War and Peace

israel                Lately, my news feed, my facebook page, and really much of my mind has been preoccupied with a single current event, the ongoing mini-war in the Gaza strip.  One cannot escape the myriad of articles, opinion pieces, news pieces (is there a difference anymore?), and blogs upon the subject, and I have hesitated to add my voice to the din.  That I have finally been driven to do so is a manifestation of the overwhelming urge to speak out in the face of the devolution of the human race.  I am not writing to appease the anxieties of my Jewish friends who no doubt secretly wonder where my loyalties truly lie.  Nor is it to sympathize with my Muslims “brothers” in the Gaza.  For I do not see that taking sides in this conflict must entail a dichotomous choice at all.  I choose the side of peace and empathy.

I have seen my colleagues and friends speak of this conflict on both sides of this issue.  Most often, it is couched in terms such as “I support Israel because…” or “Look what is happening to these poor Palestinians”.  I have seen otherwise rational people succumb to this dichotomy without giving so much as a thought to the irrefutable fact that by doing so, they are perpetuating and condoning the killing of human beings–they are somehow in their minds making it justifiable and trying to convince others of that “fact”.  Every intelligent person who re-posts an opinion piece on facebook in support of one side or the other is in a very real sense supporting the actions of that side, and there is enough innocent blood on both sets of hands.  I refuse to partake.  I would rather decry all killers, as well as all of those who support them.

I have lived long enough, in a very friendly and close atmosphere with many Jewish friends, to understand the existential threat that Israel faces.  In an attempt to flee the memory of a brutal genocide, they have landed in a place where their every neighbor yearns for their destruction.  They face the fear of attacks on a daily basis, and have no reliable partner for peace in Gaza.  One can understand if they feel the need to respond in kind to force.  But to continue to pursue a military strategy which has killed a wildly disproportionate number of civilians, while continuing to maintain lip-service towards the sanctity of innocent life, is unconscionable at best and hypocritical at worse.  Whatever the reason behind civilian casualties, be it human shields or devious weapon depots, if Israel truly cared for the sanctity of civilian Palestinian life we would have seen a wild shift in tactics to this point.

I have no love lost for Hamas, and patently refuse to support them as co-religionists.  I am acutely aware of the hypocrisy of many who spend countless breaths trying to separate themselves from Islamic terrorists, only to sympathize with them when they are being beaten simply because they call themselves “Muslims”.  Like most of my Muslim friends, I can truly say I feel no religious kinship with those violent extremists whatsoever, and my feelings for the Palestinians are limited to the “fellow-human” level.  After being democratically elected, Hamas squandered a true leadership opportunity, and instead used the bully pulpit they had been given to spew immature and reckless venom towards their neighbors.  They have lost the opportunity to show the world that they can rise above their hateful roots and lead their people to peaceful coexistence.  I wrote in a previous post how the onus was clearly and totally on Hamas to stop the violence, and they have repeatedly let that opportunity slip.

What is lacking in this entire argument is empathy.  Not the false empathy of facebook posts decrying the killing of civilians of the kidnapping of IDF soldiers.  That empathy is a crude facade for the support of violence and killing.  True empathy would involve asking more difficult questions.  What made the Palestinians so desperate that they would put their trust and their votes in an organization willing to use them as human shields and put missiles in their schools in the first place?  What did they fear more than the miserable existence they have now, and why did they have reason to fear it?  The Palestinians can also ask themselves difficult questions, such as how long they will deny the existence of Israel, and its right to exist?  What useful purpose can the insistence upon that fantasy world possibly support?  The existence of Israel is a fact, whether one likes it or not.  Moving onward from that point, one must begin to reconcile what is really relevant in negotiations with such a super power.

If these questions can be asked, and truly answered, peace can still win out.  I refuse to accept answers which bank on the irrationality of groups of people such as “Israel is a bunch of bullies” or “Palestinians just love to die as much as we love to live”.  That is blatantly false, as I am convinced that people throughout the world are basically the same.  No mother in labor in Gaza lays eyes on her infant for the first time and wishes for him/her to be a suicide bomber.  No mother in labor in Israel lays eyes on her infant for the first time and hopes that he/she shoots a Palestinian child in cold blood.  They both want what every other mother in this universe since the beginning of time has wanted, a long, healthy, and peaceful life for their child.

I will not take sides in this conflict.  I will not verbalize, I will not share, I will not “like”, I will not repost.  I will not in any way attempt to justify the inhuman activities of any party in the Middle East.  It is just plain wrong, and there is enough blame to go around.  To take sides in this conflict is to surrender all empathy to the basest martial instincts within us, and to be an accomplice to the devolution of mankind.

Pipe Dreams

draindoctorI truly enjoy the practice of medicine.  The challenge, the complexity, and the constant evolution, combined with the opportunity to continually, positively, and substantially affect people’s lives should lead to an exciting career.  However, the economics of medicine as a business have sapped much of this enjoyment for everyone involved.

As the government strives to save healthcare dollars, the hospitals and insurance companies gear up their high priced lobbyists to guide the outcome.  Thus, too often it is the third wheel, the overworked, under-organized, and often politically inexperienced doctors who bear the brunt of the changes.  As those changes accumulate, they place a greater and greater psychological, mental, and physical toll on our nation’s physicians.

Thus it is that many of my friends, who have been brilliant physicians, have left the field for careers as diverse as real estate or fashion designing.  I must admit that at times I have considered leaving as well.  Of course, the problem is that having spent a large portion of our youth training to be physicians, most of us are ill-equipped to be anything else.

