Training update

As you can tell from the graph above, I spent the winter upping my running game and neglecting the bike, in preparation for the "Mortimer 100" relay running race on March 14th. Leading up to the race, I was feeling fit and had high hopes for my performance. But one thing I had noticed during my runs was that my iliotibial (IT) bands would consistently start hurting right around the 6 mile mark on runs-- which is what I limited my running distance to. Unfortunately, I was assigned three 7-mile sections of the race.

Sure enough, my IT bands started hurting with about half a mile left on my first leg. Despite massaging them as much as I could during my rest, they started back shortly after I started my second leg, and got worse... and worse... and worse. After alternatively walking and jogging for a couple miles, I threw in the towel. It just wasn't meant to be.

Though it was bad enough that I had to have other runners finish my portions of the race, the right knee pain I have experienced over the past month since the race has been much worse. I seem to have developed a moderate to severe case of patellofemoral pain syndrome, and am unable to run or do many of the other exercises I like to do. Fortunately, I've still been able to bike some, which has ticked up in the past month as you can see. I've also started doing daily rehab exercises to strengthen my quads, which I'm convinced is the underlying issue. But with the amount of pain I'm still experiencing, I anticipate it will be at least another month before I can start running again. I'm just going to have to be patient!

Taking my injury into account, and considering that triathlons may be cancelled anyway this year because of COVID-19, I've transitioned to thinking of this year as a rebuilding year. I'm going to rehab the heck out of my legs, and be stronger than ever this time next year. My IT bands have plagued me since high school, so I know that getting my legs stronger is not going to be a quick process. But if I'm ever going to complete a half-ironman, half-marathon, relay race, or any other long-distance running, I'm going to have to put forth the effort to get beyond this limitation.

Am I a little disappointed? Sure. But I'm also thankful that the relay race brought to my attention a nagging issue I would have needed to address sooner or later anyway... and that I hadn't yet signed up for any races or even purchased my yearly USAT membership yet. Plus, cutting back on triathlon training opens my schedule up for more kayaking!

I do wish I could still swim, especially on workdays, but it looks like the river is my only option until local pools open up again. As with many things over the past month, I've had to be flexible and adapt! And with this issue, I mean that quite literally.

Hopefully in another 16 weeks, I'll have good news about my leg. Who knows, maybe I'll be able to finish a sprint triathlon later in the year. Time will tell! Be well, everyone.

Pandemic mode, episode 4

The curves are flattening. Not everywhere, and not soon enough-- but it's happening. New York and New Jersey are seeing staggering losses, but not quite the knock-out figures that had been feared. Though many community hospitals are full to bursting and refrigerated trucks keep filling up with bodies, the "death panels" and ventilator-sharing many feared have not been required, and the main emergency hospital in NYC that was set up in a convention center is not even close to capacity. Unfortunately for many places in the country, the infection rate is still so high that shelter-in-place orders will need to stay in effect for many more weeks until it will be safe to start loosening restrictions.

The crisis is hitting the poor and weak the hardest-- as all crises tend to do. Outbreaks in New York and New Jersey nursing homes alone have already claimed about 2,000 lives, while homeless shelters across the country are experiencing disasters on a similar scale. Poorer neighborhoods, where population density is the greatest and the ability to physically distance is the worst, are being disproportionately affected. And hotspots in developing countries like Ecuador are starting to show the world how horrendous COVID-19 can make things: completely overwhelmed systems, people dying without even the semblance of medical care, bodies lying in bedrooms and on sidewalks for days.

Close to home, North Carolina is starting to see a reduction in the daily case count-- as illustrated in the darker blue line in this graph:

Thanks to prompt action on the part of Governor Cooper, we have been spared a big initial wave, giving us the time to build up testing capability and await clinical trials. At Watauga Medical Center, our turnaround time for a COVID-19 test is now just under 48 hours-- not great, but a lot better than the 5-7 day period we were dealing with a few weeks ago. And we have yet to see local transmission in Watauga County, thanks to our proactive local health department.

With those updates out of the way, lets reflect a little on Bill Gates. His Ted Talk from 2015 predicting a pandemic just like the one we're facing and laying out all the steps we needed to take to be ready for it has gone viral over the past few weeks. He was just interviewed on a new Ted Talk, and the gist of that discussion was that no one took his advice and we were totally unprepared, so... told ya so? Or.... maybe listen to one of the smartest people in the world the next time he gives a Ted Talk? 

