SPOKEN LIKE (BY) A TRUE PORTLANDER

The other night when I was reading Nicholas bedtime stories, we came to a picture which resembled that above. Mind you, he is not a botanical savant like he is a zoological savant, but I asked him what flower it was. He gave me a puzzled look, even though he has seen sunflowers before. I gave him a hint- "It is something that is up in the sky." He quickly responded, "A cloud... a cloud flower." I said no and reminded him that there is a big yellow object in the sky by another name for at least half of our year here in the Northwest. With that, he nailed it- a sunflower.

I think we will be going to California for vacation this winter... southern California.

Merry Christmas!

ZOOLOGY

So how do I know my son will be a zoologist one day? Let me set the scene for you!

5:45 AM on a cold, dark morning in Portland, OR. Our minor character (aka me) is in the bathroom shaving and getting ready for an early meeting at work. There is a knock on the door.

Nicholas (having just awoken): Excuse me! Daddy!

Me (opening the door): Yes. How may I help you?

Nicholas: How do the zookeepers get the polar bears into their cage? How do they check on them once they are in there without getting hurt?

Me: They likely give them a shot that helps them sleep. Then, they move them into their new home or they do their examinations on them.

Nicholas: Oh... okay. Thanks dad!

Now do you understand the junior version of Jane Goodall that we have on our hands?

THE LONE STAR STATE

We were in Texas last week visiting family, and Kathleen attended the San Antonio Breast Cancer Conference. A few thoughts about the Lone Star State.

Indeed, everything is bigger in Texas. The portions in restaurants and at my mom's house were huge, and after meals I felt as though my stomach had shrunk or that I had, indeed, stuffed myself silly. The germs are also bigger and more virulent as 3 out of 4 of us got the "barfing illness" and diarrhea, and Cate got an ear infection requiring antibiotics. So much for R & R.

People are friendlier in Texas. Everywhere we went, people were very kind and polite even if most of 'em were Republicans!

The weather can blow in Texas, too. It was cold and overcast the entire trip... except for the day we left when it was 70F and sunny. Ugh! Maybe next year Texas will be back to its normal, mild winter self!

Sprawl is the rule and not the exception. Texans never met a transit initiative they did not vote down and never met a suburb they did not want built... especially in North San Antonio. 2 words for you- light rail- get one!

My family is all in Texas, which is to say that I will be back for more..., but only after they make the trip up here first!

P.S. Do not get me started on air travel with our beloved one year-old!

THE FINAL VERDICT

So, one of the great things about my day job is that on Tuesday afternoons I have the privilege of taking care of patients with prostate cancer. It is not always easy or uplifting, but it is always a pleasure. These men and their families allow me to enter into their lives and to guide them through the journey known as incurable cancer. They each bring their life experiences and values to the table, which makes each person and each "case" so fascinating. It is entirely human and entirely epic and that is what drew me to Oncology (Think a Camus novel on a weekly basis).

Today, I saw back a patient, a retired judge, whom I had not seen for about 2 months. He had metastatic prostate cancer that had progressed despite multiple treatments directed at interfering with levels of male hormones, which act as fuel in prostate cancer cells. He had quite a bit of left hip pain this summer and early fall, and we had radiated his hip on two occasions with minimal relief. It was at that point that I strongly advised him to try chemotherapy, which essentially is chemicals that target quickly dividing cells, including cancer cells, too, we hope. The Judge was not interested in chemotherapy at that time, as several of his friends who had died of cancer had been treated with chemotherapy. Mind you, they died of their cancer rather than side effects of the chemo, but the Judge, who realized this, felt like the side effect profile of chemotherapy outweighed any potential benefit. He sought another medical opinion and had been doing well until this weekend when he developed pretty severe pain in his opposite hip. He called the clinic and made an appointment to see me.

We discussed my concern that the cancer was growing in new places and likely causing his symptoms. He expressed understanding but still seemed hesitant to try chemotherapy. This case seemed closed, if you will, in his mind. It was at that point that I recalled an article by Jerome Groopman, the oncologist and writer from Beth Israel Medical Center and Harvard Medical School, whose pieces I have read in the New Yorker for years. I remembered one article in particular, which was later published in his book "The Measure of Our Days," when Groopman tried to help a patient, who was a businessman, decide on treatments by describing the options in financial terms. My patient seemed to have made up his mind and had been prejudiced by his friends' unfortunate experiences and the modest palliative benefit for the average person in prior clinical studies with this type of chemotherapy.

I apologized for potentially sounding like a cross-examining attorney, but I asked him to objectively weigh the evidence- I explained to the Judge that yes there are possible side effects and harms of chemotherapy but that these needed to be weighed against the certainty of harm with doing no treatment. In essence, I asked him to put back on the robe and serve as judge of the case of his life. I asked him whether something that had once seemed heinous (early days of chemotherapy) could have possibly improved or reformed over time- whether it deserved a "second chance?" What was to be gained or lost by treatment versus observation, I questioned? What did his internal law tell him?

I told him the answer was not to be found in a medical journal or textbook. It was not to be found in his head. The verdict, by which I was prepared to stand, was only to be found in his heart.

SAVING THE BEST FOR LAST

(One of) the best parts of my day, which comes at the end of the workday, is when I pick Catherine up from daycare. When she first spots me (or Kathleen), she, in what can only be described as a sprint, sprints over to us to be picked up in our arms. Cate has a determination in her eyes, which is astounding; we actually argue over who gets to be the one to go into the Toddler room to get her when we carpool because it is such a sight.

She is clearly someone who is not easily dissuaded from achieving the things to which she sets her mind and who is deeply intense... at age 13 months. And BTW, she is also super cool!

SPOKEN BY NICHOLAS TODAY

After placing a penny in a "wishing well": "I wish daddy (who was at a meeting) could be here right now!"

On the way home from Seattle: "I wish our house was closer to Seattle so we would not have to drive so long to visit the zoo."

When asked why he liked Seattle more than Portland: "My bed (i.e. the couch in the Residence Inn, where we have stayed multiple times) is very soft in Seattle."

ELECTION NIGHT

Tonight, Nicholas said to me, "Dad, why are you not downstairs watching Barack Obama on TV? It is election night, right?" Mind you, I have no idea how he knew it was election night, but my fervent following of last year's election clearly made an impact on him. Maybe someday he and I will grab our popcorn and sit in front of the tube on primary nights, Convention night, and election night. I can only HOPE so.

ANIMALIA

One of Nicholas' first loves is animals. He has always had an affinity for animals even though we have no pets and no plans for pets...ever. I remember when he turned one, and we took him to the National Zoo in D.C., where they were holding a birthday celebration for another one year-old named Tai Shan, a baby panda. While he surely cannot remember that day, Nicholas speaks fondly and evocatively of that day. This, no doubt, is due to the fact that he has asked us countless questions about what we saw, what the day was like after he learned of that trip. Simply put, he has a photographic animal memory.

This is best exemplified during our trips to the zoo. When I exclaim, "It's a wild boar!" He will correct me and say, "No dad! It is a Visayan warty pig...obviously!" He seems to really thrive on studying the animals and has memorized all kinds of crazy facts about them- "Did you know______!" I can envision him as a very driven and delighted biologist one day.

In addition to his encyclopedic knowledge of animals, Nicholas has also amassed quite a collection of animal figurines. He probably has figurines for 50-75% of the animals he has ever seen, and the kid has been to a lot of zoos: the Oregon Zoo, National Zoo, San Antonio Zoo, Austin Zoo, Como Zoo, "New Zoo" in Minneapolis, San Diego Zoo, Seattle Zoo, and the Vancouver Zoo. He pretends that some of the figurines he has are the ones he does not have, and he often makes it known which animals he lacks ("I don't have a ___!")
Several weeks ago, we decided to bite the bullet and stop putting a pull-up on him at night. We told him after the first "dry" night that he would get a sticker every morning that his underwear was dry and that once he got to 30 stickers, he could get a new animal. He had recently watched a National Geographic video about the African savanna, and he fell in love with the Cape buffalo (see above). He said he wanted that... for sure. I could not find one in any of the stores, but I finally found one online and ordered it. One week ago, it arrived. Nicholas still does not know that we bought it for him and is uncertain if we will be able to find one.