When I was considering what else I was at least partially qualified to do, I felt that as an interventional cardiologist, a natural fit may be to train to become a plumber. Of course, leaving my practice and going back to school would likely require going into debt, but that is the same situation most medical school graduates find themselves in.  Unfortunately, there are so many plumbers out there, and so much competition that I would need a truly unique business model to differentiate myself from the rest and be successful.  And so it is that I present to you, my valued readers, my seven point business model for a successful plumbing business:

1)  I pledge to be available to treat a plumbing emergency within thirty minutes of being called. Any time, day or night.  I will never charge extra for after hours work.  If you have a clogged drain, I promise it will be open within 90 minutes after calling me.  This holds true even if you can’t or won’t pay me.

2) Once I have fixed something in your house, I pledge to be available or have a similarly qualified plumber available at all times, 24/7/365 for any plumbing related questions you might have.  At no charge.

3) Feel free to use your plumbing any way you like.  Flush a diaper or two.  Pour Dran-o down if it gets clogged.  Leave the shower running and the drain stopped.  I will fix it.  And if it’s an emergency, see point #1.  Because every person has a right to working plumbing.

4) I will personally take responsibility for all the work I do, and help bear responsibility for anything else that goes wrong anywhere in your house with any system (electrical, HVAC, etc).  After all, houses are complicated, and everything interacts.

5) In an effort to make sure plumbing services are available to all homeowners, I and the other plumbers in the area will pledge to accept the same fee schedule as each other, which we will allow the government to set at what it deems fair and adjust it yearly.  This holds true even if our costs for tools go up, and the government decides to cut our fees 30% a year.

6) I will only charge you a small portion of your bill.  You may designate a benefactor of your choice to pay the rest.  I will take full responsibility to collect the remaining money from said benefactor.   Even if they refuse to pay or underpay significantly, I will absorb that loss rather than come back to you for the difference.

7) If I feel, in my professional plumbing opinion, that you need a new faucet but the benefactor you choose only wants to pay me to repair the old one, I will either a) replace the faucet at my own expense or b) if I fix the faucet, I will take full legal responsibility should it fail again and flood your entire house.   I will allow the benefactor the right to tell me at any time what they would and would not like to pay for, even after the work is done.

You know, on second thought, maybe I won’t change to plumbing after all. It doesn’t seem different enough.

Free at Last

In 2008, my wife and I had the opportunity to perform our pilgrimage of Hajj.  Like many other people, I found it to be a transformative experience.  Despite the crowds and the complex logistics they necessitate, my overwhelming memory is one of peaceful tranquility, unity, and brotherhood with the rest of the Muslim Ummah.  Most people have similar transformative experiences, the most notable of which was that of Malcom X, whose Hajj induced transformation led to the complete spiritual recalibration of an entire movement.  Many Americans attending this year, unfortunately, will have an incredibly different experience.mecca

The details of this year’s horrific Hajj violence are still, slowly, being revealed.  The basics seem to be that a group of Salafis broke into the American camp at Minah (a small tent city outside of Mecca where Muslims on Hajj stay in minimalist conditions), and after confirming that they were Americans and Shi’ites, proceeded to attack and attempt to kill them.  Grave statements were made, with threats of rape, beheading, and cannibalism directed at the Shi’ites.  Police stood by in tacit, and at times active support with their co-religionist attackers.

Salafism is a particularly radical movement within Wahabbist Sunni Islam, the official religion of the Saudi regime.  It is perhaps best known because of its adherence by Al Qaeda, the Taliban, and Osama Bin Laden.  It is based on a purely historical approach to religion, with wistful longings of yesteryear and absolute disavowance of any progression in thought or action, combined with an “ends justifies the means” approach to halt such progression.  As the “purest” of the Wahabbis, Salafists enjoy the support of the Saudi regime, both actively when convenient and tacitly when expedient.  During my trip to Hajj, the Salafists displayed their disdain for Shi’ites by barring my wife from the prophet’s mosque, defacing my prayer rug, shouting insults at me, and confiscating my prayer books.  These seemed egregious affronts at the time, but are downright trivial compared to the life-threatening attacks they have been emboldened to attempt this year.

If there is a silver lining here, it is that this event (if it gets the press it deserves, which is so far doubtful) will serve to highlight in stark relief just how different the branches of Islam are, and how far removed from terrorists most Muslims are.  Most of my friends find it incredible when I try to explain to them that if an Al-Qaeda terrorist had me and a non-Muslim in his sites and only one bullet, it would be used on me.    This is not hyperbole, unfortunately, but a Salafist truism.  In Salafi eyes, as a Shi’ite I am a Mushrik (one who ascribes to others the greatness reserved for God), a much greater sin than being a non-Muslim.

When Muslims try to convince others that they eschew and condemn terrorism in the strongest possible terms, their pleas are often met with an undercurrent of skepticism.  However, this event and its ramifications should erase any doubt of that fact.  These Salafi terrorists have, by their very actions, at once shown themselves as irreverent of the basic teachings of Islam, and declared mainstream Muslims as enemies.

