To Err is Human…

Few religious events from any faith evoke such a visceral emotional response as the observance of Ashura does for Shia Muslims.

Historically Ashura (literally “tenth”) commemorates the Battle of Karbala, where the grandson of the Prophet Mohammed (sa), Husain ibn Ali (as) was slaughtered along with his family upon orders from the Ummaiyad Caliph. The tale is rife with heart wrenching sub-stories of cruelty, barbarism, torture, and the cold-blooded murder of innocents. However, one of the tales that grips me most and resonates loudest is not one of cruelty or torture, nor one of valiant battle; but rather one of forgiveness, humility, and redemption.

Hur (as) was an officer and commander in the Umaiyyad army. When Husain’s caravan reached Karbala, Hur was the person responsible for stopping them from proceeding further to Kufa (their destination). He did so within sight of the Euphrates River, a major source of fresh water in the arid desert. But he would not allow them to reach the river to replenish the coffers– a major taboo unheard of among the Arab cultures. By the tenth day of the year, Ashura, Husain’s family had been out of water for three days when open hostilities were declared.

Hur participated in this torture of innocents both actively and tacitly. Before the declaration of hostilities, Husain asked for a bit of time so he could lead his men in a prayer. Importantly, he asked Hur to do the same for his own men.

Immediately touched by Husain’s unshakeable faith and devotion in the face of overwhelming suffering and thirst, Hur realized that he did not want to be associated with the torture and murder of such noble people. Although a major commander in Ummaiyad army, Hur defected and begged for forgiveness from Husain and from God.

Husain forgave Hur and immediately granted him permission to join his army. He even granted him the great honor of being first to go to battle, where Hur was eventually killed by his former comrades. Though this may seem a dubious distinction in today’s world, in the ancient Arab culture there was no greater honor.

Today, when the story of Husain is told, Hur’s story is always told first. Here is a man who committed perhaps one of the worst atrocities imaginable in this scenario–stopping Husain and his family at the place of their massacre, and withholding water from all (women and children included) in the desert heat. It was only in the very last moments of his life that he realized his mistake and sought forgiveness with a clean heart. Even so, this genuine repentance earned him a tremendous honor. Now, 1400 years later, he is still remembered–not for his evil deeds, but for his noble one.

Who among us has wronged or been wronged so severely that forgiveness and redemption seem out of reach? Surely, none more so than Hur. At those times, he reminds us that God lives in each of our hearts– and with God, all things are possible.

We Are the 99.

The recent “Occupy Movement” has highlighted the fact that though a group may be in the majority, it does not follow that its rights are necessarily respected. Specifically, the movement refers to the “99%,” those of us in the population outside the top 1% financially who are victims of a broken system. This post, however, is devoted to another 99%–one which is much less well known.

I am referring, of course, to the percentage of doctors who will be sued for malpractice.

According to a recent study published in the New England Journal of Medicine, 99% of physicians practicing in “high risk” specialties (such as Internal Medicine, General Surgery, OB/GYN, and yes, Cardiology) will face a malpractice suit before the age of 65. But that’s just high risk specialties. In “low risk” specialties (such as dermatology, ophtalmology, and psychiatry) that number drops to a paltry 75%.

These numbers serve to illustrate a point that practicing physicians know all too well–the malpractice system in this country is badly broken. After all, a good indication of a problem might be when a “low risk” specialty has only a 75% chance of being sued. A system in which between 75-99% of providers of any service will be sued is necessarily a system laden with skewed incentives, unrealistic expectations, and held hostage by outside forces.

Not all doctors of course, deserve the benefit of the doubt. There are bad doctors out there who put profits or personal gain ahead of patients, and deserve to be sued (sometimes repeatedly). But if we, as a society, have reached the point where we honestly believe that 75-99% of our healers fall into this category then we have truly lost any semblance of trust and civility.

