We affix wheels to chairs (or a “wheel-chair” if you will) and we find this helps our patients a great deal in achieving some independence and reducing the sores, blood clots, and infections associated with confinement to beds. I think he would still require someone to help him move around in the wheel-chair but I think he would spend most of his day in the chair, clearly more than 8 hours.

I would like very much to have Mr. X's medical insurance pay for one of these devices but I am told that he would need a letter with a clear explanation of the equipment and spelling out exactly how he would benefit from a wheel-chair. This, in addition to the written prescription and the forms I have already filled out. I hope I have succeeded with this communication. If so, the 45 minutes of unpaid time I have spent talking with the medical supply company and composing this “letter of medical necessity” will have been well worth it for this unfortunate man. Thank you.

Dr. Sour Puss, M.D.

Thursday, June 19, 2008

Perfect Day

Today was a perfect day.

A rare day when I finished work at 3. The sun was shining so I left early, came home, and rode my bike to the gym. On the ride home, I passed by Edith Macefield's house. She was the little old lady who captured Seattle's attention by refusing to sell out to a developer for a reported one million dollars, so she could live out her days in the house she'd lived in for 42 years. Back story here. She died two days ago, and as expected, there was a makeshift memorial in front of her place.

Further down the Burke Gilman trail, I came upon this site:

The Fremont Solstice parade is this weekend and the traditional belly dancer brigade was out practicing their routine. I love this town.

From there, I headed to the PI where T-Dog was waiting for me with a pitcher of Maritime IPA. After a few beers, my man Greg showed up unexpectedly and kept the party going into the evening.

Sunday, June 15, 2008

The Old 97s Show

It was a beautiful.

Looking around the lobby, I could identify with every gently aging hipster and there wasn't a single douchebag in three hundred dollar jeans anywhere in sight. The only people under the age of 35 were the children of the concert goers who were encouraged to bring their families. I was reminded, once again, why I love this town.

We had bought our tickets well in advance for the actual show scheduled later that night. But the local independent radio station sent out an email a few days ago inviting donors to a special on air noon time performance at the Triple Door. So there we were among the 100 or so nursing bloody marys or sipping coffee on a Saturday morning while the band did their sound check. A few minutes later, I would be sitting comfortably 10 feet in front of one of the best American bands going right now.

Most of us were older people with careers, financially stable enough to support independent music, but young enough to proudly admit to having our minds shaped by bands like The Clash, The Pixies, and Sonic Youth. Many, like me, probably played in basement bands on the weekends, not because we harbor fantasies of being rock stars but because it's a riot.

You'd think a bunch of upper middle class wannabe hipsters going to see the current heart throbs of the indy music scene would be sorta sad. But as these people danced themselves silly with their 4 year olds, they wore their tattoos and leather and beer guts with grace. The energy of the band, the total lack of visible corporate sponsorship, and the genuine joy of the audience all made me realize how fortunate we are to live here in Rock and Roll City, USA. These are my people and I am at home here.

Saturday, May 31, 2008

Don't Think I've Forgotten (Cambodia's Lost Rock And Roll)

This has been absolutely rocking my world lately.

The music for the compilation Cambodia Rocks came to the American market via a tourist backpacking in Cambodia who bought some cassettes off the street in Phnom Penh. On these, he found an amazing collection of psychedelic garage music recorded by Cambodian artists in the late 60s and early 70s. These were eventually released on CD by the label Parallel World, but because the original source was an unlabeled cassette tape there was no identifying information about the artists. Some of the music was recorded by people who were big stars in Cambodia prior to the Khmer Rouge and eventually the artists and songs have been identified, and as such are labeled in the that first WFMU link above. All links on the WFMU blog are downloadable MP3s.

At first I thought this was just a curiosity, a story of a quirky subculture of lost music brought back from obscurity. But as I have listened more and explored other music from the genre (Pen Ron, Sin Sisamouth, Rous Sareysothea) it has become so much more for me. There is a newness, an energy, an exuberance, a freedom to this music that can only be found in the very best of popular music. There are undertones of surf music, psychedelia, punk rock, and even funk in this music which is surprising when played by musicians from South Asia who carry all of their own musical history and influence and infuse it into this spicy new creation. The music is technically proficient but there are subtleties that are so distinctly different than anything you hear in American garage music. The 16th note pattern of rhythm on the ride cymbal, the way the wah is applied half way through the guitar solo, the line of melody and the register that the singer is using.

