Dr. Sour Puss

My Boeufcake side project

2011-12-26T20:57:00.000-08:00

Ravi and rock out most every night together and honestly I didn't think much of it until we accidentally got caught on video by my sister tonight.

Sashi Carl 11.11.11

2011-11-11T21:36:00.000-08:00

It's true, he looks exactly like his older brother.

I was a little worried I'd be jaded by the time the Two-dle was delivered, but thankfully I'm just as over the moon as I was when the Doodle was born 2 years ago. After Ravi's intrauterine growth restriction and crash c-section for a 5 minute decel down to 70, we chickened out and decided to skip the drama, scheduling our repeat c-section well in advance. I have to say leaving the chaos of several consecutive 60 hour work weeks at the CHC and a 2 year old who literally bounces off the walls at home, I appreciated the calm control of an electively scheduled c-section, it was the least stressful 45 minutes I'd had in months. Overmedicalization of child birth be damned, this was civilized.

I think our prep work with Ravi paid off big time. Within 2 minutes of meeting the baby, Ravi says, "I want to hold my baby brother!" Within 5 minutes, he was stroking his hair, kissing his face, then honked his nose.

"Ravi, do you think we should take your baby brother home with us?"

"Yeah! He can live in the Green Room!"

Courtesy of Wilson...

2010-09-11T19:54:00.001-07:00

Probably the only people in the world who think this is funny are in the picture.

ug

2010-07-15T21:53:00.001-07:00

At the risk of sounding self-important, there are times when my job feels like I'm staring all the pain, suffering, injustice, and inhumanity in the world straight in the face, alone, and yelling ineffectually as hard as I can at it.

Today was probably the hardest day I've had since residency and I didn't even go in to the hospital.

Just another heart warming story from the front line...

2010-04-20T21:59:00.000-07:00

She was 16 and unexpectedly pregnant. She had been randomly assigned to me by our Maternal Support Services nurse and I had never met her or her family before. During those first few visits with me, she was an emotional pancake, completely flat. Silent except for the most basic responses.

Have you felt the baby move yet?
"Yes."

Are you having any more morning sickness?
"No."

Adopting my best sensitive doctor bedside manner, I would gently but repeatedly try to get inside her head, but she would give up nothing.

How are you feeling about the pregnancy?
"Fine."

Are you anxious about it?
"No."

Is your family supporting you?
"Yeah, I guess."

Is there anything else you want to talk about?
"No."

I would later discover that she, her mother, and her younger brother became patients of our clinic after her alcoholic abusive father had finally driven their car through the front room of their house and they had fled to a nearby domestic violence shelter. One of our outreach nurses had identified them as a high risk family and had them establish care with us. Now that she was pregnant, she would have to leave the shelter and the support of her mother to find a new place to live. That new place turned out to be the home of her baby's father, someone she hardly knew.

I was really concerned about this woman's affect and had talked several times with our MSS nurse about what might happen with this new mother and child. I continued to see her and she remained unengaged and withdrawn until her 20 week ultrasound. The day of the test, I got a call from the ultrasound technologist; she was pretty sure this baby had a cleft lip, maybe worse and we should probably do a more detailed evaluation. "Do you want us to tell the patient?" She asked. Concerned that I hadn't been able to read my patient's emotional state for the entire first half of the pregnancy , I told them to send her back to my office.

In my job, you have to be comfortable breaking bad news, but there are times when it is especially difficult. When a patient isn't able to understand the medical issues, for example. Or when someone doesn't have the social support to handle the burden they are given. Or when that person has already had to deal with a string of emotional traumas. I braced myself for the perfect storm.

I spent 45 minutes explaining what was going on. Your baby isn't going to look normal. You are going to need a much more detailed evaluation because your baby might have other birth defects. You should see a genetics counselor. Your baby is going to need surgery, probably several, actually. Your baby won't be able to breast feed; yes, if it's really serious there could be a feeding tube, it depends how it goes. I sorry. I know, this is bad news, but we'll be able to deal with it. Don't worry I will be here with you the entire time.

Somehow, and I don't understand from where she summoned it, this sudden news seemed to bring things into sharp focus for her. She came out of her shell. She was emotionally invested in what was going on. Now during her visits, she was the one asking all of the questions. She did everything we asked; she met with the genetics counselor, she went to the Craniofacial surgery clinic, she learned all about feeding a child with a facial malformation. She toured the hospital and took birthing classes. She created a place in her life for a special needs child. When I'd walk into the room to see her, she always greeted me with a smile.

Fortunately, this did appear to be an isolated malformation and her pregnancy proceeded without other events. We still couldn't say exactly how serious the cleft was, whether this child would need one or two surgeries or six or seven. But I did know I had a mother who was going to be confidently prepared as much as is possible. When I gave her the same advice I give to all my pregnant patients nearing their due date, it took on a special significance. "I know you're a little nervous about this, but don't worry. When the time comes, you will know instinctively exactly what you need to do."

When she did go into labor, it was midnight, and unfortunately I wasn't on call until the next morning so I didn't get the word until I arrived at the hospital, just after she had delivered. In the hallway I ran into AF, the doc on call, and she was beaming. She had been up all night with my patient and couldn't say enough about how wonderfully she did and what a beautiful family they made. "It's like pierced Madonna and Child," referring to my patient's multiple facial piercings. "When I told her you'd be here in an hour, her face lit up."

I walked into the room and her face did light up. It is always amazing to see that blissed-out look of love in a mother's eyes as she holds her new baby but to see it in this woman's eyes was honestly a career highlight, a rare reward for years of slogging it out in the urban underserved primary care trenches where most stories seem to end badly. If there was anything wrong with this baby, you would never know it looking at his mother.

As she handed the baby to me, I could see that his cleft was actually pretty serious, probably the worst case scenario, involving the entire palate and extending through the nose. He's going to need several surgeries over several years. Now the work really begins. First order of business: figure out how to feed the baby.

Mom listened closely as we brought in lactation consultants and speech therapists during those first days in the hospital. She became increasingly confident with the special bottles and nipples we gave her and she firmly committed to giving her baby only breast milk, even if it meant having to pump all of it and gently using the special squeeze bottles that worked with her baby.

The baby is now one week old. Mom is still completely in love and the baby has nearly regained his birth weight. He looks great.

A lot of times, you look back in awe at the history you have with certain patients, honored to share in those intimate moments of crisis. You witness them take terrible, overwhelming news and summon all their stregnth to try and create something positive. It's the most basic human struggle and it's the reason why I chose medicine. The situation with this baby is unique in that I'm able to look ahead; this kid is going to go through a lot of medical care over the years, and I'll get to be a part of it. I choose to believe he's going to have a great life and I have the privledge and responsibility to do what I can to make that a reality.

First show!

2010-04-04T22:19:00.001-07:00

So we survived. We were pretty stiff but it was a fun experience, no major screw ups, and we had a great turnout, somewhere between 100-200 I would guess. Muchas gracias to Brad Kosel for putting this all together. We are so lucky to have friends that do these kinds of things.

We also learned that people from Walla Walla are really nice. The Table of Contents are fantastic and have a great CD. Go get it on iTunes right now.

Thanks to everyone who showed up and humored us at our first gig. We're totally psyched for the next one.

The Health Care Bill

2010-03-22T10:01:00.001-07:00

Dear Tea-Bagger,

It's going to be alright.

I know you are scared.

The Cold War was very frightening and we thought Communists were going to kill us all, or at least destroy our freedom-loving way of life. I remember it too.

And I know you don't understand the health care bill. To be fair, it is very confusing and complicated. And the only information your side has given you amounts to "your money is going to kill unborn babies" "the government is going to unplug grandma from life support" and "we can't afford it." It's a shame that in an information-laden society, ignorance is so fashionable, but try to consider who has the most to gain by your ignorance?

I have spent the last 12 years on the front lines of the failing American health care system. Shit, I have seen dozens of people literally die from it. I spend my free time reading medical economics journals and watch lectures by health policy experts. I consider myself fairly well informed about the current state of things, which is to say, sometimes even I am overwhelmed and confused and frustrated. But I think you can trust me when I say, this is going to be a good thing.

And I say this as one of the people who is going to foot a large part of the bill for the rest of you.

No it's not got going to fix everything. Those who called even the option for citizens to band together and buy group insurance policies "Socialism" saw to that. But consider, for the first time, this bill acknowledges, codifies, and plans realistically around a principle that has already been in effect in this country for decades: in the richest country in the world, with the best hospitals, best medical schools, and best technology, we all deserve some kind of access.

Now, I understand, the libertarian streak in you wants to say "Well I pay for my access, everyone else needs to man up and pay for theirs." Yes. Yes, you are absolutely right. And this bill takes us much closer that idea than we've ever been.

You see, whether you like it or not, no one is turning uninsured pregnant women onto the street to deliver their babies in gutters. No one is going to let a man bleed to death in front of a hospital. And the check you write to your hospital or your doctor or your insurance company already includes the cost of not turning those folks away. Now, you can stand in front of my clinic and try to prevent those who can't pay me from walking in, but most of us who got in to health care choose to help people and we're not comfortable doing that.

Thanks to Smart Liberals at Elite Academic Institutions, we have a pretty good idea of what it costs to deliver this emergency, last chance medicine that you and I already pay for. What this bill does is creates a line item for this care, separates it out from the bill you are getting from your doctor, and then figures out a more rational system to pay for this where the uninsured pay more of their fair share. Yes, some of the freeloaders (and I am fully aware this includes some of you right leaning libertarians who don't carry insurance because you consider yourself healthy; until you show me your notarized affidavit announcing you will not seek any future medical care that you cannot afford, I'm going to lump you in with the freeloaders, okay) will be required to pay a bit more into the system they already benefit from. Some of the money will come from tanning parlors. And some will come from rich people like me who can afford it.

Again: This is money that rich people like me are already paying for the emergency care of the uninsured.

Ok, Mr. Rich Conservative who doesn't believe in welfare or helping people, can you at least acknowledge that a simple idea like this sounds like it could be in your own economic best interest? I mean, if nothing else, this bill says that you won't get stuck with the hidden costs of taking care of these welfare moms and illegal immigrants, now, instead of your hospital, your elected representatives can debate directly how much of your hard earned money these low-lifes deserve. This is exactly what happens every year in such right-wing strongholds as Canada.

But if you've made it this far, let me clue you in on a little secret. Doctors, those modern day pill peddling sorcerers, have actually figured out how to make caring for these people (the ones you are already paying for, the ones who now are going to foot more of the bill for themselves) cost less. In fact, most new therapies have to prove that they save money and prolong productive work life before they are approved or paid for. Every day, hundreds of untreated diabetics walk into the hospital and are newly started on kidney dialysis (on your dime); we would only need to prevent a few of those cases to provide insulin to all of the rest of them.

