Elections

 It is certain there are more sophisticated manners of understanding and portraying the current American predicament. But as someone with scant understanding of the mechanics of societies and exiguous historical perspective, feeling is the apparatus I deploy. Feeling soaked in the current. Taking cues in pitches of voices, smiles, and grimaces. And from that perspective, the best I can characterize the prevalent feelings is that of lost innocence. 

For a non-citizen bystander in this country, the strife this country has gone through in the past several years has a distinct essence. It is largely an expression of existential angst of  a segment of the population that has banked its identity and entitlement on a narrow set of racial and religious affiliation.  In the bubble it has lived in, perhaps afforded by the military and economic superpower status of the country, it has no connection to the real suffering-- of material poverty,  oppression with no pathway of escape, randomly inflicted harm with no prospects of restitution, institutional violence as a tool to "keep people in their place." It has mistaken lethargy in lassitude of prosperity as suffering. And is trying to shake off this dullness in imagined reality. A reality where its existence is threatened by some external factors. External factors where it does not have to take any ownership, emotional connection. No wonder immigrants, black and brown people are the root cause of all its ailments. No wonder its religion is threatened by godless people and people who worship other gods. If you stack these claims against measurable markers the results are agonizingly comical. But that is a largely useless exercise. It has no interest in validity of these acclaims. Because the primary purpose of this manufactured reality is to shake off that mental fog of an aging entitlement. It knows that the tool is constructed of lies but it needs it to transcend the rut. The visceral feeling it has evoked-- that it's existence is under threat-- is what ultimately matters, wakes it up, enlivens it. And it is a strong feeling. Affirming of some vitality. They appear almost possessed, teeming with angry energy, ready to be cruel. 

When the moments have been opportune, it has not hesitated to flash that underbelly of cruelty. In caging children. In snatching children from their parents. And not even bothering to keep track of parents such that there are hundreds of children adrift without parents. In the violence of words and body language when it speaks of others-- immigrants, racial minorities, sexual minorities. 

As an immigrant, this guise of the country is profoundly disorienting.  A central premise, I assume, when someone leaves the comfort of their surroundings to a new society, is their perception of the benevolence of that society. If they perceived it as harmful, I would surmise, there is no incentive to move. In this collision of expectations and the current reality, we, the immigrants, have lost our innocence. At anytime, of the 10 persons you see on the street, you are now equipped with an understanding that 4-5 of them very likely have a visceral animus towards you even before he/she speaks a single word, just because of the way you look or talk. 

Citizens of this country are voting. And we hear the emphasis that the outcome is going to have monumental consequences. It may be true to some extent. A slide down the path of further cruelty is guaranteed if one of the sides wins. But it is also equally clear that there is going to be no easy healing. We are talking about lost innocence, possessed population that has dabbled in cruelty. These things do not seem to have facile solutions. In the mean time, the major question at the personal level will be- how do we preserve decency amidst acrimony, if not for ourselves, for our children who have had to witness this human ugliness?

Pandemic Meets Politics

Diseases are ruthless. The real ones. Those that afflict human beings, persons. Someone's loved ones, someone's children. Not necessarily those in the textbooks; those are too neatly folded. Too precise. Too predictable. This is a lesson we physicians learn rather late into our training, at least that was the case with me. Brash certainty borne of assiduously memorized facts are challenged by reality. Completely convinced of a particular diagnosis after an elaborate history and physical exam, a puny blood test with normal result delivers a noxious blow to the plump ego of a diagnostician. An ego caressed by superior performance in classrooms, knowledge tests. A missed critical piece of information leads to an unwarranted pursuit that is a waste of everything good. An arrogant dismissal of some other colleague's ability blurs a perfectly rational treatment choice and on subsequent introspection flames an agonizing humiliation. Time and again personal hubris collides with objective reality that does not fit the smoothness of knowledge, certainty. It forces you to factor in uncertainty. It forces you to factor in non-conformity. 

To perform well, we still need knowledge, more the better. We still need to memorize colossal amount of facts. But certitude is best left behind. Our treatment decisions are ultimately probabilities that have to dance with the unknowns of a complex human being. Those among us who are exemplary physicians are skilled at ranking facts, humble of the uncertainties that lie ahead, masterful at sensing patient's priorities and fears, motivated by utmost good faith in assuaging suffering. Ultimately, treatment we do is still a best effort. Not a guaranteed intervention. Reality continues to offer disappointments, surprises, gratification. Our personal hubris is clobbered, hopefully, in the process. We learn of a newer reality where our performance and expectations are appraised in relative certainties, relative successes. 

We surrender our hubris to the ruthlessness of diseases. And try to cajole, trick, fool the disease wherever we find its weakness. It is not really a heroic job. A rather cunning and tedious one. 