Tonight, after I told him how proud I was of him for being such a big boy, he said, "Dad, it's okay if you cannot find me a Cape buffalo. I can pretend my longhorn is a Cape buffalo!" I was so moved that I almost marched downstairs and brought the buffalo right to him, but I decided not to. It will be much sweeter after he makes it through the month without having an accident and "earns" it. While this feat will represent one more step away from childhood (sniff, sniff), it is to be celebrated. These are the moments that remind me why I am one of the luckiest men (and dads) on Earth.

HALF THE SKY

Little Cate had her first birthday last Wednesday. It is hard to believe how quickly time has passed since her birth on that glorious Fall day last October. She is one of the most spirited people whom I have ever met, and she seems to be someone who feels as though we are incapable of comprehending what all is going through her head. Her teacher at daycare said that Cate thinks she is 2 years old and that she might just be 2 years old, intellectually. I have a sense that she is going to (already is) be one precocious kid. While "glass ceilings" surely do still exist in this country in 2009, I believe that Cate, herself, and the loftiness of her dreams and ambitions will be the main determinants of her success. Unfortunately, in most of the rest of the world, women and young girls face much more dire obstacles.

No one has written more extensively and persuasively on this topic than Nicholas Kristof of the New York Times. His columns that appear twice per week in the Times serve as a bully pulpit for the world's forgotten and oppressed. He and his wife, Sheryl WuDunn, with whom he shared a Pulitzer prize for their reporting from China during the Tienanmen Square crisis in the early 1990s, have a new book out called, "Half the Sky," which is a discussion about how oppression of women worldwide (and especially in the underdeveloped and developing world) is the challenge of our time. The title is taken from Chinese proverb that says, "Women hold up half the sky," which stresses women's importance to us all. Improving the lot of women in the 3rd and 4th worlds is not just a moral issue, in Kristof's mind, it is also an economic and national security imperative. I have only read the first few chapters, but I can say already that if you only read one book this year, read "Half the Sky."

Last night, I had the good fortune to hear Mr. Kristof, who is a native of Oregon, speak and discuss his views on the world and on the plight of women worldwide. His stories from his encounters with the world's oppressed will break your heart, but in every account, there is some measure of triumph and some kernel of hope. He also rouses his readers' consciences to think beyond our own comfortable existences and to contribute to improving our world one person at a time (you, too, can get involved by going here). At the end of his talk, he took questions from the audience. Some 10 people asked questions, some of which were self-serving (my non-profit www.fillintheblank.com....) while others were polemical ("Don't you, as a man, feel hypocritical writing a book about oppressed women?"). I, too, felt the need to express myself, so I arose from my seat on the 4th row and strode to one of the two microphone stands and took my place in line behind an elderly woman. When it was my turn, the moderator announced that mine would be the last question of the night. Of note, the moderator had clearly stated at the beginning of the Q and A that "the best questions are... actual questions." I spoke into the microphone that I had both a comment and a question (probably a few snickers were heard). It went something like this:

"First, I want to thank you for coming to Portland. Your writing and your work disprove the adage that one person cannot make a difference and that one person cannot change the world. (Applause...) You are in a town where 90% of the populace voted for Barack Obama, and I am not sure if this is an issue of news coverage, but why has this President not been more out front on the issue of global oppression of women? We give billions of dollars annually in economic and military aid to many of the chief offenders. We can send 40,000 more American men and women to fight in a war, or we can build 40,000 schools to truly try to make our world a better and safer place (Raucous applause). What are your thoughts?"

Mr. Kristof thanked me for my question and said it was a good one on which to end. He replied, that he thought that there had been bright spots in the first 10 months of the Obama Administration and that this Administration's good works had not been sufficiently covered in the press, but he did go on to say that we must hold the feet of our leaders (and particularly those whom we admire and worked so hard to elect) to the fire. He said we should demand as much of them and expect as much of them as we did of former President George W. Bush. He said that the US has the power to lead on this issue, but it will only happen if we force our elected officials to lead in this crusade to improve the lot of women worldwide.

After the talk, I went up to him and shook Mr. Kristof's hand. I told him that I was an oncologist and that, in many respects, my work also allowed me to experience both tragedy and triumph every week and that I understood the joy that he derived from his work which took him into some of the darkest places, figuratively and literally, on this earth. The hopefulness that underlies his work (and mine and the attitude I want both my children Cate and Nicholas to espouse) was best captured in an anecdote he shared during his talk about the story of a young man who was walking on a beach scattered with starfish. The young man proceeded to throw some of the beached starfish back into the sea. An older gentleman, who was also standing on the beach, said to the young man, "There are thousands of starfish. Throwing a few back cannot possibly make a difference." The little boy, as he threw another starfish back into the sea, said, "Tell that to this starfish..."

SOMEONE TO WATCH OVER ME

So, whenever I leave the house without Nicholas, during his waking hours, he insists that he follow me outside (weather be damned, darkness be damned) in order to watch me leave. Mind you, he does not want to do this from the front door or even the front porch. He likes to stand on our sidewalk to watch me run off or drive off. At times, it is a little painful to get him dressed or help him use the bathroom prior to having him come out and watch me depart, especially when I am (invariably) running late.

Once we get outside, he always runs up to me, prior to my leaving, to ask, "Which way are you going to go, daddy?" I am struck by how sweet this is and how one day he will grow tired of this ritual and will eventually find his old man uncool. However, these moments (and when I write this blog) remind me how lucky I am to be his dad and to be his friend. That, I will always cherish.

THE AUDACITY OF HOPE

Today, I met with the wife of one of my late patients who died this summer after a very long battle with prostate cancer. The appointment was arranged by our social worker, who thought that bringing Mrs. __ back to meet with her husband's providers would be therapeutic for her. Mr. __ had been diagnosed with metastatic prostate cancer over 10 years ago and had responded very well to initial treatment until I met him a little over 2 years ago. Mind you, the average life expectancy for patients with cancers like his is about 3.5 years. During the course of his various treatments under my care, his wife always accompanied him to his appointments, and she kept him honest by not allowing him to downplay side effects and symptoms. I could tell that they had a very loving marriage by the fact that they seemed to "bicker" in a very endearing way during their visits.

For much of the visit today, we just sat back and listened to her recount the tale of Mr. __'s final days. She spoke freely and without prompting about the symptoms he experienced and about how he did not seem to be in pain at the end. She was tearful through much of the visit and became quite upset near the end of her account when she described how Mr. __ had stated that he had wanted to die at home but that he had become very short of breath before his passing, which prompted her to call 911. The paramedics arrived, and he was taken to the hospital, where he eventually passed away within several hours. She had been married to him for 40 years, had given him 3 children, had been with him for every step of his journey with cancer, had given him his medicines, advocated for him with his doctors, and served as his primary caregiver when he went on hospice, but she said she felt as though she had violated his dying wish to pass away at home and hence had let him down. She thanked us and said she felt blessed to have us care for Mr. __ and her, but I could sense that she felt as though he had died in vain.

I wanted Mrs. __ to know that her husband's life and his death had great meaning to all of us in the room. When I see patients like him, invariably they have read the statistics and know how grim their prognosis may be. They are looking for hope- not false hope, but the possibility that their cancer may not take them too soon, that they might make it to their 12 year-old son's high school graduation or their 21 year-old daughter's eventual wedding...someday. I always bring up the outliers, like Mr. __, with these patients, and I know it provides them some relief. Although he never knew it, Mr. __'s course has brought solace and hope to innumerable patients whom I have encountered since meeting him. I shared this with Mrs. __ today because I thought she needed to know what her husband's resolve, strength, and his story meant to me and to countless other patients today. I thought she deserved to know that today.

