Friday, March 30, 2012


"...the death of a dream"

Yesterday, I wrote a letter that was long overdue, say by a few weeks. It had rattled in my mind for that duration of time. Should I or should I not? What would be the implication of the letter? How would the receiver see it? What would be his primary reaction? Would he or she think about the content? Would he spend time mulling it over about the issues addressed in the letter? What would be his final interpretation? How would he react to it?  These and all sort of arcane thoughts had plagued my mind. It was an adventure into a mine-field, every step a tortuous end or a crippling one. Every moment of that delay, a harrowing detail. And every thought emanating from such a delay, led to a built-up scaffolding of a tall skyscraper of infinite height without a concrete foundation.

And today, I received the reply. The time for such questioning as posed in my letter had long since passed. Huh? What?

Since 1564, up until today and probably, as long as there are readers of Shakespeare on this planet, Hamlet’s soliloquy is and will be considered the greatest of all. The essence of “to be or not to be” lies not in the beautiful caricature of the human mind, but the dilemma of the human decision-making. The torture of a indecision is reflected in the last few lines of this beautiful prose:
“…and lose the name of action.”

So is over thinking a sine qua non to inaction? 

Is it the death of all process? 

Is it the death of all dreams?

Think about it, for a minute.

If the wheel had not been invented, would we be sitting in a Chevy with the radio blaring the Bohemian Rhapsody? If the propellor had not been contemplated or even if thought of, but never put into action because of safety factors would we have flight? If the jets engine was considered unsafe because of the combustive nature of fuel, air in a contained environment next to the passenger-humans, would we have traveled to space, the moon and beyond. Would we have a Hubble Telescope spinning in space to peer into the 13.7 billion years old Big Bang?

In medicine, from direct transfusion between two individuals in the midst of wars resulting in the knowledge of incompatibility secondary to immune challenges, to the value of organ transplants is a single thought and direct action. From an artificial Aortic patch boosters to the artificial ventricular assist devices to keep a human alive for a cardiac transplant, from an ocular implant to a sensory implant in the occipital part of the brain to view the world, all such progresses have been behind huge mountains of impediments. Yet they happened, because someone said, “to be..”

You dream of a rocket ship with plasma driven drives, or regenerating hearts or kidneys on the scaffolding of inlaid tissue, or manipulating the genetic structure to calm the waters of a survivability gulf between naturally acquired mis-sense of information on the DNA, to a humanly corrected version of the same. These are the qualities of human endeavors. Not all is thought through in philosophical debate ad infinitum. Sometime, somewhere, there is a moment where the questions that arise will be answered better with time through trial and error then just by contemplation. If we are to consecrate our humanity at finding flaws through the arduous process of nitpicking, then inaction is the most viable answer to all questions.

I remember a very intelligent young patient, once during a consultation bringing forth reams of paper, gathered via internet and libraries, about his disease and hashed objections to each issue he set forth to consider. In the end he left with the same mindset that he had arrived with. Six months later, was back asking for another opinion. He had wandered from person to person, place to place interacting and accumulating information but had yet to pull the lever. Unfortunately for him he never could be convinced to pursue any path, not the standard of care nor the experimental trials. This was the “With this regard, their current turns awry and lose the name of action.”

We humans have circadian rhythms that enable us to perform at peak capacity. The converse side to that is during the ebb, everything slows down and productivity grinds to a halt. It is during those non-productive periods that we do a lot of “mind-wandering” you know the sort that makes you think random thoughts and you jump from one to another in no specific pattern. You know, you’ve had them before and enjoy dwelling in them every now and then. They are a part of the human day-dreaming. The problem with this mind-wandering, day-dreaming scenario is, that it clutters the brain and drives the brain to use its Insula-(r) and prefrontal cortical activity for no specific reason. It is like idling the car at high RPM and letting it run out of fuel. So a more linear but comprehensive approach might be better, for instance listening to music and contemplating on the rhythm of your breathing or better yet call it “meditating.” This relieves the Insula and the Pre-frontal cortex of the brain to relax and get freshened up for the real job of constructive productivity. Too much of everything is akin to too little of anything. So, saying “focus” and "focusing" are two separate and distinct processes, the latter is infinitely better. Trying to coerce the performance by force is counterproductive because the cerebellum part of the brain that controls complex motor activity is not within the purview of voluntary control. So, allow it to happen naturally by clearing the mind. It is a pity to see a boat adrift in the water.

