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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What Residency Looks Like LXX: Early Discharge

Sometimes residency looks like an adult beverage to mark the end of summer after your attending lets you out of the hospital an hour early. This one is a slushy made from frozen strawberry lemonade + apple-flavored whiskey + the juice of a lime.

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