Hidden Gems and a Guarantee



This is an open letter to everyone everywhere, especially people who live in small communities such as mine:

If you drive to work, you are missing out.   If someone offered you an opportunity to improve your health, enhance your happiness and creativity, boost your self esteem, and even make you richer, what would you say?  Many might think it would be an offer that was too good to be true– a scam; what’s the catch? There is no catch; I want to share how commuting to work on foot or by bicycle can do all these things. It can be a bit addicting, but this addiction is a good thing.

First the obvious: a self-propelled commute is exercise, and regular exercise has tremendous benefits for health. Physicians typically recommend exercise in the range of 30 minutes five days per week because research supports the notion that this amount of exercise reduces the chance of developing chronic diseases (heart disease, diabetes, arthritis, as well as many cancers, for example). For many people who live in small communities, work is within range of a 30 minute walk or bicycle ride.

Another clear benefit of walking or biking to work has to do with money; everything costs much less than driving. Compare a new pair of shoes or a bicycle with the cost of maintaining a car and paying for fuel, and there is no contest. Cars as a means of getting to and from work in America have become an expensive habit, and sometimes a good way to break a habit is to realize how expensive it is.

The hidden gems with a non-motorized commute, however, have to do with creativity, self esteem, and happiness. While exercise in itself has been shown to boost these qualities, I believe exercising while going to and from work increases these traits much more.

Whether it is preparing for a busy day, solving a problem, or finding solutions to conflicts, the time on a bike or walking allows the brain to wander, to consider out-of-the-box solutions, to be creative. Personally, some of my most creative thoughts occur before or after work while I am pedaling away. It is the exercise combined with the time of day combined with being disconnected from computers and smart phones. Just as some of the best vacations are when one is in a remote location and “unplugged,” some of the best parts of the day are when one is alone, in that transition between work and home. It may sound crazy, but it is a mini mind and body vacation, a time to figure things out.

But, one might say, “exercise is hard, I’m tired after work, it’s windy, and no matter which direction I am going, it’s up hill!” There is no argument from me– I agree entirely. However, in these sentiments lies exactly the reward, and why I have come to enjoy my commute more and more over time. There have been many times when I have walked out the clinic door, tired from a busy day, and thought about getting a ride home. And there have been times, half way home, when I have wondered where my strength had gone. By mustering the strength, though, I almost always get on my bike, and I always get home just fine. I have gradually realized what this has done for me. My body and brain have become stronger and stronger, and I have faith in my ability to succeed. Self esteem, inner confidence, resilience, whatever you want to call it– I’ve got more of it now, and my commute has helped me get it.

Meanwhile, I have come realize over time that getting to work on bike or foot has made me a happier person. We all want to be happy, and it is well known through research that exercise improves mood and decreases the chances of becoming depressed. This mood-enhancing effect of exercise occurs right after an exercise session, as well as over the long term with regular exercise. In other words, biking or walking to work is a handy tool to improve the chances of having a good day at work. And what is really remarkable is if one adds up all those good days at work, the result is an improved chance of being happy at work in general. Everyone spends a lot of time — most of our adult life, actually– at work, why not improve the odds that we will be happy during that time, that we will like our job? I think this is in a sense an important foundation of job satisfaction.

It takes longer to get to work in the morning and there are errands and tasks to complete that require a car…. the list goes on and on. Changing or creating new habits is difficult, and it is common at first to see numerous seemingly insurmountable barriers. In reality though, there are creative solutions to almost every barrier, and meanwhile it is rewarding in itself to plan for and achieve new healthy behaviors. And of course it can be done; I witness patients changing behaviors every day in the clinic. I never cease to be amazed at the strength and determination of the human spirit.

My advice is to treat yourself and leave your car at home. Whether your commute is by bike or by foot, I guarantee (how often do doctors guarantee anything?) that with time you will be healthier, happier, richer, more creative, and have greater confidence in yourself.