This reminds me on a golf course one day, while I was having a whale of a time accumulating pars, somewhere on the thirteenth fairway, my golfing partner suggested that, I point my left foot outwards a little more for better power. The result, my friends, was dramatic and immediate, what followed were double and triple bogeys for those remaining six holes. Needless to say, I learnt a lesson that the brain analysis came into play and the automaton activity of muscle memory went out to pasture (was lost). Too much attention is the same as too little. Paralysis through Analysis!

A Scientific American article in 2009 reported “…In a 2008 study psychologist Sian L. Beilock of the University of Chicago divided novice and skilled golfers into two groups and instructed them to perform a series of golf putts. The researchers encouraged members of the first group to take their time, whereas they exhorted members of the second group to swing as quick­ly as they could. Novice golfers performed less accurately when speed was emphasized, but skilled golfers showed exactly the opposite pattern: they performed best when told to execute quickly and faltered when advised to take their time.”

 So dream! The more dreams you have the better it is. But to fulfill your dreams of the sleep, you must have an open book, a clear mind for the day.


Ives-Deliperi, V. L. et al. (2011). The neural substrates of mindfulness: An fMRI investigation. Social Neuroscience.

Mareike B. Wieth & Rose T. Zacks (2011): Time of day effects on problem solving: When the non-optimal is optimal, Thinking & Reasoning, 17, 387-401

Wednesday, March 28, 2012


How are you at home?”
“No, I mean with family and friends?”
“I don’t have many of those, but I have my books. You cannot find better friends then that.”
“But, you must have someone to share life with?”
“No, I had a cat once. But she died a couple of years ago.”
“So you are alone?”
“Can you get another cat or a dog?”
“No. Mangles, was the best cat and is irreplaceable.”
“Sorry to hear that.”

He was fifty, trim, dressed in baggy jeans and a shirt with grease marks on the elbows of his shirt. He was quiet with very little to say. His eyes sunk deep into the orbital cavities and a small upturned nose. He had thin frail hands with soft palms that had never seen hard labor. Mostly a hermit, he had lived his life in isolation. He lived in the isolation of his fears in a small hut by the countryside. He had just been diagnosed with cancer. The prognosis was good, the disease isolated and in its infancy. Surgery would render it curable. The future was bright for him.

And yet two months later he was dead.

What happened?

In our simplified version of the world where cause and effect are the inimitable values we place on ourselves as solvers of great riddles; we become believers in our own fairy tales.

There was more to this loss then meets the eye.

The shimmering link that creates and molds our lives is also the same link that strengthens us or destroys us. The sense of closeness and togetherness is the sense that delivers us from isolation. Bereft of this link, our internal mechanism finds chaos and entropy.

Mammals have the limbic neural network within their brains that longs for attachment to resonate with another. The closeness between two mammals gives the rite for thriving. A pair of swans, a man and a dog, a husband and wife, a pair of lovers, a girl and her cat, all such pairings have the inexorable continence of defeating.
Romanian Children

Children deprived of their mothers love, affection, proximity, coddling, renders them into despairing individuals that live abbreviated lives. In fact monkeys deprived of their maternal attachment become isolationists and act out in rude, aggressive behavior without knowing the bounds of when to lay down arms; they sometimes will fight to the end. Rats deprived of their maternal bliss will fail to thrive and die prematurely just as their human counterparts.

This connection is more than holding hands. It is the tinkering within the neural circuitry of the brain that undergoes modulation to liberate various hormones, immune humors and cytokines to fortify its defense. I don’t mean to reduce it to a chemical armory, but there is truth in that. The brain is plastic. It is reshaped by the events that precede it. 

The epigenetics that control the DNA modulation and explicated activity also control the brain growth. The human link is the strongest armament against outside threats. A loner will not survive against the vicissitudes of the world and its many inflated evils. The human touch is like a shield against the whips and scorns. Love is the protection against the slings and arrows.