The story has a heartbreaking end. While all of this was fluorishing in Phnom Penh, ominous political events were brewing in the countryside surrounding the city. The U.S. began bombing rural targets in Cambodia which were supplying the Viet Cong in neighboring Vietnam. This destabilized the country with rising terrorist activity in the jungle. The U.S. supported a coup against the Cambodian prince and the general put in charge could not hold back the communist Khmer Rouge which was gaining power among the rural Cambodians. Eventually, the Khmer Rouge took control of the country and began a four year reign of terror under Pol Pot which resulted in the deaths of millions of artists and intellectuals, including most of the people who made these recordings.

The video I embedded is a trailer for a film that documents the story. As I understand, they are still looking for funding to complete the project.

The Los Angeles band Dengue Fever has picked up on this genre and they have three full length albums of covers and original music. I would have liked to catch them at Sasquatch this year.

I was first made aware of this music by this post by the always amazing Flapjax at Midnight on Metafilter.

Thursday, May 15, 2008

Way to go, Gays!

Unmistakable sign that love may yet win out over hate.

I think the cover photo says it all.

And I don't really give a shit if this is a Sneaky Republican Trick. It's a human rights issue and it pisses me off that 27 states have banned gay marriage because certain rednecks think it threatens the strength of their marriage. It doesn't even make any sense -- at least when white people try to keep minorities down, there is a certain kind of logic to preserving their hold on power. But all this is about is allowing two people the freedom to love each other. And what could possibly be more important than love, especially these days?

Tuesday, May 6, 2008


Crossing the finish line was one of the most emotional moments of my life. To get there, I had to call upon something I didn't even know existed inside me. Around mile 22, it felt like my body was not physically able to carry me any further. The only thing that propelled me after that point was heart.

After training through several continuous weeks of rain and snow, we had woken up to a bright sunny day in Vancouver. Shireesha and Peregrin flew through the half marathon. Ben got struck with a gastrointestinal flu 3 days before the race which wiped him out so he wisely switched from the full to the half marathon which he ran in less than 2 hours. For the full marathon, Matt and I managed to stay together for almost the entire first half, and though it was really nice to have a partner, he and I both knew he'd finish a half hour before me. You can read Matt's account here.

What we didn't count on though was that it took each of us 30 minutes more than we'd planned. I was surprised because I had sailed through my longest training run at 20 miles. But no one told me that the miles get exponentially more difficult between 20 and 26. I was running on less than empty and the only thing you can call on to drive you forward is pure emotion. Matt had the foresight to have our names printed on our team shirts and that turned out to be important. All through the race, I could hear people shouting "Lookin' good John! You can do it John!" Those words of encouragement from strangers became more intense and appreciated the closer I got to the end.

26.2 miles. Just under 5 hours. Only 2 of the original members of Team Brawndo made it across the full marathon finish line. But we had lots of support from Robin, Kim, Darius, and Kathleen who turned up with megaphones, signs, and colored wigs to cheer us on. And of course, Ben, Peregrin, and my little Shireesha were there waiting for me as we crossed the line.

I would do it again in a second. Each week I felt a sense of accomplishment as I was able to run further and further than I ever had before. For those last six miles in Vancouver, I was alone in the universe, just me and the challenge. Running 26.2 miles is right at the edge of what is and isn't possible for most people. I feel like a different person for getting right up to that edge and then forcing myself over.

Thursday, May 1, 2008

May Day

The International Longshore and Warehouse Union is closing all west coast ports today to protest the ongoing wars in Afghanistan and Iraq. I see a lot of these guys in my practice since we're sandwiched between the Ports of Seattle and Tacoma. Not your typical radical socialists, actually most of them have seen a lot of hard living. For the most part, these guys come from the kind stock that are being fed to the U.S. military meat grinder and *a lot* of them are vets.

It's dangerous for those in power to allow these guys the luxury of a political voice. High school educated blue collar workers are usually spend most of their time struggling to stay ahead of debt and health care bills. But give them stability and good benefits and suddenly they have a lot to say about what it takes to create a just society. It's an historical quirk that Longshoremen still have powerful union protection and I wonder how much longer it will last. But more power to them.

Monday, April 14, 2008

20 miles

So I am sitting here with a beer, 800 mg of ibuprofen, and a Vicodin -- the preferred cooldown regimen for us marathon athletes. I have successfully completed my peak training week with a 20 mile run today. It's all downhill from here as I taper my runs until the Vancouver Marathon on May 4.

