Category: society

#IstandwithAhmed

      Around 1991, as a 7th grader, my fascination with science far exceeded my prepubescent fascination with girls. For that year’s science project, I decided to explore the world of energy by exploring traditional sources (i.e. fossil fuels) and looking at potential future sources (solar, nuclear etc.). I did a comprehensive report, doing most of my research at libraries (you know those buildings that housed books!). I also did a lot of reading in encyclopedia Britannica (RIP!). In addition to a comprehensive 15 page written report, my teacher suggested everyone bring something in class that could demonstrate what we had learned.
       I was impressed with what I had discovered about nuclear energy and decided to bring an orange to class to demonstrate the processes of nuclear fission and fusion. Standing in front of a class of 30 snickering and giggly teenagers, I explained how the orange was an atom and splitting it (fission) would create juice i.e. nuclear energy. Conversely, smashing together the separated pieces would also result in a citrus shower i.e. nuclear fusion. And with that explanation, I put on one of our science aprons, a pair of our chemistry goggles and aggressively smashed my orange down the middle using a knife I brought from home. 
      Those early teenage years were hard enough as it was. But I fondly remember this because it reminds me of my love for science and one of the early examples of how I overcame shyness and insecurity to stand in front of an audience. I wouldn’t have recalled this moment were it not for the story of a young Muslim teenager and science tinkerer from Irving, Texas who was arrested like a common criminal for bringing a homemade clock to school. 
    I am frightened to think what would’ve happened today if I tried to do a science demonstration by bringing a knife to class. I probably wouldn’t even had made it through the school doors because of metal detectors. The mere sight of young Muslim male with paper thin arms, wielding a butter knife would’ve resulted in a SWAT team descending upon my school to whisk me away in handcuffs. My parents and sister would be intensely interrogated and humiliated. With the rampant bigotry and xenophobia going around today, maybe my parents would think seriously about going back to Bangladesh. Or if we stayed with the stain of being a suspected criminal, would I have the courage to continue to pursue my passions or just settle into a life of acceptance of the old (and now reborn?) American reality that perhaps all men are not created equal. 
   But something terrible did happen to me on that fateful day in 1991 where I brought a knife to class. I got a “B” on my mediocre report which drew the intense ire of my parents. It was probably one of those sentinel moments that are emotionally magnified as a teenager which led me to work harder in pursuit of my goals. But what happened to Ahmed is far worse than a bad grade on a science project. I hope with the same intelligence that he uses to create, tinker and build, he is able to realize that it’s not his fault he was born in the post 9/11 world. And that regardless of how the world may view him and try to bring him down, this is still a great country where someone bright and hardworking like him will have the opportunity to become successful, make a difference and change many hearts and minds.
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Another day, another shooting

Another day, and another senseless act of gun violence.

I sat down tonight to start writing about my experiences working as a locums primary care physician in the heartland of America and the Indian Health Services.

There’s a lot to write about, in terms of the myriad of chronic diseases facing this population and the stressed healthcare services that’s trying to care for them.

Cancer, heart disease, diabetes, tobacco abuse, alcohol abuse, obesity etc etc.

I forgot about one particular epidemic until I received a push notification on my phone about the shooting in Lafayette, Lousiana.

Another city, different from where I’m working but still uniquely American, trying to persevere through violence perpetrated by some who believe was just a person. Other’s who will attest he’s a person who culturually and perhaps legally was allowed to obtain an unneccssary appendage of violence.

In tragedy, the natural tendency is for people to come together.
When it comes to tragedy from gun violence, we seem to grow further apart as a nation, debating the merits of a vestigial amendment. This too, another uniquely American reality.

Another shooting and another night of mourning.