Afterwards, we hugged and held each other tight, with no attempt to fight back the tears, and no other words were necessary.

AND SHE'S OFF

Little Cate started walking recently, and there is no stopping her now. Here is one example of her new-found ambulatory skills.

THE TRUE FACE OF HEALTH CARE REFORM- UPDATE

I was informed by our Social Worker that Mr. W. qualified for a subsidy by my hospital, and he was eligible to receive his anti-cancer treatment one day later. Safety nets such as this help seal some of the many cracks in our health care system, but they are band aids and do not apply to the 40 million Americans who lack health insurance of any kind.

You can share your own health care (horror) stories at the Obama administration's health reform site.

THE TRUE FACE OF HEALTH CARE REFORM

I was confronted by the tear-strewn face of a patient's wife today. I had spent 30 minutes explaining to the patient, Mr. W., and his wife that he needed to start shots to lower levels of testosterone, which acts like fuel for prostate cancer cells, because his cancer had recurred and was growing rapidly. That discussion and an in-depth overview of the many side effects of this form of medical castration drew no tears. It was only after the couple who has Medicare, without an insurance supplement, were informed by the clinic that their 15% share of the cost of these $4000 shots, given every 3 months, was $600 that a handkerchief was necessary. They were not able to afford this shot as they are on food stamps currently and have exhausted their savings. They left without receiving this non-curative, but life-extending and symptom-reducing anti-cancer treatment today.

The 'birthers,' 'tax patriots,' and Republican Congress talk about health care reform as an affront to humanity, as a form of socialism, and as the end of civilization as we know it. They see Obama as the enemy... as the Joker... as a shadow of themselves. They do not get it or are blinded by their own racism or desire to see the President and the Democrats fail.



Anyone who has had a recent medical bill or a serious medical illness, whether or not they have insurance, clearly understands and can explain the fierce urgency of now when it comes to health care reform. The aforementioned opponents of reform need look no further than Mr. W and his wife's tear-strewn face (and their own faces in the mirror) to see the true embodiment of those whom our medical system and society fails everyday.

A HAPPY MARRIAGE

Last night I finished reading the new novel by Rafael Yglesias entitled "A Happy Marriage." It is easily the best book of 2009 and perhaps the best book I have read in the the past decade. You may have heard about this novel on NPR, which details a couple's relationship over thirty years. The main character Enrique Sabas, like the author, published a novel as a teenager and is a screenwriter, and the novel details the lives of Enrique and his would-be wife Margaret Cohen, who eventually comes to struggle with cancer. Of note, Mr. Yglesias was married to the artist Margaret Joskow for thirty years, and she passed away of bladder cancer in 2004. It is hard not to speculate that the events which unfold in this book are largely autobiographical, but Scribner and Mr. Yglesias clearly offer this book as a work of fiction. Only Mr. Yglesias knows for certain what details from the book actually occurred and which are fictional, but the reader is allowed a sneak peek into Enrique's and Margaret's life.

The book shifts alternately between the past and present in the lives of this couple. In doing so, the author takes the reader on a roller coaster ride of a marriage. Through much of the novel we are left to wonder whether this truly was a happy marriage, and the question of what it means to love someone remains unanswered to the protagonist and the reader until the very end. The protagonist, Enrique, is what gives this book its life and its verity, and I cannot recall another literary figure with whom I have felt a greater kinship. This book, more than any I have ever read, made me think about my own upbringing, my own choices, my own shortcomings, and my own marriage and family. I also thought a lot along the way about the difference between pleasure and love.

Pleasure is a state of gratification due to another person- being with someone who always has the witty quip, the seemingly flawless body, the ostensible disinterest in anything outside of you. This is something that is commonly experienced early on in relationships- think the third date after the incompatibles have already been weeded out in favor of the possible soul mate and the nerves have been calmed since the first date (see "A Happy Marriage"). This state, like that engendered by a good drug, is utterly euphoric but also unsustainable. As one spends more time with an individual (dating, marriage), the whole of a person is exposed day in and day out. One might call this revelation a person's true self, but that would seem to suggest that early interaction between two people is mere play-acting. I think this is an oversimplification. People are complex. They want to be accepted before they allow themselves to reveal the parts (which are no more "real" than those initially divulged but) which are less likable.

Love, on the other hand, is a state of affection for another person in many cases despite that person and their needs or shortcomings. Anyone can find the character in the romantic comedy (think Zooey Deschanel in "(500) Days of Summer" or Julie Delpy in "Before Sunrise") winning, but in our day-to-day relationships which are often suffused with disagreements, differences of opinion, diapers, and an utter dearth of emolument, it is easy to feel unfulfilled. Show me someone with a long view of relationships who can still appreciate and enjoy the person with whom they share that quotidian, seemingly banal existence, and I will show you love.

I suppose what drew me in to Enrique Sabas and Margaret Cohen was the fact that Mr. Yglesias wrote a book about what he knew best- love, life, loss, and longing (but not necessarily in that order). In this blog, I have attempted to write similarly, perhaps with some success, because to write about that which one does not know or does not feel rings hollow and offers no comfort to the soul (one's own or one's audience's). In that sense, there is no more profound book than "A Happy Marriage," which revealed to this reader how lucky he is/how flawed he is and exactly what the definition of a happy marriage is.

In a book review, i.e. plot synopsis, from the New York Times, the critic Dinitia Smith stated that in this book, "he (Yglesias) has found the novel of his life." Her words refer less to Mr. Yglesias' "autobiography" than to his achievement. I leave you with a passage from "A Happy Marriage," which I found to be particularly poignant. I hope to not lose sight of these words and this book in my own daily life with my wife, my children, my family, my friends, and my patients, but Mr Yglesias has done his part to make forgetting these truths quite difficult.

"In that pre-dawn twilight, returning from his father's death to the life of his wife and children, he had a dim consciousness, saw a faint outline of the rampless bridge between birth and death, and death and birth, that people traverse all their lives convinced they are on a highway to somewhere new."

A MAN FOR ALL SEASONS

Today, we lost Senator Edward M. Kennedy, aka Ted Kennedy. He was a giant among men, and he earned the nickname "The Lion of the Senate" after 46 years of service. My first exposure to politics and Democratic politics (capital D) was through my father. He revered the Kennedys and often spoke of the time during college when he shook President Kennedy's hand. To him, the Kennedys represented everything that was great about America- a family of Irish Catholics who worked hard, made the highest sacrifice with their public service and their own blood, and who never ceased to look out for the little guy despite their station in life.

While Teddy was considered to have the dimmest prospects of all the Kennedy boys for success, his contributions to Americans and people the world over may have been the most profound of any of his family. The list of his legislative accomplishments is far too long to review here tonight, but they include: S-Chip, the Voting Rights Act, OSHA, Americans with Disabilities Act, and No Child Left Behind. He was also able to work across the aisle, and I was struck by the tone and words of comfort expressed by Republicans today after news of his passing. Despite that, he was a liberal through and through, and he was one of the few Democrats to vote against authorizing the Iraq War in 2002- how prescient.

He knew how to give a great speech, and he will go down as one of the greatest orators of our time. Who could forget the eulogy after RFK's shooting, the concession speech at the 1980 Democratic National Convention, and the addresses at the nominating conventions for both John Kerry in 2004 and Barack Obama in 2008? He was America's senator and the face of the liberal wing of the Democratic party. Teddy is, to a great extent, why I am proud to call myself a liberal, and why I always viewed it as a compliment whenever a conservative critic attempted to malign Barack Obama or another candidate by saying his legislative record was to the left of Kennedy.