Honestly, I believe I should get some kind of extra credit for doing this in Seattle. 6 months ago, I came up with a training schedule (largely lifted here) and entered it into my calendar and since then I haven't missed a single workout. I have run in rain. I have run in snow. I have run in hail. I have run in the dark. I have run hungover. I have run at 10 pm on a Friday night. I have run and run and run.

I spent weeks planning for today's run, testing out clothing, trying different routes, sucking down different kinds of energy gel on different schedules (Clif Shot with 25 mg caffeine taken at 1 hour, 2 hours, 2.5 hours, and 3 hours if you must know). I ate pasta all day yesterday and even skipped the beer during band practice. And all of that was almost for nothing -- I started hacking all night from a respiratory virus and I woke up with thunderstorms in the weather forecast. But I decided to tough it out and instead of running towards Woodinville on the Burke-Gilman, I decided I would run seven times around Green Lake. If I am going to get caught in a downpour I am not going to let it happen 10 miles from home.

To tell the truth, this has been an amazing experience. I really did not think I would get this far. To put it in perspective, I was a pack a day smoker through med school and was an occasional smoker until October 27, 2007. The farthest I had ever run was maybe 5 miles. I like beer and pizza and cheeseburgers more than any runner should. But today, I made it. 20 miles. Running. The only stops I made were to fill up my water bottle and to take off my jacket.

For me, running has always been about the music. I finally have become comfortable enough to run without music, but it is just so much more fun when your head is full of thumping techno or screaming guitar distortion. The problem is, with these super long runs I starting getting really bored. I tried listening to podcasts for a while. Tried not listening to anything for part of the run. Eventually, I discovered what works best for me is just putting a lot more work into the playlist. Today's playlist took me a couple of days to put together, but it really did the trick nicely.

1. Battle Without Honor or Humanity -- Tomoyasu Hotel
Remember, from Kill Bill? You gotta start big!

2. Battle Flag -- Lo Fidelity Allstars
3. Thunderstruck -- AC/DC
Hard to pick the best AC/DC song for running. I like this one for the riff that kicks in right after Brian Jones sings "I was shakin' at the knees, could I come again please? Yeah the ladies were too kind. You've been - thunderstruck" You know the riff.

4. The Ecstasy of Gold -- Ennio Morricone
5. Angel -- Massive Attack
6. Mama Said Knock You Out -- LL Cool J
I'm sure I hated this when it first came out. This is a hell of a work out song though.

7. Wake Up -- Rage Against the Machine
8. Carmina Burana:O Fortuna -- Boston Symphony
9. Valkyrie is Dying -- The Fucking Champs.
I knew one of these guys in college. Now they play complex distorted butt rock that occupies a space between Rush and The Boredoms. Kicks ass in small doses. Induces migraines in large amounts.

10. Cochise -- Audioslave
When I hear this I can't help but think of the greatest movie evar, Talledega Nights.

11. Right Here, Right Now -- Fatboy Slim
Right here. Right now. Right here. Right now. Right here. Right now...

12. Miserlou -- Dick Dale
The album version of this song features much more impressive guitar work than the Pulp Fiction version. Did you know Dick Dale is left handed? Like many left handed guitarists in the sixties unable to find lefty guitars, he would play a right handed guitar flipped over. However, unlike Hendrix or McCartney, Dick Dale didn't bother to restring the guitar for a lefty. That's right, Dick Dale, the King of the Surf Guitar, played guitar upside down. Without a pick. That's pretty bad ass.

13. Black Betty -- Ram Jam

That is all I have to say.

14. Fuckin' In the Bushes -- Oasis
15. Ace of Spades -- Motorhead

Ok, this isn't bad. 6 miles down. Feeling pretty good. Time to goo.

16. Welcome to the Jungle -- Guns N'Roses
17. Immigrant Song -- Led Zeppelin
You know, I think I may finally be over Zeppelin. Except for the fact that Mrs. Sour Puss hates it so you *know* this is gonna keep getting played at our house.

18. Son of a Disgruntled X-Postal Contemplates His Life While Getting Stoned Behind the Winn-Dixie While Listening to Metallica -- Alice Donut
Aside from having the most awesome song title ever, this song features two of the greatest metal guitar riffs in history, side by side. This song is the reason why I own a wah pedal. I just fucking love that sound.