I will grant that your leaders, Mr. Tea Party, are correct that the key to reform is to drive down costs. I don't need to tell you that the status quo isn't an option. $1200 a month for a family of four? For insurance that does less and less. Let's put it in a way that you might understand: you haven't gotten a raise in ten years because of health care. And if we do nothing, you may never get a raise again, with all of your increased wages going to health care costs. So of course, even you recognize the need to do something.

It is impossible to know if this bill really will drive down costs; it seems likely at least, and there is a whole lot of Research from Smart People and Evidence from Other Countries (even some Friends and Allies) that this will happen. Consider though, that insurance companies currently have very little impetus to control costs and indeed in the three decades they've run things they haven't done so. Once you get sick enough (or old enough) to stop working, you are dumped onto a public system to foot the bill for your hemodialysis or your motorized wheelchair. And that's assuming they haven't already succeeded in denying coverage for your pre-existing condition. And guess what? This bill addresses all of these issues as well: preventing denials of coverage, or life time caps on medical coverage, or preventing them from dropping groups of enrollees simply because one of the members suffered a catastrophic medical problem. Insurance companies will, for the first time, be accountable for the cost and quality of the service they purportedly sell: health care.

But I acknowledge that we don't know for certain what's going to happen in the long term. And I hear you are scared. And I hear you don't want to change. And I hear you don't trust politicians. But I have found in life that the best way to cope with a scary problem is knowledge and an honest accounting of the situation. This bill, not perfect, and not comprehensive enough, takes a giant step forward. We'll keep working on this thing, together I hope.

And, as a country, if we let fear and division stand in the way of what's right -- at Gettysburg, in the Depression, at Normandy, in Selma -- where would we be?

Sincerely, and compassionately, and in good health,

Your Family Doctor

Note: I am referring to "freeloaders" "welfare moms" and "low lifes" facetiously above. My direct experience working with uninsured people for more than a decade is that almost uniformly they want to pay their way. They want the security of durable medical coverage and understand the value of it, they just lack the means to buy into the system that is currently available. This bill honors working people all over the country who've been screwed for far too long.

Rock and Roll Derby April 3

2010-03-08T07:36:00.000-08:00

First show April 3. I don't think anyone in the band got into this with the intention to do anything other than play or have fun in the basement and maybe record, no plans for playing live ever. Hopefully no one expects much, but we always do have fun playing and it will be good to see all our friends come out. We have about 10 original songs at this point and 5 potential covers but will pare that down somewhat. This band is strictly influenced by the indie pop we grew up with: Pavement, Weezer, Pixies, etc. with a healthy butt rock seasoning.

Shane Macgowan and Friends 'I Put A Spell On You' in aid of Concern Worldwide's work in Haiti

2010-02-28T09:35:00.001-08:00

So much great stuff in this video. Comparing to the retarded We Are The World remake, it's like what (Ain't Gonna Play) Sun City was to, well, We Are the World. Nick Cave scarier than ever, Shane Macgowan actually emoting and not stumbling or slurring. And Johnny Depp's passable guitar solo (I love it, compared to Vince Vaughn standing around like a fat dumb shit in the World video).

And of course, the choice of song is awesome, playing right into Pat Robertson's horrific condemnation of the people of Haiti as voodoo-practicing Satan worshipers.

Check out this one of Screamin' Jay Hawkins' early versions:

Dear Pat Robertson

2010-01-17T07:57:00.000-08:00

Letter to the editor in the Minneapolis Star Tribune, January 14, 2010

Dear Pat Robertson,

I know that you know that all press is good press, so I appreciate the shout-out. And you make God look like a big mean bully who kicks people when they are down, so I'm all over that action. But when you say that Haiti has made a pact with me, it is totally humiliating. I may be evil incarnate, but I'm no welcher. The way you put it, making a deal with me leaves folks desperate and impoverished. Sure, in the afterlife, but when I strike bargains with people, they first get something here on earth -- glamour, beauty, talent, wealth, fame, glory, a golden fiddle. Those Haitians have nothing, and I mean nothing. And that was before the earthquake. Haven't you seen "Crossroads"? Or "Damn Yankees"? If I had a thing going with Haiti, there'd be lots of banks, skyscrapers, SUVs, exclusive night clubs, Botox -- that kind of thing. An 80 percent poverty rate is so not my style. Nothing against it -- I'm just saying: Not how I roll. You're doing great work, Pat, and I don't want to clip your wings -- just, come on, you're making me look bad. And not the good kind of bad. Keep blaming God. That's working. But leave me out of it, please. Or we may need to renegotiate your own contract.

Best, Satan

(LILY COYLE, MINNEAPOLIS)

A much more charitable, christian, response to this sad, old, fearful politician preacher man can be found by Don Miller on Relevant Magazine's website:

Regardless, it was sadly irresponsible for him to make such a devastatingly shocking statement in the context of great hurt. Can you imagine giving the eulogy at a funeral and starting out by saying “before I tell you about God’s grace, let me make it clear that little Johnny deserved to die because he stole candy from a store.” There is something wrong with a person who would do this. These people are often, themselves, controlling. They are wired to build empires, and in order to build empires you have to get people to do what you say, and if you have God standing behind you threatening hurt and pain, you can motivate people.

And for speaking the voice of the truly outraged bleeding-heart liberal, I'll take Jon Stewart any day:

Transcript:

Pat Robertson, sitting in front of a CBN Disaster Relief Fund Banner

You know, Kristie, something happened a long time ago in Haiti, and the people might not like to talk about it. They got together and swore a pact to the devil. They said 'we will serve you if you get us free from the French.'
True story. And by whatever sense they have been cursed by one thing after another.

Stewart [Stunned silence]

Shut yer pie hole old man. Out of all the things that you could draw on from your religion to bring comfort to a devastated people and region...
[Brings out a large bible]
Look how big your book is! Look at ... [leafs through bible]
'The Lord is close to the broken hearted
he rescues those who are crushed in spirit.'
'Fear thou not for I am with thee. Be not dismayed for I am thy god, I will strenghten thee.'

But you decided to go with "tough titties devil folk"!

Have you read this book?!?! [gestures with bible]

'From the depths of the earth you will again bring me up though the mountains be shaken and the hills be removed. "Yet my unfailing love for you will not be shaken nor my covenant of peace be removed" says the Lord who has compassion on you.'

I mean that almost sounds like it's about %&$#ing earthquakes!

You've got all this, but you went with an urban legend about a deal with the devil.

[imitating Robertson]
"Wheeeel none of this would have happened if those people hadn't drank all those pop rocks and coke."

These are terrible events! Can't we put aside ideology for a second?

Here's to you, Tony

2010-01-11T21:32:00.000-08:00

Neither of us ever discuss it, with each other, or with others. It seems so improbable to me that there's really nothing to say about it.

20 years ago I met this Australian foreign exchange student at Berkeley. We had an instant connection, an affinity that seemed like we were destined to play a major role in each others lives. We even shared a birthday. We spent the winter after we'd met driving across the US together.

Over the years, despite being in the pre-internet era, we stayed in touch, writing letters, sending care packages, the occasional phone call. He even came back to the states for a visit.

Flash forward 10 years. I move thousands of miles for school and residency and eventually end up in Seattle. Tony, living in Paris, meets a wonderful American woman, they fall in love and decided to get married and move to her home town: that's right, Seattle. Our wives become best of friends and now, 20 years later, we both have sons that were born three months apart.

As I tap this blog entry out on my iPhone, he and Jen are out together at a party for a much needed break and I am babysitting in their home, their infant son peacefully asleep on my chest.

Life is truly wonderful and magic.

On a much lighter, funkier note...

2009-12-19T17:57:00.000-08:00

How on Earth did I miss this? 1972 recording by Italian pop star Adriano Celentano with the unwieldy title Prisencolinensinainciusol.

So so sad

2009-12-02T15:50:00.000-08:00

7/2/03-11/30/09

Shireesha and I both commented that we'd never lost anyone as close to us as her.

Leela Lou. Little Lou. The littlest little. Little Scoop. Leela-pants. Little Fluff.

She played the foil to Kali's straight man. She was the playful one, carrying her favorite ribbons up and down the stairs all day long. No twist tie or string was safe with her around, and no empty box left unsat in. Little tufts of fur could be found all over our house, left over from some sudden pounce on something, often on her sister Kali.

There was just no end to the fur. I'd said before that you could construct a new Leela from what we would vacuum up on a weekly basis. Sometimes we'd catch her munching on giant ball of it after cleaning herself. I could be traveling in some far off place and pull out a sweatshirt and find it covered in traces of her hair. Now there are bits of her everywhere in places like India.

She was the most interactive, personality-filled, friendliest little kitty I'd ever known. She could carry a back-and-forth conversation with people for hours, with the vocabulary of a small child. I'd be sitting at the computer and before long I'd feel an outstretched paw on my knee, and I'd look to see her pleading eyes; I'd uncross my legs and Leela would climb on my lap and purr happily for hours in front of the warm glow of the screen. We'd have parties with crowds of people in our home and Leela, having been bottle fed by humans at birth, would make a dozen new friends, wandering from person to person all night. In quiet moments in front of the TV, she'd get on my lap and I'd unconsciously start petting her; within minutes she'd be rolled on her back with arms outstretched over her head in kitty-ecstasy. She slept on our bed almost every night.

She was weirdo too. If Shireesha was in the shower, she'd paw and scratch and mew incessantly at the bathroom door until someone opened it. Once open she'd usually just stand there and look at you. Any time a tin can was opened, Leela would come running, though to my knowledge, she'd never been fed canned food or tuna. On the rare occasion it was tuna I was opening, I'd give her some only to see her turn her nose up at it. She'd go crazy chasing the reflections of shiny objects on the wall. Don't even get me started about the laser pointer. She'd never known her mother, having been abandoned by a feral cat and bottle fed by the kind woman whose garage she was lucky enough to be born in, so she took to suckling on the tummies of us, her surrogates.

She was hysterically funny. Once, when we put on the DVD documentary Winged Migration, she was immediately and instinctually transfixed by the long quiet shots of birds in the wild, though she'd never been outside or actually seen wild birds. She used to chase the CNN ticker across the bottom of the screen. I would often wake up and find that she'd made a comfy nest of my old dirty clothes on which to sleep on. If she was in a feisty mood, I'd reach down to pet her and she'd take a swat; this would be followed by a long boxing match, my two index fingers versus her on her hind legs, never with her claws extended.

She was beautiful. A perfect little gray tabby with orange splotches on her body. Long fur that would fluff out in all directions. Big round eyes and giant paws with tufts of fur sticking out. When I first came to pick out two kittens from the litter she was born into, she was the first one that caught my eye.