The world has been locked in a struggle with Islamic terrorism dating back many years before the 9/11 attacks–a hazy war of attrition, where recently lines have been blurred and allegiances have been sometimes unclear.  While Muslims have long argued that the terrorists did not represent the ideals of Islam, the terrorists’ profligate use of Islamic symbols planted seeds of doubt in even the most ardent observers’ minds.  However, these latest acts of terrorism brazenly flaunt even the most basic traditions of Islam and of the Prophet (SA) himself, leaving no doubt as to their true allegiance (or more accurately, lack thereof).   Through their overreach, these Salafis have effectively surrendered their Muslim identity completely.  If seen for the opportunity this represents, this event potentially frees the Muslim community from being held hostage by this fanatic fringe once and for all.

And so we shall once again condemn these acts of violence categorically, this time with the surety of innocent victims of terrorism.  We, the Muslim Ummah, have nothing in common with these barbarians, who would attack Hajjis in Mecca, and threaten cannibalism and rape.  Though they may use our symbols, they do not share our beliefs.  It has finally become clear to the world that they do not follow the teachings of Islam, and that they wish absolutely no goodwill for us, nor us for them.  Though mainstream Islam has been attacked, it is through this attack that we may have found our freedom, at last.

Public Disservice

The U.S. Capitol is photographed through a chain fence in Washington Anarchy is upon us, at least technically.  The Federal Government of the United States of America has ceased function as of yesterday.  This is a dramatic, though unfortunately not unprecedented, situation born of political discord and disagreement.  For most countries, this descent into anarchy would signal the beginning of a failed state, the imminence of a coup, and the breakout of violence.  Luckily, for a nation as traditionally stable and great as ours, it should only portend of increased rancor and brinksmanship.  However, this shutdown represents an important symptom of a potentially terminal illness in our system of politics and government.

We have always prided ourselves as a nation of laws, and not men.  By that, simply, I mean that laws are enacted through a regular and collective process, and each and every person residing in the United States are held to those laws.  The Affordable Care Act (ACA, Obamacare), a federal system of regulating the insurance industry, was enacted into law using these mechanisms, albeit amongst significant debate and controversy.  Opponents of the law then raised a real concern that it was outside the constitutional limits set on federal government.  A Supreme Court challenge was raised, and the law was deemed constitutional.  Much can be said about this law, but nobody can challenge that it was passed, enacted, and validated through completely regular channels and is constitutional (by definition, inasmuch as Supreme Court precedent defines constitutionality).  At this point, opponents of this law continue to have choices.  They can push for repeal and see if they can get sufficient votes, or they can bide their time until the next election and see if they can get sufficient votes.  To date, they have not been shy (nor have they been successful) about either of these options.  However, refusing to fund the law of the land is not one of their options and is tantamount to aiding the violation of said law, under the doctrine of accessory liability.

Arguing that the government shutdown is due to the Democrat’s intransigence and refusal to negotiate about the ACA is thus a non-valid argument.  The ACA is the law of the land, like it or not, and any debates about it occurring between the legislative and executive branches is unconstitutional.  Whatever further debates are to be had must be confined to the judicial branch.  The tea party branch of the Republican Party would do well to read the constitution they so claim to support.

Please understand, I am not saying this as a supporter of the ACA.  In fact, as a tax payer, a physician, and a small business owner, I stand to lose in at least three different ways through its implementation.  I also feel that it is too contingent upon insurance companies dealing in good faith, something they have not traditionally been known to do.  However, my opinions or the opinions of anyone in Congress are totally immaterial to this argument.  The simple fact is that as it is the law of the land, Congress must pass appropriate funding for it.  There exist avenues to reconsider this law, however withholding funding is not one of them.

Our constitution, like the ACA, unfortunately depends on individuals acting in good faith for the greater good.  It depends on civility and cooperation, and assumes that the ultimate goal of those involved is the good of the nation.  Unfortunately,  those assumptions no longer ring true.  Many of those involved in government are spending too much time and energy working on the next election and short term gains for their party rather than long term gains for their nation.  Rules are changed routinely by those in power to their own benefit, and then ignored or complained about just as routinely when those same people are no longer in power.  This is in contrast to both moral and ethical principles, which dictate that (especially in such a cyclical environment), rules be followed by those in power even if it is in their short term detriment.  Episodes such as the current one are thus both reinforcing causes and symptoms of a deep seeded political dysfunction which threatens the basic assumptions of our founding fathers and exposes the holes in the Constitution.  Either we resolve to improve our collective character, or we amend the constitution to legislate away our failings, or we are doomed to witness the decline of our international hegemony.

Ramadan Kareem?

Ramadan-Kareem-ramadan-kareem-1280x960Tonight marks the first night of Ramadan, the Muslim holy month of fasting and prayer.  Though this is one of the most important nights of the year for Muslims, and Islam is (by some accounts) America’s second largest religion, this fact will likely go completely unnoticed by most of the American population.

The American people take rightful pride in possessing a working knowledge of other cultures in our midst, especially those which attract a significant number of adherents.  Note the acceptance of Jewish traditions in the American culture.  Though by most estimates the numbers of Jews in the United States is lower than that of Muslims, the acceptance and knowledge of Jewish traditions and holidays is much better permeated into the American psyche than that of Muslims.  For instance, schools are often closed for “staff development days,” which happen to fall on the major Jewish holidays Rosh Hashanah and Yom Kippur and city sponsored banners advertise good wishes for Rosh Hashanah (the Jewish new year).  In juxtaposition is our shared experience of constantly having to answer and explain what Ramadan is, how long the fast is for, and what Eid is.