While his dedication to public service is unmatched in the modern era, he also had his own personal failing including an episode of cheating while at Harvard, a role in the death of a young woman at Chappaquiddick, struggles with his weight and alcohol abuse, and rumors of womanizing. It was those failings that were brought to light in real time, which made Ted Kennedy the most scrutinized Kennedy of his generation. It was also what made him seem the most real of any of that dynasty and what endeared him to many of his constituents and Americans whose lives were affected by similar problems.

The political scientist Norman Ornstein put it best today when he said about Teddy, “He was a quintessential Kennedy, in the sense that he had all the warts as well as all the charisma and a lot of the strengths. If his father, Joe, had surveyed, from an early age up to the time of his death, all of his children, his sons in particular, and asked to rank them on talents, effectiveness, likelihood to have an impact on the world, Ted would have been a very poor fourth. Joe, John, Bobby ... Ted. He was the survivor. He was not a shining star that burned brightly and faded away. He had a long, steady glow. When you survey the impact of the Kennedys on American life and politics and policy, he will end up by far being the most significant.”

You will be missed Teddy...

THE MUSIC MAN

This is a video of Nicholas participating in a "Toy Symphony" with the Portland Symphony Orchestra from Laurelhurst Park in Portland on 8-15-09. It speaks for itself.

AIN'T NO MOUNTAIN HIGH ENOUGH

This past weekend I read, from start to finish, the book "Mountains Beyond Mountains" by Tracy Kidder about the physician Dr. Paul Farmer. The book chronicles the story of Dr. Farmer from his childhood, to his work as a volunteer and student of anthropology in Haiti, to his days as a medical student, resident, and fellow in Infectious Disease in Boston, and to his numerous pursuits to rid the world of suffering, particularly in the poor. I had first heard about Farmer from an article in the New Yorker many years ago. It was one of those classic articles in the magazine that goes on forever, but which is entirely compelling. I had the good fortune to meet Dr. Farmer and to go on rounds with him at the Brigham and Women's Hospital in Boston when I was a visiting Chief Resident there in 2002. Unfortunately, I joined the team near the end of rounds, but I found Dr. Farmer to be both incredibly personable and captivating. His belief in the primacy and divine right of health care is enunciated best in this piece from NPR's "This I Believe" series.

Farmer's work with the poor in Haiti is the focal point of this book, and much of the focus is on the hospital Dr. Farmer helped build in Haiti called Zanmi Lasante, Creole for Partners in Health, which is the name of Farmer's global health non-profit organization. In the book, Farmer quotes from Virchow to summarize what motivates him, "Physicians are the natural attorneys of the poor…and social problems should largely be solved by them." This book and this quote reminded me of the patients I served during the course of my early medical training, which took place in county hospitals in Houston and Dallas. In both cases, these hospitals were the only place the poor in these communities could get quality medical care. Particularly in Dallas, however, I still feel as though the level of emergent or inpatient care these patients received was among the best in the world due to the drive and passion of the physician residents and attendings who worked in Parkland Hospital. What we lacked, however, was easy access to outpatient care and services and a system of community outreach to help patients improve their lots in life (educational services, social services, job training). Without the latter, can a patient or a population truly thrive? The answer, in my experience, as I saw the same patients present with the same problems over and over (congestive heart failure exacerbation due to the fact that salty canned foods were more affordable than fresh vegetables, asthma exacerbation because steroid inhalers were too costly or because of the poor air quality of the inner city, etc, etc) was clearly no.

I read a review of "Mountains Beyond Mountains" by Abraham Verghese after I finished the book, and in it he describes Kidder's book the following way:

''Mountains Beyond Mountains'' is inspiring, disturbing, daring and completely absorbing. It will rattle our complacency; it will prick our conscience. One senses that Farmer's life and work has affected Kidder, and it is a measure of Kidder's honesty that he is willing to reveal this to the reader. In 1987, a book called ''And the Band Played On'' changed the direction of my career and that of many physicians of my era who decided to devote themselves to the care of persons with AIDS; I had the same feeling after reading ''Mountains Beyond Mountains'': that after I'd read the book something had changed in me and it was impossible not to become involved."

I had the same sense after I turned the last page of Kidder's book, and I find it quite impossible to sit on the sidelines and to not work, in some small way, to ease the vast suffering which plagues our world. The mountains out there may be high and the troubles that the world faces may be vast, but is there a more worthy endeavor than helping those who are less fortunate? I leave you with a quote from my hero Albert Camus, which summarizes Paul Farmer's life and his life's work:

"I leave Sisyphus at the foot of the mountain! One always finds one's burden again. But Sisyphus teaches the higher fidelity that negates the gods and raises rocks. He too concludes that all is well. This universe henceforth without a master seems to him neither sterile nor futile. Each atom of that stone, each mineral flake of that night filled mountain, in itself forms a world. The struggle itself toward the heights is enough to fill a man's heart. One must imagine Sisyphus happy."

WORDS BY WHICH TO LIVE

If you ever want a good dose of fear, become a doctor or a parent. I have certainly had some very scary moments during my medical career and most of them involved young patients (unlike my current practice of prostate cancer patients) who had very serious but potentially reversible illnesses (e.g. a 20 year-old asthmatic to whom I gave medicines to paralyze him, in order to facilitate placement of an endotracheal tube and mechanical ventilation, whose vocal cords I could not quite visualize for 60 seemingly interminable seconds in the middle of the night during residency, a 27 year-old whose fruity breath from across the room, due to the accumulation of ketones, and whose slow, deep Kussmaul's respirations betrayed a diagnosis of new onset diabetes and life-threatening ketoacidosis, and my own son whose audible wheezing and shortness of breath at the age of 5 months taught me to respect the virulence of Respiratory Syncytial Virus. I cite these examples not for dramatic effect but rather to highlight the incompatibility of life with inadequate oxygen content, abnormal pH, or inadequate perfusion of one's tissues.

Last night, I had a scare of a very personal nature. Little Cate had been having loose stools for about 4 days. She had been drinking okay, but her appetite for food was poor. Yesterday, however, she began to refuse even bottles while her diarrhea continued. A babysitter watched her during the day, and when I returned home, the sitter said she had not had any wet diapers, although she had had plenty of loose stools. To anyone in the medical field, there are a few simple nitrogenous credos, "no urine, no life," "urine is golden," etc, etc. I feared that she was severely dehydrated and that she would not be able to make up for her GI losses by taking food or drink by mouth. Thus, I threw her in the car and headed to the ER.

I was met by Kathleen and Nicholas there, and we were quickly taken back to a room. The nurses attempted to stick the little one for blood work and placement of an IV. First try, no success. At that point, I decided to take Nicholas out of the room in order to not make his rejection of the medical profession 100% certain (currently at around 99%). We came back in 30 minutes, and 3 additional tries later there was still no IV access. Cate took a few sips of water, and the senior nurse suggested we simply encourage her to drink more and re-assess in 1 hour. Mind you, I am a pretty diplomatic guy and physician, but I flat out told her that that was stupid. The patient was clearly volume-depleted and had not been taking enough in by mouth for several days. No amount of oral consumption was going to ameliorate the situation... fast enough. I told her that we needed to try again. A different nurse was called in (it is funny but the best nurses for procedures always seem to have some goofy article of clothing, and this nurse was no exception in his Sponge Bob tie over his scrub top). He was able to secure an IV and obtain labs after his second attempt, and the re-hydration commenced.

I took Nicholas home after that and Kathleen stayed with the baby, who was admitted to the Peds unit. Little Reese (Cate's middle name) was kept overnight, and about 7 hours after IV fluids were started, she finally made urine and wet her diaper. I was not aware of this until this morning... after a night of little sleep and much worry. I have never been so happy to hear that she needed a diaper change; again, urine is golden! Cate was discharged today and is taking food and fluids better. Although her illness, a case of Enterovirus gastroenteritis, has not completely resolved yet, we expect it to run its course in the next few days.