A Muslim doctor gets on an airplane…

     The recent events of Tamera Ahmed on a commercial airline and the alleged discrimination and Islamophobia she endured, got me thinking about my own experiences in the air. Fortunately, I have never experienced anything as blatant as the events described by Ms. Ahmed. But as a Muslim-American, I’ve become too keenly aware of the growing specter of Islamophobia across the world. Whether it’s at a TSA security checkpoint, sitting at a terminal or falling asleep inside the plane, I have to admit I sometimes wonder if someone is watching me, thinking I’m capable of committing harm. To those that continue to subscribe to beliefs that all Muslims on an airplane are a potential danger, I offer my own personal experiences that are the opposite.
     I’ve had the privilege of twice responding to a request for medical assistance on an airplane at over 30,000 feet. The first time, I was a senior resident flying home with my wife from a well deserved vacation. The flight attendant requested anyone with medical training to assist a passenger who had collapsed near the forward bathrooms. Without hesitation, I looked at my wife and headed to the front of the plane in my jeans, t-shirt and baseball cap looking nothing like a physician or a stereotypical dangerous Muslim for that matter. I ended up converging at the front with a nurse and a radiologist on the flight. Without access to a CT scanner on the flight, the nurse and I quickly took charge of the situation :-).  We came to the conclusion the the elderly lady had a vasovagal episode brought on by a lack of sleep, and the effects of alcohol at high altitude on a body altered by gastric bypass surgery. The flight attendants were understandably worried and repeatedly asked me whether the flight needed to be diverted for an emergency landing. I reassured them and gave my blessing to press forward towards our intended destination. After the flight I caught up with the lovely lady outside in the terminal while paramedics assessed her. She was extremely gracious in expressing her gratitude. In addition to her, several random passengers expressed their appreciation. One gentleman was particularly thankful that I didn’t divert the plane and take away vacation time with his girlfriend.
     A second and similar episode occurred on another flight a few years later. This time, a passenger that was battling a stomach bug, vomited and subsequently also passed out. I once again marched to the front of the plane to assist the passenger. But this time, as I spoke to the passenger, his sister  next to him started to feel ill and weak. She too almost passed out from a vasovagal episode triggered by watching her brother heave. Fortunately, both passengers were ok as I reassured them and the flight crew that everything would be fine. And once again there was an outpouring of gratitude from a variety of people.
     As physicians, we are reminded early in our training and throughout our careers to treat all patients equally. I certainly did not ask who or what those passengers were on my flight. They were  people in a vulnerable situation who needed some help. Perhaps they even harbored the same biases and fears that plague the bigoted passengers on Ms. Ahmed’s flight or the policy makers of the airline she flew. It wouldn’t have mattered. What matters is that the vast majority of proud Muslim-Americans like myself continue to advocate unity and peace while in service of everyone in our communities regardless of sexual orientation, race, religion or any other identifier. We are your teachers, lawyers, waiters, engineers, plumbers, mechanics, nurses, doctors and all others. And occasionally we are also your guardians in the sky.
 
 