The roots of this problem are varied and complex.  They lie in political, economic, and social realms, all of which cannot be dealt with here.  But at least partial blame is to be placed at the feet of one of the least likely of suspects: The Muslim (Hijri) Calendar.

The debate surrounding the Hijri Calendar embodies and symbolizes many of the obstacles that are faced by Muslims attempting to gain acceptance in Western society.  It breeds discord among different branches of Islam, preventing us from presenting a unified front; it appears rooted in antiquity, with dependance on physical moon sightings; and it seems to beg for non-integration with the west, with its rotational nature.

It is important and vital that if Muslims ever want to gain acceptance in the greater realm of Western Society, they present a unified basis which Westerners can learn about.  As it is, how can we expect non-Muslims to take the trouble to learn about more than a hundred different traditions within Islam, when we persist with petty differences over major issues?  That is, how can we expect a national observance for Eid-al-Fitr when we can’t even agree when Eid-al-Fitr should be?

A fixed calendar based on the lunar cycle is possible in today’s society and is the first step towards Muslim reconciliation and acceptance.  Many sects already follow a fixed lunar calendar and find that agreement with traditional moon sightings is excellent (such as the Fatemi branch of Shia Islam, of which I am a follower and which has followed a fixed calendar for millenia).  In contrast, the practice of actual moonsighting leads to vast disagreement among Muslims, all sorts of variations of interpretation vis a vis modern technology, and serves to make Islam the unfortunate butt of many jokes.

Such a movement has gained momentum among pragmatists and even the Saudi Arabian government (who fancy themselves the leaders of the faith, but have yet to convince many others of that position).  It is still greeted with scorn by many traditionalists, however.  It is interesting that these “traditionalists” have no problem using digital atomic clocks to determine prayer times, or complicated spherical geometry algorithms to determine prayer direction, and yet they persist in their opposition to using astronomical calculations to determine moon phases.
We Muslims also face another major challenge.  Our lunar calendar (as with most Lunar calendars) is shorter than the Gregorian calendar by 11 days a year, so that every three years or so, the Muslim year is shifted backwards approximately a month compared to the Gregorian year.  This keeps the calendar in excellent concordance with the moon, but in total discordance with the seasons.  This also keeps non Muslims in total ignorance as to when our holidays occur and prevents any sort of institutionalized acceptance of our observances.

Our Jewish brethren, who faced similar problems about a thousand years ago, solved this discordance through intercalation.  In short, a thirteenth lunar month was added every three years or so to keep the calendar “luni-solar”, ie in concordance with both the lunar cycles and the solar seasons.  This has allowed Rosh Hashana and Yom Kippur to reliably occur in the early fall, with Passover reliably occurring in the early Spring, and has helped all of these observances gain greater acceptance in Western Society (though this was not obviously the initial goal of this change).

Intercalation was actually tried with the Arabic/Hijri Calendar in the pre-Islamic era and the early Islamic era, in a practice called “Nasi”.  Though there was no intercalated month, per se, there was a rotating cycle where every three years, one of the months would be twice as long as the others.  On the first year of the cycle, this extended month would be Muharram (the first month), three years later it would be Safar (the second month), etc.  The term Nasi actually refers to the now defunct pre-Islamic first month of the Hijri calendar, occurring before Muharram, but later outlawed by religious proclamation.

The process of Nasi was eventually outlawed, seemingly because during the phases of the cycle, extensions were eventually added to the four sacred months (Rajab, Dhul-Qaad, Dhul-Hajj, Muharram).  A fixed intercalation (such as the periodic lengthening of Safar), would circumvent this issue as well as maintain the Quranic proclomation that the year should only be limited to twelve months (though granted this seems suspiciously like a loophole).

Changing and modifications of calendars has tremendous precedent, and when a concerted effort to do so is undertaken dissenters rarely persist due to the sheer confusion involved.  Moreover, the new calendar often totally erases memory of the old calendar.  The transition from Julian to Gregorian calendars is an excellent historical example.  Initial peasant revolts quickly died out, and today there is no mention among Christians that Christmas (for example) might not “really” be Christmas due to changes in Western calendars.

I am not advocating a return to pre-Islamic practices of Nasi or any other intercalation. This would require a paradigm shift with tremendous ramifications which would shake the core of Muslim identity.  But if we are ever to garner any credence as a culture to be respected, we must at the very least put our own house in order.  The entire Muslim Ummah must agree on a fixed calendar so that we may present a unified set of basic beliefs to those wishing to learn more about us.

iAddiction

smarphone-addictionSome would say that I am the last person who should be writing a piece about smartphone addiction.  But, at the same time, there are few more qualified to write about the subject than someone with experience.  As an interventional cardiologist, I am dependent on my phone for my livelihood, and often my patient’s lives.  As such, I have no option to turn it off or to ignore it.  Over the years, however, my phone has become much more than a tool of communication, and I have become increasingly dependent upon it in every aspect of my life.

When Apple launched the smartphone revolution in 2007 they made a significant error in naming it, choosing to call it the “iPhone“.  This moniker labeled the device as a phone first and foremost, and relegated its other functions to secondary features.  As any smartphone owner can attest, the telephony features of these devices are truly incidental to their vast capabilities.  These devices serve as nothing less than virtual windows which look out simultaneously onto every corner of the world, peering into every country, every library, every movie theater, and every resource.  The fact that they can also make telephone calls is almost gauche.