If we choose to believe that the vast majority of our doctors are not incompetent and negligent, then it stands to reason that many, if not most, of these lawsuits are unnecessary, without merit, or frankly frivolous. While 75% of low risk specialists will be sued, only 19% will eventually pay claims (ie, lose or settle). Much of the remaining 56% of suits are likely, when examined, frivolous or at least without merit (not all, because as everyone knows, even people who are right can lose lawsuits).

These lawsuits, while perhaps not costing the physician in actual indemnity, carry with them a significant cost to the physician and the population. The practice of “defensive medicine” (tests ordered to prevent a lawsuit, or whose primary use is to defend ones’ self during a lawsuit) has become so commonplace that the term is now obsolete. The reason is that the legal standard for malpractice is based on the “standard of care” (what one’s peers would do in a similar situation). Defensive medicine has become the new standard of care, and thus any practice of logical, pragmatic (non-defensive) medicine is at risk for malpractice exposure.

This may explain why estimates of the costs of “defensive medicine” by lawmakers (who are coincidentally mostly lawyers) vary in the 1-2% range of health care expenditures, whereas an analysis of a survey of doctors who are actually practicing puts this number at 34%. Whereas the lawmakers may use “standard of care” as their baseline (the legal definition), doctors would tend to identify defensive medicine as testing which pragmatic, logical medicine obviates the need for. In my own personal observations, the latter number is clearly more accurate than the former. If doctors would truly be allowed to practice based on clinical accumen and physical examination, the use of CT scans, MRIs, and nuclear stress tests (all very high ticket items) would decrease by orders of magnitude… Importantly, with little discernible difference in outcomes.

The issue of “standard of care” (the legal standard for malpractice) has gotten so bad in fact that doctors have been placed in virtual no-win situations, making one wonder how even 1% ever escape being sued. For example, a doctor has been successfully sued for screening a patient for prostate cancer, and recommending treatment of the cancer which resulted in complications. The complaint? That most medical studies and societies have shown no benefit in screening for prostate cancer. A doctor has also been successfully sued for not screening a patient for prostate cancer, leading to a delay in diagnosis. The complaint? While screening has never actually shown a benefit, it is clearly the current “standard of care.”

How should this misuse of the American judicial system be righted? Much smarter minds than mine have tried and failed at this endeavor, though admittedly most of the failures were due to politics rather than policy. The answer, however, lies with incentives (as it does with all aspects of human behavior). Remove the incentives for unnecessary lawsuits and increase the penalties for frivolous lawsuits and the problems should correct itself.

While the rights of the plaintiff must be protected, the rights of the physicians cannot be ignored. Compensation for the legal fees or “closure of practice” losses (opportunity cost for weeks of sitting in court) of the prevailing physician would be a start, but would admittedly discourage those of limited means from seeking compensation for true loss. The most important move would be the transfer of all malpractice proceedings from jury trials to arbitration courts. Currently, malpractice trials are low on fact and objectivity (qualities we prize in our physicians?), and high on emotion and loss. Juries, usually medically unsophisticated, fall trap to the same smooth talking snake oil salesmen that convinced the plaintiff to sue in the first place, and for that reason often side with the plaintiff inappropriately (leading to a large number of physicians and insurers to settle out of court so as to “not risk it”). An arbitration court made up of three or more judges trained in medical malpractice (though, importantly, not medicine) would allow fair proceedings based on objective evidence and help even the playing field.

However it is achieved, a fundamental reworking of the malpractice system is mandated in order to control medical costs and allow for accessibility to medical care. This article in the New England Journal serves to highlight in the strongest and starkest terms the extent and severity of the problem, there can be no more ignoring or denying it.

We are the 99, and we demand a solution.

The Trip of a Lifetime

The Muslim month of Zil-Hajj has begun, and that means that millions of Muslims from around the world have congregated in the holy city of Mecca for the annual pilgrimage of the Hajj.  I had the distinct honor and opportunity of participating in this pilgrimage (required once in a lifetime for every Muslim who has the means) in 2008.  Every year since then around this time, I reflect on that life-changing experience, and think of my friends who may be there now making experiences of their own.