When the Bells Tolled for Me

     Empathy is a big topic in medical education. How do we teach and nurture it in the next generation of doctors? Personally, I’ve noticed that students and residents with personal experiences as a patient often “get it.”
      I’ve had a few personal experiences as a patient and I think it’s helped me gain perspective. Fortunately none of my experiences were life threatening, but one them did leave a big impression.
     In the fall of 1991,  I woke up on one morning with a strange sensation. I had difficulty speaking and drool was intermittently falling from my mouth. I wasn’t in any pain and I remember finding the experience unusual and funny. My father had already left for work and with the situation unclear, my mother sent me to school with an appointment for our family physician later that day. I was happy to go and didn’t want to miss school early in the year. I remember later that morning, despite how my mouth felt, I volunteered to read a section of my social studies text book. I always considered myself an adept reader, but that day I sounded incomprehensible. I even remember the quizzical look on my teacher’s face after my attempt. I quickly realized I would have to hold back my enthusiasm for education for 1 day until my doctor could fix my ailment.
     My family practice doctor was a nice Indian gentleman with silvery grey hair. I remember vividly that his office was also his only examination room. Right next to his large, expensive wooden desk and leather chair, was an examination table, up against a wall lined by his innumerable degrees. It felt like I was being seeing in his home rather than in the sterile exam rooms I’ve grown accustomed to. I don’t recall the details of the visit, except that he had diagnosed me with Bell’s Palsy, given me “steroids,” and a consultation with Neurology. As a teenager, I found this amusing but my parents were extremely concerned. They were so concerned that any run of the mill neurologist wouldn’t do. We had to find someone affiliated with one of the major teaching institutions in New York City.
     We were lucky to get an appointment the following day. After an hour long subway ride, we were in front of a neurologist who was affable, intelligent but also eccentric with hair that only had chance encounters with a comb.The details from this part of the story are foggy. All I really remember is the concern on my father’s face after the doctor advised that we immediately go to the emergency room. For reasons that I don’t recall, my neurologist was concerned about meningitis.
       My inpatient story began like many others in the ER. The most vivid memory had to do with lumbar puncture (LP). My father consented for me, as a pleasant male ER resident explained the procedure and how pain would be minimal and to expect some post procedure headaches. I remember laying on my left side facing a wall 6 inches from my face with my arms clutching my knees close to my chest. With my bottom and back exposed, I felt the warm anesthetic burn its way through my back, while the rest of me shivered in the cold room. My father had to wait outside for what seemed like an eternity. The resident was talkative and friendly but I found it hard to focus on anything else besides my fatiguing arms and lower back. I recall several attempts at him guiding the needle to find the sweet spot. It didn’t hurt but the repeated pressure and prodding of the apparatus was unnerving. After several minutes, the physician proclaimed success and asked me what color did I think the fluid was. I guessed red. To my surprise it was serenely clear.
      I woke up the next morning with a terrible headache and nausea. This was definitely much worse than the actual lumbar puncture. I couldn’t enjoy the view from my window overlooking the East River while the smell of the hospital food made me that much more ill. Despite that, I was happy to see my eccentric neurologist who walked in like the Pied Piper with several medical students in tow. They stood around me, in a semicircle with their shiny white coats, smiles, enthusiasm and words of encouragement. The neurologist demonstrated his cranial nerve exam to the students with my Bell’s palsy playing a central role. The student’s marveled and I felt really special. I wish I could say this was that sentinel moment in my desire to be a physician and medical educator. But honestly, at age 13 although I fancied being a doctor one day, my real priorities in life were baseball cards and video games.
      The days that followed were less about my Bell’s Palsy and more about a nasty pathogen. Although the results of my lumbar puncture were negative, the Varicella Zoster virus (Shingles) reared its ugly DNA. First it was  having a party under the covers of my ear canal which many years later and only in medical school did I learn to call it Ramsay Hunt Syndrome. Soon after, it had found itself on the tip of my tongue in what turned out to be an extremely painful aspect of my illness. I could barely eat for the next several days. To this day, I’m not exactly sure if the steroids that I initially took triggered the Shingles or whether it was the Shingles itself that precipitated the Bells Palsy. Either way, it was a terrible and frustrating combination of events.
     My last distinct memory of this event was the day of my discharge. Like any patient, especially a restless teenager, I couldn’t wait to go home. The night prior, the IV line placed in my ante-cubital fossa gave out and a night float intern haphazardly (after several attempts) placed a new line in my wrist. Probably 6 to 8 hours after that, this too infiltrated and started to cause pain. My family and I rang for assistance. As minutes turned to what seemed like an hour, pain became agony as a huge bleb formed at the site, stretching my skin while likely causing pressure on the carpal tunnel underneath. I squeezed my mother’s hand as hard as I could and squinted my eyes trying to endure the pain. I’m not sure how long I waited, but I remember the catheter being pulled and the immediate relief that came right after. A large fluid filled blister was left behind on my wrist. I was allowed to go home with instructions not to manipulate the blister. Of course one day it did pop, leaving behind exposed underlying tissue that I took care of myself for several days. Luckily it never got infected, but it did leave behind a scar that I still possess today.
    There are a few other tidbits to the conclusion of this story. I parleyed the illness into a new video game system from my parents. The scar on my wrist gave me a tiny bit of “street cred” with my teenage friends. I quickly lost that  “street cred” when I regained my ability and confidence to read out loud in class (4-6 months later).  I missed over a week of school and when I returned, I got a lot of hugs from girls who would otherwise ignore me. And I remember my class portraits that year. I had an ugly crooked smile to match my ugly multicolored shirt. Most importantly, it was a vivid experience that’s given me perspective and a story to share in my life as a physician and medical educator.

