Portland: Washington Park

In part to adjust to Pacific Time, and in part because I wanted to see Portland instead of the inside of yet more buildings (the cabin fever of conferencing in a hotel set in early), I planned most of our activities to be outdoors. There are a number of parks in and around the city for walking/hiking, among them Washington Park on the west side, where the zoo, Hoyt Arboretum, a children's museum, Japanese Garden, and the famous International Rose Test Garden are located. There was hardly anything blooming this time of year in the City of Roses.

First we hiked up a residential hill in search of “Portland’s favorite tree,” a redwood that won the honor in a in the last popular election of the kind, in 1987. I had noticed a pin in Google Maps, but the GPS was slightly off that day, so we sort of cast about for several minutes until Dear Husband finally noticed the small metal plaque buried at the base of the trunk that declared this particular tall tree (and not the tall ones 50 feet away) as the supreme tree in a city that has many lining its streets and filling its green spaces. I didn’t get a good picture of its towering greatness, but this snarky blogger did.

Then it was on up the hill even further—DH: Pittsburgh, I thought you prepared me with hill training!—to Washington Park. Right there at the entrance is the Lewis and Clark column, donated by the good people of the states of Oregon, Idado, Montana, and Washington in 1903. It enjoys pride of place at the formal entrance to the park, but as monuments go, it’s one of the less ostentatious I’ve ever seen. 

Down the slope a little ways stands Sacagawea’s statue. She carries her baby, Jean-Baptiste, on her back and points west (away from the Lewis and Clark column, incidentally). Alice Cooper sculpted it on commission by the Committee of Portland Women for the Lewis & Clark Centennial Exhibition that was held in Portland in 1905. (This was earlier than I suspected--I assumed she hadn't been added until the 1990s.)

We continued deeper in the park to find the Oregon Holocaust Memorial, which may be one of the best (read: most accurate) I have ever seen. A brick path leads from a “European” streetlamp toward an arc of granite. It is strewn with discarded items in bronze: a suitcase, a violin, eyeglasses, a teddy bear, a baby shoe. On the memorial wall is a large chunk of text expertly describing how the Nazis dragged Europe into chaos and destruction. Then come a series of quotations from victims, including the one that seemed to tie the memorial together: "If you got off of the train with your little bag the Nazis knew you had something personal, something special inside. That bag was the last thing they took before they took your life." On the back side are the names of murdered relations of Oregonian Jews. This visit was especially poignant as we were there on Rosh Hashanah.

Last stop on our monument tour was “The Coming of the White Man,” by Hermon Atkins MacNeil (1904). Two Native men, one older, one younger, stand on a pedestal amongst the trees facing east, toward the Columbia River. It was the most difficult statue to find, as there was no signage, although a parking lot had been conveniently provided for anyone arriving by motor vehicle (we were on foot). We were not entirely sure what the point is: Chief Multnomah appears resolute, while the younger man is agitated (to violence? Is the object in his hand part of a torch or a dagger?) or maybe just surprised. The title does not name the figures we see, but rather the historical figures they saw: the white man/men not represented in metal. In this way the statue and its title appear to erase the Native American presence all over again, although they are standing right in front of us. Why did the designer decide to “honor” Native Peoples by depicting a Native reaction to Lewis and Clark, rather than as members of nations and cultures that existed independently of Europeans (and continue to exist)?

Did you miss the post about the Japanese Garden (I've added a new photo since it went live)? Have you ever seen a Chinese Garden?

Portland: Chinese Garden

Second day, second garden: Tuesday we visited the Lan Su Chinese Garden, whose name combines characters from the Mandarin for Portland and for its sister city, Suzhou. It means "Garden of the Awakening Orchids." We arrived early in order to be able to buy our tickets and join the free Kung Fu class that was held on the patio. (Every day they offer a different discipline to try; I suppose if you had a membership you could attend each week.) We spent a chilly hour learning how to move from our pelvises and how to roll a ball of qi with a woman visiting from California and another guy. The instructor, Andrea, is part of the Flying Tortoise studio.

Although we were very cold, the time we spent in the class had allowed the sun to rise over the building, improving the light. We followed the circuit of the compound, taking lots and lots of pictures. While Dear Husband favored the Japanese Garden for its spaciousness and greenery (click for post), I liked the Chinese Garden better, because of the constant juxtaposition of architecture and nature.