Survival is guaranteed to those that live in togetherness. Religion by virtue of its sense of belonging advocates the strength in numbers, as does a close-knit society. Togetherness is all.  We are to each other the existential pillars of support.

Romeo in his pleadings to Friar Laurence:

“And say'st thou yet that exile is not death?
Hadst thou no poison mix'd, no sharp-ground knife,
No sudden mean of death, though ne'er so mean,
But 'banished' to kill me?—'banished'?
O friar, the damned use that word in hell;
Howlings attend it: how hast thou the heart,
Being a divine, a ghostly confessor,
A sin-absolver, and my friend profess'd,
To mangle me with that word 'banished'?
Friar Laurence:
I'll give thee armour to keep off that word:
Adversity's sweet milk, philosophy,
To comfort thee, though thou art banished.

Yet 'banished'? Hang up philosophy!
Unless philosophy can make a Juliet,
Displant a town, reverse a prince's doom,
It helps not, it prevails not: talk no more

The hurt is plain to see. Romeo’s banishment is like death to him. No words of living life without his Juliet are enough to supplant the terror of being without her. He sees death without her. Life is not worth living. Romeo’s love for Juliet is the guiding light, the spark, and the consummate eternal focus of his being. Without it he is no more.

Humans need this fondness for one another, this togetherness for survival. Without such, lives are scattered to the ache of longing and thence to the dust of antiquity and the ruins of mortality.

We as humans thrive in the presence of others. We yearn for praise, for honor and ultimately for acceptance from another. It is in this acceptance we derive the benefits of togetherness, of that link of survival and growth. This link of love makes us thrive and grow as a person, while isolation makes us wither into a Kaczynski or a Hannibal.

Death comes to all. Yet the link of love wards it away for as long as it can till the battered countenance of our fragile being is dissolved. Our human links give us the will to survive. Our love makes us grow. 

Mary Ainsworth

Mary Ainsworth a Canadian psychologist determined the security and insecurity of a child is directly dependent on the mother's direct involvement with her child. The aloofness creates the insecurity that damages the future for the child.

Patients with cancer without a support structure have lived abbreviated lives in spite of all available resources while on the flip side those with the most abject horribleness of disease-ridden bodies have survived longer with love then chance or statistics with probabilities would have earmarked for them. Outliers both! Cancer patients need the support structure that they themselves can foster. No outside support is needed. No outside help is required. Just link and love and the strength of survival will come from within the blossoming warmth of another.

That patient died because he had lost his cat “Mangles.” The will to survive and the strength of connection had been lost for him. He had been banished from the kingdom of his comfort. His only connection to life had been in the form of a cat.

So it is for all of us to create a large repository of friendship, of connections, of togetherness, of support, of belonging so that we can survive the arduous and the arcane life-limiting battles that time can throw at us.

Yes, Link to Love and Love to Link! Our survival depends on it!

Thursday, March 22, 2012

e pluribus unum ~ the one

Or... Bastardizing Medicine for the one!

"Truth is one, paths are many."~ Gandhi
But in deference to Gandhi, do all paths really lead to the ultimate truth?

Outside the window is a beautiful image of the mountain enriched with trees and a smattering of homes, a chimney top and winter swept white snow. It is gorgeous in all its resplendent glory. But obstructing that view are these branches of a large hunter fir tree. The branches sweep across and limit half of the view. Annoying to say the least. After having half a thought to have the tree cut down, I have relented.

There is something about the sweep and brazen nature of these branches that attracted my attention. The branches at their anchor are bereft of the fir but trailing to their periphery they are burgeoning with life. More interesting is the reach of the branches to gain access to the sunlight. The branches seek the light and using the ingrained Fibonacci mathematical construct of arrangement, the branches have sought out the most advantage. “The tree design made 20% more electricity and collected 2 1/2 more hours of sunlight during the day. But the most interesting results were in December, when the Sun was at its lowest point in the sky. The tree design made 50% more electricity, and the collection time of sunlight was up to 50% longer!” (13-year old Aiden Dwyer ~ )

And then there is the squirrel that jumps from one branch to another in an apparent playful mode with its bushy tail wagging behind always in search of an acorn. He tracks back to the trunk and then down to the ground and disappears. Leaving behind to plod its way on the web, is a tiny spider hard at work with its spinnerets creating a silky trap for its future meals. 