Every day that we had her I was conscious of how special she was and we knew how lucky we were. This happiness led to an almost paranoid fear for her safety and well being. The first time I took her to the vet, I literally told him, "I'm here to make sure she lives forever, because I can't bear the thought of losing her." And despite the frequent hair balls, she was healthy, happy, and active all her life.

We came home from our Thanksgiving in California Monday night and when she didn't come running to the door to greet us, we knew something was wrong. Within seconds we heard the frequent meowing that only comes from a kitty in distress. She was lying on the carpet in the basement in a pile of urine and feces, unable to move her hind legs. Shireesha burst into tears and my heart sank, thinking the worst - that she must have broken a leg while we were gone. When I rushed her to the Veterinary ER, the story was much worse. Her legs were cold, she was insensitive to pain, and her heart was racing in an irregular pattern. The most common explanation, the vet explained, was a congenitally weak heart which dilates over time and clots form in the pooled blood inside. These clots can break off and travel within the cat's circulation, often to the distal aorta where they choke off the blood supply to the lower half of the body, a condition which is exquisitely painful. The fact that Leela wasn't in any apparent discomfort was ominous. Best case scenario: partial paraplegia with very high likelihood of recurrence. Okay, I said, do absolutely everything you can to save her, not quite grasping what they were saying. I called Shireesha and told her she should come up to the hospital.

As we held her in our arms, it was obvious she was scared and uncomfortable despite the sedatives they gave her. We decided to be aggressive with care over night, completely unprepared for the sudden shock of our previously healthy six year old kitty now dying. We said goodbye. At about midnight we received the call from the vet. Leela had a deterioration in her heart condition and had died.

It's been two days now and I'm still overcome with grief. I'm ashamed at being so affected by an animal. I have a small child. I'm a doctor and I deal with illness and death everyday. I'm not entitled to mourn such small things. I guess I'm lucky I've not experienced a lot of personal loss in my life. Right now I just want to feel her absence, as though this will keep her alive with me longer. I've been told me that writing helps one to cope with grief, so here I am. I'm going through the motions of life but the suddenness of all this has left me in a state of shock to say the least. There are reminders of her recent presence everywhere around the house, impressions in pillows and those ubiquitous tufts of fur. Her sister Kali, who never spent a night without her until Monday, just now seems to comprehend that she's really gone.

Still, I recognize I am better for knowing the lightness and sweetness she brought into our lives for six happy years. I know things will get better, she was just a pet and pets die. But I miss her.

My precious Leela. Leela with the pink nose and the big furry paws. Leela with the weak heart.

My Little Lou.

I love my job part two.

2009-11-15T19:22:00.000-08:00

Last night, as many of my high school friends whom I hadn't seen in years gathered to celebrate Kevin's 40th birthday, I was stuck in the hospital, sitting at the foot of the bed of one of my favorite patients. I was on call, attending for the residency, and trying to figure out how to deliver this patient's baby who'd arrested at 8 centimeters dilation. Her temperature was rising and the fetal heart rate was showing signs of distress.

For 40 weeks, this patient had greeted me with a huge smile at each prenatal visit. She was so excited to be pregnant again, having miscarried her last pregnancy at 13 weeks the year before. She had no insurance, and most of her family was in Mexico, so for her the care and support she received from the clinic each week was literally a lifeline. Each visit, I'd work so hard to reassure her that things looked normal, diffusing her anxiety with humor. I knew she and her husband had wanted a boy and so early on, long before her ultrasound, I laid my hands on her belly and told her "Yes, definitely a boy, you can tell just by feel." When she came in with her ultrasound results two weeks later, she and I had a huge laugh at the report of a single, healthy male fetus, despite the fact that I had a 50% chance of guessing right.

At her last visit the week prior, realizing I was going to be on call this weekend, I told her, "I want you to come in and have the baby on Sunday, this is what works best for my schedule," as if she had any control over the situation. When I received the page from OB triage announcing her arrival in active labor, I wasn't the least bit surprised.

Yet, I had really been hoping to make it to Kevin's party. All night I watched the clock. At 6, I thought, if we could get her membranes ruptured, maybe we'll deliver by 7 and I could get there by 8. At 8 I thought, if we could rotate the baby I'd get her delivered by 10 and I could still get there by 11 to say hello. Now it was midnight, the Sunday morning she promised me had arrived, I had abandoned hope of making it to see my old friends, and things were looking hairy.

We started oxygen, we tried position changes, I rotated the baby's head, I called an obstetrician, the first step in a process that usually results in C-section. But she was strong, focused, and determined and despite my plans to be elsewhere I was right there with her. At 130 am on November 15 she delivered on her own a beautiful healthy boy.

I finished my paperwork and drove past Kevin's house on my way home, surprised to discover everyone still up. Despite my exhaustion I still got to visit with my old buddies and share pictures of our kids. I told Kevin all about the delivery earlier and we both laughed at the fact that the parents decided to name this child that shared a birthday with my friend, "Kevin."

But the thing that blew me away the most, just as I left the hospital, was the look in my patient's exhausted, blissful, and grateful eyes as she told me, "Thank you for the work you do."

I swear I don't make this stuff up.

Oh no.

2009-11-13T09:43:00.000-08:00

Matt Haughey, founder of Metafilter and user #1, is in the hospital and twitter is probably going to crash with the flood of well wishing. -->: #mathowielove

Guy tweeted his own seizure. That's hardcore geekery.

Get well soon, Matt. Metafilter is the only website that matters.

House passes health care reform

2009-11-08T08:34:00.000-08:00

I love Wonkette's headline this morning: "House Votes to Kill Your Grandmother & All Christians, 220-215."

The House bill, which has to go through further watering down in the Senate and is a *long* way from becoming law , is a step in the right direction. Problem is, I think we are *far* past the point where "steps in the right direction" are going to take us where we want to be: quality, accessible, evidence based health care. I honestly think that, with the exception of health care providers and people with serious medical problems, very few Americans understand how far we are from that goal and how entrenched the institutions are that are trying to keep us from this goal.

I am all for market based approaches that improve quality and drive down costs. The problem is that quality and cost aren't where insurance companies are competing. They compete with strong arm negotiations with hospitals, denials of coverage, and lobbying money. This bill, while setting up some standards for fair competition, is also requiring the American People to give more money to the insurance industry. I personally am just skeptical that they won't find other clever ways to screw us; their primary allegiance is to shareholders, not patients. Yes, this bill does currently include a limited public plan (which I highly doubt will make into the Senate bill) but (as I understand it) it is a self-funding plan for individuals without employer sponsored insurance who are going to be forced to buy something, and it will compete against similar plans offered by private insurers. Pretty weak tea. Anything that doesn't allow a person with employer provided insurance to opt into a public plan, you know, in case they're curious about what consumer-driven health care would really look like, falls short.

If our legislative branch wasn't totally corrupted by lobbyists, the negotiations should have started with "Socialize all medicine now!" and settled for the optional public plan. I am not a communist, I just want a better health care system that's in-line with the rest of the civilized world.

Best Joy Division Cover Ever Made

2009-09-09T12:48:00.000-07:00

Krugman: Why market can't cure healthcare

2009-07-26T08:40:00.000-07:00

There are a number of successful health-care systems, at least as measured by pretty good care much cheaper than here, and they are quite different from each other. There are, however, no examples of successful health care based on the principles of the free market, for one simple reason: in health care, the free market just doesn’t work. And people who say that the market is the answer are flying in the face of both theory and overwhelming evidence.

Paul Krugman, New York Times Op-Ed, July 25, 2009

STP 2009

2009-07-13T20:27:00.000-07:00

Last year I wrote about what an amazing time I had riding the Cascade Bicycle Club's Seattle to Portland Ride and how I just knew I'd be doing it every year for the rest of my life. This year, things went a little differently.

It started well enough. Clear skies, 80 degrees. Greg finally got a new bike. Things seemed all set. It's no surprise I'm not as fit as I was this time last year, but I had a few long training rides and I was ready.

Filmore left early to ride with the Major Taylor Project but got a flat almost immediately after the race began. After replacing his inner tube, as he went to pump it up, his tire stem snapped off in his pump and he had to wait 30 minutes for someone to stop and help him out.

I lost Greg and Matt in a pack of cyclists somewhere around Auburn. About 10 miles later when I still hadn't caught up to them, I thought to myself: "Those assholes, they can find their own damn ride home." I met up with Fil in at the lunch stop in Spanaway and he asked if I'd seen Greg and Matt. Apparently Matt caught a flat right when I lost them and I breezed right past them without seeing them or stopping.

Despite this, we made it to Centralia faster than the year before. After showers, it was straight to the McMenamin's for beer and pasta. A couple hours later, with full stomachs, we were getting ready to pack it in for an early night when I heard them turn on the Tour de France over at the Beer Garden. Ok, I'm not quite sleepy yet, I'll just go over and watch for a bit...

Wound up making some new friends that night who had bought a bunch of alcohol they were looking to get rid of. Some people can party. What was I thinking?

Woke at 5 AM to the sound of rain drops on the tent and 50 degree weather. This was going to be interesting. Sporadic showers and pervasive wetness with occasional hail followed us for all of day 2. We were pretty much riding into the cold front with a moderate head wind the entire day. It was good to have the support of my friends and we took turns drafting most of the way, but I don't think I could say that any part of the ride was "fun." In fact, it is hard to think of specific day that was more miserable; if it weren't for trading jokes with Matt, Greg, and Fil and laughing at the ridiculousness of the situation I don't think I would have finished the ride.

We rolled into Portland at 5 pm, significantly slower than last year. Meritxell was a sight for sore eyes and she is a saint for coming down to pick us up. After standing in the shower line for an eternity in our soaking wet, freezing cold cycling clothes we finally got warm, dry, and fed (oh my god -- East Burn, Portland, Oregon -- words cannot describe how awesome this place is) and we loaded up and came home.

It was an adventure and it had its moments, but I think each of us, separately, decided somewhere on the road between Rainier and Scappoose that this was the last time we'd do this. Next year we'll come up with our own tour.

Glenn Beck Agrees US Needs Another Al Qaeda Attack To Protect Us From Immigrants?

2009-07-01T19:19:00.001-07:00

Holy shit. Just wow.

*Borrowed without permission just to underscore Tom Tomorrow's point.

An oldie but a goodie...

2009-06-25T21:09:00.001-07:00

This is what my basement sounds like

2009-06-24T17:34:00.001-07:00

Bouefcake has 9 or 10 proper original songs by now. It's pretty hard to share songs that you've lovingly crafted with a skeptical public. Songs can be very personal and it's easy to be self critical about even the smallest recording mistakes. Usually we'll work out various parts for weeks, trying out different ideas and someone will spend days coming up with lyrics.