It is set up as a wealthy family's villa. One architectural technique they use is the “view within a view,” windows or doors that (re)frame dioramas. This not only simulates infinite space but allows for the artful display of conspicuous consumption.

According to the guidebook, there is more than 600 tons of the statuesque rock from Lake Tai in China in the garden (left image). The rock has been eroded under the surface of the lake, creating shapes that catch light and shadow and invite contemplation. Looking from bottom to top is supposed to simulate climbing a mountain.

There were of course a large koi and lily pond, bridges, a waterfall, and a couple of buildings with exhibits about a home altar (above), botanical illustration, women’s work, and the study of a Chinese scholar. We treated ourselves to a satisfying lunch (steamed dumplings for him, noodles with tofu for me, tea and moon cakes for each of us) while someone played a kind of lute. As a rare souvenir to hang when we get home, we bought a crane embroidery from Shouzou.

Below is the scholar's study. I took the second photo through an opening in a wooden screen, and the repeating window effect continues with the window and the decorated porch beyond it. How could you not love all that latticework?

Above left is the "moonlocking pavilion," so named because it seems to capture the moon (reflected in the pond) in its arms. Below you can see how close the rest of the city was.

This was a very filling lunch, I think because the moon cakes may be meant to be shared. You can see half of my red bean cake on top; it has a sort of dark, earthy taste. DH prefered his lotus seed cake, which was lighter and sweeter ("the vanilla of mooncakes").

This is a backlit photo of the two of us on a covered bridge overlooking the koi pond. Afterwards we walked over to Powell's City of Books, where DH patiently waited for me to scan the spine of every book published on Nazi Germany, and many of the books published on World War I. We also ogled the rare books--some of which are very old, some of which are oversized comics, and some of which are worth thousands of dollars--and did some Christmas shopping. Then we took the tram home for a quiet restaurant dinner and a soak in the jacuzzi tub.

Coming soon: posts about Washington Park and Multnomah Falls!

Portland: Japanese Garden

We are in Portland, Oregon, for a "working vacation"--I have a conference at the end of the week, and Dear Husband had never been to the Pacific Northwest either--so we did some sightseeing together.

Top of our list for places to visit in Portland was the Japanese Garden, which is said to be the most authentic of the kind outside of Japan. Professor Takuma Tono (Tokyo Agricultural University) designed it in the late 1950s to incorporate numerous different styles on the site of the old zoo. The Garden opened in 1967 to visitors, and it has been added to and expanded upon as late as 2017.








You enter by ascending a serpentine pathway up the hillside to a "village" of buildings (visitors center, display area, gift shop, cafe). Unfortunately, their next art installation opens at the end of the week. So we had to content ourselves with wandering through the gardens, two 30-40-minute loops, each time with a break to sit quietly in the far corner in front of a burbling waterfall.

After collecting ourselves, we walked back out of Washington Park to the trendy Alphabet District, where we met an old friend for fancy ice cream at Salt & Straw: chocolate-kissed zucchini bread for me, cloudforest chocolate hazelnut cookies and cream (made with coconut cream) for Dear Husband. Sea salt with caramel ribbons is their most popular flavor. Then it was home to snuggle under a blanket on the couch for me, and a nap for DH, until we were hungry enough for dinner at vegan restaurant Blossoming Lotus.

This pavilion is part of the Flat Garden. During busy times it has exhibitions, including bonsai.

At the Lower Pond in the Strolling Pond Garden. (The cranes are statues, the better to ensure every

visitor gets an Instagrammable photo with "wildlife"?)

Outbuilding in the Tea Garden; tea house constructed in Japan and shipped to Portland in pieces behind it. Classical features include rustic stepping stones and lanterns that give the sensation of a long journey out of the cares of the city into relaxation in the countryside.

Flower arranging and dragon statue.

Heavenly Falls, from the side. They were taller than they appear here, and quite loud.

Strolling Pond Gardens such as these were popular on estates during the Edo Period (1603-1867) as demonstrations of wealth and a luxurious lifestyle.