It's hard to imagine that Bill Gates' recommendations were not heard by some in the federal government's bureaucracy. He's freaking Bill Gates, who along with his wife runs one of the largest charitable organizations in the history of mankind and is almost single-handedly wiping polio off the face of the earth. When he talks, smart people listen. But if you listen to the talk closely, you can tell that he realizes his prescriptions are a tall order, politically speaking. But nothing in the talk sounds all that hard to implement, other than finding the motivation to commit to it in the first place. 

Furthermore, you'd think we would have learned over the last few decades that Black Swan events are actually quite common-- and that we ought to prepare for as many of them as we can. Events like 9/11, the Great Recession, the Fukushima meltdown, and Brexit were all massive shocks at the time. Further back, the world wars, oil tanker spills, and the sinking of the Titanic are just a few other examples. The problem is that our lives are affected by them so much afterward that they don't seem that unexpected in retrospect. 

We can all plan for crises in the future by stocking up on essential supplies and gaining as many practical and survival skills as we reasonably can. But the government (I hate to say, as a recovering libertarian) is obligated to play a pivotal role in preparing society by taking steps that no one in a free market would take, but which will be critical in preventing and dealing with future crises. In addition to preparing for pandemics, governments should get out in front of AI technology in a way they have certainly not with Big Tech to date. There are plenty of steps that should also be taken to mitigate the risk of nuclear war, accidental nuclear detonations, and conventional wars. And climate change remains the greatest and ever-growing threat to our planet and human civilization. Yet lawmakers continue to dawdle and allow petroleum industry- financed Republican lawmakers to cast doubt on the very present reality of climate change with endless specious arguments. And every day, the planet heats up a little bit more.

I have grave doubts that our government can ever get out in front of any of these issues-- at least the way it is currently structured. Like Ezra Klein and Elizabeth Warren, I believe-- I know-- that "big, structural change" is critical if we are to be able to address the challenges we now face and those which are just around the river bend. These issues transcend any particular electoral cycle-- but nevertheless, each election is critical if we are going to be able to thread all the needles we need to thread at the same time and come out intact on the other side. Though I have doubts that Joe Biden is the right person to lead us into these changes, I know that until Donald Trump is out of office, every day that passes is precious time-- critical, life- and planet-saving time-- that is irretrievably lost. 

So although I didn't intend for this post to get political, here we are again. If you're an American eligible to vote and residing in a swing state (like North Carolina), perhaps the best thing you could do for the country and for the planet in 2020 is to vote for whoever has the best chance of beating Donald Trump. If enough people do that, we may start getting ready for coming crises before their waves crash upon our shores. 

Until next week, stay calm and self-isolate on.

Pandemic mode, episode 3

As expected, New York City exceeded 100,000 confirmed COVID-19 cases this week, and fully descended into Coronavirus hell. Watching the train wreck from afar, I could still feel a bit of the pain from the overwhelmed hospitals, doctors, nurses, and morgues-- and the heartbreak of thousands of personal tragedies. Obituaries of prominent people have started to appear. Shortages of ventilators, PPE (personal protective equipment), and beds are becoming acute, and testing shortages continue to plague the health system.

A silver lining is that the doubling time in the US increased from 2.5-3 days to 5-6 days. Most places are starting to see the effects of social distancing measures started 2-3 weeks ago. Though North Carolina confirmed about 1,500 cases this week, that is hardly an exponential rise from the nearly 1,000 cases the week before. Hopefully new confirmed cases will actually number less than 1,500 this week, but we'll see.

Watauga County, and a great many counties like it, has seen a few imported cases but is yet to see local transmission. With over two weeks of social distancing now under our belts, it seems that we passed the first test. The virus did not catch us unawares. Hopefully we will develop the ability to rapidly test for the virus here in the coming week, since it's inevitable that, sooner or later, local transmission will start to occur. But hopefully it will be a low rate of transmission, and we will not need the capacity we have developed at the hospital to deal with a huge influx of Coronavirus patients.

Confirmed US cases now exceed 300,000, though I suspect the real number is at least twice that when accounting for testing delays and untested cases. Soberingly, that represents only 0.1-0.2% of the population, while many experts predict over half the country will contract the virus before it burns itself out or a vaccine is available. With aggressive measures and improved testing, I'm not convinced that's necessary, and hold out hope that a relatively small minority of Americans will contract the virus before we have a vaccine. But again, we'll see.

