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.

A Dark Night

On July 20th, shortly after midnight, a 44 year old neuroscientist suffered a massive heart attack while driving down the freeway.  His car spun out of control, killing 12 innocent bystanders and wounding scores of others.

This didn’t actually happen (that I know of).  But I hope for the reader to take a moment and reflect on how they reacted to the above paragraph, and compare it to the paragraph below:

On July 20th, shortly after midnight, a 24 year old neuroscientist opened fire in a crowded theater.  Twelve people were killed, and scores of others were injured.

A very different reaction to that news, I would think.  Unfortunately, however, the second event did occur, and many innocent lives were lost as a result.

The reaction to the first paragraph is usually a feeling of remorse, and a reflection on the fragility and randomness of life and death; accompanied by a feeling of sympathy for all the victims (including the driver).  However, feelings about the second paragraph are more often going to be dominated by anger, blame, and sympathies for the victims (exclusive of the shooter).  Therein lies a major key to understanding this human tragedy.

In our society, mental and psychiatric illness is not treated in the same vein (no pun intended),or with the same degree of respect, as physical illness.  Despite countless years of research indicating the physiologic basis for psychiatric disease, the basic feeling remains that somehow the person suffering from the illness, whether it be depression, psychosis, neurosis, or any other manifestation, is to blame to some degree.

Gun control advocates have been quick to blame lax gun laws for the shooting, and they have been anxious to use this shooting to restart a national discussion about gun control.  I don’t disagree with them, or with the premise that our gun control laws are too lax in this country.  Unfortunately, while they are addressing an important issue, they are missing the true root of the problem.  The fact is that this man suffered from a severe psychiatric illness which hijacked his actions.  And the sad fact is that even if guns were illegal, his illness would have demanded of him that he either find a way to obtain them, or use whatever weapons were at his disposal (such as tear gas and explosives–which he did use) to wreak the havoc that he did.

Assuming news reports are correct, the man, James Holmes, considered himself to be the “Joker” from the second Batman film–a character who sees himself charged with a mission to expose society’s ills through the institution of anarchy.  The shooter’s methods, like the Joker’s, were deliberate, highly organized, and intelligent.  I am not a psychiatrist, but these characteristics are highly consistent with psychosis, likely schizophrenia.  It is unclear whether this was ever even diagnosed, much less treated.  In fact, when the suspect’s mother was called, her first words were “you have the right person.”  This intimates that the family was potentially aware of these tendencies, even if they were in denial.

I would contend that Mr. Holmes’ psychiatric disease was allowed to progress to this homicidal conclusion precisely due to our inability as a society to deal with it as a true medical illness.  The taboos associated with psychiatric disease of all variants are so strong and pervasive that patients are often unwilling to seek treatment, families remain in denial, and proper precautions and treatment are not undertaken.  Imagine the reaction among his peer circle or his employers if he told them he was taking medications to control schizophrenia, and compare that to the reaction they would have if he told them he was taking high blood pressure medication.  These social mores are a strong disincentive to seek treatment; and a lack of treatment is what leads so many psychiatric patients to end up at the end stage of their disease–gravely disabled, a danger to themselves, or a danger to others.  The end stage manifestations then reinforce the social taboo, and the vicious cycle continues.

What happened in Colorado is inexcusable, and I am not suggesting a lack of culpability on the part of the shooter by any means.  However, if we are to use this tragedy as a springboard to a social discussion, let’s make sure that we at least have the correct discussion.   I believe that as a society, we should grieve for all the victims of this heinous, preventable strategy, including for the young man whose brain was hijacked by a relentless disease.

Of Crime and Punishment

It’s playoff time in the NBA. A time when I force my family to forsake primetime television for professional basketball.  A time when I am continually forced to ponder one of the deeper questions in life… Why does the last three minutes of a basketball game take half an hour?

The answer to anything more than a casual basketball fan is clear.  The culprit is the intentional foul.  To those less familiar, this technique is when the trailing team will intentionally foul the other team in an effort to force them to “work for their points” by hitting foul shots.  By percentages as well as anecdotes, this strategy can work by forcing more of the game to take place with the clock stopped (lengthening the game, much to my wife’s chagrin), as well as putting the onus on the leading team to make foul shots.

There is a deeper question here, however.  One that we often ignore, perhaps because it is just too hard to answer.  Merriam-Webster defines a foul as “constituting an infringement of rules in a game or sport.”  That is clearly the case in basketball, where impeding an opposing players ability to move in an unimpeded fashion or to take a shot (or to sometimes even remain standing) is universally considered an infringement of the rules.