19. Genesis -- Justice
20. Smack My Bitch Up -- Prodigy.
If someone had told me back in the early 90s when we were going to warehouse parties in San Fran that one day Prodigy, Aphex Twin, and Moby would be superstars I would have laughed. The scene seemed impervious to commercialization.

21. Bodies -- Drowning Pool
22. Without Me -- Eminem
23. Thunder Kiss '65 -- White Zombie
24. The Good, The Bad, and the Ugly -- Ennio Morricone
Come on, you know it's super cool.

25. Sabotage -- The Beastie Boys

Ok, 10 miles now. Starting to feel some pain and the rain is really coming down now. But I'm half way there now and if I did my original route I'd be turning around and heading home now, so that gives me a little lift.

26. World Destruction (Meltdown Mix) -- Afrika Bambaataa
27. Full Metal Jackoff -- Jello Biafra and D.O.A.
This is the best thing Jello Biafra ever did and that's saying something. Nothing kicks a run into high gear more than 14 minutes of righteous political ranting over thick muddy metal. Everyone thought Jello was a little paranoid back then but it's time he got some credit for being right. About. Everything.

28. Paranoid -- Black Sabbath

Four laps around Green Lake down, 3 to go. I am really starting to hurt now. Must keep remembering to drink. Time to goo again and maybe stretch out those quads.

29. Hanging Tree -- Bob Mould
30. Making Me Nervous -- Brad Sucks
This guy is a MeFite and his music is really great. His album is downloadable here.

31. Goin' Against Your Mind -- Built to Spill

Ok, pain subsiding now. Let's just ignore it and pick up the pace a bit. You know, there's not that many people who could come even this far and I just sailed past the half marathon mark.

32. Goofy's Concern -- Butthole Surfers
33. Comfort Eagle -- Cake
34. The History of Utah -- Camper Van Beethoven
35. (I Was Born In A) Laundromat -- Camper Van Beethoven
They were such a great band live. So glad I got to see them (twice) back in the day. Wish I could find those set lists I snagged at the shows.

36. Teen Angst -- Cracker

My friend goo has a real tattoo. She won't mind if I tell you. Goo. Goo. Goo. Time to goo. I am starting to get delirious.

37. This Is a Collective -- Consolidated
38. Consolidated -- Consolidated
This is the kind of music my friend Ben would make if he had learned to play an 808 instead of a bass.

39. Lose Yourself -- Eminem
40. Skankin' to the Beat -- Fishbone
You're skankin' to the east. You're skankin' to the west. You're skankin' with the rude girl with the really big breasts.

41. There Is a Mountain -- Donovan
I fully intend to cross the finish line in Vancouver with this silly song playing. I have no idea what it's about but I just love the line "First there is a mountain, then there is no mountain, then there is."

42. La Moda -- Ennio Morricone
43. Open Up Your Heart and Let the Sun Shine In -- Frente!

I just passed 18 miles, my longest run ever. Oh my god, I think I am going to do it!

44. Suspicious Minds -- Fine Young Cannibals
45. POWER SONG!!! I Fought the Law -- The Clash
46. Jay Wrestles the Boa Constrictor -- Groove Collective

Wow. I did it. Holy Shit. 20 miles. This is incredible.

Monday, April 7, 2008

Washington 43rd Legislative District Caucus

Awww man. I haven't had much time to post lately. Such is life. There are constantly things happening worth writing about so hopefully I'll get more up later. I blame work but also this marathon training thing. I tell you, running 10 miles in the evening after a 12 hour day ain't easy. I am really going to enjoy having my life back in May.

I did go to the 43rd Legislative District caucus this weekend. This was an experience. The regular caucuses that everyone knows about and hears reported in the news are really just the first step in the process. At the precinct caucuses two months ago I was elected a delegate (more like no one else wanted to do it actually) to the District caucus. There, you elect delegates to the congressional district caucus who then elect delegates to the national convention. I was curious about the whole process and this year there is a great deal of interest in going to the national convention since it is likely that the Democratic nominee is going to be chosen during the convention itself.

So you show up to your district caucus and sign in for your candidate and depending on who shows up and who changed their mind, the delegates to the next level are apportioned out and then elected by each campaign. After signing in, you sit in a big hall where the District chair reads the rules. Then a supporter for each candidate gives a speech. First, Obama's speaker took the podium. Ed Murray, the long time 43rd District Senator who is openly gay gave an impassioned speech that rallied the troops. He began with "My partner and I got engaged 2 decades ago. Won't you allow us to get married?" The place erupts in a standing ovation. I fucking love Seattle.