“For what are we born if not to aid one another?” 
― Ernest HemingwayFor Whom the Bell Tolls

   

The eager Salesman and the stubborn Doctor.

     I really don’t enjoy going into a store with a planned purchase only to get hassled and cajoled into purchasing something different. The fact is, with so much information at our fingertips, I decide ahead of time what I want and the price I’m willing to pay.

     Recently, I dropped my smart phone in the toilet bowl.

(Take 1 minute to laugh at me.)

     This event forced me to run to my wireless store and purchase a new smart phone. Despite having done my research, my anticipated 10 minute purchase turned into a 45 minute battle of wills between an eager salesman and my practical sensibilities.

     He couldn’t have been a nicer guy. In his mid twenties, he had energy and enthusiasm for his job that likely made him very successful. His great attitude won me over and I let him do his sales pitch despite fully knowing I only came in for 1 specific purpose that I wouldn’t veer from. He used numbers, diagrams, compliments, (even mild insults!), jokes, clever colloquial lines all to convince me I was making a huge mistake not heeding his advice. In the end, he relented, went to the back of the store and came back with my phone.

     As he was ringing up my purchase on his tablet,  he made one last ditch effort to win me over. In the process, he asked me what I do for a living. I told him I was a physician and suddenly, the entire tone of our conversation changed.

He paused, gave me a forced smile as I watched the wheels spin in his eyes. For the 1st time I sensed the smallest hesitation in his sales pitch and instead of talking about his product, he came back with this:

“How do you treat vertigo?” 

     I felt bad that I made him expend a lot of energy  knowing he’d fail. I humored him and we switched roles. Standing in a quiet corner of the store, I began asking him all the questions I normally would. After a few minutes of trouble shooting, we changed the symptom description to “disequilibrium” instead of vertigo and I reassured him while encouraging further evaluation with his primary care doctor. He seemed grateful but I couldn’t help notice a morose coming over him.

     He explained to me he always worries about something terrible happening to him just like his sister. I delved further to find out several years prior, his 16 year old sister died of a pulmonary embolism. His voice lost clarity as he fumbled around his tablet muttering how all the bad doctors ( pediatricians, ER etc)  missed the diagnosis. He chuckled recalling how an x-ray went missing but was subsequently found and clearly had abnormal findings. Although I didn’t ask, I presumed the x-ray was later found as part of some litigation process.

     I couldn’t imagine how it must have felt to lose a sister when you are a child yourself. I could understand the frustration and anger under his breath that probably took years to soothe. An unexpected death of a loved one is always a tragedy especially when it seems the answers are so obvious and in the hands of the physicians entrusted to figure it out. I felt terrible for him, as he pulled out his own smart phone to show me an old picture of her,

     As objective physicians we always contemplate alternatives. I didn’t know the physicians that treated his sister, but I empathized with them a little bit We are taught very early on in our education that pulmonary embolism is one of the trickiest diagnosis and easy to miss. We are taught about pre-test probabilities and chest pain in a teenager is statistically much less likely to be a life threatening condition. I imagined that could have easily been me, a well meaning physician doing their due diligence and something terrible like this still happening. As a physician, we never get comfortable dealing with the death of a patient. It’s even more difficult when there’s an unexpected death and you’re left wondering what else you could have done. These very personal emotions are occasionally twisted, tossed and turned through malpractice litigation ; a process after which physicians are left confused, numb and questioning their purpose. This is a burden many physicians carry to their own grave, quietly without any expectation of assistance or pity.