It becomes clear then, that in the almost universally popular sport of basketball, players are encouraged to break the rules of the game on a regular basis simply because the punishment they endure is more advantageous to them on the whole than following the rules of the game.

Would this action be allowed anywhere else in society?  Would we condone a homeless man partaking in a violent crime, simply to get free room and board (albeit in a jail)?  How about the man with a severe illness who robbed a bank so that he might go to jail and get taxpayer funded healthcare?

Are rules and laws in society at large only applicable to those for whom following them is advantageous?  If so, by analogy of the NBA, it should be perfectly acceptable to tell a child to rob a bank, because even if he/she gets caught, they will only spend a few years in jail, but the potential upside is tremendous.  If rules are only meant to be followed when they are to our advantage, they cease being laws and become merely guidelines.

There are many examples of sports mirroring life, and bringing out the best in us through healthy competition and fair play.  But a society, such as the NBA, where rule-breaking is universally condoned when it is advantageous to the offender sends the wrong message to our children about acceptable behavior in society as a whole.  The NBA seriously needs to consider rule changes to make the punishment fit the crime, and to make playing by the rules advantageous to all parties.  (My humble suggestion, a shooting foul on a missed basket should be worth three free throws)

NOTE: This is not meant to be a “crotchety old man” essay (though lately I feel more and more like one).  Rather, a serious look at the moral and ethical implications of the concept of an intentional foul.  I would welcome any and all feedback to these rhetorical questions from basketball fans and non-fans alike.

Open House, Open Mind

LA Masjid

Our new masjid… Just part of the Mohammedi Center Complex

Friday, May 5th 2012 was a red letter day for the Dawoodi Bohra Community of Los Angeles–my religious community.  Our new masjid (mosque), under planning and construction for over a decade, had finally been finished.  On Friday, we hosted multiple civic, interfaith, and community leaders to visit with a reception, tour, and a lunch.  After that program, we opened up the masjid complex for the entire local community and neighbors by way of an open house, and guided tours.

To understand the significance of this event, consider this: I am forty years old and have been a Muslim all of my life.  This will be the first masjid I have ever belonged to as a member.

The event was also important in that it was out of the ordinary for the Bohra community.  We tend, for better or for worse (and I feel, mostly for worse), to be a tremendously private and introverted community.  The upside to this is that we do not concern ourselves about what others do or say about us, manifesting a communal self confidence that belies our small numbers and minority opinions.  The downside of this is that we are also unconcerned with spreading the  goings-on within our community to the outside world.  I am not talking about proselytizing, I am talking about simple neighborly sharing.  While we have nothing to hide, it becomes the natural perception that we do.   And there is little more frightening in America than a Muslim with something to hide.  This event went a long way towards changing that introverted attitude within our community as a whole, and our leadership in particular.

Time will be the only true arbiter of whether opening up our community to outside scrutiny was truly a beneficial decision.  After all, increased visibility can be a double edged sword.  But if the outpouring of support and positive media coverage we received are any indication, the favorable ramifications promise to be manifold.

From a personal perspective, this was a vitally important day as well.  As a physician, I live largely in the public eye; interacting with a large swathe of the local population from all occupations, socioeconomic classes, creeds, cultures, and races.  I live locally, and as such my personal lives and professional lives often intertwine (ie: hypertension advice in the bread aisle at Pavilions).  As my mosque is also local, it was inevitable that my religious life (a large component of my personal life) would eventually intersect with my professional life.  I was long dreading that day, however, and working hard to avoid it.  Perhaps I was partly motivated by insecurity over my clothing and customs; but mostly I was pessimistic about the non-Muslim population’s ability to accept Muslims as anything other than crazy nut-job terrorists as their default opinion.

The experience I had in this regard pleasantly surprised me.  Multiple people from my professional life, including patients, hospital administrators, colleagues, referring doctors, and sales representatives attended our function.  In interacting with them, though dressed in my traditional Muslim outfit, I was able to easily summon the professional confidence that I project in any other situation.  Far from the embarrassment I predicted I would feel, I felt comfortable and able to be taken seriously and treated with respect.