Dennis Kucinich was still on the ballot when Washington caucused and he actually had 2 delegates (out of about 1400) so he got a speech as well. One of his delegates bravely stood up and spoke fairly eloquently for 10 minutes about the party principles that Kucinich espoused and how his campaigns have shaped the races. Awesome.

Next up, Hillary. "Hillary Clinton's representative is still in transit and will be here shortly." Um, ok. "In the meantime, does anyone have any jokes?"

A few procedural questions were fielded from the floor. Suddenly a man walks down the aisle and the crowd erupts. "While we're still waiting for the Clinton representative, we have a special guest speaker. Please welcome the Honorable Jim McDermott." The congressman from Washington's 7th congressional district is wildly popular here and he routinely is re-elected with >80% of the vote. One of the few who spoke out against the war, he had a cameo in Fahrenheit 911.

He gives a speech about the amount of work that needs to be done to get the Democrats back in the White House and to start undoing the damage done in the last 8 years. He talks about how a spirited campaign is good for the Democrats. It keeps us in the news, debating our issues on our terms. "It's because we are all different. We have a diversity of views. We think differently. That's what makes us Democrats. If we all thought the same, we'd be Republicans."

After McDermott's done, the congregation is getting restless. Motions are made to move on without the Clinton speaker. Someone shouts "We all managed to wake up and get here on time!" This looks really bad for Hillary. Motions are made to let someone else speak. Finally, an hour half after the caucus starts, Hillary's representative is here. "Ladies and gentlemen, please welcome, from Los Angeles, Sean Astin."

You have got to be kidding me. 1400 people have been sitting here waiting for the Hillary Clinton campaign to fly in a Hollywood actor to speak for her? Don't get me wrong, Samwise is one of my favorite LOTR characters, but seriously? He proceeds to give some off-the-cuff remarks that don't really say anything about Hillary and includes small talk about his daughters and his trip up from L.A.

He's a nice enough guy, but could there be any more stark contrast between the two campaigns? I mean, a guy who really doesn't have much to say but has a ton of name recognition, flies in from 1500 miles away to speak to a crowd that is >80% Obama and includes people who have been organizing their communities and donating substantial portions of their time and money because they desperately need to believe in the future of their country. There are large numbers of people here who, for the first time in their lives, have decided to get involved in the process, neighbors who have resolved that there are things worth fighting for and a candidate who is worth their energy. And Clinton sends us an actor?

In the end, enough people either changed their vote or went from uncommitted (yes that's right, some precincts decided to send uncommitted delegates to the next level) that Obama actually picked up a delegate.

Next, the two campaigns split up to actually elect their alloted delegates. I signed up to run but their were 400 people running for 53 spots and there were some long time Obama volunteers running, armed with signs and campaign flyers (note to self: if you want to go to the next level you need to come prepared). All 400 of the people had the right to give a 30 second speech and when they decided to go alphabetically starting with the letter after my last name, I took that as a sign and happily crossed my name off the list. Did you know that it is party policy to have gender equality among the convention delegates? There were separate ballots for men and women and you had to vote for 26 of each. They also explicitly tell you to favor persons of color and persons with disabilities when you make your selection. Pretty cool.

I was really glad I went. I met a lot of interesting people and it was great to see how the process works. Would definitely attend again. Democracy is awesome and we need to make sure the forces of evil don't take it away from us.

Friday, March 14, 2008

Poor prognostic signs

I was just finishing up my charting on a Friday evening and when I realized I was writing in volume IV of a patient's chart.

It's a poor prognostic sign when your medical chart is measured by volume number.

This got me thinking about other poor prognostic signs I'd seen recently.

It's a poor prognostic sign when your white blood cell count is greater than your hematocrit. It's an especially poor sign if your respiratory rate is greater than your heart rate.

We have health questionnaires that we send home to people to fill out before they come in for their preventative visit. Sometimes the forms come back after sitting at the patient's house, reeking of cigarette smoke. These forms then get filed in the patient's chart. It's a poor prognostic sign when your medical chart smells like cigarette smoke.

It's a poor prognostic sign when your doctor sends you to a zoo for anything.

"Doctor, I've lost 45 pounds and I've hardly had to change my diet at all!" is a poor prognostic sign.