The Right Tool


fullsizerender“I’ve got to use the right tool,” I thought to myself as I attempted to pound a nail into the wall with the bottom of my coffee cup. Kneeling on the exam room table, I was attempting to hang a picture on the wall before the clinic day began. I have all sorts of useful tools in my clinic – scalpels, special scissors and a multitude of precision instruments for surgical procedures and other medical care. But on that day I did not have a hammer for pounding in a nail to hang a picture. I smiled, and reflected on how comical I must look, awkwardly perched on the exam room table trying to put a nail in the wall with a coffee cup. I had opted for what was convenient but not what was appropriate. Without the right tool, I was not successful in getting my job done and was wasting valuable time. Hoping I was now a little wiser, I climbed off the exam table with the picture, walked back to my office, picked up my stethoscope, and began the clinic day seeing patients.

Using the right tool is critical. I was immediately reminded of this as my first patient – a 65 year old man – came in for a physical. As is the case for many Americans, the biggest threat to his health was the risk of having a heart attack or a stroke. He had several important risk factors for heart disease: he was overweight, had high cholesterol, high blood pressure, and was recently diagnosed with diabetes. He needed to lose weight, but weight loss was difficult for him. During the course of the visit we discussed his weight, and he shared with me that he was trying the “Ketosis Diet” to help him lose weight. He had read about this diet on the internet and purchased a book. He explained the diet was rich in cheese, bacon, and other meats. Apparently by avoiding all carbohydrates and eating mostly fat, one loses weight. The diet fit in nicely with his existing eating habits. After considering his diet, I cautioned that the types of foods he was eating were exactly the type of foods medical research recommends avoiding to prevent heart disease. I attempted to steer him towards the right tools – heart healthy foods and physical activity – for his job, the job of preventing a heart attack.

When it comes to preventing disease, individuals need to stop pounding nails with coffee cups. Pounding a nail requires the right tool: a hammer. When it comes to medicine, the hammer is science. Evidence based research – the scientific process – is the perfect tool for promoting health and has an excellent track record. Modern medicine has been successful at preventing and treating disease because of the scientific process. To make health decisions based on the latest internet popular opinion is using a coffee cup instead of a hammer to pound a nail.

Healthcare providers need the truth of science to guide them in making sound recommendations for both individual patients and for the population as a whole. Vaccines are a perfect example. Vaccine medicine is medical science at its best, in that it offers a clear example of scientific research that originates in the laboratory, and that is later applied to people and populations to prevent deadly infections. Every day, vaccines prevent diseases that could have been; every day, vaccines save lives. Thanks to science, Polio is almost eradicated from the globe and the Americas have been declared free of Measles. Meanwhile, looking forward into the future, Zika – a more recent threat – may well prove to be a short chapter in history books, as a number of promising Zika vaccines are currently undergoing clinical trials. Vaccine science is the right tool to prevent infectious disease.

The scientific process is critical not only for advancing medical care and vaccine science, but is vital to all realms of scientific research. Whether it is medicine, public health, or climate change, science is the best tool to understand our world. Science has a proven track record; it works. The alternative to using science is nothing more than a popularity contest of opinion. If we as a society choose to value proclamations devoid of facts over scientific research, we might as well equip all the carpenters in America with coffee cups. We need to choose the hammer and get the job done; science is the right tool to improve health, prevent disease, and has the potential to make the world a better place.

Medical Detectives Explore Mystery of Mumps Outbreaks


The past year was a big year for the mumps virus. With 5,311 cases in 2016, the United States experienced the most mumps infections since 2006. The majority of the outbreaks occurred in the Midwest, however Washington State recorded 486 cases in the past 5 months. Mumps was a very common viral infection prior to the development of a vaccine in 1967, and for over the past 50 years has been well controlled. In attempting to understand the recent increased number of mumps infections, a rational explanation is that the affected individuals had not received all of their routine MMR (Measles, Mumps and Rubella) shots. However, the mumps infections have in fact occurred in populations where individuals have been up to date on their shots, having received the recommended two doses of MMR at around 1 and 4 years of age.  The question remains then, why has the mumps virus made such a commotion this past year?  Has the mumps vaccine become less effective? What does this mean for routine MMR vaccination in the United States? The recent rise in mumps cases has raised intriguing questions such as these for scientists to explore and attempt to answer.