That's not the case with these two songs. These ones basically came out as is, with Kevin improvising the lyrics. In fact, with The In Security Song, we literally made it up about twenty minutes before this recording was made; what you're hearing is exactly the third time we played it through. Somehow, it is so much easier letting go of things that you didn't try hard to create.

Sewerage

The In Security Song

VH-1 Classic

2009-05-27T17:16:00.000-07:00

Ok, my new favorite hobby: bouncing Ravi to sleep watching VH-1 Classic late at night with the Wikipedia open, reading about where these bands are now.

For instance, did you know that the bassist for the Red Rockers is Paul Westerberg's manager? Or that one of the guys from Musical Youth died at age 24 of a congenital heart condition? Or that The Stranglers are still touring, and that their drummer is now seventy years old?

Ka-boom!

2009-05-25T09:23:00.000-07:00

"Your infected cyst is ready in room 1. It looks bad, are you gonna drain it?"

It was bad, probably six inches across. These things can get pretty nasty. Imagine the ugliest pimple you've ever seen and then think of the pint of foul smelling cottage cheese mixed with pus inside. Why do these always get scheduled right before lunch?

"Yeah, we need to drain it. This is a good procedure for the nurse practitioner to learn how to do, can you call her in?"

So with the cyst all prepped and numbed, I was explaining to K, my nurse practitioner, how you have to push down hard right after you make your incision, when the pressure is the greatest, in order to extrude the thing all at once and...BLAMMO!

Cheesy, rotting pus all over the walls, the table, and the ceiling. Miraculously, K and I were unscathed.

When it was all done, we came out of the room to talk to the medical assistant.

"Um, we're not going to want to use that room for the rest of the day."

Milk Man

2009-05-04T16:56:00.000-07:00

I mentioned in a previous post that breast feeding is extremely difficult. Well, after watching my baby-mama torture herself over the past two weeks, I can no longer stand idly by:

That's right, male breastfeeding. Not only is it possible, but it's healthy, and it's my paternal right.

Discover magazine did a fairly serious take on this in 1995:

There are numerous conditions under which injected or topically applied hormones have produced inappropriate breast development and milk secretion in humans, both in men and in nonpregnant or non-nursing women. In one study, male and female cancer patients who were being treated with estrogen proceeded to secrete milk when injected with prolactin. Lactation has likewise been observed in people taking tranquilizers that influence the hypothalamus (which controls the pituitary gland, the source of prolactin), in people recovering from surgery that somehow stimulated the nerves related to the suckling reflex, and in women on prolonged courses of estrogen and progesterone birth-control pills.

All these cases involved medical intervention, but it is not always necessary. Mere repeated mechanical stimulation of the nipples suffices in some cases, since mechanical stimulation is a natural way of releasing hormones. For instance, sexually mature but virgin female marsupials can regularly be stimulated to lactate just by placing another mother’s young on their teats. Milking of virgin female goats similarly triggers them to lactate. That principle might be transferable to men, since manual stimulation of the nipples causes a prolactin surge in men as well as in women.

According to this home birth website:

I knew these two wonderful guys, very dear friends of mine for years. A mutual acquaintance of ours was pregnant, unplanned, and did not want to do the whole "adoption thing" so when the guys approached her about taking the baby, they just proceeded as if it had been a planned surrogate pregnancy. The guys were adamant that the baby should get breastmilk. So when she was in her 7th month we bought a really good quality breastpump and Ian started pumping, every 2 hours during the day and once during the night. He was wonderful about it! He used an SNS (supplimental nursing system) after she was born, with donated milk from several friends who were nursing. He was making milk but not a full supply. By the time the baby was 12 weeks old he was making a full milk supply! He stayed at home with the baby (he was a massage therapist) and nursed her exclusively until she was 8 months old!! I don't think many people outside their intimate circle knew about it, I'm sure folks would have had a fit if they'd known...but I thought it was wonderful!

Suite101.com has an interesting article about male lactation as well:

It is important to realize that you may not be able to produce enough milk to sustain your child on breast milk alone. Don’t be upset - there are special supplements that are delivered externally, by a tube near the nipple. They were invented for women, but work equally well for men...

There are three herbs that are effective at helping breast-feeding: blessed thistle, alfalfa, and fenugreek. Of these, fenugreek is considered the most effective. There are also herbs that can slow down your milk supply and make successful breastfeeding difficult: herb Robert, lemon balm, oregano, large amounts of parsley, peppermint, periwinkle herb, sage, sorrel, and spearmint. Some drugs have a side effect of causing lactation and it seems like the best one may be Domperidone (Motilium™). Raglan has also been used to induce lactation, but it can't be used for extended periods of time without serious side effects.

Finally, there is this inspiring story about a Sri Lankan widow who found he had the ability to breast feed his children after his wife's untimely death:

Colombo - A 38-year-old Sri Lankan man, whose wife had died three months ago, appears to have the ability to breastfeed his two infant daughters, doctors said on Wednesday.

The man, from the central town of Walapone, lost his wife during childbirth.

"My eldest daughter refused to be fed with powdered milk liquid in the feeding bottle.

"I was so moved one evening and to stop her crying I offered my breast. I then realised that I was capable of breastfeeding her," the man admitted.

Dr Kamal Jayasinghe, deputy director of a Sri Lankan government hospital, was quoted as saying it was possible for men to produce milk if the prolactine hormone became hyperactive. - Sapa-AFP

So yeah. As concerned parents, we are committed to breast feeding our little Babu; it is the healthiest thing for him and only natural. What better Mother's Day gift could I give my beloved wife than to inject myself with hormones, take a bunch of supplements, and stimulate my nipples all day long to produce the milk I need to relieve her of the burden of the 2am feed? I think both her and the baby would appreciate the effort.

Holy crap, I'm exhausted.

2009-04-29T09:16:00.000-07:00

I promise not to turn this into yet another daddy-blog, but it's true that I have done very little in the last week outside of child care.

Some observations:

The level of exhaustion is nowhere near residency training. Newborn care is incessant, there is no time where you are free from responsibility, but I haven't had to do much thinking and there have been regular nap periods. I have lost my ability to do simple math problems such as figuring out the tip on take-out food.

It's amazing how much laundry one tiny little six pound human being can generate.

Breast feeding is difficult. Extremely difficult.

The ergonomic design of baby gear is incredible. I'm consistently impressed at the attention to tiny details that make your life easier. The way the car seat clicks in and out of the base. The handles on the laundry hamper are exactly where you want them. The way the baby bjorn holds Ravi exactly where he wants to be, without any back strain whatsoever.

The lithium battery on our TV remote went 3 days ago. This was a major crisis and we had to have one flown to the house overnight.

Baby care is all about rhythm and it is a team sport. Ideally, it goes diaper change --> feed --> burp --> nap --> repeat. It's pretty easy to get into a pattern of feed --> burp --> feed --> diaper --> short restless nap --> diaper --> feed; this is a Very Bad Situation. If both of us are functioning like a coordinated team, and the schedule doesn't get screwed up by something like a doctor's appointment, each parent can get 1-2 hours of relative freedom every three hours. Thank the gods that Shireesha and I have been working from the same playbook through all of this. I can't think of anyone I'd rather share this responsibility with.

Wet babies are extremely slippery and cute.

I'm really surprised by my capacity to love this child, but I am probably more surprised by my capacity for patience. By all rights, I should be totally pissed off when it's 3 am and he's been fussing for 2 hours and won't go to sleep. But I'm not.

I would do absolutely anything for the well-being of this child.

Despite a few frustrating nights, I think we've been doing pretty well. Shireesha's been going out for walks almost every day, and I've managed to exercise several times. The three of us made it out to the Ballard Farmer's Market at day 6 and I got to go to the My Bloody Valentine show on day 7. We even had band practice on Sunday. Ravi is gaining weight, he's clearly able to focus his vision on faces and seems to have a preference for his mother and father over other people. His feeding is getting better. I'm not sure what is going to happen when I go back to work but I think uncertainty and problem solving are probably the defining characteristics of child-rearing.

Ravi John

2009-04-20T23:09:00.000-07:00

As the dawn broke over a clear sunny spring day in Seattle, Ravi John Sourpuss was delivered on April 20, 2009 at 5:13 AM to his previously ambivalent parents who now understand the true meaning of love.

Namesake

Meaning

2009-04-20T15:02:00.000-07:00

I am so friggin happy right now. I am totally, completely, blissfully in love.

More later...

Dateline Seattle: Swedish Hospital

2009-04-20T01:28:00.000-07:00

We are at Baby-Con 5...this is not a drill. Shireesha is resting comfortably, contemplating the wonder of epidural anesthesia.

Staff Benda Bilili

2009-04-18T18:28:00.000-07:00

Well, I'm at home still waiting for the Babu, but it gives me a moment to write about my latest musical obsession. With Konono No.1's Congotronics in 2004 and Jupiter's Dance in 2006 it seems like the most interesting music I've heard in recent years is being made in Kinshasa, Democratic Republic of Congo. But far and away the most astonishing of the bunch is made by a group of polio-stricken paraplegics and abandoned street kids living on the grounds of the Kinshasa zoo who call themselves Staff Benda Bilili.

This clip comes from Jupiter's Dance:

In 2006, the United Nations Development Programme helped them produce a song called "Let's Go and Vote" which became wildly popular in the run up to the Congolese elections and was reportedly responsible for a 70% increase in voter turnout. The track became one of the most recognizably popular songs in the history of central Africa. For all this, the musicians were paid about $50 each.

Well they finally have a real album out on Crammed Records and it is fantastically good. From the record company's website:

The band's mesmerising rumba-rooted grooves, overlaid with vibrant vocals, remind you at times of Cuban nonchalance, at other times of the Godfather of Soul himself. You can hear echoes of old-school rhythm and blues, then reggae, then no-holds barred funk...

The songs were recorded out in the open, mainly in the zoological garden near centre ville, using a dozen microphones, a MacBook laptop and a 100m mains cable fraudulously connected to a deserted refreshment bar nearby.

The album is available on both iTunes and Amazon and I hope it brings them all the success they deserve.

Born at the Right Time

2009-04-01T17:02:00.000-07:00

The other day I had my first dream about the baby, due any day now. I never dream, or at least remember my dreams, but this one was so vivid, the kind of polysensory experience where you hear, touch, and smell what's happening and when you wake up and you aren't sure it wasn't real.

In the dream, I was holding little Babu in my hands just after he'd been born. He was crying and squirming, still glistening with amniotic fluid, his rubbery white umbilical cord still hanging from his tummy with a steel surgical clamp attached to the end. I found myself completely overcome with emotion, sobbing uncontrollably. Looking down, I saw in this one brief moment the limitless potential, a clean empty canvas upon which I would paint the world.