Most people are familiar with the "O" sign; when a demented, dehydrated, and obviously ill elderly patient is transferred to the emergency room their lips are often drawn in and their mouth is fixed into the shape of an "O." A more grave sign is the dreaded "Q," when the tongue begins to hang out of the corner of the mouth. The O / Q shift is considered a poor prognostic sign.

An ER doctor is Arizona has worked out a calculation: Number of Tattoos/number of teeth in head X blood alcohol level. A number greater than 50 represents a 50% probability of being bitten by a snake.

There are a lot of poor prognostic signs based on weight. One of the most widely validated is IQ less than the weight of the patient in kilograms. That's a poor prognostic sign.

If the number of clinic visits per year is greater than two times the age of the patient, that's another poor sign.

One of the great things about being a doctor is that you get to peer into a world that is totally foreign to many Americans, a world populated by characters whose struggles are at once noble and pathetic. People go to doctors because we are both empathetic and clinically detached. It is this dance that I do with my patients that keeps medicine interesting for me and allows me to continue to be present in the lives of people whose concept of normalcy is so fascinatingly different from my own. Empathy tempered by objectivity.

With some patients the only empathetic response that would seem appropriate is despair. How else can you deal with a 400 pound person who cannot sit on a toilet who comes in because he has a bedsore that is infected with fecal bacteria? But if the doctor despairs, it denies the patient the objective consultation they deserve so we all have to figure out how to maintain our distance. Black humor is sometimes the only way to cope.

Tuesday, March 4, 2008

Seattle Driving

Ok, so I'm running at Green Lake yesterday and I come up to an intersection with a traffic light. The light changes red so I wait patiently, bouncing up and down on the corner. A car starts moving into the intersection, and in the middle of her own green light, she stops and waves at me to cross the street in front of her. Cars behind her are honking and I am using my most colorful language to remind her that she's come to a stop in the middle of an intersection. The light turns yellow and she can tell I am not going to cross in front of her, so she rolls down her window to give me this wounded look as if to say, "How could you refuse this beautiful act of kindness I have offered you" before driving off. Yeah, fuck you, lady.

Only Seattle.

Monday, February 25, 2008

Stevens Pass

So despite spending most of my free time this winter training for a marathon, I did manage to get up to Stevens Pass last week. Stevens is 2 hours away in the Cascade mountains. We're having record snow this year. I went up with three of my best friends: Kim, Darius, and Kevin. Darius got a helmet cam for Christmas and we had some fun with it.

Kim, Me, and Kevin

Sometimes I just can't believe they serve alcohol at ski slopes. Especially to a guy like me who clearly looks like he's going to hurt himself out there.

Marathon training update: I just finished my first half-marathon! And it felt really good! Check me out here.

Sunday, February 10, 2008

Obama, decisively.

So I had no idea what to expect.

The 43rd district of the Washington State Democratic Party is known for being very active. I remembered going to the caucus in 2004 and to various meetings all held to strategize ways of unseating He Who Cannot Be Named. I was impressed and energized that so many in my own community were as outraged as me and it made me glad to call a place like Wallingford home. But this was 2008. I had my own fairly strong preference for presidential candidates and I knew Obama had a shot here; still, I hadn't seen any local polls, there were only a few posters around town for Obama, and I knew that the possibility of America's first woman president would galvanize a large segment of potential Democratic caucus-goers.

My first clue came on Friday night.

"Did you hear about the rally? Fil tried to go and couldn't even get near Queen Anne."

"The same thing happened with my coworker, he said people were so packed outside that you could not move."

Obama had held a rally at Key Arena that day in which a 17,000 person standing room only crowd heard him give a 50 minute speech while thousands more surrounded the stadium outside. I heard several people say they simply turned around when they saw the crowd that extended for several blocks around the arena.

The next morning I read a New York Times story on the Washington state caucuses. Hillary Clinton had drawn 6,000 at a local university but seemed resigned to losing the state. The Times made this rather insulting statement:

But Mrs. Clinton, who has not done as well in the caucus states as Mr.
Obama has, winning only two of nine so far, suggested that she did not expect to win in Washington, as many of her supporters would be too busy working to break away from their schedules and spend the time to caucus for her.

“If this were a primary, where everybody could vote all day, I’d feel pretty good about it,” she said. “But it’s not. It’s a caucus.

So that morning, all of us unemployed slackers with nothing better to do than give up our Saturday to make the country a better place made our way up to the local middle school, feeling good that Hillary's support seems to be people who aren't able to do more than check a box on a ballot. As we drew near to the caucus site, it was clear that something remarkable was happening.