     As he finalized my purchase, I completed my thoughts coming to the conclusion that no matter what the circumstances were, he went through a tragic experience and nothing can change that. I was happy to see he survived  and had become a very good salesman with a good attitude and great smile. But on this day he didn’t get the sale he wanted. I regained my connection to the digital world with a new smart phone. I’m hoping he regained the tiniest bit of faith that doctors despite being fallible, listen and care.

Health Insurance ; A prerequisite to the American Dream

The American dream is alive and well. We still live in the land opportunity where hard work is the ticket to endless opportunities. On the contrary, bad health poses a major impediment towards fulfilling that dream. Besides the physical toll of an illness, the financial cost of an illness can make the American dream impossible to achieve. Millions of people without health insurance everyday face the spectre of their dream becoming a health care nightmare. Recently I got some great news about a family member who immigrated to the U.S a few years ago. A middle aged man with a wife and 2 kids, he came ready to do whatever it takes to secure a future for his family. An educated man, he struggled to find employment. He latched on to several different jobs that helped continue to build his skills but was given no health care benefits. He didn’t qualify for Medicaid and couldn’t afford private health insurance. Just like many Americans in this situation, his health took a backseat. But recently, he was finally able to secure a job that offered benefits including health insurance. He now had the security that seemed like a natural prerequisite towards pursuing his own American Dream. He took this opportunity to finally seek out world class healthcare. From a distance, I began to get caught up with what was happening with his health. Fortunately, he didn’t have too many medical problems besides benign prostatic hyperplasia (BPH). It was significant enough that he was referred to a urologist. He felt lucky to find a local well renowned urologist with many positive reviews (both online and word of mouth) that also took his excellent new health insurance. After 1 visit, it seemed like he was appropriately placed on some medications to try to alleviate his symptoms. What was surprising is that he was also placed on brand name testosterone replacement. Immediately, skepticism towards testosterone replacement therapy began to engulf my thoughts. I began to wonder if my family member was another victim of the “Low T” marketing campaign. Furthermore, I was shocked to find out that within weeks of seeing this doctor, he was being offered greenlight laser prostatectomy. Granted I am looking at this case as an outsider. But without trying various types of medical therapy at optimal doses and for significant periods of time, the recommendation for surgery seemed very premature. Since then, my family member has been directed to a second opinion.
Health insurance is an extremely high priority issue for most Americans. It is the sensible thing to attain, whether it is to ensure wellness or treat illness that might otherwise derail a lifetime of hard work. But my family member’s reward for obtaining health insurance wasn’t good health but rather a glut of potentially wasteful and dangerous medical care. As we continue to expand health insurance in an attempt to cover all Americans and provide them access to care, we have to continue efforts towards curtailing health care that is not evidence based, wasteful and only serves to fulfill the American dream of providers and drug companies while taking advantage of hard working naive citizens. 

Our healthcare and "The Wire"