Pretty powerful stuff for someone whose attitude thus far in the pregnancy would best be described as "mixed ambivalence tempered by hesitant anxiety."

Appearing elsewhere in the dream was a more sinister figure, a patient I had seen earlier that day in clinic. This person wasn't your ordinary down-on-his luck drug abusing crazy person that we see all the time. This was a very seriously distrubed man, alcoholic, bipolar, with anti-social personality disorder, one year out from a twenty year sentence for murder one. He had been dragged in to clinic by his girlfriend who had just witnessed yet another 2 week long drug-fueled manic rampage. I was in the exam room contemplating how in the world someone gets so screwed up when she began to tell me about the time she went home to visit his family. What followed was a description of family dynamics that ranged from indifference to outright verbal, and then physical, abuse compounded by a history of sexual abuse.

I've taken care of literally thousands of families, from telling patients that their pregnancy test was positive, to taking care of their newborns in the hospital, to doing their kids' check ups, to dealing with behavior problems that develop in school. In the enduring war between Nature and Nurture, I come down firmly on the side of Nurture. I believe so strongly that any kid has the potential to grow and excel in the right environment and yet there are so many ways that the people on the fringes of society can get it wrong. Thoughtful, well adjusted parents simply don't raise bad kids yet inexperienced, stressed out parents so rarely raise good kids. On occasion, I have seen childbirth transform a few people into curious, careful, and doting parents, and it is inspiring to see, but this is sadly the rare exception.

Tony and I got into a discussion the other day about the things a newborn baby comes pre-programmed with. Lately, a trend has emerged to promote more paternal bonding, presumably to awaken some predetermined neural path that gives the baby a special emotional bond with their father. At these births, the newborn goes directly from mom's bare stomach (where studies show this increases maternal bonding and successful breast feeding) to dad's bare chest. I think this is a little silly, as babies at birth probably don't even conceive of the existence of any other people besides their mothers, but whatever imparts a sense of nurturing and responsibility to the male parent has got to be a good thing.

It's a strange limbo I'm living in right now, anticipating the arrival of my son yet holding an open heart free of expectations. I've always believed that music captures the wonder of emotional truth better than any other form of expression. When I was discussing this on Metafilter, someone suggested to me a song I'd never heard, called Born at the Right Time. Paul Simon wrote it about his son.

Down among the reeds and rushes
A baby boy was found
His eyes as clear as centuries
His silky hair was brown

Never been lonely
Never been lied to
Never had to scuffle in fear
Nothing denied to
Born at the instant
The church bells chime
And the whole world whispering
Born at the right time

Me and my buddies we are travelling people
We like to go down to restaurant row
Spend those euro-dollars
All the way from washington to tokyo
I see them in the airport lounge
Upon their mothers breast
They follow me with open eyes
Their uninvited guest

Never been lonely
Never been lied to
Never had to scuffle in fear
Nothing denied to
Born at the instant
The church bells chime
And the whole world whispering
Born at the right time

Too many people on the bus from the airport
Too many holes in the crust of the earth
The planet groans
Every time it registers another birth

But among the reeds and rushes
A baby girl was found
Her eyes as clear as centuries
Her silky hair was brown

Never been lonely
Never been lied to
Never had to scuffle in fear
Nothing denied to
Born at the instant
The church bells chime
And the whole world whispering
Born at the right time

Dancin' Dr Pepper

2009-03-14T16:13:00.001-07:00

I just came across this video I took a couple years ago and I think it's pretty funny. This was taken at Xian's birthday party. He survived a bad scooter crash earlier that year and had just been discharged home so we threw him a surprise medical-themed party. Brian showed up as Dr Pepper and danced his booty off.

Nonstress test

2009-03-09T14:02:00.001-07:00

Isn't this like the cutest photo in the world?

I love you so much, Shireesha.

The Ultrasound Before Christmas

2009-03-07T23:46:00.000-08:00

I never understand why people want to share their baby's ultrasound pictures with the world, but isn't this one creepy? Our little Babu is 34 weeks now. He reminds me of Jack Skellington.

Leela and Kali

2009-03-07T13:34:00.000-08:00

Kali gets on the internet.

Leela flames out on Metafilter.

Kali updates her Facebook page.

Bluebeard's Castle

2009-03-01T11:24:00.000-08:00

Shiree and I just attended our 37th (!) opera, The Seattle Opera's production of Bluebeard's Castle, a wholly engrossing twisted and dark psychological production. Every aspect of the performance, the music, the story, the set, the singing, and acting contributed to one of the most memorable evenings of opera I've had and was a perfect example of why we keep going back. Seattle, for being a pretty small city, is lucky to have such a world class opera.

The music, written by Bela Bartok 90 years ago is surprisingly modern with its loud-quiet-loud repeating pattern and quietly looping background melodies which perfectly suit the narrative, a series of dark revelations about a woman's new groom, a mysterious man with whom she fell in love and eloped before knowing him perhaps as well as she should have.

The story begins with a narrator appearing in front of the stage who tells us that the story exists as much in our minds as it does on the stage, setting us up for the powerful metaphor that the dark secrets that hide inside us are like the locked rooms in the basement of Bluebeard's castle.

The music begins with Judith and her new husband arriving at his castle, a dark stone set that suggests a vast underground hallway, with bars closing over the only gate off in the distance, and series of seven locked doors along one wall. Judith notes that the castle is cold and the walls are damp. She's scared and she begs her husband to open the doors to let in the light. Bluebeard refuses but finally relents after Judith makes it a test of Bluebeard's love.

The first door opens and red light comes pouring out, illuminating the opposite wall with an undulating red pattern. It's a torture chamber drenched in the blood of Bluebeard's victims. Bombastic music ensues as Judith sings of her shock. As she comes to grips with the unsavory work that goes along with her husband's title as Duke, she tells Bluebeard she must know what's behind the other doors.

Behind the second door, we find Bluebeard's armory, again the weapons are stained with fresh blood.

Bluebeard tells Judith he cannot allow her to see anything else, but she persists and he gives her the next three keys.

Room number three is looking better, a golden light pours out through she doorway and she finds a mountain of treasure and jewels, but it's only on closer inspection that they too are covered in blood.

The fourth door is a beautiful garden, full of bright flowers and the music begins to change, it's gentler. The shadow of trees blowing in the soft breeze illuminates the inside of the castle. But as Bluebeard sings of the beauty of his gardens, Judith again sees blood and realizes that the garden has been watered in blood.

When Judith opens the fifth door, we hear loud, loud, majestic music. Blue and white light project onto the castle wall, suggesting a view of Earth from space as they look over the vast lands that Bluebeard has conquered, at the cost of the blood of his enemies. Bluebeard pleads with Judith, let this be enough, please go no further. But she cannot resist the temptation to see more.

With the six door, we see a smooth peaceful lake. The music becomes quiet and sad as Judith runs her hands in the water and she is told that it is a lake of tears, though the question of whose tears is left to the imagination of the audience.

Bluebeard is adamant about her not looking beyond the seventh door, but Judith embraces him and repeatedly tells him how much she loves him. That if he doesn't allow her to see the final room she will start to believe the rumors that he has murdered his previous wives.

What?

I won't spoil it by revealing what happens next*, but it's Hitchcockian in the extreme, and one of the great moments in opera. It must have totally bowled people over when Bluebeard's Castle debuted in Budapest in 1918. The psychological overtones are intense but given the abstract, unreal nature of opera, it all just worked and, as my friend Jeremy said afterward, there is no other artistic medium that gets away with this.

*Ok, here's what happened. The seventh door is unlocked and there is a perfectly still lake of blood. A woman dressed in a bridal gown, soaked in blood, slowly rises from the lake and begins to walk across the stage. She is followed in sequence by two other women in bridal gowns, and all three join Bluebeard as he sings about how much he loved his previous wives. Judith sees that each bloody bride is more beautiful than she, but terror strikes her when Bluebeard now calls her the most beautiful of them all. The three bloody brides then descend again into the pool of blood and disappear. Judith begs to be spared but is sucked down into the pool of blood and disappears as the seventh door closes. The final line of the opera is uttered. "All shall be darkness, darkness, darkness."

10 Things I Love About Community Health

2009-02-23T15:34:00.000-08:00

Well, it's been about a month in the new job and I'm still finding my feet a bit. New hospital, new patients, new computer system, new staff. It's about as disorienting as moving to a foreign country where you don't speak the language. You know what you've got to get done, you just have no idea how to do it. But people have been very helpful, and it's coming along faster than I thought. Today was my first day rounding at the hospital with the residents, which introduces a whole other dimension of complexity to the job, but it was fine.

So far, it's really lived up to my hopes and the contrast with the "normal," insurance-funded system of health care has been stark. I have no idea why I stayed away from community health for so long. Every day when I make the seven block walk home, it gives me pause to reflect upon all the things I'm loving about this job.

1. The patients.
It's a community health center; its mission is to see people who otherwise have no access to health care. You'd think the patients here would bring in a truck load of unfixable problems that have been neglected for years (and certainly there are a few of those), but for the most part the patients are really focused on their one or two big problems, they want to get better quickly, and they are extremely grateful for the care they receive.
Contrast this to my previous practice, where patients were paying through their noses for access to a doctor whom they viewed as an agent of an inherently unfair system. The average patient in B-town would postpone care, store up a laundry list of problems for their visit, and then expect the doctor to do all of the work taking care of them. Isn't that what they're supposed to be getting for their $1000 a month premium?

2. My coworkers.
Everyone I interact with, from doctors, to nurses, to social workers, to the janitor chooses to work here, to serve this community, and usually they are making a financial sacrifice to do so. And still getting a job here is competitive. Every day, it is obvious that everyone is thankful to be here. There is nothing like a shared mission from which to draw sustenance and motivation. And because everyone wants to be here, there is a level of competence among the staff that I frankly haven't seen anywhere in health care before.

3. Support services.
In the community health system, there is an acknowledgment that providing effective primary care to a needy population has to involve a whole lot of other disciplines that cross over with medicine: social work, behavioral health, dental care, nutrition, and education. It's incredible to me that, as far as insurance companies are concerned, a 15 minute visit with a doctor is adequate time to tell a patient everything they need to know about diabetes. Or to diagnose their complicated psychiatric problem. Or to counsel them on quitting drugs. Yet this is exactly what I spent the last 7 years in B-town trying to do, having no other place to turn to, or at least no place that my patients would go. On site here, we have social workers, interpreters, a clinical psychologist, psychiatry 2 days a week, a fully staffed dental clinic, a diabetes educator, 2 nutritionists, and several other support services.