In 2004, the first caucus I had ever been to, people were fired up. It seemed like the entire city came out in force. The nominee had not been completely decided yet, Howard Dean hadn't flamed out and Kucinich was still in it. Our precinct had about 20 people show up and we had a lively ,reasoned discussion, unified in our disgust for the Republicans. I went away thinking about how great the process was, that I had really participated in my democracy.

This year would be different. There were easily 100 people per precinct, and about 20 precincts total (each precinct only includes 200 households, Democrat and Republican). And more astonishing, 8 out of 10 people were wearing an Obama t-shirt, button, or sticker. There were many people who had never caucused before. There were people I knew from work or the gym that I hadn't even realized were neighbors. Nearly all said they had never felt this way about candidate before and were a little surprised to find themselves coming out to support him.

The caucus began, as they all do, by someone reading the rules aloud to a room full of several hundred people. "Before we begin, the DNC has asked that we all stand and say the Pledge of Allegiance." We all looked around each other uncomfortably. Flag waving nationalism is not something indigenous to Wallingford.

A lone voice from the back of the room shouted. "Come on, this is Seattle!" Everyone laughed. Then we stood and said the pledge before we broke into groups to do something truly patriotic.

I was going to bring cupcakes for each Obama supporter, but in retrospect I am glad I didn't. I would have spent $300 on my precinct alone. Instead, knowing that any speech I would give would be limited to less than a minute, I had three short deal killers for anyone thinking of voting for Hillary.

1. She voted for the war, the greatest crime that has been committed in my name in my lifetime. Now, one may argue that really she was voting for inspections with teeth, but come on -- everyone in the world knew what that vote was really about. She even voted against an amendment that would force the president to come back to congress before invading. Supporters might explain that we were still in the midst of post 9/11 hysteria, that it was an understandable lapse in an otherwise fine legislative record; but the U.S. needs a leader with the moral courage and wisdom to stand up when it is called for and if she couldn't do that then, how can we trust her to be the leader this time of crisis call for? No, Obama, wasn't in a position to cast a vote in the Senate, but he did give an impassioned speech at the time against using military force and honestly, that's a cop out excuse for Hillary.

2. She can't win. Clearly, Obama speaks to independent swing voters and people who don't typically vote. People recognize that this is a new kind of leader, who doesn't take money from lobbyists, who knows how to compromise to get things done, and who knows how to take a tough moral stand when it is called for. If Hillary runs against McCain, a republican who can appeal broadly to independent swing voters, there is no way she can win. The Republican party is largely in disarray and cannot agree on a candidate but I don't think you could come up with a democratic candidate who would mobilize them more than Hillary Clinton.

3. There has been a Bush or a Clinton working in the White House since 1980. The U.S. does not, and should not, support oligarchies. People want a change.

Of course there are thousands of other specific reasons and I was armed with Shireesha's iPhone if I needed to look up statistics. But in the end it didn't really matter. The initial vote broke 72 to 14 in favor of Obama (4 delegates to 1 delegate). There were 6 undecideds, 4 of whom changed to Obama, 2 remained undecided. (One of the undecideds was a neighbor who reasoned "Both candidates have virtually identical platforms. If Obama's only advantage is that he's the candidate of 'hope', that's not a good enough reason for me to support him."). During the discussion period, while I was making small talk with my neighbors, Shireesha actually convinced a Clinton supporter to change to Obama. So the final vote went 77-13, four delegates for Obama and one for Clinton.

The caucus process is a good one. I firmly believe it is too easy for someone who's ill informed to cast an irresponsible vote. I mean, I get to see a real cross section of America in my practice and it is shocking, really, how misinformed people are. The political process in so much of America goes like this: Rush Limbaugh --> the ear of some 80 year old guy with borderline dementia --> checks a box on a piece of paper and mails it in. Think about it: a little old lady in a nursing home whose opinion is entirely informed by Reader's Digest has as much say in the election as someone with a graduate degree who travels the world, reads three newspapers, and has daily on line political discussions with other educated professionals from all over. It's controversial and smug, but I'll say it: if you can't spend part of one day defending your viewpoint to your neighbors, maybe your opinion shouldn't matter so much.

So at the end of the day, feeling good about the caucus process, they asked for people to serve as delegates to the state convention and I volunteered. Should be a hoot.