A few months ago, I finally started watching “The Wire.” For anyone unfamiliar with it, “The Wire” is a police drama on HBO that takes place in Baltimore, Maryland. It takes a hard look at inner city drugs and violence from the multiple points of view of an incredible tapestry of characters. It’s a wonderfully gripping show and I give kudos to the creator David Simon for painting this haunting and tragic picture of modern urban Americana.
I don’t watch a lot of TV, but right now I can’t stop thinking about this show. The show has a lot of social commentary and I’m finding its messages everywhere around me. No, I don’t work in the inner city, though I’m somewhat familiar with it. I grew up in a humble New York City neighborhood that over the years started to struggle with drugs and violence. I did my residency training in downtown Philadelphia, and as a young doctor saw many facets of inner city life from a medical perspective. Although I don’t currently work or live in the harsh inner city streets, I do exist in a place that is failing its citizens just like “The Wire.” Our healthcare system sometimes seems just as tough, destitute and hopeless as the streets of Baltimore as depicted on the show. 
Instead of street drugs, we have diseases in healthcare. But the story of “The Wire” isn’t about the drugs itself, but rather how its omnipresence shapes the lives of the entire ecosystem. The same can be said for diseases in healthcare. Diseases are the constant in healthcare and how all the players deal with its presence is diverse and fascinating. But drugs in the show and diseases in healthcare are not the antagonists in these stories. The TV show makes this painfully clear. Any attempt to physically remove drugs from the streets by arresting the end users is an exercise in futility. In medicine simply fixing one artery, treating one infection, doing one CT scan or taking a pill, solves a problem temporarily for the end user  (the patient) but does little to answer the bigger question of why someone struggles to overcome a chronic illness or in the case of “The Wire” why citizens struggle to climb the social ladder out of the ghetto. 
The show also has an incredible cast of characters. Most of them have positive attributes and an innocence that is constantly challenged by drugs and violence. I feel for  these characters. As I watch them, I cross my fingers and hope they find a way out before the “the game” catches up with them. As a primary care physician, I peer into the lives of my patients just like the characters in the TV show. I get to know them, their hopes, dreams, and their intentions while they face difficult odds against conditions like morbid obesity, diabetes, psychiatric illnesses, HIV and heart disease. I cheer for my patients while hoping that my interventions will avert some catastrophic event in their life. In “The Wire” a teenagers’ dream to become something in this world may get derailed by a random act of violence that inevitably pulls them into a life of drugs. In my world, a heart attack, stroke or any other random medical malevolence sets of a chain reaction that often makes it very difficult to meaningfully recover from.
The show also shows the perspective of the police department, the good guys. I like to think I’m one of the good guys. Instead of the guardians of the law, I view myself as a guardian of health.  In the show, the police department is depicted as a bureaucratic mess with leaders pushing misaligned incentives and convincing the hard working street cops they are doing the right thing. Street level arrests (aka “rip and runs”) of low level drug users and dealers are depicted as ineffective to curtailing drug violence and therefore a complete waste of resources. Nevertheless, arrests fill up stat sheets for the police department and numerically give the false impression that good is being done. As a primary care physician, I feel like the street cops, at the front lines of healthcare. Instead of arrests, I’m trying desperately trying to achieve numerical benchmarks which some might think are good indicators of excellent medical care. Although these numbers look good on paper, I question how effective they are in the grand scheme of changing healthcare outcomes and improving lives. True investigative work that looks deeply into patients’ lives to solve and treat root cause is not rewarded in our healthcare system nor are the investigators appreciated who take this approach in the show.
Finally, I’ve read that the creator of the “The Wire” views his show as a modern day Greek tragedy. Greek tragedies often describe a doomed people who exist at the mercy of angry, greedy, vain and selfish Olympus gods who hurl lightning bolts, pestilence and misery at their subjects. In “The Wire,” the modern gods come in many forms. Politicians, police commissioners, corporations, drug kingpins all have a responsibility to protect and help their followers, yet inevitably fail them time and time again to their own benefit. In my world, the gods are politicians, insurance companies, drug companies and perhaps the physicians themselves. In their efforts to serve, politicians fight over policy decisions while people remain without insurance. Insurance and drug companies continue to profit despite questionable business practices that often hurt average citizens. Too many physicians, despite their best intentions, mired in debt and bureaucracy blindly plunge ahead doing more and more in a fee for service world without ever stopping to see if we’re not only helping but also hurting our patients.
Occasionally I get asked about the myriad of healthcare related TV shows and which one is the most realistic. The easy thing is to point to any show that has doctors in it, be it a comedy, drama or reality show. Though “The Wire” isn’t about healthcare, its themes are very relevant to what I see every day as a primary care physician. With one more season left to watch, I’ve unfortunately come to expect a tragic hopeless ending. With several seasons left of my own story in primary care I expect many tragic story lines. But in this case, hopelessness will never be in the script.