I suppose I never realized the parallels between medicine and parenthood, both of which should be about helping people by identifying problems and their gravity early and then instituting the appropriate courses of action to solve/prevent said serious problems. This may be encapsulated in a simple phrase from the Hippocratic Oath- "First, do no harm!" Harm can occur as easily through acts of omission (not placing the IV for a clearly dehydrated child or not teaching one's children about safe sexual practices) as it can by acts of commission (performing an unnecessary procedure, which leads to a poor outcome, or spoiling one's children). The answer in this situation was not to take an inferior course of action, a seemingly easier course of action, and to hope for the best; we all knew the baby needed an IV, but it's placement was not easy given her dehydrated state and poor veins. The answer was to do the right thing, the hard thing, which was the only tenable solution to the problem. That is how I have tried to practice medicine, and that is how I try to raise my kids. "First, do no harm!" Words by which to live.

A WORK OF ART

"A guilty conscience needs to confess. A work of art is a confession."
-Albert Camus



One of the most important things in life, if you ask me, is art. Whether it be music, painting, literature, or even dance, art has the ability to transform the way one feels and thinks. The foundation of much of civilization has rested upon cultivation and appreciation of art, and I can identify with that. I am not sure exactly when an interest in art developed in me, but I love most modes of art.

My favorite art form is music, mainly rock but also classical, bluegrass, world music, etc. My friends have been instrumental, no pun intended, in turning me on to various bands- the Smiths, Soundgarden, Martin Sexton, Jeff Buckley, etc. However, I discovered one of my current favorite bands, Bon Iver, all on my own. The lead singer is Justin Vernon, and their album "For Emma, Forever Ago" was hailed by many as the best record of 2008. I could not agree more. A clip of an impromptu a cappella performance of their song, "For Emma" in a hallway in Paris may be found here.

This song never ceases to amaze me or move me, and I think it is because there is a confessional quality in Justin's words and notes. I do not know exactly who "Emma" is, but I feel like I know her. Perhaps that is the true measure of great art- reaching the audience and bringing them into the artist's world while they also bring the artist into theirs.

A "JANUARY PICK"

One of the people about whom I have not written extensively in this blog is my wife Kathleen. We met a little over 10 years ago in January, 1999 when I was an intern and she was a 3rd year resident in Dallas. She was very good friends with my senior resident, and she stopped by our team room to talk to her friend one day. (Of note, when I interviewed in Dallas as a 4th year medical student, about one year before that, I went on rounds with her team, although she and I did not really converse at that time. I do remember thinking she was cute, though). That day, in the rounding room, when we met for real, I realized we had several common interests: running, movies, and a love of literature. I had started a book club as an intern for the express purpose of meeting women, so of course I asked Kathleen to join us. We were reading "The God of Small Things" by Arundhati Roy. Shortly thereafter, we started going out, and on our first date Kathleen was at my place and asked me if she could use my phone for a long distance phone call. I said yes, and she called her future boss, Craig Nichols in Portland, to accept a Heme-Onc fellowship position for 1 year from then. Neither of us expected that our relationship would progress to anything substantial in that time frame... or so we told ourselves.

However, as we continued to date and the time came for Kathleen to move to Portland, it was clear that we had strong feelings for each other. We decided that Kathleen should still go, but we decided to make a go at a long distance relationship. The first 2 years were spent between Portland and Dallas, but in the final year of our separation, I was in Baltimore for my own Heme-Onc fellowship. I guess 1/2 a continent apart was not enough of a challenge for us! We somehow survived those 3 years apart with a mixture of nightly phone calls and Q4-6 week visits. Nonetheless, I would not wish a long distance relationship on my worst enemy. Anyway, Kathleen relocated to Baltimore, and we were married shortly before her arrival. We eloped and got married in City Hall in Manhattan. Why NYC? You could say too many Woody Allen movies, but, in our minds, if one is going to elope and get married in a city hall, shouldn't it be in NYC?

We lived together and worked very hard during our first 2 years together in Baltimore; I was in the lab, and Kathleen was in private practice in Annapolis, MD. We spent weekends in D.C., Philly, NYC, or at home. We went running together, biking together (including a hellacious bike trip through the ghet-to, but that I will leave for another time), and enjoyed the company of friends. I knew she was an amazing friend and wife, but I do not think I truly came to appreciate her until the day our son was born, and I almost lost her.

One day past her due date in July, 2005, she went into labor on the way home from a full day on her feet in the hospital. Despite the fact that the July intern on call tried to convince her that maybe she had just an episode of incontinence rather than her water breaking ("um, there were chunks," thank you), we went into the hospital for a prolonged bout of labor on pitocin, which is used to stimulate uterine contractions. Sixteen hours later and after a failed epidural for much of the night (it was finally replaced by an Anesthesia attending before shift change at 7AM- remember folks this is July with new housestaff in the hospital), the decision was made to deliver our child with forceps. He came out, and we were both in tears. Shortly thereafter, Kathleen felt faint; her blood pressure had dropped, and she was having profuse uterine bleeding. The cavalry came in, and she was resuscitated.

I have never been so scared in my life. A lot went through my head in those interminable minutes. How could a moment of utter joy turn into such a nightmare so quickly? How can they not get IV access? Where is the central line kit- I will have a line in in 2 minutes! How can I possibly lose the woman whom I love more than any whom I have known who has just given me a beautiful son? Fortunately, the bleeding stopped, and Kathleen stabilized, but not before she had lost 1/4 of her blood volume. We took our little boy home together just 2 days later, which is a tribute to her resilience- she elected to take oral iron and refused a blood transfusion; I told you she is tough.We have since had another child, little Cate.

I must say that as much as I had appreciated Kathleen before we had children, parenthood has helped me realize how lucky I am to have found her and married her. As much as I love the kids, this is dwarfed by her devotion and selflessness to them. Perhaps this comes from having carried each of them for 9+ months, but I think it is deeper than that. She senses that this is the next phase of our lives together, and (like everything she has done in her life which she has valued: family, science, medicine) she is giving her all to it. The loss of her own mom when she was a teenager probably left her with an understanding that we are here "until further notice" and that everyday is a gift. No one need remind her of that on a daily basis.


This was best exemplified when we were in Vancouver 2 weeks ago. A friend had recommended a great Indian place called Vij's, which is called "the best Indian restaurant in North America." Kathleen dropped me off at the front around opening time for supper while she parked the car with the kids. Miraculously, there was an opening, and I was seated. I quickly discovered by looking around at the decor and clientele that this was not a highchair and kids' menu kind of place, and I wanted to make a run for it. A few minutes later Kathleen arrived with the kids in tow. She sensed my unease, but she just smiled and said that no one was asking us to leave and that it would be okay. She helped entertain little Cate and filled her with Cheerios until she was calm/sated. It was the best Indian meal I have had in my life (sorry mom!): BC spot prawns and halibut with black chickpeas in coconut-lemon curry and beef short ribs in cinnamon and red wine curry with warm greens. Kathleen was right; we all survived the meal intact... thanks to her.

To summarize how I feel about my wife, I turn to a political analogy I heard for the first time last summer when the respective nominees were considering running mates. There was talk of the advantage of various candidates and what they would bring to the ticket. There were "September picks", ones who would provide a huge bounce out of the convention but not necessarily win over voters on election day (see Palin, Sarah and think one-night stand). There were "November picks," ones who would win over a crucial state or demographic group (see Clinton, Hillary and Palin, Sarah in Senator "Hail Mary" McCain's wildest, most drug-addled dreams and think fling), and there were "January picks," ones who might not move a single voter into one's camp but who would allow the President to govern most effectively throughout his/her term (see Biden, Joseph and think partnership). What I have discovered (and which I try not to forget) is that my wife is a "January pick" through and through. While I loved our care-free dating days and newlywed days, her true character, strength, and resolve have been most apparent since we left the B.C. (before children) phase of our lives. Nicholas and Cate could not have wished for a better mom and I a better wife and best friend.