A very refreshing aspect of the scientific process is that when events don’t quite make sense, scientists approach a problem by attempting to observe and note the facts, and then study the possibilities with objective research. With the recent increase in mumps infections, researchers are actively involved in the process of being “medical detectives.” They are looking at the data, evaluating possibilities, and figuring out how to test their ideas. While we do not yet know why the mumps outbreaks have occurred, there are clues that may offer insight into this mumps mystery.


The mumps infections have typically occurred in vaccinated populations, in which people have been living in high density environments, such as college campuses. This close proximity makes transmitting germs easier. Meanwhile, the mumps component of the MMR vaccine is good at preventing mumps infections, but not quite as good as the measles and rubella components. For example, the measles vaccine prevents measles infection with about a 98% success rate. Mumps “vaccine efficacy” is a little lower, at approximately 88%. This slightly lower vaccine efficacy can allow the infection to spread more readily. In addition, after a child receives the second MMR at age 4, the level of mumps protection declines gradually over time, which also increases the possibility of infection. All of these reasons – high density living situations, good but not great vaccine efficacy, and declining immunity over time – may have contributed to the mumps outbreaks.


However, perhaps some the most fascinating reasons why mumps has had a big year may have to do with the “big picture” perspective. Scientists know that some viruses naturally go through cycles over time, where infections increase at somewhat regular intervals. For example, before the advent of the rubella vaccine, rubella epidemics occurred every 7-8 years. It is possible that mumps may have a similar natural history, and perhaps this past year was time for a natural epidemic to occur. If this is the case, the vaccine could have blunted the spike of infections but not prevented it altogether. With this hypothesis in mind, it will be interesting to see if mumps naturally quiets down over the next couple years on its own accord.


In addition, measles and rubella have been completely eradicated from America, such that new cases in The United States are imported from travelers arriving from other countries. Mumps on the other hand has not been eradicated from America, and may be circulating within the country more than previously thought. It is known that approximately one third of mumps infections occur without symptoms, which in turn could enhance spread of the virus without our awareness, or “below the radar.” This phenomenon could have contributed to the increased number of infections. These are some of the thoughts scientists are considering, but they are only ideas at this time. Similarly, it may make sense for a third dose of MMR in the setting of a local outbreak; however, objective data is necessary before making this change.


Lastly, an interesting – and reassuring – observation from the recent mumps outbreaks is that while mumps infection occurred in several thousand people this past year, no complications of the infection have been seen. Before the vaccine was routinely used, mumps infection was associated with a 4% risk of hearing loss, 4% risk of pancreatitis, 30% risk of inflammation of the testes or ovaries, and resulted in approximately 5% of patients becoming hospitalized. This raises the question of whether those recently infected with mumps in fact had enough protection from the vaccine to prevent potentially serious complications. At this time we don’t know, but this is another hypothesis that scientists are exploring.


Medical epidemiologists are doing their fact checking in an attempt to understand the mumps outbreaks better. While science may sometimes be portrayed in the popular media as stodgy or lacking creativity, our current mumps mystery illuminates just how creative science can be with problem solving. Scientists have to “think outside the box” to figure out these problems, both in formulating possible explanations as well as determining how to use the scientific process to test their ideas. In addition, nothing is a given- no matter how good an idea it may seem – until it is supported by the evidence of high quality research. In fact, in science nothing is really ever permanently a “given” as science promotes an ongoing process of evaluating and reevaluating. However, the more research studies that come to the same conclusion, the more likely a concept may be true.


While there have been an increased number of mumps cases this past year throughout the country, and it is not entirely clear why, there are interesting observations – or clues – for researchers to explore. It will be exciting to see what our creative, problem solving medical scientists discover. In the meantime, be sure to encourage MMR childhood vaccination.  A profound consideration is that use of the MMR vaccine has reduced mumps infection by approximately 99% compared to the pre-vaccine era.