Just as a child bored in school may stare wistfully out of their classroom window, so too will a smartphone user turn to their virtual “world window” for an escape when faced with even the mere suggestion of boredom.  As long as anything anywhere in the world is more interesting than what they are doing (and when is that not true?), the temptation to be virtually transported to that activity may prove irresistible.  Teacher droning on?  A good time to look at movie reviews for the flick you want to see.  Conversation take a dull turn?  Let’s join a facebook friend on their Hawaiian vacation instead.  In addition, smartphones provide instant access to references which we may have otherwise ignored.  The annoying feeling one gets when they can’t recognize an actor on TV would probably go unnoticed, but with a smartphone in hand it can be remedied immediately.  The congenial debate with a friend over meaningless historical trivia can be solved immediately, to absolutely nobody’s lasting benefit.  The examples, and the possibilities, are truly endless.

This kind of power and access can be detrimental however.  Numerous scientific studies have warned us of the deleterious effects of being too “plugged in.”  Instant access to all of the world’s data causes us to place unreasonably high expectations on ourselves and others for accuracy, speed, and connectivity.  Such expectations can lead to dangerously high stress levels, deterioration of interpersonal relationships, and eventually a total dependence on the information stream.

Smartphone addiction is the end result of such pressures.  The user not only feels the need to continually access the information stream, but eventually considers it essential to existence, wondering how he or she ever lived without it.  One crucial point of this relationship is that while the addict may consider this access “necessary,” he or she may not actually enjoy it; in fact craving of the object may actually be linked to simultaneous feelings of repulsion for it.   To speak candidly, I fall into the latter group.  I occassionally resent being tethered to my smartphone, but until recently found no way to actually divorce myself from it, while upholding the responsibilities I have to my patients.

Everyone must deal with this issue in a method particular to their own circumstance.  Given my need to constantly maintain a certain minimum degree of connection, this continues to be especially difficult for me.  One solution I have found is simply turning off cellular data and wifi when I come home, effectively transforming my smartphone into a “dumbphone” capable of phone calls and texts (allowing my patients access to me), while not allowing me to look out of my virtual window.  Of course, the power is mine to turn data back on with a few swipes.  I have found that the time it takes to make those swipes, however, allows me the requisite time to reflect on the relative importance of what I am doing, and prevents me from absentmindedly accessing my information feed.  In those precious moments, I can ask myself the questions my Sensei taught us in order to bring about focus in martial arts training, “Where am I? What am I doing? Is it real?”  When it comes to my smartphone, most often the answers are not encouraging.

Another solution I hope to implement soon is the addition of a “smart watch”.  Perhaps it is an addict’s delusion to believe that a device designed to increase connectivity can actually be used to decrease it.  I am hopeful, however, that by allowing me to screen phone calls and text messages without ever touching my phone, I will be less tempted to access the other features of my phone every time it rings or dings (which unfortunately is quite often), or to immediately respond to every communication.

I have resigned myself to always having an increased level of connectivity due to my chosen profession; a day has not gone by in the last seven years when I have not been in touch with patients, the hospital or the office.  However, the novelty of the capability of our current devices has worn off to the point where we, as a society and as individuals, need to make serious decisions about curtailing our use of these technologies in order to preserve the operation of the most powerful computer we own–our minds.

State of the Heart

heartThis year, I availed myself of the opportunity to once again attend the Annual Scientific Sessions of the American College of Cardiology in San Francisco.  It was a special year because a former mentor and current friend from my Cedars-Sinai days, Dr. John Harold, was inaugurated as the incoming president of the ACC.

The meeting was an opportunity to reconnect with old friends, and to learn a lot about the state of the art in cardiology, as well as explore some of the current challenges.

Too much of a good thing?

The cardiology community has anxiously been awaiting JNC-8 and ATP-4 for some time now.  These expert consensus statements  will serve as updates to our guidelines on the treatment of high blood pressure and high cholesterol, respectively.  Nobody knows yet (except the writers) what the recommendations will be, but certain themes are beginning to emerge.

One of the themes that I saw emerging quickly was the idea of “overtreatment”.  While the well intentioned writers of previous guidelines recommended very strict control of blood pressure, for example, a plethora of recent data has suggested that lower may not necessarily be better.  In fact, there is now a preponderance of data suggesting a “J shaped curve” for blood pressure control in cardiac risk reduction; meaning that as blood pressure goes lower than a certain “sweet spot”, cardiac risk may actually increase.  This may be especially true in the elderly.  There are many theoretical reasons to have believed in this relationship, but the interesting findings is to show that we begin to see it even at “normal” readings.

Ends don’t always justify the means

Similarly, cholesterol control has often focused on getting bad cholesterol (or “LDL”) down by any means necessary.  The most effective method of doing so has always been HMG-CoA reductase inhibitors (“statins”), but many adjunctive therapies exist that also lower LDL.  The problem is that while these therapies lower LDL, they have not been shown in any large-scale way to significantly reduce cardiovascular risk.

These meetings held particularly bad news for Niacin, a popular B vitamin, which failed in its second consecutive large-scale clinical trial to have benefit.  CETP inhibitors, another promising new therapy, fared no better (so far) though they simultaneously lower LDL and raise HDL (good cholesterol).  Combine these findings with the findings that statins benefit even those with low cholesterol levels who have had heart attacks, and you have fairly convincing evidence that statins reduce risk over and above their ability to lower cholesterol.  Thus, I believe the newer recommendations should focus on statin therapy rather than LDL reduction, with the addition of adjunct cholesterol medications only in cases where statin therapy is impossible or insufficient.  For those concerned about adverse consequences of statins, it has been conclusively shown that for most people on statins the benefits clearly and massively outweigh the risks.  In addition, newer therapies to counteract the muscle aches with statins are showing more and more promise.