Despite all the continued uncertainty, many things started to become clear this week. New Jersey, Chicago, New Orleans, and Miami have emerged as the next epicenters of the crisis. Smaller but more concentrated hotspots in the town of Albany, Georgia, and towns in Colorado, Connecticut, and Idaho, exemplify the danger the virus poses to communities of all sizes. A pattern of flare-> social distancing -> curve-flattening -> relaxation of restrictions -> resurgence seems to be emerging from Asia, and I'm sure we will see that pattern start to play out in the coming two months.

Italy's crisis peaked last week and started to improve, though thousands of new cases are still emerging there every day and their nationwide lockdown will continue to be enforced for at least a couple more weeks. A report also came out that the virus has a rapid 4 day average serial transmission time, and that asymptomatic transmission accounts for a disturbingly large percentage of the transmission, making social distancing an absolute imperative and public mask-wearing a very good idea.

Calls for a relaxing of restrictions in relatively spared regions will start to arise in the coming weeks. In fact, a few midwestern and southern states like Alabama, Iowa, and the Dakotas still haven't ordered residents to shelter in place, though that will change if a hotspot emerges in one of those locations. Which seems inevitable. As our ability to rapidly test becomes a reality, hopefully we will see the emergence of a smarter, more targeted approach to social distancing. Until then, stay calm and self-isolate on.

Pandemic Mode, episode 2

This is the second of what I anticipate will be a weekly update on life during the greatest pandemic in over a century. Because it's clear that's what we'll be living through for the next several months, at least.

The overall story of the last week has been the exponential rise in cases in the US, accompanied by a growing knowledge about the virus and consensus regarding the severity of the pandemic. "Social distancing" is now a universal phrase, and the resultant anxiety has palpably seeped deeper into the collective consciousness.

According to reports, many in Britain are in a state of shock as prime minister Boris Johnson, Prince Charles, and several high-ranking ministers have contracted the virus. Elsewhere, Italy and Spain are continuing to struggle with what is hoped is the peak of the pandemic's first wave. India has completely shut everyone inside for 21 days in hopes of avoiding additional stress on its fragile healthcare system. China, on the other hand, has relaxed some of its restrictions as new cases have plummeted, at least initially.

The sober, wartime mentality was punctured earlier in the week by Donald Trump's relapse into denialism, claiming that he thought the country would be back to work by Easter. Which is less than three weeks away. And which would clearly be catastrophic. His insatiable lust for a return of the bull market of his first three years in office has served to only derange his already-catastrophically-impaired decision-making capacity.

This is mainly mentioned to highlight the utter lack of leadership at the federal level. We are all starting to pay an incalculably steep cost for raising such an incompetent, narcissistic, and irresponsible human being to the office of president. We don't need a great leader. We just need someone who has the basic level of competence to set the right tone for the nation, consult with experts to make some big important decisions, and delegate serious policy-making to competent people. 

A correlate with Nazi Germany comes to mind. Not Trump to Hitler (necessarily), but rather how loyalty was elevated above competence in placing people in power, resulting in a cast of fools trying to making decisions and utterly failing every step of the way. Unfortunately, that's all we've seen the past 2 months from this administration, and all we can expect to see until a new administration hopefully takes power next January.

A silver lining is that half of the states have taken bold steps to stem the pandemic. Though this may be slowing the progress in more rural areas and in a few cities like San Francisco, it clearly has been insufficient in most cities. A week ago, Italy was shocking the world with its  25,000 cases. Today, the US has over 120,000-- 52,000 in New York alone, with skyrocketing numbers in New Jersey, New Orleans, Chicago, Detroit, and elsewhere.

As expected, reports out of New York in the last couple days have started to mirror those coming out of Italy from the previous week. Because of New York's size, the situation has not yet gotten as dire as Italy, but I am certain I will be stating a different case a week from now, when the US will be closer to a million cases and New York in the hundreds of thousands.