COVID-19 pandemic is ravaging the world. As of today, over 200,000 people are recorded deceased from the disease. The actual mortality is likely much higher as not all who died from the disease are tested, particularly in resource-starved countries. Newspapers report heart wrenching stories of lives lost. Young, old. Colleagues working heroically in healthcare settings. 

While a pandemic is beyond the scope of my expertise, certain characteristics do not feel far off from what we see in clinical care- just magnified at a staggering scale. At this phase, uncertainty is the emphatic attribute of the disease. And we are best served recognizing this. All the understanding we have of the disease is based on very short-duration information. This disease has not played out in its full extent yet. So we do not even have a tangible data set of disease characteristics. Our interventions are guided by interpretations of these limited information that are likely to evolve continuously as more information is gathered. So the prime question is how best to make decisions when best practices are not known. 

This quandary is a familiar sentiment for medical trainees (which we are lifelong to a varying extent) when confronted with a clinical situation where we have no previous experience or knowledge base to tap into. The usual remedy to this predicament is we draw on the wisdom of someone who has dealt with the situation before. Or someone who studies or researches these problems on a daily basis. Sometimes these are known problems to them and a simple resolution occurs with gratifying result. At other times, this is equally perplexing problem but they have broader insights into the overarching patterns and nuances. Their hunches are more likely to be successful than ours. Recognizing and trusting these skilled persons is an art form as well. Better ones among us are better at doing it. 

As we look at the global response to pandemics it is not hard to see who are doing better than others.  And it is clear where the disease is met with hubris, society has not fared well. Unfortunately, the country I currently live in, my second home, falls into the category where disease was met with an utterly incapable political leadership crippled by cocksure callousness nurtured by sheer stupidity. It is painful to read or watch the news of the political response from the federal level. Conspicuously absent is a notion of grief in this ongoing daily devastation of human lives. Happening in thousands. In this nation, currently, grieving for others is a personal enterprise. It is not happening at a collective level. Shamelessness of political leadership is just stunning. 

The devastation that could have been has probably been mollified somewhat by heroic efforts happening at local levels. But there is no doubt that lack of an organized humble leadership at the national level, that could avail the extraordinary expertise of extremely capable people who think about these issues everyday, has cost a lot of lives. 

When a ruthless disease demands an agile response, a leadership whose sole qualification is brazen contempt for the lives and dignity of "others" does not seem to be a good match. 

Round Them Up

Round Them Up

O brothers

My dear brothers

My brothers of fate

Let us

Round them up

Those of filth

Of poverty

Smelling of sweat

Smelling of fear

Smelling of desperation

Begging at our borders

Let us

Snatch their kids

Kids of lesser worth

Kids of lesser innocence

Kids of others

From wailing mothers

From crying fathers

And cage them

Who cares where they are

Who cares if nobody knows where they are

Children of lesser worth

Parental love of lesser worth

Human attachments of lesser worth

Let them cry in hunger

Soak in their excrement

Be terrified

Be terrorized

Let them learn my wrath

An apt lesson for childhood

For these lesser creatures

Of my magnanimity

Of my grandiosity

For I am born with these privileges

Round them up

Round them up

Those who toil in the scorching sun

Those menial workers with temerity to do what I do not want

Those living in shadows dreaming of something greater

Those filths juxtaposed to my unimpeded entitlement

My birthright privilege

O my brothers

Of myriad shapes and forms

How would I do this without you?

If not for you nodders and winkers

If not for you cynics convinced that cynicism is bravery

How would I venture to new zeniths of cruelty

Mind you, the only means

To teach a lesson

To these filths

If not for you people of god

How would I justify acts of cruelty

Guaranteed you have the heaven for I belong to a clan

As long as I hate gays, aborting mothers, others that are not us

You give me passages for every rationalization I need

You have helped me shed kindness

For it is a worthless attribute

that demands unnecessary sacrifices

When we could just congregate in the gilded halls, just you and me

Ensuring heaven belongs to us

Only to us

If not for you masters of words

Academics and pundits and policy wonks and elites

who have finessed the art of reducing the others to economic worth

Skeleton measured in dollars

How suave you can be

Beauty it is

Seeing you bury my barbarism

In your drawls and pauses

Feigning objectivity

How sweetly you dehumanize these filths

And anesthetize the people of your kind

Numb to my ventures in cruelty

For they see dehumanized economic elements

you give me the stepping stone

O brethren

Who have given me so much

I promise you awe

You will be amazed at what is possible

Had you not started with dog whistles

How would we have reached thus far

We can now spite at the others with pride

Tear their family apart

Cage their children and revel

Bang their door with our fiery fists

Sending chills down their spine

Behold the sight of soggy, prone, entangled corpse of a father-child in last embrace