Air Pollution and You


Air pollution is a problem. We all know it is not healthy to breathe polluted air. However, everyone needs to breath; we have no other choice but to inhale and exhale (roughly 23,000 times a day) as we venture out into our community to work and live our lives. We notice the annoying symptoms of scratchy throats and itchy eyes, but the most profound damage to our health occurs deep in our lungs, where the particulate matter settles.

Locally as well as globally, air pollution is an increasing health concern and is taking its toll on human health. The International Energy Agency recently released a report attributing an annual 6.5 million premature deaths to air pollution worldwide. Particulate matter in the air increases the risk of being hospitalized and dying from pneumonia, heart attacks, strokes, and asthma. In addition, research has shown that when air quality is poor, mental health conditions such as anxiety are more likely to worsen, and pregnant women are more likely to go into premature labor. Those most vulnerable to the adverse health effects of air pollution are our children and the elderly.

There is little argument that air pollution is a concern. Somehow though, it often seems to be someone else’s problem. It is easy to blame someone else’s burn pile or inefficient wood stove. And yet, whether it is burning firewood, yard waste, or irrigation ditches, many of us play a role in producing air pollution. The smoke from burn piles or chimneys may seem as though it drifts up and far away from us, but the truth is that most of it stays in our local atmosphere. For our valley, our local air pollution is in general home grown: particulates from wood smoke are produced in Kittitas Valley and are inhaled in Kittitas Valley. During the winter months, high pressure systems – those bright blue winter skies – trap our pollution here for all of us to breathe.

Residents of Kittitas Valley pollute Kittitas Valley air, are harmed by air pollution, and can help reduce air pollution. Since air pollution is our own problem that we have created, we – as individuals – must contribute to the solution.

Learn more about how your health is effected by air pollution:

1. The American Lung Association: http://www.lung.org/our-initiatives/healthy-air/
2. Moms Clean Air Force: http://www.momscleanairforce.org
3. The CDC: https://www.cdc.gov/nceh/airpollution/default.htm

Know when local air quality is poor: https://fortress.wa.gov/ecy/enviwa/

Take individual action:

1. Replace an inefficient wood fireplace or stove with one that is clean burning. Talk to your neighbors and encourage them to do the same. There is financial assistance to do so: https://hopesource.us/woodstove.
2. Check out the helpful information provided by The Kittitas County Health Department: https://www.co.kittitas.wa.us/health/programs/environmental-health/air-quality.aspx
3. Instead of burning yard waste, take it to the transfer station composting center: https://www.co.kittitas.wa.us/solid-waste/waste-prevention.aspx.

Air pollution is quietly harming your health and the health of your loved ones. Poor air quality occurs from our individual actions, is difficult to escape, and is something each one of us can do something about. Our air quality will likely only get worse unless we do something about it.

A Voice in the Night


bicycle-hd-wallpapers-2012It was a typical January night in Kittitas Valley: a chilly twenty degrees, scattered snow flurries, and plenty of snow on the ground. Fortunately the roads were mostly bare however, and I was able to be on my bike commuting to work.

While riding my bike home from a day at work, I like to notice my surroundings as I roll by, while at the same time think about the day’s events. It sometimes seems to be a little bit of a balancing act between paying attention to the here and now as well as thinking creatively about work or home.

I think I was in the midst of the later thoughts – creative daydreaming as I like to think of it, when a large pickup truck slowed down, pulled alongside me, and rolled down its passenger side window. In general, while riding my bike and a vehicle – especially a big one – slows down alongside me, I get a little nervous. A truck is big and a bike is little; meanwhile, the notion that this was at night as well as it was a large truck heightened my senses, and made me feel a bit uneasy.

“I appreciate your interest in safety, young man,” a man’s deep voice came clear and loud through the window. Looking into the cab, all I could see was darkness.

Somewhat surprised and not sure what to say, I said, “alright!”

Just as clear and deep, he replied, “thank you.”

“Sure!” I said, still struggling somewhat as to how to respond.

He accelerated and drove off into the night.

Over the past few months I had upgraded my rear light system to improve my visibility, and my lights must have been be working!