Sand and Stone Garden, from above. These kind of "dry landscape" gardens were developed in the late medieval period (1185-1333) to capture the beauty of blank space. They are for contemplation, not meditation.

View from the bench at our happy place in Portland, the Natural Garden. Apparently this was originally supposed to be a mossy Hillside Garden, but the terrain was too inhospitable, so it was redesigned with plants to evoke all four seasons. Bet it would look great in spring with pink azaleas, or in high autumn with red and orange foliage. As it was, the tiny maple leaves looked like so many stars against the bright sky.

What Residency Looks Like LXXIV: Team Leader

The baby's name tag reads "Team Leader." It's in better
shape than the one-armed bandit I had to use in
medical school.

Sometimes residency looks like CPR training. I staged this photo with a dummy baby and my pocket card while taking a CPR recertification course. The situation was a little bit ridiculous, as my cohortmates and I had unknowingly signed up for a course that ran 4pm-midnight after our usual daytime responsibilities. We later figured out it had been meant for nurses to do as a second shift or on nights. ("Lunch" was scheduled for 8pm.) Nevertheless, we watched the cheesy videos and repeatedly saved the dummies from asthma, cardiac arrhythmias, and septic shock in between trading stories from the ED and the PICU. I briefly found it interesting that everyone (not just the MD-types) was required to be the Team Leader for two cases. It's a role I assume I will be assumed to take, but there's not always a physician available, and a seasoned nurse is more than capable of running a code team (better than an unseasoned doctor, I can assure you). We helped each other out, cracked a lot jokes, and because the instructors kept things moving, we actually got out a little after 10pm. We're now certified for the next 2 years, until we have to do it all again. Hopefully at more normal hours.


p.s.--This experience reminded me of my very first WRLL post, about practicing intubation. Interestingly, it is the one skill we didn't do at this course.




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What Residency Looks Like LXXIII: Screen-INGO!

Sometimes residency looks like playing bingo with health screening guidelines over lunch. The current Med-Peds fellow is writing his masters thesis in medical education on the "gamification" of medical training--in other words, the movement to make teaching more interesting (and effective!) than listening to a lecture by embedding learning points in recognizable games such as Jeopardy! or, in this case, bingo. The competitive feature doesn't hurt; even medical residents are easily motivated by candy, Starbucks gift cards, and bragging rights.

For the game of Screening-Bingo (aka Screen-INGO), we each designed our own bingo sheet by allocating the usual numbers. Then the fellow asked us questions about United States Preventive Services Task Force (USPSTF) guidelines for screening for things like high blood pressure and colon cancer. If you got the question right AND he drew a number you had, you could mark your board. If you got it right but didn't have that number, you could mark an earlier number that had been called OR ask to have a number re-entered into the cage if you had gotten an earlier question incorrect. At the end of the hour we ran out of time, so he just called numbers, and I was three ways away from winning before another resident got bingo.

Here is what I learned:

We're supposed to practice Evidence-Based Medicine (EBM), but not all evidence is created equally. Good evidence is Graded A (definitely do this), B (probably a good idea), C (it probably doesn't help, but at least it doesn't hurt), and Grade D (don't do it--dangerous!). Grade I recommendations are those for which there is insufficient evidence to determine whether it is good or harmful or not.

Q. Who should be screened by abdominal ultrasound for abdominal aortic aneurysm?
A. Men ages 60-75 years of who have smoked at least 100 cigarettes in their lifetime.

Stop screening for breast cancer at age 75, or when the patient has less than a 10-year life expectancy.

Screen for cervical cancer by testing for HPV every 5 years for patients who are over age 30. Anyone who has a cervix needs to be screened regularly for HPV, and even those who don't have a cervix due to hysterectomy for cervical cancer or a high-grade lesion (CIN 2 or 3) need continued surveillance.

Any young woman under the age of 25 who is sexually active needs annual testing for gonorrhea and chlamydia; from age 25, only those who have high-risk behaviors need annual testing. The level of evidence for testing men (who do not have high-risk behaviors) is I. (This topic is being updated for the latest research.)

Did you know? The PHQ2 (Patient Health Questionnaire, 2 questions) is a 97%-sensitive screen for major depression in the prior 2 weeks, with anhedonia being required for an eventual diagnosis with the PHQ9 (guess how many questions that form has?).

