Dr. Sour Puss

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 su

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 regre

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 t

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

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

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.

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!

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.

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? **Update!** 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.

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.

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 emp

“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 Jonath

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

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

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 ch

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.

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

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 m

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 fal

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.

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 mi

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 , S

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?

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

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.

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

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 t

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 d