I rode on, following my familiar route home. The interaction made me feel really good. It is always nice to be appreciated. The driver didn’t need to slow town and interact with me, but he did. He took that extra step to be friendly, put out some good energy, and appreciate something I was doing.

I rode a couple more miles, thinking about the interaction more, and it occurred to me that there was an additional aspect of the interaction I liked. He said, ” young man.” I am not exactly a young man, but he couldn’t tell.  It was dark and I was wearing multiple layers of clothes and a bike helmet. He assumed I was young because I was commuting home on my bike.

I rode a few more miles, thinking all the while about the interaction. He thought I was young because I was doing what many consider to be a young person activity – riding a bike rather than driving. Meanwhile, riding my bike – exercising – was in fact likely helping to keep my body young. Hmm. I was perceived as young because of the activity I was doing. Chronologically I am not young; but, by doing the activity, I was promoting physiologic youth. I liked the full circle of these thoughts.

That January night I was reminded how good it feels to receive an appreciation, and how important it is to give appreciations. I also received an affirmation of how exercise, regardless of age, promotes a “youthful” state of health for the body and mind. I received these gifts because an individual made the effort to notice, slow down and say thanks.

Resilience Tools, On Line and Available




  1. The power or ability to return to the original form, position, etc., after being bent, compressed, or stretched; elasticity.
  2. Ability to recover readily from illness, depression, adversity, or the like; buoyancy.

As anyone who has experienced a serious illness or injury can attest, a health crisis creates a sense of being bent, compressed, or stretched, coupled with an intense longing to return to one’s original state. Resilience is elasticity: it is bending but not breaking, being compressed but not flattened, and stretched but not torn. Cancer, injury, or any serious illness, can drag one down– often abruptly– into the murky depths of illness. Resilience is buoyancy: the ability to rise up, resurface and emerge into sunlight and fresh air again.

Having resilience during a health crisis is adapting well in the face of adversity; it is “bouncing back” from difficult experiences. Resilience requires the ability to enlist one’s own emotional, mental and spiritual strengths, and implies a sense of activation and internal motivation. For example, resilience is not closing and bolting the door and waiting out the storm. The sense of bracing or shielding from adversity is more typical of “perseverance.” Perseverance is important and can be helpful, but it is not the same as resilience.

It is this sense of action from within that conveys there is something we can do to create resilience in our lives. Resilience is not inherited; in fact, research has shown that behaviors and decisions are much more powerful than genetics in developing resilience.

Early on in my journey with cancer I was introduced to CaringBridge, which helped nurture resilience within me. CaringBridge is a nonprofit organization that enables a person or family experiencing a health crisis to create a free website. This personal website facilitates connection to loved ones. When I had cancer, I was able to communicate with my family, friends, and larger community, and they in turn could communicate with and support me. In addition, one can keep an online journal to share the logistics as well as the emotional experience of a medical journey.

The diagnosis of a tumor in my muscle was an abrupt detour on the road of life, and like many others who experience similar news, my initial response was fear and worry about the future, as well as a sense of isolation from the “normal” world most people seemed to be living in. Having resilience is associated with social connections. Individuals who feel a sense of connection and support from others are more likely to adapt well to an illness, and are more likely to recover more quickly. CaringBridge is an online medium that easily connects individuals with a support group.

Research has also shown that expressive writing and a concept called “mindfulness” help promote resilience. Initially, I had no idea that keeping a journal on CaringBridge about my treatments, experiences and struggles would have such a profound effect on my ability to cope with my illness. Writing about a difficult experience helps one gain new insights and perspectives, reflect, as well as see and articulate the positive aspects of a difficult experience. As a story is shared, someone in the midst of a health crisis not only communicates what is happening, but also may see the opportunity to influence the direction of their own narrative. Over time this expressive writing can subtly encourage the creation of a new, more hopeful reality. My personal CaringBridge journal began as an avenue for communicating information, and gradually evolved into a journal that shared a variety of emotions I experienced, and expressed gratitude for the multitude of people in my life who provided immeasurable support. Writing helped me reflect and better understand my journey; writing gave me strength.