Another reason that LDL lowering may not track risk is that we are focusing on the wrong endpoint.  Most cholesterol particles contribute to the deposition of cholesterol in artery walls, with the notable exception of HDL.  Thus, measuring LDL is only measuring a subset of these harmful  particles.  I am hopeful we will see a shift in our guidelines towards increased recognition of “non-HDL cholesterol” as a primary goal of treatment, so we can be sure to address risk at every possible level.

The future is now

The past two decades have seen tremendous changes to healthcare delivery and economics.  While it is convenient to blame “Obamacare” for many of these changes, the fact is that there is plenty of blame to go around for both political parties, from SGR adjustments, to Medicares C and D, to the PPACA.  The upshot of all of these changes is the attempt to achieve substantial cost savings to Medicare by cutting physician reimbursement–this is a rare area of agreement for both political parties.  Physicians have long warned that this would lead to future reductions in physician accessibility, and that future has now arrived.

The same story was heard and overheard time and again at this conference.  Physicians leaving medicine to pursue other careers.  Physicians leaving insurance based practice to go to “concierge” or cash practices.  Physicians fretting over making ends meet in the era of unfunded mandates and regulations combined with almost continuous cuts to reimbursement.

I think much of the public doesn’t realize that the average physician in practice is basically a government employee.  We work for no money upfront and then petition the government or another agency to please pay us whatever it thinks our work (already completed) was worth.  As most private insurances are pegged to Medicare rates, however, every cut in government spending translates into a direct cut in our reimbursement.  At the same time, mandates such as electronic health records and insurance pre-authorization for every activity increase our bottom line significantly.  This is not a model for a successful business, and is the main reason that  more and more doctors are abandoning the field completely (one of the best doctors I trained with is now in the fashion business).  Many of those that stay are forced to cut overhead by cutting accessibility or services offered, or worse yet forced into gimmicky side businesses and unnecessary testing.

It has now gotten to the point that the most popular seminars and symposia at this conference were not so much about medicine as about business–cutting costs in an era of declining reimbursement.  It is an unfortunate truth that many of the most promising innovative technologies and treatments at this conference may never become available because of an economic climate which deters access, innovation, deliberation, or collaboration.  We can only hope that going forward, our legislators are able to wriggle free of the iron grip of the insurance and hospital lobby, and recognize the engine that makes health care run, the physicians.

License to Kill

I was wrong. Or at least partially wrong. gun-constitution-2

Last July, in the wake of the Aurora theater massacre, I contended that the uproar over gun rights it had provoked was misplaced and that the important national conversation should be about mental health care. While that truly is an important national conversation, the events in Newtown, Connecticut have served to sharpen the focus on a discussion over gun rights which is overdue and sorely needed.

The President immediately engaged this issue, culminating in his signing a myriad of executive orders proposed by his blue-ribbon gun control panel. Now, action on those orders and “legislative suggestions” will be hotly debated in Congress over opposition from the gunmakers lobby (in the guise of the NRA) and a debate over the second amendment.

The Second Amendment

The second amendment to the constitution states:

A well regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed.

Any reading of this text must be enjoined with a sense of historical perspective. This amendment was written for a fledgling nation with no standing army whose peoples had just succeeded in armed insurrection against their government. In that situation, to disarm the people would have been akin to disarming the state, leaving it totally defenseless.

Today, in the face of history’s largest professional standing army and state controlled national guard troops, this point is moot. For those who are so distrustful of our government that they would like to reserve the right of armed insurrection, I would remind them that it is no longer the romantic ideal it was in post-colonial America. Today, we simply refer to it as treason.

But there is a clearer and more important point here that overshadows the others. The first three words of the second amendment read “A well regulated…” Even our founding fathers realized that if we are to codify a right to bear arms into our constitution we must allow and even mandate the regulation of these firearms. Even for those who oppose gun control legislation on the basis of literal interpretation of the bill of rights, and persist in the near diefication of our founding fathers and consecration of our constitution, the need for firearm regulation could not be more plainly spelled out.

Slippery Slopes

Another argument against gun control legislation stems from the fear that such regulation would start us down a slippery slope towards the prohibition of privately owned firearms. However, I believe this argument is short sighted.

If the goal is safe and legal gun ownership (as it should be) there is no better tool to achieve this than regulation of gun ownership. Licensure and background checking, biometric devices and trigger locks do not infringe on an individual’s right to keep or bear arms—they enhance those rights. By weeding out criminals as well as those without requisite training in gun safety, such regulation would remove any remaining social stigmata towards legal gun ownership and allow law enforcement to better track and confiscate those weapons likely to be used to harm others.

In my state of California, we require drivers safety courses, licensure, and insurance before someone can operate a motor vehicle—a tool designed to transport but with the ability to kill. Yet, none of these things are required for ownership of a gun—a tool designed with the express intent to kill.

Slippery slopes can also slant both ways.  Many opposed to gun control legislation advocate for arming teachers as a tactic to combat school shootings.  Such fortification of our schools would simply shunt our societal vulnerabilities to other venues such as malls, movie theaters, and even churches.  Eventually, we will end up in a heavily armed society, where each citizen will be virtually expected to carry a firearm simply to avoid victimization. Such a society would make us no safer, and would simply serve to verify the adage that “an eye for an eye makes the whole world blind”.  That is a slope I am deathly afraid of sliding down.