and celebrate it as a trophy

Of the success our spite bodes

Let us

Round them up

Who cares we sit on gold

Anything wasted on them is a loss

When what we are really after is

to shake dignity out of their existence

To teach them servitude

For our grandeur depends on servile others

Our self-worth feeds on their fears

Let us

Round them up

My brothers

I know you will be there

In solidarity

As long as it is about the others

No morals will stop us

For we have sloughed our empathy,

No horrors will bother us

You will find reasons for every atrocity we have to commit

You will tuck your tail and follow me

For we are marching to a wonderland

Where it will be only you and me

And no others

Let us

Round them up

Hiss

EMRs and Alternative Facts

As students of medicine, we have always placed an esteemed emphasis on "history taking." A process of listening to the patient while gathering clues to the ailment. William Olser, often described as "Father of Medicine," had this to say on the matter:

"By historical method alone can many problems in medicine be approached profitably." 

It is still a dictum we hold close to our heart and try to impress upon our students and trainees.

Alas, Dr Osler lived in a world without electronic medical records (EMRs). I sometimes find myself pausing in embarrassment while gathering information from the patient alongside the EMR. "How many doses of zoledronate infusions have you received so far?" I would be asking the patient while simultaneously pulling up the medication administration record. They would tell a number that turns out to be completely different than what has actually been given. As we find out a different record of actual medication administration, patient winces, and I blame myself for putting her on the spot by asking the question. I could have just explored the EMR beforehand to gather that data for something that I can hardly rely on patient's memory. And over the years I have learned how unreliable it is to base decisions based on patient recall. On my good days now, I would have performed a thorough exploration of patient's EMR and gathered necessary information before I enter patient's room to talk. Good students of medicine these days put due diligence in gathering exhaustive information from EMR. I am certain Dr Osler would have emphasized this in more eloquent terms were he around.

Still, the importance of listening to patient holds an irreplaceable import. There are no descriptions of patient's emotional states by a clinician's notes that can substitute a voyage of thoughts in a calm absorption of  patient's patter. No algorithm of information can match the patient's descriptions of their priorities and beliefs. You might have the right answers for the disease afflicting the patient. But listening and talking with the patient is where you build the trust. Ultimately, we humans are not automatons making decisions on rational choices. Our patients weigh their trust on us to adopt our recommendations. We might be brilliant in medical sense but if they do not find an emotional plane of trust, they might not adopt our solutions, even if by objective measure it is a wrong choice.

A good doctor in the current environment is one who can be exhaustive at data gathering from the EMRs, capable of listening and connecting to the patient, agile in compiling information needed to manage the issue in the most evidence-based manner, able to synthesize emotional information with objective data, and masterful in conveying the information in literally and emotionally understandable terms to the patient.  

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Recently, we have been introduced an oxymoron term "alternative facts." While the messenger received some serious criticism, unfortunately, there is a populace who share her belief. If we were to heed the back and forth between the protagonists and antagonists of the alternative facts, we might find ourselves confused about the reality itself. If we do not belong to any particular ideological camp, we might throw our hands up in the air and say the world is an illusion anyway! There is no reality!

As I think about this I can not help going back to the EMRs. There I see two discernible aspects of realities in that interaction:
1. Objectively verifiable information (e.g. the information about what date, time zoledronate was administered)
2. Interactions involving feelings/thoughts

The objective information is fixed and incontestable. If the patient has received medication only in this facility and there is no reason to doubt the accuracy of documentation, that information is incontestable. There is no subjectivity.

But in our human interactions not everything is objective and fixed, we rely on feelings and perceptions. We imagine. We dream. Not by threading the plausible and actual but rather freewheeling in the cloud, in the subconscious, beyond our realm of reasons and rationality. Do I like this doctor? Does he sound reliable?

We are entitled to an unbridled freewheeling in the perceptual realm. But if we try to claim that objective reality should also acquiesce to our perceptual world, that's when the problem springs. When we start claiming that our feelings of the number of zoledronate administered should trump the objective documentation of administration, there is a serious problem. There is the world of "alternative facts."

I do not want my doctor to rely on her feelings about the objectively verifiable information to decide on my health. It is also clear that the society should not rely on "alternative facts" to run the governance.   

Martin Luther King Jr (MLK) Day

There were warnings of freezing rain. Although it is a hospital holiday today, I am on call. Black ice-covered driveway greeted my journey to the hospital for rounds. Roads were largely desolate. It was a while before I saw any car. Sky was gloomy and dark. Skidding here and swerving there, I reached the hospital. I rounded with a competent clinical fellow and we were done by the afternoon. I drove back home. As I was attempting ascend up the steep driveway to my garage, the car protested. On the ice, the car veered in wanton. It would slide to the right, glide to the left, drift backwards but not up. 