4. The expectation that I will push myself beyond my comfort zone.
There's been a lot of times where I've been scared as shit over the last month. Having to deal with stuff I've only read about or haven't seen since residency. Things that would have been referred to a specialist without a second thought when I was in private practice. Complicated office surgeries. Small children with mysterious symptoms that don't add up. Really seriously mentally ill people. For the most part, trying to find a specialist that is willing to see a sick, uninsured patient quickly turns out to be more difficult than figuring out what to do myself. These patients come to me with nowhere else to turn and when I'm able to work through a complex problem, it's a total thrill. A little bit of cowboy medicine right here in Wallingford.

5. Not dealing with insurance paperwork.
Yes, medicaid, medicare, and the state disability program have paperwork, but it is nowhere near as pointless and time consuming as the insurance paperwork used to be. I cannot tell you how many hundreds of hours of my life I spent filling out prior authorization forms for non-preferred meds ("Because doctor, Prilosec makes me feel not right.") or wrangling payment for things that insurance claimed were pre-existing conditions or trying to get a wheelchair into the hands of a little old lady. Insurance companies put up a wall to deny payment for most everything nowadays, and all of that somehow comes back to the primary care doctor's desk. Now I have one set of forms that more or less make medical sense, and they are for important things like food and housing money for the guy who can't work anymore because of his cancer.

6. Delivering babies.
I love delivering babies and doing newborn care. I had planned to do it when I was in training, and did a bunch of extra obstetric rotations in residency before I got sucked into the toxic job from hell. After my first two years in practice, I figured there was no way I would be able to get my skills back, let alone find a hospital that would credential me to deliver babies. Very few family doctors in Washington state are willing to take on the malpractice insurance burden anymore. But it's something that is totally consistent with the philosophy of family-centered medicine and I've always missed it. The community we serve at the new clinic has nowhere to go for obstetric care, and because of the low reimbursement, the hospital and our back-up obstetricians are happy to have us do these deliveries. My partners are so glad to have another person in the rotation and have been extremely supportive in mentoring me through my first dozen or so deliveries.

7. Learning Spanish.
Who hasn't told themselves, "You know, it would be really good for me to become more fluent in Spanish"? With a patient population that is about 50% Spanish speaking, I might finally get beyond "¿Tiene fiebre?"

8. Teaching.
I have two mid-level providers that work with me, a nurse pracitioner and a physician's assistant, who are just great about knowing when to ask questions and refer people to me. In addition, I will be a clinical faculty member for the Family Medicine Residency program at the hospital. I love it when people ask me clinical questions or I'm teaching a new procedure to someone. It reminds me that at this point in my career I actually do know some stuff and it's really neat to help other providers develop new skills.

9. Loan Repayment.
Ok, I haven't officially heard whether this was approved or not (The Washington state government, from which this money flows has an $8 billion budget deficit), and I *did* take a pay cut to work here, but just the fact that this possibility exists is awesome. Last year, I was paying about $1500 a month in student loan repayment and it was going to take me about 25 years to pay it off. Since taking this job, I ramped up my repayment to get me done in ten, and should loan repayment come through, I can do it in five. For a guy who's not sure he's going to be practicing medicine in five years, with a kid on the way, this is huge.

10. Humane work schedule.
In the insurance-funded world of health care, salaries are entirely production-driven. If you're not in the clinic billing patients for your time, no one's getting paid. My old job was 0.8 FTE which meant I was scheduled for 32 hours of patient contact per week, which ensured that I would be in the office for 60 hours a week. For an 80% job.
Because our funding isn't entirely based on patient volume, our clinic acknowledges realistic schedule limits. A full day of seeing patients is pretty long: 10 hours on your feet, face to face with patients, often skipping lunch. Sometimes you're up in the middle of the night on call. Full time here is capped at 28.5 hours of patient contact, 23.5 if you're on call. Schedules are blocked out for meetings and medical education. As a clinic run by family doctors, it is expected that every one be able to go home to their families at a reasonable hour, a revolutionary concept in medicine.

So the job is still new and I keep telling people I'm waiting for the other shoe to drop. Certainly, hours will get longer as I get busier and I'm taking call. But this job leaves me with a sense of satisfaction that I haven't felt in medicine in a long time and I might just be able to stick it out for a few more years.*

*This should not be taken as evidence of any emerging optimism from Dr. Sour Puss. I remain firmly convinced that, in the long run, everything in the world is in a constant downward spiral and that the worst possible scenario is also the most likely one. Furthermore, everything bad that happens to me is someone else' fault and everyone is goddamn idiot except me.

A technologic milestone!

2009-01-25T12:08:00.001-08:00

Yes, I just threw away an Ipod.

What an age we live in.

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

2008-12-31T10:04:00.000-08:00

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.

Busy busy

2008-12-23T12:40:00.000-08:00

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.

I am out of here...

2008-11-18T19:09:00.000-08:00

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.

Baby!

2008-11-17T15:24:00.000-08:00

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.

Obama like me

2008-11-05T13:54:00.000-08:00

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

Washington State Proposition 1000

2008-11-03T12:52:00.001-08:00

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.

Early Voting

2008-10-24T12:04:00.001-07:00

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!

Dengue Fever

2008-10-22T09:14:00.001-07:00

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.

Batman vs. The Penguin: The Debate

2008-10-15T13:15:00.001-07:00

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.

Michelle Obama: Be not afraid

2008-10-09T21:25:00.001-07:00

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.

New patients

2008-09-20T15:58:00.000-07:00

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

Obama talks like a fag

2008-09-13T16:01:00.001-07:00

“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.

Patriots and Nationalists

2008-09-04T17:46:00.000-07:00

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

Obama, McCain, and health care.

2008-09-01T10:25:00.000-07:00

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.

McCain

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

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 naïve 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.

350+

2008-08-17T09:02:00.000-07:00

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?"

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

2008-08-16T09:18:00.001-07:00

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.

Music!

2008-08-03T21:32:00.000-07:00

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

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

2008-07-26T13:28:00.000-07:00

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?)

Letters of Medical Necessity

2008-07-23T13:06:00.000-07:00

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.

Perfect Day

2008-06-19T22:42:00.001-07:00

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.

The Old 97s Show

2008-06-15T14:25:00.001-07:00

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.

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

2008-05-31T11:06:00.001-07:00

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.

Way to go, Gays!

2008-05-15T14:13:00.000-07:00

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?

Success!

2008-05-06T11:23:00.000-07:00

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.

May Day

2008-05-01T08:11:00.000-07:00

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.

20 miles

2008-04-14T16:26:00.000-07:00

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.

Washington 43rd Legislative District Caucus

2008-04-07T10:15:00.000-07:00

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.

Poor prognostic signs

2008-03-14T16:54:00.000-07:00

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.

Seattle Driving

2008-03-04T18:19:00.000-08:00

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.

Stevens Pass

2008-02-25T19:25:00.000-08:00

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.

Obama, decisively.

2008-02-10T12:15:00.000-08:00

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.

Mira Nair and Shantaram

2008-02-02T18:35:00.000-08:00

I just saw the film The Namesake, after having read the book last year. It is an incredibly moving story of an Indian man who comes to America as a graduate student and raises his family here where they struggle to balance their own cultural identity with the pressures of assimilating into the United States. The thing that is so remarkable about the story is actually that it is so unremarkable, having been repeated tens of thousands of times by many different Indian families, including my own adopted one. I think Mira Nair, the director (who also directed Monsoon Wedding, Salaam Bombay, Mississippi Masala, among other films) did it justice. She has such a way of capturing on film whatever it is that makes India such a beautiful, complex place. And she does this by portraying scenes on the street with a realism that is at once ordinary but also astonishing.

So I finished reading the book Shantaram by Gregory David Roberts on the plane back from India. It's this mostly true story, about an Australian political activist who becomes a heroin addict. He had been given a 20 year prison sentence for armed robbery when he escaped, ultimately making his way to the slums of Bombay. There, he redeemed himself, learning Hindi and Marathi, establishing a free clinic, falling in love, and generally being embraced by the inhabitants of Bombay. He also joined the Indian mafia, went to live in a rural village, acted in Bollywood movies, and fought with the Mujahadeen in Afghanistan.

Aside from being a totally amazing, engrossing thousand page adventure story, it is also a love letter written to India with some brilliant observations about the country, from the perspective of an outsider who is taken in and ultimately becomes Indian.

Some samples:

"And the Indians, they love most of all. Your little friend may be beginning to love you...It happens often and easily, for the Indians. That is how they manage to live together, a billion of them, in reasonable peace. They are not perfect, of course. They know how to fight and lie and cheat each other, and all the things that all of us do. But more than any other people in the world, the Indians know how to love one another...India is about six times the size of France...But it has almost twenty times the population. Twenty times! Believe me, if there were a billion Frenchmen living in such a crowded place, there would be rivers of blood. Rivers of blood! And as everyone knows, we French are the most civilised people in Europe. Indeed, in the whole world. No, no, without love India would be impossible."

"At first, on that first journey out of the city into India, I found such sudden politeness infuriating after the violent scramble to board the train. It seemed hypocritical for them to show such deferential concern over a nudge with a foot when, minutes before, they'd all but pushed one another out of the windows. Now, long years and many journeys after that first ride on a crowded rural train, I know that the scrambled fighting and courteous deference were both expressions of the one philosophy: the doctrine of necessity. The amount of force and violence necessary to board the train, for example, was no less and no more than the amount of politeness and consideration necessary to ensure that the cramped journey was as pleasant as possible afterwards. What is necessary? That was the unspoken but implied and unavoidable question everywhere in India. When I understood that, a great many of the characteristically perplexing aspects of public life became comprehensible: from the acceptance of sprawling slums by city authorities, to the freedom that cows had to roam at random in the midst of traffic; from the toleration of beggars on the streets, to the concatenate complexity of the bureaucracies; and from the gorgeous, unashamed escapism of Bollywood movies, to the accomodation of hundreds of thousands of refugees from Tibet, Iran, Afghanistan, Africa, and Bangladesh, in a country that was already too crowded with sorrows and needs of its own."

"This is not England, or New Zealand, or Australia, or wherever the fuck else. This is India, man. This is India. This is the land of the heart. This is where the heart is king, man. The fuckin' heart. That's why you're free. That's why that cop gave you back your phoney passport. That's why you can walk around, and not get picked up, even though they know who you are. They could've fucked you, Lin. They could've taken your money, Khader's money, and let you go, and then get some other cops to bust you, and send you the fuck home. But they didn't do it, and they won't do it, because you got them in their heart, man, in their Indian fuckin' heart. They looked at all what you did here, and how the people in that slum love you, and they thought, Well, he fucked up in Australia, but he's done some good shit here, If he pays up, we'll let the fucker go. Because they're Indians, man. That's how we keep this crazy place together -- with the heart. Two hundred fuckin' languages, and a billion people. India is the heart. It's the heart that keeps us together. There's no place with people like my people, Lin. There's no heart like the Indian heart."