Locally, North Carolina just topped 1,000 cases, over half of which are in Charlotte and Raleigh-Durham. Those areas are on shelter-at-home, while the rest of the state will be starting that on Monday at 5pm. Watauga County sits at just 5 cases, and we have yet to see any inpatient cases or local transmission outside of a single household. Watauga Medical Center has barred all visitors except for spouses of delivering mothers and family members of dying patients. All staff are being temperature screened on our way into the hospital each shift. Policies are in place and the COVID ICU and intermediate units are up and running. I am personally caring for the COVID rule-out patients this week, and have been encouraged at the rapid pace of change. After weeks of preparation, we are nearly as ready as we can be, excepting the continued lack of rapid COVID-19 testing capability-- which is by far our greatest limitation in terms of caring for possible COVID patients and conserving PPE (personal protective equipment). If reports are to be believed, responsibility for this lack rests squarely at the feet of the FDA, which delayed all testing development for the entire month of February. But no matter who is responsible, heads should roll. My job and the job of thousands of healthcare providers is markedly more difficult without rapid testing capability. And most importantly, patient care is suffering, even before we have any actual COVID patients in the hospital. 

The dark clouds continue to gather, and the rain has started to fall. But the silver linings remain. Distributed work (ie working from home), a beautiful concept, is starting to see its day in the sun. Service industries are being painfully disrupted, but much will rise from the ashes. People are having to be more intentional about staying connected.  And the world is starting to see the value of competent leadership... and the steep price that must be paid where it is lacking in trying times.

Stay calm and self-isolate on.

Pandemic Mode

Like everyone else, I've been amazed at the pace of change over the past few weeks. Though I've been receiving a flood of COVID-19 emails for the past month, it has not struck home until much more recently. The first in-person impact I recall occurred thirteen days ago, when I found out that a friend's son's highly-anticipated college spring break trip to Ireland had been cancelled. Around that time, I started hearing about universities' plans to extend spring break and possibly go to e-learning for the rest of the semester. The next day, on March 9, my small group met at my house, and though there was some minor conversation about Coronavirus, there was little to no thought that that would be the last time we would meet for months. North Carolina had hardly seen any COVID-19 cases, and Watauga County certainly hadn't. I did start taking action as the medical director of the Community Care Clinic to implement reasonable and recommended precautions, which started changing on a near-daily basis that week. On Tuesday, Mindy and I visited my grandfather at his assisted living facility in Charlotte, not supposing that the facility would be put on lockdown just 2 days later. On Thursday, March 12, I still felt little risk to teaching my 1-day obstetrics course to 11 missionaries at EQUIP Ministries in Marion. I tried to remember to not shake anyone's hands, but that was about it.

That evening, however, I found out that all professional and collegiate sports had been indefinitely cancelled after an NBA player tested positive. I also got an email from my church that all services were being cancelled, and a text from a friend letting me know that the Banff Mountain Film Festival (which would have been today) had been cancelled. On my way back from Marion, I listened to a Sam Harris podcast that raised my concern that the supply chain might be disrupted. After discussing that with Mindy, she started stocking up on supplies. I also started considering the need to cancel my yearly college friends' get-together and other upcoming trips. The following day, I started hearing about schools shutting down, and court was shut down halfway through the day before Isabella's case was heard (earning Mindy's ire after she had sat around court for 1.5 days)

Though I still ran a relay race on March 14, everyone was careful to not shake any hands, and plans for a post-race hangout were scuttled. But even then, Mindy and I decided to go out to eat at a restaurant by ourselves-- where I made sure to wash my hands, of course. Much like my small group a few days earlier, I scarcely imagined it would be the last time I would eat at a restaurant for months. Though that may seem foolish just a week later, a complete restaurant ban still wasn't within my imagined realm of possibility at that moment.

But that was to change extremely quickly. I found out that night or the next morning that all NC public schools had been shut down, that gatherings of more than 100 people had been banned, and that someone in Watauga County had tested positive for COVID-19. When I drove to the hospital on the morning of March 16 after nine days off, I hardly recognized the place. There were traffic cones everywhere and a checkpoint on my way in where I had to show my ID, like a military base. That day, I had to test a patient in whom I could not reliably rule out COVID-19, and more patients like that would come over the course of the week. Preparations for dedicated COVID units swung into high gear, and emergency staffing and other plans were drawn up. The next day, March 17, the restaurant and bar ban dropped, and community life ground to a standstill.

Yesterday, I had planned to meet with a friend here at my house to hang out, but his family had already started to "hunker down." Now that we're both off work for a few days, Mindy and I are starting to "hunker down," too, though there is of course no chance that I will be called off of work. I've realized that I have a duty to avoid having to self-quarantine, since my services may be urgently needed at the hospital in a matter of weeks-- so I should therefore avoid any unnecessary contact with other people.

There are a few things I'd like to say about all this. Obviously, all of these developments are bad for the economy, and it's easy to become anxious about finances. To minimize that, I'm trying to meditate and journal more. And will try to time my entry into the market appropriately.