Rights and Regulation

The existence of a right does not preclude its regulation. Freedom of speech is regulated to exclude libel, slander, and speech inciting public harm or violence. Freedom of expression does not allow for violence towards others, and freedom of religion does not tolerate human sacrifice.

Guns are designed expressly to kill.  Though they are (and should forever remain) legal, this plain truth demands that they be regulated with a commensurate degree of severity.  Certain fundamental protections must be put in place as the violence in our society escalates. Licensure for gun ownership must exist and be requisite on gun safety training and background checks. When a gun license is administered to an address where a child resides, there must be a stipulation for a locked ammunition cabinet and a separate trigger lock. Consideration should be given to requiring gun owners to show proof of insurance in order to provide a financial disincentive to irresponsible use. And finally, those firearm accessories designed specifically to promote the indiscriminate killing of human beings, such as armor piercing bullets and high capacity magazines, should be banned except by an exceptional licensure mechanism.

Since the horrendous attacks of 9/11, our nation has struggled with a fundamental balance of civil liberties and societal security.  The current discussion is merely an extension of the same question.  None of these measures as I described would infringe on a law abiding citizen’s ability to keep or bear arms. Critics will also argue that none of these would have prevented Columbine, Aurora, or Newtown. But I’m not interested in how we could have prevented the last massacre. I’m interested in preventing the next one.

Behind the Veil

 

(not actually my wife)

(not actually my wife)

Recently, my wife of fourteen years informed me of her decision to start wearing a rida most of the time.  For those who don’t know, a rida is an Islamic garment of modesty, consisting of a long skirt and an upper “pardi” which covers the head, hair, torso, and arms while leaving the face open.  It’s an issue that I know she has been struggling with for quite some time, and one that is complicated by tremendous peer pressure from both sides of the issue.

Her husband hasn’t helped too much either.  In fact, I have made no bones about my opposition to this decision throughout the years.  Personally, I am not yet comfortable with overt displays of Islamic culture in the United States due to significant pervasive Islamophobia in our society.  My personal experience is rife with acquaintances who delude themselves into thinking that their garment and/or grooming choices have not held them back in any way from advancement professionally or personally.  I also remain steadfastly opposed to choices dictated by guilt or a misplaced optimism about acceptance in society.  Further, and perhaps just as important, I feel my wife’s choice will significantly hamper the outdoor lifestyle we have grown to love in Southern California–wither our rough and tumble hikes, sojourns to the beach, or Christmas break ski trips?

In the end however, I hearken back to my first sentence.  My wife informed me.  The decision was entirely hers (and then some).  I did make the effort to ensure that she is not motivated by guilt, nor bowing to the ever-present peer pressure (wasn’t that supposed to disappear after high school?).  She is clearly attuned to the limitations these choices will impose on her professionally and socially.  It is just that she simply, remarkably, does not care.  She has decided that pursuing her acceptance of herself is much more important than seeking the acceptance of the myriad of people of varying importance in her life.  She has even decided that her comfort level with her choices is more important than my comfort level with them.  While this last point upset me considerably at first, it is emblematic of a supreme self-confidence that I cannot help but admire.    It displays a confidence in who she is, what she wants, and how strong our relationship is that I can only marvel at.

For those in the United States who continue to insist on portraying Islamic headcoverings as evidence the subjugation of women, I wish they could be privy to our conversations–A muslim woman arguing to wear a veil against a man pleading for her to dress less traditionally.  This is not the Islam the media loves to portray, but the real Islam practiced by real people.

There is a saying “guns don’t kill people, people kill people.”  An analogous comment could easily be made about the objectification of women– “clothes don’t objectify women, society objectifies women”.  A woman parading around in a bikini on a beach is at just as much risk for being wrongfully treated as a sex object (one to be lusted after and ogled) as a woman wearing a hijab (one to be owned and subjugated).  Just as a woman’s swimsuit can be seen as anything from a piece of athletic apparel to a tool for sexual objectification; so too can a hijab vary from a willful choice to a tool for subjugation (as it is too often portrayed and used).  In the end, it is up to us as a society how we treat women regardless of how they dress.  Just as it is crass, rude, and wrong to say a woman “deserved” sexual misconduct because of her titillating clothing, it would be equally wrong to imply a woman “deserved” to be treated as a second-class citizen (or worse yet, pitied) because of her Islamic dress.  The fact is, a woman has a right to be treated with the appropriate respect for her character, not for her fashion choices.

In the case of my wife, her choice to wear a rida is the polar opposite of an act of subjugation or domestication.  It is an act of supreme self-confidence and pride in her culture, a recognition of her priorities, and a challenge to the rest of society (and to her husband) to show her the dignity she knows she deserves.  It is not an act of defeat, it is an act of victory.  Because I know this, I cannot help but respect and support her decision, though I continue to disagree with it.  After all, this independence, confidence, and intelligence is what has always been what is most alluring about her–not her fashion choices one way or the other.

Four More Years!

After almost four years of active campaigning, the time has come.  In just a few days, America will collectively choose a president.  On November 6th, I will be casting my vote for our current president Mr. Barack Obama.  I believe this decision is important and complex enough to expound upon somewhat further; not for reasons of persuasion or justification, but rather for communication and documentation.