Likewise, the implicit distrust and default skepticism which I thought would greet us in the countenance of our visitors never materialized.  Their support for our community was clearly genuine, and not just the thin veneer of politeness I expected.  Their joy at our successful accomplishment, their welcoming of us as part of the local community, and their willingness to learn about Muslims and Bohras with a truly open mind was evident.  Obviously, there is a clear selection bias at work, as those who harbor fear or resentment of us were unlikely to attend our event.  But the number of people who did attend, and who were genuinely encouraging clearly indicated that my previous pessimism was at least over-rated (though unfortunately probably not totally unfounded).

Last Friday represented a “coming out party” for our community as a whole; as well as for me as an individual.  Both were long overdue.  In a sense nothing concrete has changed, however.  Those who hate us or fear us still will, this event did not involve them by their own choice.  Those predisposed to an open mind may have developed a positive attitude towards us.  I am not planning to start going to work wearing my traditional topi and kurta or otherwise advertising my personal beliefs.  The only thing that has palpably evolved is perceptions– ours, theirs, and mine.  Perhaps that means everything has changed after all.

Destiny’s Child

“Our destiny is frequently met in the very paths we take to avoid it.”
Jean de La Fontaine (1678–1679) and Master Oogway (Kung Fu Panda, 2008)

The Reverand Thomas Robert Malthus (1766-1834) was once ostracized for his relatively obvious theory that human population would be limited by the ability of the earth to provide sustenance. As resources became rare, he postulated, “preventive checks” (such as abstinence and contraception) would slow population growth, while “positive checks” (such as disease, pestilence, and famine) would serve to maintain human population at sustainable levels.

Occurrences of these positive checks soon became known as Malthusian Crises. Crises are born of population growth out of proportion to resources, and consequently serve to reduce population levels back in line with resource availability.

Until recently, it was thought that modern technology had rescued us from this cycle, and made Malthus’ theories obsolete. Just as natural selection stops when civilization begins (another topic for another time), so too did our technological prowess shield us from the Malthusian cycle of population boom and bust.

The examples of technology being used in this way are manifold, but certain concrete examples are readily apparent. Newer agricultural technologies to help combat famine, the use of medications and vaccines to combat disease, epidemic, and pestilence, and greater communication and transportation technology to deliver these treatments, supplies, and personnel to necessary areas.  In this way, the advent of modern technology helped to sustain population levels out of proportion to “natural” resources.

With time, advances in computing technology have become such that many tasks which were previously relegated to human beings can now be handled by computers. In fact, whole fields have been decimated by the use of computers. Telephone operators, whether at a central switchboard or a company switchboard, have been almost wholly replaced by voicemail system.

Think of the lowly greeting card. In the past, there was someone hired to write them (Longfellow Deeds?), another to design them, another to print them. They then went to a distributor, who sold them to the local Hallmark store. The Hallmark store employee sold them to you. You put them in the mail, and the mailman delivered them. Currently, one can log on to any number of sites where electronic cards are available. With a few clicks of a button, you have fired the distributor, hallmark employee, and mailman (while at the same time hiring fewer programmers and internet engineers).

Thus, while technology can increase accessibility of scarce resources, it also serves in a very real sense to make other resources more scarce–those of jobs, and consequently wealth. In doing so, it encourages growth in a relatively resource poor environment, and sets up conditions to precipitate a Malthusian Crisis on a scale potentially much greater than those it has helped avert.

Unfortunately, there is no going back from this brink.  The fact remains that the world’s population continues to grow at a pace greater than the amount of human jobs needed to sustain it.  There are simply too many people, and too much automation, to allow for adequate levels of sustenance.  Through this lens, we see that unemployment and fiscal crisis are not necessarily direct results of the failed policies of one government or another, but a historical inevitibility.  As such, no amount of legislation or specific fiscal policy will be able to reverse it.  And, to top off the good news, the situation is likely to get much much worse before it gets better.  The logical end to this cycle is a “positive check” (the word positive is Malthus’, not mine) the scope of which may be unprecedented.  After all, the wheel of history cannot be stopped from turning.

Conrad Murray– A Smooth Criminal?

The trial of Dr. Conrad Murray, the physician involved in the death of pop sensation Michael Jackson, is well underway in a Los Angeles area courtroom.  Dr. Murray stands accused of involuntary manslaughter in Jackson’s death.  The accusation is that Dr. Murray used lethal doses of the anesthetic propofol and insufficient monitoring equipment to sedate Mr. Jackson (at his request), and that these actions caused the death of Mr. Jackson.