Defeated, as I waited at the bottom of the driveway for some brilliant idea to materialize, I could not escape the irony of this day. A day commemorating a man who sacrificed his life peacefully striving for racial justice. Today, it feels as if the world is back to square one. The West staggers in an amnesiac stupor, completely oblivious of its treacherous past, as if it is seeking a calamitous jolt. No wonder the day appears weepy. And the town frozen in its wistful tears. 

Over a pile of snow on the sidewalk adjoining the driveway, I made an attempt. One side of the car was on grass now.  Riding the crunchy friction, I made it to the top of the driveway. The vehicle will witness this blubbering night while I seek warmth with my family inside. 

Artha

Dear son Artha, 

Not long ago, your mommy and I were rewarded the knowledge of your conception through a positive urine pregnancy test. It is hard to describe the exact feeling of seeing those lines turn color on the pregnancy test kit. An abstract announcement of life. Precipitous. Somehow, fragility has piggybacked that moment and trails to date. That we have a fragile and precious existence bestowed upon us and told: you are responsible. Anxious about your safety, “one-day-at-a-time,” we have told ourselves since.  

A notion at that moment, you asserted your presence in mommy’s nausea and anorexia. We saw you for the first time as a wormy construct on the ultrasound. On the second ultrasound, your structures became clearer; we could make out your head, heart, hands and feet. We even knew that you are a boy! Very early in a cool spring Maine morning, you decided to make entry into the external world. Mommy writhed in pain for hours while daddy was consigned a role of passive witness (remember, that is one reason why we boys will always remain the inferior sex- we are biologically incapable of that sacrifice). You came screaming. Those were the most genial decibels your parents have experienced in their lives. When I saw you for the first time, somehow, it did not feel like a first encounter. It felt as if I had known you always. Introduction was needless.

It has now been over eight months since your arrival. You sit stably. You smile abundantly. You speak in syllables. You like company. You like outings. 

Well, that is your daddy's attempt to express your development in tangible terms for a process that is much more nuanced. If you asked daddy to sum his experience of witnessing your growth and parenting so far, it would be this: Daddy had thought parenting would mean teaching you things to help grow to a more mature individual. What he has realized is that it is more of a role of servitude. Servitude to an innocence that has certain needs. It is parents who are taught things. Taught by being positioned in extremes- a crying baby amidst sleep deprivation, you can not resolve what is bothering, can you maintain your patience? We constantly try things, learn new things; you keep changing, we try to keep pace. At this stage, we are the learners. Daddy's dear friend says, as you grow there will come a time when you will look up to us to learn things. I trust that. It seems to me that we are in for a journey where we will learn from each other, always.

Forever yours, 

Dad.  

Turkey Dinner

On Christmas eve, we decided to cook turkey dinner. Late after work we headed to the grocery store bustling with last minute shoppers. Not finding the 12 lbs turkey that Ina Garten's recipe called for, my wife and I were weighing in our options, picking up a few frozen turkeys in the horizontal freezer,  to see if there was anything close to the recommended weight.

"Good luck with getting turkey ready for tomorrow," said a woman, leaning towards us from the opposite end of the freezer.

"Yeah? Why?" I asked.

"You won't be able to thaw the turkey on time," she replied. I proffered that we could leave it out at room temperature overnight. She countered that it will destroy the turkey. She was right. They generally recommend thawing the frozen turkey in the refrigerator compartment allowing 24 hours for each 4-5 lbs. We were stuck.

"You could thaw it in cold water, changing water frequently, or you could get a fresh turkey that should be in that area," she pointed to another area in the meat section. We had no idea that there were fresh turkeys in the store. We thanked her  and got our fresh turkey. It cooked well and we had a gratifying dinner. 

She must have felt a pity for a mixed race Asian couple, in the heart of rural Maine, trying to cook a quintessential American dinner but at the verge of utter failure.  In this society where people live a very individualistic life, value privacy of other people, and avoid gazes, stares at public places, her silence would have gone unnoticed.  Rather, it would be the norm. Instead, she decided to break the norm and save a stranger's turkey dinner.

If we watch or read current American public debates portrayed in the news and in the conversations of demagogues vying for power, it is very easy to get wound up. It is easy to identify with one side or the other and start huffing and puffing. But I am afraid, these are 

exercises born of desires to simplify reality, to create heroes and villains for writing history. In the lives we live, however, kindness is born in non-reasoned goodwill, outside the usual norms, and across the superficial distinctions of identities, in mundane everyday spontaneous interactions. Heroism is not what is pursued but a spontaneous majestic, abstract excellence.

Fortunately, human history favors excellence in us. It favors kindness in us and not cruelty. It favors creation and not destruction. Yes, our cruelty and destructive tendencies can do great damages and suffering but they are not our triumphant attributes.

Hope more of us, and more often, we have the courage like the lady across the freezer, to have kind intentions, and kinder feelings.