The Economy.  This topic is incredibly complex and is wrought with dueling statistics and expert panels.  Even the most ignorant of the myriad experts on either side know much more than me on this topic, so I will not deign to try to judge among them.  However, I believe that Mr. Romney’s plan for the economy relies entirely too much on trust.  Trust that the economy will grow at an accelerated rate to help him afford his tax cuts.  Trust that “job creators” will reinvest  their tax savings to hire more workers, rather than cash in profits or take them overseas.  And finally, trust that we will forget that the “Reagan Recovery” he so hopes to emulate led to one of the largest explosions of the national debt in history.  Mr. Obama inherited an economy in free fall, which arguably hit its nadir about six months into his presidency.  To expect us to be completely recovered in only three years is to defy the cyclical nature of history.

Foreign Policy.  Mr. Obama’s foreign policy can seem at first glance to be somewhat muddled and haphazard.  However, I believe this stems from the inherent complexities of international relations in our interconnected world.  I much prefer Mr. Obama’s painstaking deliberation to treat each situation uniquely as well as his wholehearted attempts at multilateralism to Mr. Romney’s one-size-fits-all, with-us-or-against-us approach.  Mr. Romney’s attempts to attack Mr. Obama for being “soft” in Iran or Syria leave no room for him to maneuver except to embroil the United States in more foreign wars which we cannot afford.  Further, while it is vitally important for us to have an unquestioned staunch ally in a volatile region like the Middle East, that is no excuse to equate Israel’s national interests with our own.  While they often do align, and mutual protection is a foundation for our alliance, our national interests must be our own, and must be the President’s focus at all times.

Health Care.  It actually matters very little who becomes President in this regard.  The fact is that Medicare is an extremely expensive entitlement program our nation can no longer afford.  For political reasons, neither side is willing to directly cut benefits to voters, and both sides have pledged to save money.  This must necessarily result in reduced reimbursement to healthcare providers–and subsequently to indirect reductions in benefits through more providers dropping Medicare patients, rationing of care, or the market producing less or lower quality physicians.  The one alternative solution, sweeping malpractice tort reform, has unfortunately not made it to the conversation during this cycle.

Civil Rights.   Mr. Obama has been no saint on civil rights, from failing to close Guantanamo to quietly continuing warrantless wiretapping and other surveillance.  However, the Republicans have squandered the Muslim vote for a generation through a replay of their Southern Strategy.  By systematically demonizing Muslims at the party level, they have made it impossible for us to vote for them.  Michelle Malkin (who advocates placing all Muslims in internment camps) may be a fringe player in the Republican party, but Michelle Bachmann (who advocates a Muslim witch hunt to root out Muslims in the federal government), Herman Cain (who would apply a Muslim litmus test prior to hiring anyone), Newt Gingrich (who compares Muslims to Nazis), and Tom Tancredo (who advocates bombing Mecca and Medina) are most certainly not–in fact, all of them ran for president under the Republican banner.  Add to that the right’s insistence of propagating the Obama crypto-Muslim story as a slur and you have a veritable definition of Islamophobia.  Even the current nominee, Mr. Romney, said in a debate he would not consider a qualified Muslim for a cabinet level post since Muslims do not constitute a large enough proportion of the population to justify it–a reasoning that should also exclude a Mormon from becoming president.  Hiring or not hiring someone based on their religion is a violation of their civil rights and fundamental American principles, and no American (Muslim or otherwise) should allow such violations to creep into governing philosophy.

Leadership. This is perhaps the toughest to judge, and the toughest to quantify.  However, certain anecdotes truly cement this in Mr. Obama’s favor.  First is the decision to green-light the mission to kill Osama Bin Laden.  While in retrospect it seems like an easy decision, prospectively it is much muddier.  There are a myriad of ways this mission could have gone disastrously wrong.  Imagine being engaged in Pakistani airspace by fighter jets we had sold them.  Or storming the compound and mistakenly killing innocent women and children only to find intelligence about Osama’s whereabouts were wrong.  Or having Osama escape, and chasing him through a sovereign country’s streets only to have our strikeforce overcome by a violent mob of Pakistanis.  Almost any alternate scenario would have been an international embarrassment or worse, and would have led to a premature end to Mr. Obama’s political career.  Yes, it is easy for Mr. Romney to say in retrospect he would have done the same thing now that the outcome is known.  It takes leadership and courage to proceed with an uncertain outcome.

Another major test of leadership came this summer, when Mr. Biden unwittingly dragged his boss into the fray of gay marriage.  Mr. Obama was already fully engaged in a re-election campaign which he knew very well would be a fight for the center-ground of the electorate.  Yet, he used the opportunity to state his own personal viewpoint (which risked alienating many middle ground voters) without pandering or massaging it, and without forcing its acceptance by others.  Mr. Romney, by contrast, has shown time and again that he is unwilling or unable to stand up to even the fringes of his party, as evidenced by his newfound criticism of Planned Parenthood–an organization that he found worthy of charitable contribution just a few short years ago.  I simply cannot and will not cede the right to appoint lifetime Supreme Court Justices to someone who has shown a remarkable inability to withstand political pressure.

Mr. Obama has not been a perfect president by any means.  He has not been the president I imagined he would be nor, I venture, the president he imagined he would be.  However, he has certainly made considerable progress amid formidable challenges and united opposition.  Mr. Romney, by contrast, has revealed himself as weak-willed and short-sighted.  On November 6th, I will proudly vote to give Mr. Obama the second term he has earned.

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