Shortly after my return, I was asked to blog about my experience at City of Brass, a blog run by my dear friend (and celebrity blogger) Aziz Poonawala.  After the benefit of years of reflection, I believe my initial account still rings true, and can help Muslims and non-Muslims alike understand the undeniable but unfathomable allure of Hajj.  I have reproduced my initial post below:

Hajj: A Near Death Experience

Having recently returned from Hajj, I am bombarded by that well meaning question by all of my friends and loved ones… “How was it?”  Unfortunately, all I can answer is an inadequate “fine”, or even “great”.   Why?  Words can’t really describe the experience, especially hastily chosen words in a usually hurried  conversation.

How was Hajj?  Was it awesome?  Was it a life changing experience?  Was it spiritually fulfilling? Was it physically rigorous?  Yes.  All that for sure… But even that seems to leave something out.  Not in the level of superlative, but in the level of quality.

To me, Hajj was best described as a journey through death and back.  How would you describe that?  You simply can’t.

The first thing you learn, even before you leave, is that your Hajj is your own, and no one else’s.  Your experiences, your hardships, your prayers, your choices are all unique to you alone.  So it makes sense that this interpretation of Hajj is mine alone, and may not be the experience of others.  It may not even be ‘correct’ in the sense that I have not gleaned it (to the best of my knowledge) from any sabaq or sanctioned text.  Yet to me, it is as plain as day.

Hajj, in many ways like death, is a pinnacle, a climax of a Muslim’s life.  Something to be looked at with equal parts excitement, respect, and trepidation, mixed with a healthy dose of downright fear.  And yet you realize that though you may fear it, your life is marching inevitably towards it as a fard (required) act.  For me, I felt a call, so clear it was almost physical, that this was my year to go.  And when that hit, there really was no choice but for me to make the trek this year.

The first true act of Hajj is putting on Ehram clothes.  For men, two simple pieces of unsewn, unadorned cloth, wrapped around your body in much the same way as a traditional burial shroud.  You shed every accoutrement and accessory of this world.  Everyone looks the same.  The cardiologist from Los Angeles was sitting next to the street sweeper from Bangladesh (really!), and nobody could tell one from the other.  This was a powerful moment, saying goodbye to the worldly station you have worked so hard to achieve.

The trip to Arafat is the climax of the act of Hajj.  You stand before the sun and pray.  Much like Muslim beliefs of qiyamat (the day of judgement), you stand before Allah and you pray.  You pray with an intensity you have never before experienced.  The most fitting description I have read (but cannot take credit for) is that you stand before your God naked.  Stripped naked of every crutch or protection you have come to rely on.  There are no worldly accessories.  It doesn’t matter how much you make, or what you own.  It doesn’t matter who your dad is, or your mom.  You may stand next to your spouse, but you are utterly and completely alone.  Standing there in your burial shroud, praying before God, with only your Iman (faith) and your Amal (works) to speak on your behalf, stripped of every conceivable comfort or connection of the world.  This is an accurate description of Arafat day, but it is also an accurate description of what Muslims are taught will happen to each of us when we are called to account after death.

Arafat day is the most exhausting of Hajj.  Though it is not the most rigorous day, the trip down from the mountain of Arafat is a mixture of feeble jubilation with intense spiritual, psychological, and emotional fatigue.  Your trip through death is over.  Your accounts have been settled.  You have been cleansed of sin.  But you have been left with nothing in this world, you sleep under the stars, exposed to the elements.    It is time for rebirth.

On your return, you shave your head, just as we do for newly born babies.  You begin your new life with a tawaaf (a trip to the kaabah), hopefully beginning things on the right foot.  What better way to start off your new life than with an act of total obedience and submission to God’s will?  You return home, and remove your (by now dusty and dirty) Ehram clothes to begin your life anew.

When I finished, my number one feeling was one of traversing the plains of death, facing its trials and tribulations, and returning reborn.

How do you sum that up in a hallway when a colleague asks “How was your trip?” There’s only one realistic answer.  “Fine, thanks”.