Since expressive writing is an in-the-moment process, it can also encourage staying in the present. The present is the best place to be during a serious illness. Thinking about the future when one is scared is often fraught with the worry and anxieties of “what-if’s,” which can then lead to more and darker “what-if” scenarios. Meanwhile, lingering in the past can foster a sense of loss about a life that is lost, or lead to the “should-have” and “could-have” thoughts that impede adapting in healthy ways. Staying in the present is the essence of “mindfulness,” and has been shown to promote resilience.

I learned that the antidote to the fear and isolation that can occur with a serious health event is connecting with others, opening up rather than hiding, sharing, and staying in the present. Through writing and social connection, CaringBridge gave me tools that promoted resilience when my world turned upside down.

If you know of someone experiencing a serious health crisis, introduce them to CaringBridge. In doing so, you will help equip them with valuable tools that foster internal elasticity and buoyancy. You will increase the chances the person you care about will respond to their illness in adaptive ways that promote healing. In sharing the gift of connection, the seeds of resilience are sown, nurtured, and are given opportunity to flourish.

Listen to Dr. Merrill-Steskal’s interview with CaringBridge Founder Sona Mehring.

What’s in a Name?


How can we know when seemingly insignificant events in our life will impact our lives in ways we do not foresee? We can never know; it is only years later, when we look back and gain perspective do we gain appreciation.  The experience I would like to share was not earth-shaking or what one might describe as particularly profound; rather, it was merely one of those light, amusing life experiences.  Nonetheless, it was an experience that I recall with a smile, and an experience that has helped my vision in naming this blog.

It was 2006. My wife, son and I stepped forth from our rented apartment on the first day of a long awaited trip to Italy. Gabe had been studying the Renaissance in his elementary school “challenge class” and Anne and I had, in the distant past, both had formative experiences in childhood or college while in Europe. It had been many years since we had been in Europe, and it was Gabe’s first time.

It was a bright beautiful morning in May. We walked down a bustling street in Rome, and looking for a place for breakfast, we spied a busy cafe and entered to sights of wonderful looking pastries and the rich smell of espresso. We pointed, smiled and attempted a word or two of very rudimentary Italian to indicate which pastries we were interested in. And then I ordered my coffee.

Anyone who knows me knows I like coffee. I drink a fair amount of coffee, but it is not as though I drink pots and pots of it.  I like it strong, I like it black,  and I like it in those tiny little espresso cups so I can savor it, nice and hot.  Upon first glance at the small espresso coffee cups in the Italian cafe that day in 2006, it was quickly apparent to me that even a “double” espresso was not going to be adequate; so I ordered a “triple.”

“Tre?! Tre?! No, doppio. ”  The Italian man said, shaking his head emphatically.

I learned right away that a “triple espresso” was not allowed. Judging by the look of surprise in his eyes, it was as if I had asked the impossible. It was single or double. I attempted to explain that I really did want a triple espresso; but no, sorry, a triple was just not an option.  I ordered a double (doppio) espresso, enjoyed it immensely, and  then went on to order another double espresso.

This experience was one of those funny little events that happen while traveling. I’ll never forget the look of surprise in the Italian man’s face as I asked for that triple espresso. I didn’t know it at the time, but the stage had been set for “Triple Espresso MD” to be born. Not long ago,  Anne and I were bouncing different names for the blog off each other, and perhaps because we were once again traveling in Europe, in a moment of inspiration she exclaimed, “Triple Espresso MD!”  It was instantly clear she had hit upon the perfect name for my blog.

I think it is safe to say that proposing a “triple” espresso that day in Rome was not exactly a brilliant insight or a think-outside-the-box new idea. I merely wanted what I thought was an adequate amount of coffee. Still, “triple espresso” symbolizes to me an attempt to look at issues a little differently, from a fresh and creative perspective. In addition, the name is imbued with a sense of humor and makes me smile. And of course, lets not forget that espressos are packed with energy; it is my hope that this blog energizes readers to live a healthy life.

“Triple Espresso MD” is a place for creative and fresh perspectives on health and medicine. I you enjoy it as much as I enjoy my espresso!