Secondly, things might get pretty lonely, especially for people who are out of work or who have to work from home. Since I'll still be working, that's less of a personal concern, but I still feel it on my current days off when Mindy is working. But the good news is that Mindy and I have had a lot more time to hang out and work as a team around the house. We've already noticed the relational dividends from the increased quality time.

Furthermore, now that we see cases in Charlotte and the Triangle starting to exponentially rise, it's obvious that all the measures put in place over the past week have been the correct calls. And the naysayers one would come across just days ago have all changed their tune. So kudos to Governor Cooper. I can only imagine that the controls are going to get stricter over the coming days and weeks.

On a larger scale, there's no question that the federal government in general and the Trump Administration and FDA in particular have horribly bungled their response to this emerging crisis. If they had taken the right steps at the right time, we would not have to be waiting for 3-5 days for a COVID-19 test result, and places like New York, Seattle, and San Francisco would not be experiencing the beginnings of a true crisis. I have no doubt that we will experience a catastrophic reckoning from the current administration's incompetence.

Everyone is rightly worried about following the path of China and Italy. With the measures that North Carolina has put in place over the last week, I think it's unlikely we will see that kind of crisis locally, though it's still possible, especially in the Triangle and Charlotte. I'm optimistic that we will be able to flatten the curve, at least moderately. Though the exponential growth in cases over the last week may seem to be telling another story, there is a lag time of several weeks to the effects of our current efforts. Only time will tell if what we are doing is enough.

The best comparison for the past few weeks and the coming months from my lifetime is 9-11. As we all know, the world has never been the same since then. And the same will be able to be said for the current crisis. In the meantime, don't take any unnecessary chances. Stay well, stay calm, and isolate on.

Keto January Recap

Every time I told someone over the last month that I'm following the ketogenic diet, I got a quizzical look and some version of, "Why are you doing that? You don't need to lose weight!"

I get it, people. I promise I don't have an eating disorder. Whether most people realize it or not, the ketogenic diet has benefits far beyond weight loss. These include:

• Improved cognitive function and decreased brain fog
• Improved mitochondrial function
• Conserved glycogen during moderate aerobic activity (70% of VO2 max)
• Improved autophagy and potentially reduced long-term cancer risk
• Decreased insulin release, and thereby decreased systemic inflammation

And that's just the start. I'm excited to see more and more research emerging each year around various other salutory effects of keto-- the list just keeps growing!

Now that I've finished my three-week experiment with it, I have a few personal observations I'd like to share, broken down by week:

• Week 1: lead-in week. Did not check my ketone level. Felt ok. A few headaches. Immediately lost 5-6 pounds of water weight, which is was happened last time I went keto. Started drinking water with salt, lemon juice, and a splash of apple cider vinegar in the morning to replete my electrolytes. Decided to monitor my blood ketone level (using my new Keto Mojo monitor) rather than track my macros, which would have been just too much work this time around. 
• Week 2: mild ketosis (levels 0.5 - 0.9). Workouts were poor since I had no glycogen and was not yet keto-adapted. More headaches. Had to push through this week. But I did notice that I was very full for 6-7 hours after eating my late breakfast of cheesy eggs, presumably the effect of both the satiety that comes from a high-fat diet and the anorexic effect of ketones.
• Week 3: moderate ketosis (level was 1.2 at beginning of the week, then I ran out of ketone strips. Presumably it was at least 1.2 afterwards). Workouts improved as I became more keto-adapted. Headaches decreased and had little brain fog, although I still got headaches if my sleep was disrupted. Gained back about 4 of the pounds I had lost. Felt essentially back to normal. 

Though it's not something I've decided to follow long-term, I do plan to continue the habit of going keto every January-- probably with a tweak each year, to keep things interesting. It's quite possible that this habit alone will extend my lifespan by 5 or even 10 years-- though I'll never know for sure.

So whether you're fluffy, lean, or something in between, the ketogenic diet serves as a master metabolic reset. If you do it right, you'll be glad you gave it a try. Let me know if you do!