CUTTING FOR STONE

I recently finished the new, debut novel by Dr. Abraham Verghese entitled "Cutting for Stone." In ancient times, "cutting for stone" was the act of surgically attempting to extract mental illness/madness. The Hippocratic Oath, which I, myself, took 11 years ago (has it already been that long?) states that one will not do this. Those Greeks were wise!

I first became acquainted with Abraham Verghese in 1994 when I was a medical student in Houston. He gave a lecture, or rather a reading, from his first non-fiction book, "My Own Country." It is the story of an Ethiopian-born physician of Indian descent who came here on the "cowpath to America" to do residency training in a small, rural hospital in Tennessee populated by foreign grads; he had no other opportunity. He went on to do his Infectious Disease training at Boston University, a pre-eminent center in its time. Subsequently, he returned to rural Tennessee, and "My Own Country" chronicles his life and practice there as someone, like the young, gay men with AIDS whom he treats, who has never had a place of acceptance, a home, a country to call his own. For me, it was not until medical school that I found a community to which I truly felt I belonged (see Amit, Asim, Donohue, Swurz, Chap, etc).

His second book, "The Tennis Partner," details his friendship, played out on the tennis court and beyond, with a medical student who is a recovering drug addict. I had the good fortune to hear Abraham read from this at the Dallas Museum of Art during my residency and to meet him afterwards. He was every bit the gentleman and inspiring figure I imagined he would be. In many ways, this blog, my way of sharing and recording my thoughts on life, family, and medicine, springs from his example. .

"Cutting for Stone" is described as fiction, but the influences from Verghese's own life are obvious. The novel is set in Ethiopia and revolves around a set of twins born to a nun, Sister Mary Joseph Praise, who dies in childbirth in the opening section of the book. The man, who is presumably the twins' father, Dr. Thomas Stone, a legendary surgeon, hastily leaves the mission hospital, at which he and Sister Mary had worked closely together for years, in despair soon after her death. From here the novel recounts the story of the twin boys named Shiva and Marion Stone and their growing up in 20th century Ethiopia. It is a story about love: filial (the love of a son for his adopted mother and father and for the specter of the biological father whom he never knew), brotherly, and also romantic (the love of a young man for a young woman whose flame cannot be easily extinguished...despite her best efforts). It speaks to the power of this emotion despite class, race, and distance, and the strength of this emotion even within a young, awkward, persistent teenage boy who felt he had found someone special (Been there, done that).

I will not "spoil" the story, but when I closed the book after reading the final page on a transcontinental flight back home to Portland, I had tears in my eyes. I cried not only because of the beauty of Abraham's words but also because someone had written something so personal and yet which I found to be so resonant of my own life, my own thoughts, and my own story. While I respect the critics in the New York Times Book Review, there is an intangibility, a transcendence in Abraham's writing that may be lost on experts of literary criticism but which is not lost on those who have felt like they were on the outside looking in for much of their lives. It is my belief that it was for us that "Cutting for Stone" was intended.

THE BOY WHO WOULD BE KING

Today my first-born, aka Mr. Nicholas, sporting the crown above turned 4. It is hard to believe that he was born in 2005 after a very, very long and scary labor. It seems like yesterday when I first held him in my arms as tears streamed down my cheeks. He has become quite the young man since that time, and, as much as one's lifestyle takes a hit after kids, I could not imagine my life without him.

He has taught me a lot in the past few years. Principally, stubbornness and particularity are family traits, and love knows no bounds. I am sure I will have the same feel for little Cate, who turns 9 months tomorrow, as she begins to take form and grows into the person whom she will become. I have always been a very teleological person, sort of an anti-Siddhartha (another would-be king- see Hesse, Hermann), but my children and a day like today remind me of the importance of enjoying the journey and taking it all in. There is joy in that!

EVOLUTION

A common trait among higher order organisms is the capacity for motility, which did not happen overnight. As you can see little Cate has evolved from a precious little lump into an on-the-go 9-month old girl. Watch out!

WHAT'S IN A NAME?

Last week, I attended my first City Council meeting as a concerned citizen. Of what was I concerned? There was a proposition by a Portland Planning Committee to rename my street, 39th Avenue, to Cesar Chavez Blvd. A hearing was scheduled for that night, and the Council was to vote 2 weeks later. I was not in favor of the move mainly because I thought it would be a pain in the ass to change all of our legal documents and not so much due to the intended honoree. In fact, I was opposed to renaming my street JFK Way, Obama Ave, or anything else for that matter. It was a classic case of NIMBY, Not in my backyard.

The City Council chambers were full with 2 distinct groups of people: young, brown people and older, white people. I was one of the few "crossovers." There were polarizing forces on both sides: the ardent pro-Chavez ("Cha-vez") folks thought this was pay-back for decades of racism, and they thought re-naming 39th Ave, which is predominantly residential and runs almost exclusively through parts of town populated by white people, would be a way of sending a message. Many on the other side proposed that a park, a farmers' market, or a community center would be more fitting. The worst of the "Save 39th" crowd said that they should name a school after Mr. Chavez ("Shav-ez" in their Anglo speak) because "maybe it will teach those people how to speak English." I must say my perception of the process and Portlanders grew increasingly negative after 3 hours of waiting for my turn to speak.

However, when my time to speak came, I had a greater appreciation for the moderates on both sides. My arguments, summarized below, reflected that sentiment:

"I have lived in 6 other cities and many of them had streets named after MLK or Cesar Chavez ("Cha-vez," thank you), but that did not make them tolerant. In fact, Portland is the most tolerant city, in which I have lived, but I don't feel that tonight. None would argue that Mr. Chavez is not a hero, and none would argue that there has not been discrimination in this country. However, how do we and you (the City Council) move forward and honor Mr. Chavez' contribution and all of our citizens contributions?

We honor Mr. Chavez and all Portland's citizens by promoting tolerance and diversity, by bringing all concerned parties together to find a solution. What an example for our kids. Isn't this what President Obama, whom many have channeled tonight, did in 2008? Isn't this what Cesar Chavez did? Make a lasting and worthy impact and move this city forward by honoring all its citizens including the 90% of residents of 39th Ave who have proclaimed their disinterest in having their street renamed in a recent City of Portland survey.

This is not a black and white issue; this is not a brown and white issue. If symbolism is your goal, be bold and make a lasting impact by naming/building something new, such as the new bridge spanning our river which unites both sides of the city. Unite activism and democratic sentiment! Whatever you do, consider the whole community! Isn't that what Cesar Chavez would have wanted? Isn't that what both sides of this issue want?"

With that, I left the lectern and walked out into the cool night air of the city... that I still love.

DREAMS FROM MY FATHER

Today is Fathers' Day. It is a holiday which I used to cherish, but in recent years I have come to dread it despite being a father myself. My parents had a rather messy divorce 4 years ago, and I had not spoken to my dad until last fall- hence my dread of this holiday until recently. During those 3 years when we were not speaking, I convinced myself of several things: 1) I was extremely busy and had no room for family drama 2) I could make it on my own without a father in my life 3) My father needed to make the first move to repair our frayed relationship. Then, I came to realize the foolishness of all these excuses. It happened the day Tim Russert, one of my other heroes, died last year. With all of the tributes to Mr. Russert after his death, I was reminded of the importance and power of fathers in our lives, whether they are absent or present.