The real issue in this trial is not about doses of a medication or types of cardiac and respiratory monitors, however.  The over-riding and precedent setting issue of this trial is the charge against Dr. Murray and the type of trial being conducted.  Dr. Murray is accused of involuntary manslaughter, and is thus facing a criminal trial brought by the state.

When boiled down to its essence, however, Dr. Murray was hired for his medical services by Mr. Jackson.  In the performance of those medical services, Dr. Murray displayed incompetence in the dosing and usage of the medication propofol, and gross negligence in the monitoring of his patient.  This incompetence and gross negligence led to the death of his patient, Michael Jackson.  This is clearly an egregious case of medical malpractice, a civil charge brought by the family or other survivors.

The difference between these charges is extremely important.  Involuntary manslaughter, in this case, refers to “death during the commission of a lawful act which involves a high risk of death or great bodily harm is committed without due caution or circumspection”.  Medical malpractice, on the other hand, requires four components to be proven:

1) A duty of care was owed by the physician

2) The physician violated the standard of care

3) The person suffered a compensable injury

4) The injury was caused in fact and proximately caused by the substandard conduct.

Physicians deal daily with life and death decisions, and their actions, negligent or otherwise, can and do result in the death of those in their care.  This particular fact, combined with the fact that no other field is charged with such obligations, is the entire purpose behind the development of medical malpractice laws to begin with.  In a very real sense, medical malpractice laws exist to provide a rational exemption to physicians from charges such as assault, battery, and manslaughter.

I cannot and will not excuse or defend the actions of Dr. Murray, as they were by any standard incompetent and grossly negligent.  However, to try him for manslaughter when this is a clear example of malpractice is a distortion of the legal system which sets dangerous precedents.  Doctors are not immune to the law by any means, but during the act of practicing medicine, as the very practrice of medicine carries a high risk of death or great bodily harm, doctors are and should continue to be held to the standard of malpractice rather than criminal manslaughter.

The proper sanction against Dr. Murry would be revocation of his license to practice and malpractice proceedings along the most severe lines.  And in the case of almost any other plaintiff, this would have been the case.  This case, however, is different and to deny its differences would be false.  In my own medical community, a patient recently died when having an outpatient surgical procedure by a doctor who was not qualified to perform said procedure and gave the anesthesia himself (which he was also not qualified to do).  This incident made the local news, and may result in license revocation (probably with a stay if he takes certain useless “medical care” courses) and a fine.  But the fact is, this doctor has been busted for the same thing previously and no action had been taken to date.

But Michael Jackson? That’s a different story.  As a public figure and a relatively beloved one at that (we can go into the psychological scrubbing of ones images and selective memories of one’s actions after their death another time), the public outcry was likely irresistable.  A very public spectacle with very severe punishments (what, you mean he’s not even going to jail?) would be necessary for the appearance of justice to be done.

In the state of California, malpractice awards are capped.  One million dollar awards per occurrence, for a total of three million dollars a year.  Such awards would (rightfully) be viewed as a veritable joke to the Jackson family, and would in no way sate the hunger of the public for justice.  In contrast, the ensuing wrongful death suit after a manslaughter conviction will be uncapped, and substantial.

The fact is then, that just as different standards of care exist for the rich and the poor, so then do different standards of justice apparently exist for their doctors.  If we are to argue that health care standards should be equalized across the socioeconomic spectrum, which is no doubt a noble goal, we should also strive to equalize justice across the socioeconomic spectrum.  And the trial of Dr. Conrad Murray is in clear violation of that principle.

Allowing Dr. Murray to be convicted of manslaughter will set a precedent which will have far reaching ripple effects.  It will open up potential litigation against many doctors whose patients die during the deliverance of medical care, either careful or negligent (negligence need not be proven for charges to be brought, after all).  This will serve to render malpractice tort reform and capitation utterly useless.  Insurance premiums will rise and consequently availability of health care will drop.  Costs of health care will increase as defensive medicine is redoubled out of fear of criminal litigation.  In the end doctors and their patients will be harmed.

Dr. Murray should have known what he was getting into when he signed on as Mr. Jackson’s personal physician.  And if Michael Jackson had been any other Joe Somebody, he never would have allowed the deviances in care which he did with Mr. Jackson.  So perhaps it is poetic justice, if not real justice, that by treating his patient differently because he was rich Dr. Murray will now be exposed to a different standard of justice because of his patient’s wealth.