Q. When should you recommend discontinuing Colorectal Cancer (CRC) screening?
A. Most people should be screened for CRC until they are 75 years old, or a 10-year life expectancy. [In practice, the first colonoscopy has the highest yield, so getting one at 50 is the most important. I am more likely to encourage my patients to get that first scope than I am to lean on them to get the second or third.]

There's a great risk-assessment tool for the BRCA gene for breast and ovarian cancer: Gail. If a patient is determined to be high risk, the prudent thing to do is to refer to a genetic counselor, NOT order genetic testing.

Vitamin D for fall protection is OUT, physical therapy is IN.

All women of reproductive age, no matter their sexual practices, are recommended to be on 400mcg (0.4mg) of folic acid daily, as 50% of pregnancies are unintended, and this nutrient is required for early neural-tube development.

Did you know that patients who use intranasal drugs should be screened for Hepatitis C? (We assume they mean non-prescription drugs.)

Although we routinely order full "hepatitis panels," the USPSTF recommends we screen for Hepatitis B with only a surface antigen test (Hep B S Ag), not core antigen, PCV for viral titer, etc.

All adults at least 18 years old should be "screened" for hypertension by taking their blood pressure taken in the office, but you shouldn't officially diagnose them unless you have at least one value from outside the office, due to the prevalence of white-coat hypertension.

Hormone therapy for primary prevention of any chronic condition (such as cardiovascular disease) in post-menopausal women is a grade D recommendation.

All people aged 15-65 years old should be tested for HIV at least once in their lives. You can always re-test them, and test others, as necessary.

All women of reproductive age should be screened for intimate-partner violence (grade B), but the evidence is grade I for other kinds of patients. Many of my colleagues ask at every physical exam anyway, whether it's an adolescent or an elderly patient.

Finally, a baby aspirin every day. I don't remember what the question was--maybe how to reduce the risk of pre-eclampsia? That's been in the news the last week.

"Th-th-th-that's all folks!"


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What Residency Looks Like LXXII: Get your Goetz's

Sometimes residency looks like the caramel candies an attending brought the team to "sweeten the deal" of accepting an admission from clinic. They were all gone by the time the patient was discharged.

I remember Goetz's Caramel Creams fondly from my childhood, and that may be because they are a Baltimore original. Now owned and operated by the fifth generation of Goetzes, the business was originally a chewing-gum manufacturer until gum materials became scarce during the two World Wars. They also make Cow Tales, but I don't think I have ever tried one of those.

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What Residency Looks Like LXXI: Mediated Knowledge

Doctor: "I'd like a second opinion on your self-diagnosis--so a random guy from the waiting room is googling your symptoms."

Sometimes residency looks like a comic strip about the rejection of medical expertise--on both sides of the physician-patient relationship!--that your father clipped and mailed to you. It's stuck to the whiteboard in the workroom for the "Junior Hospitalist" service, which is a team of one attending and three to four residents, who act as "pre-ttendings." As "pretend attendings," we see patients and make clinical decisions mostly on our own. It's a good chance to practice semi-independently before we become real attendings.

We're also learning about using point of care ultrasound (aka POCUS) to look for pneumonia, fluid around the lungs, heart function, fluid in the abdomen, and veins for IVs. Some people argue that POCUS is the future of the physical exam, that physicians either won't use stethoscopes, or will use them even less than they already do. I've been thinking a lot about this, as I am slowly making my way through Jacqueline Duffin's dissertation/first book, To See with a Better Eye, a biography of Rene Theophile Laennec (1781-1826), the inventor of the stethoscope. He called it "le cylindre" (the cylinder), because at first it was a tube of rolled up papers, and then it was a hollow column of wood that he turned on his flute lathe. Even though "stethoscope" means "to see inside the chest," that instrument is used to hear sounds coming from inside, whereas POCUS uses sound waves to "see" inside the body. Actually, we don't "see" directly, as with an endoscope; instead, we see artefacts from the sound waves traveling through air and bouncing off more or less solid anatomical structures. It's mediated sight, just as Laennec described listening with a stethoscope as mediated auscultation--direct auscultation involved the doctor putting his ear directly against the patient's body. Now there's a physical exam skill they don't teach anymore.

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