I reached out to my dad after that event, and we had spoken on a few occasions. The last time we spoke was after the election of President Barack Obama. My father, a political junkie through-and-through and yellow dog Democrat who had been a Canadian citizen despite having lived here for 25 years, had become a US citizen last year... just in time to cast his first ballot for then candidate Obama. We bonded over his victory and looked forward to what would come next.. both for our country and (though unspoken) for our relationship. That was 7 months ago, and we had not spoken since.

I have come to realize after my own kids' birth that love is something that is unconditionally given to a child by a father or mother from birth. However, love is a bond that, when severed, is not easily repaired. I am not saying that it is irreparable, but its restoration takes work, effort, and time, none of which neither my dad nor I had put in. When I look at my two children and see how they, particularly baby Cate, smile at me, I see love in their eyes. I see admiration. I want to feel that again about my dad because he is probably the most important person whom I have ever known (no offense intended to my mom). He, at the age of 20 or so, came to the United States, to Wisconsin of all places, to study at the University of Wisconsin and at Marquette. He would then return to India and marry my mom through an arranged marriage. He was not satisfied to stay in India after the opportunities he had seen in the West, but he knew the path to immigration to the U.S. was long and fraught with delays and heartbreak due to the fact that it was and still is the prime destination for millions like him. Thus, he moved to a small town in the middle of nowhere in Canada- Moose Jaw, Saskatchewan to be precise, where it was much easier to secure a Visa. There, he taught in a technical institute and raised 3 kids with my mom.

When we grew older, he sensed that the opportunities that he had dreamed of for himself when he wished to settle in the U.S. might now be more of a possibility and might be realized by us. We moved to Oklahoma City, where my dad had a teaching position through which he was able to obtain a "green card" when I was in 6th grade. One year later, a better position came up in a better city, Austin, Texas. We lived in a suburb of Austin called Round Rock for 1 year and then moved to another suburb, which necessitated that I change schools again in 8th grade. By the time I started high school, I had been in 5 different schools in 5 years, and I was none to happy about all the moves. While, even in retrospect this was far from ideal, it was a minuscule sacrifice compared to what my father had given up not once but twice- a comfortable living and home first in India and then in Canada... all for us.

Whenever I have asked my father about why he came to the West and why he moved us to Texas, he always talked about opportunity, educational and financial... for us rather than himself. The best Canadian education was not good enough. He wanted us to get the best education and jobs in the world, American ones. He realized that the chasm between those who live without versus within America is wide, and he did not want us to have to make that journey alone as adults. He had traveled a much longer road than that himself, and, rather than view this challenge as Sisyphean, he wanted to scale those final, highest walls with us strapped to his back.

I do not think I would be the person whom I am today without both my parents' sacrifice and my father's vision. I certainly would not have dreamed, as a ten year-old boy when I left Canada, that I would have attended the University of Texas, Baylor College of Medicine, UT-Southwestern (where I would meet my future wife and mother of my kids), Johns Hopkins University, where I would see medicine and science at their finest, start my own laboratory at my current institution though I came to science so late in life, etc, etc, etc if it had not been for my father. It is not to say that I would not have been successful or happy, but I most certainly would not have the life or family I do now, which is pretty tough to beat.

When it came to time to select a Fathers' Day gift for my dad, I chose to order a copy of Dreams for My Father by Barack...a political olive branch, if you will. It seemed fitting because when I looked at my own children in the days leading up to Father's Day this year and thought of all my dreams for them, I was reminded of all my father's dream for me. I think I now have a better idea of what that title meant to Barack because my dad taught me many important things: food grilled at home comes in only one variety, "well done" (I have outgrown this one and am actually grilling some burgers, "medium-well" I hope, as I write this post) and, more importantly, one's greatest obstacles in life are one's self and the unwillingness to dream... big. Perhaps what it comes down to is this: having big dreams for my kids... dreams from my father.

THE NEXT JOHNNY ROTTEN?

Nicholas is a huge lover of music. As I have mentioned, he loves to listen to music, but he also loves to play it. Let's see... he has a trumpet, saxophone, guitar (which doubles as a cello and bass), banjo, drums, triangle (the only instrument his dad ever learned to "play"), piano horn, and tambourine. He loves to perform for us, and we are constantly being asked to join his band.

While he wants to be a diver when he grows up, he talks about playing concerts on the weekends with his band when he is bigger, which we are (currently) welcome to attend. Thus, we are currently considering guitar lessons for him. While he always treats his instruments with respect and care, the video below from the St. Paul Children's Musuem, which reflects his showmanship, gives me pause about buying him a real guitar. Enjoy!

"PEOPLE GOT A LOTTA NERVE" AT CRYSTAL BALLROOM

Neither Kathleen nor I are big concert goers, but last night we went out to see the Neko Case concert here in Portland at the Crystal Ballroom. While I love music, I must say that with each passing year my patience for concert-going and spending time with "the masses" diminishes. I attended the first 5 Lollapalooza festivals, but by the last one my impatience and misanthropy had soared to new heights; needless to say that was the last music festival that I attended, but I digress.

The doors opened at 7PM, and we got there at 7:30. After 30 minutes of standing in a crowded balcony and $6 whiskey and amaretto sours, the warm-up act came on. He "played" an interminable set of noise and mumbling and then left the stage around 8:40. More standing. At 9PM, Neko Case finally took the stage. We were positioned in the upstairs balcony at the Crystal Ballroom, which is not the ideal location for acoustics or views when a large beam from the ceiling prevents proper sound transmission (not that we could have determined this during the opening act since he made pure noise no matter where one was stationed) and when 2 swaying lesbians (not that I have anything against that) have cut in front of you to take their places. The music was great, company notwithstanding.

Half-way through though, we decided to go to the main floor. Here, the acoustics were much better, and the swaying fans were not positioned directly in front of our faces. The set ran an hour and a half and included all the numbers I was hoping for- most of "Middle Cyclone," "Deep Red Bells," "I Wish I Was the Moon," and a few from "Fox Confessor" including "Maybe Sparrow."

I do not know what angels sound like, but it is my belief that we heard a delivery last night as celestial as one can get on this earth... when we moved to the floor that is. Neko did not sing her songs last night; belting them out is a more apt description for what she did. Despite the sore feet, swaying lesbians, and long wait, this night, in sum, was a blast, and I will be back for her next show... even if people got a lotta nerve!

MUSIC AND MEMORY

Most days I drive Nicholas to school and drop him off. Invariably, NPR is turned off in favor of a CD (that is until he is dropped off and before he is picked up). Although he is only 3, Nicholas has already developed distinct musical tastes, both in the music he likes to play and the music he enjoys listening to. I have pretty excellent musical taste myself, and it seems to be rubbing off on him. He likes Jeff Buckley, Eddie Vedder, Bruce Springsteen, Feist, etc. In addition, he remembers the tracks which are present on various mix CDs and the track numbers. Mind you, he is not looking at a jewel case for the track numbers and song titles as these are mostly MP3s, and he is not controlling the stereo. He seems to have an amazing memory for all things musical and animal... and pretty much everything I can think of.

Yesterday though he asked me, "Who sings Viva La Vida?" I was a little perplexed as he has certainly heard that song many times and knows Coldplay's stuff. I told him it was Coldplay, and he quickly responded that he thought the singer was Chris Martin, who just happens to be the lead singer of Coldplay. Now you see what we have on our hands. Viva Nicholas!

If You're Happy and You Know It, FLAP Your Hands

One of the most important things in life is having great friends. I have been fortunate to have had them at all stages of my life. While I have never had a huge number of friends, the people whom I have called my friends have always been amazing people. This was particularly true during med school, residency, and fellowship. For this reason, Kathleen and I, or should I say I, have always been a little concerned that Nicholas has not made more deep connections with kids at school or in the neighborhood. Now, mind you, he is only three, and I may be paranoid. Part of my concern stems from the fact that I think he is such a cool kid; he is smart, caring, and very funny.