Roberts eventually was captured and finished his sentence before writing his novel. He has a pretty slick, and interesting, web site, which details his real life and his activities since getting out of prison.

The book was a gift for me from Daanish. Actually, Daanish picked it out after consulting with Metafilter, so in some way I guess it was a gift from Metafilter. Either way, it was a wonderful gift, and highly recommended reading for any white guy discovering India for the first time.

So bringing it back to Mira Nair...
Like most people who fall in love with a book, particularly one with a lot of striking visual descriptions or an unusual setting, I often imagine what it would look like if a movie was made of the book. In this case, there is so much that happens, I assumed any attempt to consolidate the story into a two and a half hour movie would be a mess. But then I heard that Johnny Depp had purchased the rights and that Mira Nair had signed on to direct it.

I have never seen anything like the slums of Bombay. Imagine a city, like New York, or San Francisco, only bigger and dirtier and hotter. Then imagine every empty space being taken up by shanties. Every sidewalk, every empty lot, every park. They encroach on the infrastructure of the city, into the roads, the train stations, even the airport runway. And it goes on as far as the eye can see. Given Nair's talent for giving the audience a singular, detailed, and stunning impression of a place, this film has great potential. I am looking forward to it.

The Funeral

2008-01-26T07:30:00.000-08:00

"Vasu-ana, what are you still doing here?" I was sitting in Shireesha's uncle's house in the village and was surprised to see that Vasu hadn't left for Chennai yet. The birthday party had been the day before and most people were planning on leaving early to get back to the city in the morning. Shireesha and I were going to stay and relax in the village for 2 more days.

"You hadn't heard? Your uncle Munreddy died last night. He is your wife's, mother's, mother's cousin. Very inauspicious for travel. Everyone is staying for the funeral today."

"You can come," my uncle Mohan Reddy said with his loud and authoritative, yet broken, English. "Come, see our tradition for preparation of the dead person."

"I don't know..." I said reluctantly. As a tall, loping, very Caucasian person in a remote farming village, my appearance at public events usually tended to become the focus of such events. During my first trip to Proddatur, I had to be rescued with a tractor from a mob of children who were closing in on me quickly when I went to watch the Sankaranthi rabbit hunt.

"No. Is okay. He is family. You must come to see how we make funeral." Mohan-mama is a large, jolly man with a heart to match, but past experience had sometimes left me unsure if his overtures were not particularly culturally appropriate. This is a man who, when his daughter was married, had built a castle to host his guests. Literally a castle, complete with turrets and towers and gates, in a town where many houses have dirt floors and people still draw water from wells. He and his wife moved out of the castle shortly after the wedding. But it's that combination of audaciousness and generosity that makes him well loved by everyone, including myself.

Considering the funeral, I remembered seeing the cremation pyres in Varanasi 4 years prior. While it was completely mind blowing, it was also unseemly, and gawking at the burning bodies there made the discomfort of the stares I receive in the village trivial by comparison. But this was the village. And it was family, I tried to convince myself. And I knew that whatever was involved, it would a pretty unique experience. In the end, though, I decided I was still just a tourist, not a cultural anthropologist and since I had never met the man, I should respect the solemnity of the event and stay away. Not wanting to let down my uncle, who was clearly excited about taking me to this event, I said "Well, we'll see what's happening later, but if I am not back here by 2, then go without me."

At about 3 o'clock, my wife and I decided we'd walk back to her uncle's house to have lunch and hear about the funeral.

"Can we take the short cut through the alley? I hate walking along the main road, people are always staring and wanting to come up and talk to me."

"Okay, it's this way," my wife said.

As we turned down the alley, we could see some kind of tent placed in front of a house and as we got closer, it was clear that a crowd was forming. "Oh crap" my wife said, "It's the funeral."

Before we could turn around, we'd been spotted by my uncle who was beaming with a wide smile as he stood up and waved me over. He asked the man sitting next to him to get up and offered me his chair. Right. In. Front. I supposed that the explanation that we were taking a short cut to go to his house to see him wasn't going to get me out of the funeral gracefully.

"Where the hell are you going?" I said to my wife who was leaving me on my own.

"I have to go inside with the women. Good luck."

At that point, there was nothing I could do but be gracious, humble, and awed by the turn of events that led to this suburban California boy becoming a front row witness to a traditional Hindu village funeral.

After a period of time where people paid their respects to the deceased in the front room of the house, the undertakers began to construct a bamboo stretcher. One man brought a live chicken forward. My uncle narrated. "They will bring one hen. That hen will be tied to the man." He looked intently at me and put his two fists together, as if to explain, then raised his arms to the sky, opening his hands wide.

The body was then brought to a chair in the front yard where the man's sons ritually bathed him with several buckets of water. He was then wrapped in a brand new dhoti and laid onto the bamboo stretcher, about 2 feet in front of me. "Now you will see them spread the spices." The body was anointed with turmeric, red powder, and some type of oil and then covered in flower garlands. A small fire with incense was started on the ground at the man's feet and one by one starting with the man's surviving mother, sons, and followed by the remaining friends and relations in the crowd, each person held their palms over the burning incense and then touched the man's feet.

Two Indian clarinets and a drum started blaring music as those in attendance completed their blessings. The man's sons gathered round the body and raised the stretcher to shoulder height. With the musicians leading, the gathering then formed into a procession that led down the alley. I marveled at the fact that all of this happened within hours of the man's death. They were taking the deceased to the outskirts of the town for cremation. My wife and I decided to peel off from the procession at this point, as did many of the attendants.

"Are you sure you don't want to see them burn the body?" my uncle Mohan said.

"No, that's okay. This has been quite an experience for me."

Mohan-mama smiled. "Is this how they do in America?"

Meenakshi Temple, Madurai

2008-01-24T18:28:00.000-08:00

All over southern India you can find barefoot pilgrims from all walks of life travelling along the roads. Usually they are recognizable by their matching colored lunghis or the markings on their foreheads, sometimes they carry banners or sing songs. The decision to put your job and family life on hold and walk barefooted to a sacred temple is actually fairly commonplace and pilgrims come from all socioeconomic groups. The major destinations in southern India include the Venkateshwara Temple in Tirupati, Andhra Pradesh, the Ayeppa Temple in Kerala, Kanyakumari at the southern tip of India, and this place, the Sri Meenakshi Temple in Madurai.

The temple city has existed since antiquity but the current temple was built in the 1600s. There are references to the town and the rituals celebrated there in the writings of ancient Greek historians and many of the rites have been performed essentially unchanged continuously for over a thousand years.

The temple has 12 of these towers, called gopuras, the largest of which is 7 stories tall. They are covered in small individually painted sculptures of various deities or other figures from Hindu mythology.

The temple is believed to have over 3 million sculptures.

Ceilings are painted with colorful mandalas.

Detail of gopura sculpture.

Bathing tank for ritual cleansing prior to worship.

Chennai

2008-01-18T05:44:00.000-08:00

Just a quick stop in Chennai, India's fourth largest city (aka Madras). I was prepared for the worst, but actually with Sankaranthi going on all week here in Tamil Nadu the city was relatively empty. Shireesha's giving a talk here at a hospital that has an affiliation with the University of Washington. We got a tour of the hospital but alas I was not able (or comfortable) to take pictures. The government hospital that takes care of much of the HIV in the state is a 100 year old facility that once functioned as a tuberculosis sanatorium. It was just about as uplifting a place as it sounds. I am constantly amazed at how much smarter the doctors in India are, they don't have CT scanners, they can't get labs drawn every day, and each fellow carries about 50 inpatients on their service, relying almost entirely on their physical diagnosis skills and their brains.

Although I did get out to the hospital and to Marina Beach, I spent most of the day in bed with chills and stomach cramps. It had to have been something I had at the four star hotel in Hyderabad which is ironic I guess. The only other times I've been sick here were at Domino's pizza in Bangalore, and following an all night whisky drinking binge where we ate lamb that was barbequed on the street (I deserved that one).

Here's Shireesha and our driver Madu at Marina Beach which is this enormous public beach in Chennai, about 1/2 a km wide and 10 km long. This beach took the full brunt of the tsunami but fortunately there weren't many people out when it hit, so the fatalites were in the dozens here instead of thousands as it was elsewhere in Tamil Nadu.

More at Marina Beach

We're headed to the hill station of Kodaikanal after this.

PS. The thing I miss most about home is the internet. For a country that touts its high tech infrastructure, internet access here remains hard to find, slow, and relatively expensive. I may decide to finish blogging this trip from home.

Hyderabad

2008-01-18T04:47:00.000-08:00

I'm sitting in the Hyderabad domestic air terminal and every muscle in my body bears the fatigue that only 4 days in urban India can bring. We came here by overnight train and have been enjoying 4 star hotel service at the Taj, an indulgence we usually grant ourselves midway through an India trip just so we can get a hot shower, some A/C facilitated sleep, and a real cup of coffee, not the sweetened condensed milk stuff that everyone here likes. Since we're in Hyderabad, this hotel is stuffed with American business people toting laptops. I feel smugly amused that staying in this hotel is the most luxurious thing I'll do all year while it's probably the most adventurous thing most of these other guests will ever do.

As Indian cities go, Hyderabad is nice. Only 6 million people and many were back in their villages for the festival of Sankaranthi. I'm reading this fantastic book, The Age of Kali by William Dalrymple, a chronicle of the changes brought upon the subcontinent since Independence and Partition and the chapter on Hyderabad describes a vastly extravagant city state of noblemen, wealth, and beauty that persisted until the early 20th century. All remnants of this have now been bulldozed, graffitoed, or neglected but if you really squint your eyes and use your imaginatino you can just imagine the brightly colored onion domes and vast parade grounds, now occupied by bland, underfunded governmental departments that have allowed things to fall into disrepair.

As I said though, Hyderabad is nice. Wide streets, a little development going on here. Our guide is the wonderful hadjiboy (blog), who was open enough to meet up with us and then came over the next day to show us around. Hyderabad was a predominantly Muslim city and at the time of independence, its ruler, the last Nizam, who was the richest man in the world at the time, refused to relinquish power and flee to Pakistan with all the other Muslims. The city retains a flavor that is distinct from the rest of India with mosques everywhere and all the other older building employ typical Muslim architecture. We were here for the festival of Sankaranthi and there were thousands, probably hundreds of thousands of kids standing on their roofs flying kites.

See how quiet the streets are for the festival?

Depending on how things go with health care system in the U.S., I may have to relocate, so it's good to see how much I might make as a family physician in India. 10 rupees is about 20 cents.