2020 Focus

My readings and musings over the last few months have crystallized two deep desires in me. The first is enjoying and being present for each moment. Few things sharpen your appreciation for the moment like a baby, and as I've grown in my understanding of and experience with meditation over the past year, I've come to recognize that the degree of fulfillment in life is largely determined by how undistracted a person is. Frequently entering a state of flow is a necessary condition for the good life. So whether it's feeding a baby at 5 AM or having a conversation with Mindy or swimming intervals in the pool or knocking out notes at work, I try to achieve complete focus on each moment, each appearance in consciousness-- each breath, each stroke, each thought, each interaction, each emotion. Fostering that practice will be the cornerstone of my next year. Mindy can't wait!

I'll also be exploring the subconscious over the next year. Whereas mindfulness meditation completely centers on the contents of consciousness, dream work and active imagination (which I'll cover in a future post) are practices that bring to awareness the deep well of the unconscious. Carl Jung trailblazed this field over a century ago, and by a stroke of luck I obtained an anthology of his work at Boone United Methodist's Fall Bazaar, pictured at the right below. I'm sure I'll post more on this as the year progresses and I have time to work through more of his writings. The middle book, Robert A. Johnson's Inner Work, explores the topics of dream work and active imagination in a practical way, and though I'm only now starting to dig into this book, I'm already excited to share some of the techniques and insights I gain.

As for hobbies, I will of course continue to train for and compete in triathlons, kayak as time, relationships, and rainfall allow, garden, read, and write. I'm also currently eating keto, and plan to dive back into the bongos later in the year. But my most recent passion has been stirred by the third book in the photo, Fiery Ferments-- a fun, practical, and educational exploration of the making of hot sauces and fermented foods that is the perfect marriage of my love for microbiology, gardening, and spice. I can't wait to experience and share the resulting concoctions! Thanks, Michael and Meghan!

Professionally, my work as a hospitalist will morph as Boone's new Family Medicine residency starts up in July. I'll be doing more teaching and precepting (which I love to do), and I've already started doing more bedside ultrasound and procedures (which I also enjoy doing) in anticipation of teaching the residents these topics. I'll also continue providing oversight and and medical care at the Community Care Clinic. 

So like most of you reading this, my life is full of moving parts. Meditation and taking time to silently reflect will continue to help me understand why I act and feel the way I do in each moment, and I'm grateful that mindfulness is enjoying its time in the cultural sun. But a topic far less prominent but no less essential is how to understand our subconscious. The vast well from which the contents of consciousness emerge remains a mystery for most-- but it doesn't have to be that way! I'm excited to start unraveling that mystery, and share what I learn with all you lovely readers. 

Memento mori, memento vivere.

Dan

2019 in Review (and the 2010's!)

The big-picture themes for 2019, as I stated in my blog post preparing for the year, were

"reapproaching the Bible in a new way and generosity of spirit. My goal is to be more empathetic, warm, and understanding by the end of next year than I am now. Though I'll still be reading books and book summaries and posting my reflections, I'll be more focused on the emotional and relational side of life, which is where I stand to grow the most right now. And I hope that, as a result, joy and humor will flow like never before!"

It turns out that, roughly the first half of my year was spent on reapproaching the Bible through various books, meditations, and podcasts (which was great), while I shifted my focus onto generosity during the second half, culminating in accepting a foster baby in December. I also assumed the volunteer position of Medical Director at the Community Care Clinic, Boone's only no-cost clinic serving exclusively uninsured patients. Contemplation and Action! Just what the sages always prescribe. Though I fell short plenty of times, especially in the area of presence and warmth, I can honestly say I grew across most important domains this year.

Mindy and I continue to grow and put down roots in the High Country, and the fostering process has brought us together as a team like never before. We have become more committed at Boone United Methodist Church, and have found a wonderful, supportive small group to be a part of. We also took two big trips, one to Europe and one to Colorado-- which should satisfy the travel bug for years to come!

Triathlon season was a success, and I was able to kayak a few times, though not as much as I wanted. The garden did pretty well, and I found some field mushrooms to eat in our very own pasture and at Mindy's uncle's house in Colorado-- morels, no less. I made some great strides at work, especially in the areas of procedures and ultrasound, completed my leadership program, and helped plan for the new Family Medicine Residency starting in Boone this year.

As I turn my attention to 2020, I want to take a moment to be grateful not just for a full year, but for a wonderful decade. The past 10 years have seen me through medical school, residency, marriage, deconstructions, reconstructions, major travels, a real job, and, to close out the decade... a baby! Though we don't know if she'll be with us forever or not (we sure hope she will be), Mindy and I are offering our foster baby as much love as we can give. And there's no better way to end a decade or start a new one than with that kind of self-giving love. And lots of snuggles.