Yesterday, I arrived at his daycare to pick him up at the end of the day. His teacher was reading the class a story, "Curious George Gets a Medal," perhaps the longest book in the history of printed words. I know this because I had read this tome to him the week prior while we were on vacation in Minnesota. Anyway, Nicholas appeared to be really enjoying the story. I knew this because he was flapping his arms. Flapping his arms, you say? The above video is illustrative. From the earliest age, he has always flapped his arms when he was excited, particularly when enjoying himself (above video notwithstanding). Yesterday was no different. However, the fascinating part was that after he did this, several of the kids in his class reflexively flapped, too. It was, to my eye, not done in a mocking way but rather in imitation. He, of course, was oblivious to the fact that the kids seemed to find him to be cool.

What I have come to realize is that his lack of deep connection (again, I know he is only 3) is probably a function of being a choosy person... sort of like his dad. I have never been one to form casual connections, but I will do anything for those who are my friends. I think that most people are not bad; they are just not worth befriending. I guess this makes me particular rather than misanthropic, and the little guy may be no different. I know he will make deep connections with friends as he gets older because he already has with me, and I am one tough customer.

GOT MILK?

Kathleen and I are pretty liberal, eco-conscious parents, but we are not over the top. We try to buy organic and try to avoid processed foods (drinking yogurt notwithstanding). In particular, Nicholas, in his short life, has only consumed organic milk while we consume inorganic milk. Nicholas asked me the other day why he had a different kind of milk (we both drink 1%). I replied that it was because our milk had chemicals in it. He quickly replied, "Why do you like chemicals?" I attempted to explain "half the cost," but I think the concept was lost on him. Needless to say when I was at the grocery store last night with him, I just picked up one gallon of milk for the family- organic. It seems like a small price to pay to teach your kids healthy habits and to potentially derive health benefits one's self.

CATCHER IN THE RYE?

So the other morning Nicholas said he did not want to go to school. This was after he had thrown a mini-tantrum prior to heading out the door. After some mild "voice raising" (i.e. yelling) on my part, he got in the car, and we headed to school. I asked him why he did not want to go to school. He said it was because he was tired of playing by himself. He uttered this with just the right tone of sorrow, which made me feel compelled to come up with a solution. I suggested he recommend a game of "monster tag," in which each kid would be a different Sesame Street character and in which the objective was to tag whomever was it. He said that sounded like a good plan for facilitating interaction. After dropping him off, I thought more about his response for why he did not want to go to school, and I was a little more skeptical.

Today, his teacher told me that the kids love him and find him "charming." The little guy pulled one over on his old man. While I do not doubt that he feels isolated at times (what 3 year old does not), he clearly knew which button to press. He is no Holden Caulfield, but he does know (already) how to convince people... dad included.

READING IS FUNDAMENTAL

In my opinion, one of the most important and fun things in life is reading. I remember, as a kid, saving up my money to order books from school and also constantly checking out books from the library. Once, my elementary school librarian cut me off for checking out too many books and for checking out the same book about Louis Pasteur too many times. I was undeterred, and clearly Louis made his mark on me. One of my favorite book series was called, "Bruno and Boots," which described the adventures of 2 kids in a Canadian boarding school (Think Harry Potter with high schoolers and without the wizardry). I went on to read some of the "great books" during high school and college, and I started a book club during residency to meet women who not only could read well but who were also well-read (This is how I met Kathleen, but we will save that for another post.), but my early reading was every bit as formative.

Last fall, one of our friends who is a librarian mentioned that she really liked a children's book author named Mo Willems. I am always game for trying a new kids' author as so many of them are dull (Eric Carle and Sandra Boynton excepted). We decided to check out a few of his books, and I must say I, as a discriminating reader, found them both humorous and educational. More importantly, Nicholas loves them- particularly the "Pigeon" series. One of my oldest friends from growing up in Austin gave Nicholas a copy of Mo's book "Don't Let the Pigeon Drive the Bus" for Christmas last year, and it remains one of his favorites. He has memorized most of the words from this series and can "read" them to me, which is quite hilarious. As for Cate, we have already introduced her to one of Mo's most endearing characters Knuffle Bunny (pictured above). She sits in rapt attention when I read bedtime stories to Nicholas, and I think she, too, will come to love reading.

A bumper sticker I saw today in bibliophilic Portland summed things up best, "I'd rather be behind a book." I could not agree more, and, on that note, it is time for me to get back to "Cutting for Stone," which I hope to review in this forum at a later date.

DANCE, DANCE, DANCE

This video from Nicholas' school show speaks for itself. I wish I had half this kid's talent. Suffice it to say, he is not shy!

WILL THEY BE FRIENDS?

Nicholas and Catherine seem to get along pretty well... with the exception of baths I suppose (Please see above). For the most part, they function pretty independently, but her eyes light up whenever he is talking to her, telling her jokes, or playing his instruments. He, on the other hand, does not seem to know what to make of her. He knows she is not going anywhere, and I think he is beginning to realize that that's not half bad.

The second kid is a big life changer... especially if kid #1 is at an age when he/she is quite independent (eating, toileting, entertaining him/herself). Our goal was for Nicholas to have someone beyond his parents to whom he could look for comfort and companionship and with whom he could argue about taking us in versus placing us in a nursing home one day (thank you Dave D for pointing out this virtue of having kids).

We recently started to put Catherine down for bed at night in a crib in Nicholas' room. Tonight, she woke up and cried out. Our instinct was to go up and comfort her, but we waited. Within seconds, we heard Nicholas' voice on the baby monitor trying to comfort her. Her crying stopped, and she went back to bed (You cannot make this stuff up, people).

I think Nicholas and Catherine will really come to love each other and will help each other survive us as parents. I do hope though that they'll be friends, too, because it is so obvious to me how cool they are and how much there is to love in each of them!

MUSIC AND MEANING

One of the most important things in my life has always been music. Whether it was the hair-metal bands of the 80s (truth be told, my first concert was Whitesnake in 7th grade- I know you all remember Tawny Kitaen on the hood of a jaguar (I believe)), the Smiths (clearing my throat) and Morrissey in the late 80s and 90s, or the Seattle sound and Radiohead at the end of the Millenium, I have always loved music. With the exception of the late Jake Buckley, Martin Sexton, and Coldplay, I have found the 2000s to be pretty barren musically- mainly pop music and rap drivel. I look to music not for entertainment but for comfort, solace, and shared experience- the same things I seek from literature and films.

Earlier this year, I read a great NY Times magazine piece on the singer Neko Case, from which the above picture was taken. There was also a great New Yorker piece on her last month, too. I found her story and journey both musically and personally to be rather compelling, although I had not heard a single note or lyric of her songs. I decided to listen to her new album "Middle Cyclone" on Itunes, and it blew me away. Imagine "Exile in Guyville" Liz Phair meets Patsy Cline.

I find so few songs memorable these days for 2 reasons: 1)The lyrics are unintelligible 2)The words are uninspiring. Neko Case's lyrics defy description, but suffice it to say that they are unique, intelligent, and addictive. One finds one's self humming her tunes or singing her lyrics at the oddest times of the day. That (and the fact that one is motivated to buy an artist's other albums) is the true measure of a transformational artist; I now own all her solo albums.

I do not know if my musical tastes match yours, but I would be shocked if even the most musically immature listener does not tap their toes to songs like "I'm an Animal," "People Got a Lotta Nerve," or "Fever." I encourage you to find out for yourself. While, as an oncologist, I can appreciate the lyrics below from a song called "Don't Forget Me," I think most of you will appreciate them and other Neko Case offerings, too.

"And when we're older and full of cancer
It doesn't matter now, come on get happy
'Cause nothing lasts forever
But I will always love you."