2008-01-12T19:58:00.000-08:00

Proddatur

I am sitting in a small, dark concrete room full of Shireesha’s uncles who are cracking jokes loudly, almost shouting at each other in between cackles. They are teasing my wife because I had asked how to make Andhra-style chicken. The idea that, on most nights, my wife gets home from work at 8 o clock and we order in, thus precluding me ever seeing anyone cook South Indian food, seems as incomprehensible to them as most of the things I’ve seen since arriving here would seem to my family back home.

Making Andhra-style chicken

The town we’re in has almost as many people living in it as Seattle, yet it isn’t marked on most maps of Andhra Pradesh, the state we’re in. The 8 hour drive that brought us here is the polar opposite of the bland sameness that characterizes interstate road travel in the U.S. The highway teems with more drama and entertainment that the Las Vegas strip on New Year’s Eve. Even between villages, there are never fewer than 500 people, and several of (what would be considered in the U.S.) exotic animals, within my direct view. I pass giant white temples with intricate carvings and 40 foot statues. Women and children carrying loads of crushed rock on their heads in an effort to widen the highway, a 2 lane road with at least 8 lanes of traffic – a pedestrian lane, the livestock lane, a bicycle lane, the auto rickshaw and motorcycle lane, and the lane for cars and buses which carries our motorcade – a large SUV with tinted windows followed by 2 shiny Mercedes Benz sedans. I want to roll down the windows to explain that we’re no mafia or government, we just have an uncle who is a very successful land developer. But rolling down the window to reveal my very Caucasian face would probably create an even bigger scene and I am glad I am in the car with the tinted windows. We pass a line of camels which are apparently raised as food by the local Muslim population.

Now I am on the roof of Shireesha’s uncle’s house at sundown. It’s perfect weather – 80 degrees, dry and slightly breezy. I look out across the town and further over the plain and I can smell the cooking fires. I hear the sound of 1000 birds and roosters crowing. The incessant sound of car horns is thankfully distant enough that it is drowned out by the Sanskrit chanting being broadcast by one of the temples in the town. I came up here to have a moment alone to write but I am interrupted by a woman on the roof next door. “Excuse me sir, where is your home?” in perfect English. She is going to the U.S. next month, having just married an NRI who works for FedEx in Pittsburgh.

Earlier today I walked the one block here from the uncle’s house we’re staying at and was followed by a group of 20 or so children in school uniforms, one of whom was nearly pushed into me, apparently dared to make contact. “What time is it?” After I give him the time he asks “What is your good name?” After I answer, I hear a dozen children’s voices whisper to each other “John. His name is John.” I won’t take out the camera just yet. Last time I did this, 20 children became 100 and I had to be rescued by Shireesha’s uncle on his tractor.

Shireesha's family historically have been farmers and all of the brothers still own land. This is Shireesha's uncle Bakthanath standing in one of their fields. Here, they are growing Chana Dahl (garbanzo beans).

This is one of the bigger temples in the village.

Bangalore Taxi

2008-01-07T04:08:00.000-08:00

It's the little things that strike you about this place. I think this speaks volumes.

Internet access is a little spotty but will try to post more later from Hyderabad.

2008-01-03T21:04:00.000-08:00

I am going to India this Saturday. This will be my third trip with Mrs. Sour Puss. In getting my stuff together, I came across my travel journal from my first trip in 2002 which contains these random observations:

"The village is crazy -- I'm the center of attention and it's not always good. Like there's preconceived notions of who I am and I don't exactly know what they are. I guess all I should do is smile and be comfortable."

"Charan says we are celebrities in this town. I should dress in Indian clothes...The first temple we went to [in the village] was the Sai Baba -- very new and bright. All eyes on me the whole time. I don't know who Sai Baba is -- some saint "who did good things for the people." I made the left hand mistake with the priest, accepting the offering of coconut oil...I heard a gasp from everyone in the temple."

"I keep making these cultural mistakes and I don't know how forgiving people are of them. I was definitely the center of attention [at the harvest festival in the village]. Everyone (especially kids) was staring at me. I made the mistake of approaching the kids after taking their pictures and showing them on my digital camera. Very quickly, I was mobbed and couldn't get away. One of the relatives came and had to rescue me with his tractor. After climbing in and getting above the crowd, I was driven to the other side of the field. All the kids followed us and stood about 2 feet away from me, every once in a while a shy kid in broken English would ask 'What is your good name, sir?' One kid asked me for my autograph. Later that day, I was told by Charan that I probably shouldn't go to the dance presentation, he cited 'security concerns.' "

"The poverty and ill health at Chipadu was astounding.Yet the curiosity and eventually generosity of everyone shines through. At the church I ponder what an incredibly spiritual place this place is and how utterly spiritually dead the USA is. This is why we have so much misery, illness, and crime and why we export it to the rest of the world."

"Q: Why do they have police at all of the traffic lights?
A: Because if they didn't, no one would obey the traffic lights."

"The crowds got thicker, the pushing got harder, and all I could think of was what a powerful, scary force religious zealotry is. These people believed they were in the actual physical presence of God and were freaking out! We only saw the statue of God for a few seconds."

"I love the fact that you hear a lot of ambient music everywhere here. Either the call to prayer from the mosque, some Rajasthani cultural program down the street, the bagpipers @ the Lake Palace, or random drunk Indian guys."

Will post more later from India, hopefully.

New Year's Resolutions

2008-01-01T21:13:00.001-08:00

Ok, so I have decided to run a marathon. This is a plan I actually concocted 2 months ago, but since I have managed to stick with the training program, I guess I will make it an official resolution now. Matt and Ben are going to do this with me, you can check our progress here.

I got inspired by my sister really, who not only completed the 2007 San Francisco Women's Marathon, but managed to raise a couple thousand dollars for leukemia research in the process. My sister and I both were never really very gifted athletes, both of us grew up slightly chubby in typical American style and both of us realized the benefits of exercise somewhat later in life. So if she can do it, I can do it. I have also received regular encouragement by participating in the Metafilter monthly running challenges.

I have always enjoyed running short distances. It's a fairly efficient work out for someone who doesn't have a lot of free time and it allows me to listen to loud punk rock music without anyone interrupting me. But I have never attempted longer distances, probably my longest previous run is about 4 miles. After two months of training though, I completed 9 miles yesterday, no stopping, no serious injuries (unlike Ben). It is so amazing to me that somehow I was able to actually do this. I never imagined it possible and I still have doubts that I will be able to stick with this without something getting in the way.

So assuming no injuries, we'll be running the 2008 Vancouver Marathon in May.

What did you get for Christmas?

2007-12-25T20:54:00.000-08:00

Seattle got unexpected snow for Christmas. Me and Mrs. Sour Puss went for a walk and I slipped and fell dramatically right on my ass in slow motion. It was pretty hysterical.

I got to watch my 90 year old grandmother discover video iChat thanks to the MacBook I gave to my sister. Pure magic talking to her 3000 miles away, she was absolutely astounded that the video phone had finally been perfected.

I got to watch the entire Lord of the Rings trilogy thanks to the paging operator forgetting that I was on call. There were no serious problems that I missed and by the end of Return of the King I was crying like a fucking baby, just like I always do. My wife made fun of me, just like she always does.

I got new slippers, a Star Wars Lego kit (my mom has been doing this every year since I was 20), and the book Schulz and Peanuts.

Train wrecks

2007-12-18T21:22:00.000-08:00

I've never shied away from taking care of difficult, complex patients. In fact, at my hospital, I am known for it. Some doctors won't take referrals from me any longer.

Of course, my acceptance of these challenges is not without some reluctance and it doesn't stop me from complaining about all the train wrecks that appear on my schedule daily. This year, we had a pumpkin carving contest and my clinic manager put an engineer's cap on top of my pumpkin. Chronic pain, out of control psychiatric problems, overweight diabetics that won't do a thing to help themselves, these are the things that keep my job interesting. But today I saw an actual train wreck.

Receptionist: "Dr. Sour Puss, I have Mrs. McLucky-as-hell on the phone. She said she was hit by a train."

Me: "Um, maybe we should refer her to the Emergency Room?"

Receptionist: "She says it happened last night."

Me, sighing: "Alright, work her into the afternoon."

Near Harbor Island in Seattle, there's a train that does nothing but move shipping containers back and forth, at about 5 miles per hour. Somewhere on Marginal Way, this train moves within 4 feet of a bus stop where my patient was standing talking on the cell phone, oblivious to the 30 tons that were bearing down on her. Fortunately, she only got knocked about 3 feet into the road and her injuries were limited to some nasty bruises on her back. She got a few more than her usual monthly allotment of Vicodin but there was no permanent damage.

When I was a resident in the county hospital ER, I saw a different sort of train wreck. Harborview Hospital is the only level one trauma center for Washington, Alaska, Idaho, Montana, and Wyoming. We got the radio call mid-day one Saturday that some poor depressed teenager in Idaho had tried to kill himself by laying down on a train track. He survived, and was basically fine, neurologically intact, but his face had been completely destroyed.

"They said 'destroyed'?"

"Yep, had to intubate by following the sound of the air bubbles. They're sending him up here by Airlift to have plastics take a look at him, he'll be here in 4 hours."

The ER was weirdly quiet for the next 4 hours, all of us I am sure wondering how we would handle seeing this kid when he arrived. Right before he landed, things picked up with the usual Saturday night shootings, car accidents, drug overdoses to keep us busy and since Mr. Faceless was "medically stable" I never got/had to see much of him before the Plastic Surgery team whisked him upstairs.

Getting hit by a train is sometimes a minor injury, but usually not.

First post!

2007-12-17T16:04:00.000-08:00

How does one create a first blog post? I mean, presumably no one is going to read this, right? CJ suggested I start off with a picture of a cat and that seemed reasonable.

I freely admit that half the reason I am doing this is to boost my cred over here, where currently my user profile points to the website for Elmer's glue. Plus, many of my more ranty or yahooish posts keep getting deleted with the instructions to GYOFB. So there, I GMOFB.

I thought it might be nice to have a place to vent my frustrations and observations on life as a primary care doc. I realize no one cares, but a busy 12 hours in the clinic and the hospital can put a lot of crazy ideas in your head and honestly, I think Mrs. Sour Puss is getting tired of hearing it. Not that she would ever say so. I am actually not a terribly bitter person, just vocal. I am frequently surprised when people point this out to me.

I spend a fair amount of time reading other people's blogs and I suspect I will link to things that are stated much better than I might be able to articulate. In the coming weeks, I expect I will write about training for my first ever marathon in May of 2008 as well as my upcoming trip to India in January.

Finally, I am hoping to link to some of my band's extremely amateurish recording. In my free time, I am an avid practitioner of the rock music and when I am not messing around on the computer, I am usually messing around in the basement with amplified musical instruments.