An ant tracks up the trunk of the tree in search for something as it weaves its way around the Rhitydome. 

Such wonders to behold in the near and we are constantly being pulled by the far.

As often these musings go, my thoughts wander over to medicine. We are losing the battle about the “forest for the trees.”

Each individual is a unifying glory of life. Each deserves the best we can offer in support of their health and future promise and yet, I see a large battle cry for the masses. We have suddenly jumped from the unifying principles of all patho-physiology of one and dumbed it down to the health of a society and even to the health of the world. Why and when did it happen?
Funnel Plot

We propound population-controlled studies with univariate and limited multi-variate determinants to fashion an arguments for the many, forgetting in the process the mischievous strange attractor of Lorentz. And of course one cannot forget the other jargon in popular mode today with terms like, “regression analyses,” “meta-regression analysis,” “meta-analysis,” “poisson distribution” and the “Chi-squared” virtues of epidemiological data, 

have all but abandoned the real basic and clinical science of prospective analysis where a hypothetical posit is experimented and the results validated with more experimental data. Now it is the virtuosity of the statistically inclined to create a new reality.
Poisson Distribution

No now we just jump into “data-mining” and formulate a diktat! So much for real science, now we just transmutate any collected data to suit a pre-defined purpose. You know like the one “broccoli is good for you one day and the next day it isn’t” stories. You may substitute, alcohol, PSA testing, Mammography, Chest X-Rays, CT scans and any of the other medically related diagnostics or consumables at liberty.

Didn’t it take an Edward Jenner, helping a 9-year old child of a gardener to create the focus that ultimately saved millions of lives against smallpox? Did it not take Jonas Salk to try the first polio vaccine on himself, his wife and children before committing to the world at large. 
Barry Marshall

And who can forget the Nobel laureate doctor, Barry Marshall, who swallowed a glass full of Helicobacter Pylori laden water to convince the world that peptic ulcer was indeed an infectious disease and not just about “stomach acid.”

You see, in dealing with one the process meets the demands for the many. The motto “e-pluribus unum” serves us all well. And yet, I see that now medicine is taking a tack contrary to the well-served path by using massive data files of the many to comport the medical care to the one.

Medicine is the same you know:

"Mr. Jones how are you today?"
"I am fine doctor, except for this lingering discomfort over here."
"Here, lets have a look."

It is the expressive palette of that word "here" and the limbic-prattle of his emotional nuance of discomfort that Mr. Jones displays and the doctor interprets it as a medical problem. No, the tweeted or emailed version of the same could never meet the same rigor of comprehension by the reciprocal right sided brain's Werniecki's  area .

All things change, some for the better and others for the worse. It is the intellectual property of the human mind to decipher between the two. Bastardizing medicine through regulatory fiat premised via a non-medical motive will hurt people. Medicine has long stood on the shoulders of doctors, each has cared for and mitigated many an illness, lets leave a good thing well enough alone.

Think individual and that will serve the global and not the other way around. (But please don’t bombard me about the discovery of Cholera by John Snow of England after the local disease had caused three epidemics worldwide, that the root of the problem lay in the bacterium vibrio cholerae. Yes there is a legitimate purpose for true epidemiological studies (you know like the triangulation method or better yet the wheel method, whereby all available information is availed of). The condemnation is for the abuse, via the fiat of data-mining and statistical magic to prove a presupposed internal bias - like for instance, the longer index finger is a risk factor for prostate cancer ~ that kind of horse manure!)

Don’t forget the tree for the forest, or the health for the dollar.

Think individual!


Small is the number of people who see with their eyes and think with their minds ~ Albert Einstein

Monday, March 19, 2012

Cost or Care

God has given you one face, and you make yourself another ~ William Shakespeare

"Our age has shifted all emphasis to the here and now, and thus brought about a daemonization of man and his world. The phenomenon of dictators and all the misery they have wrought springs from the fact that man has been robbed of transcendence by the shortsightedness of the super-intellectuals. Like them, he has fallen a victim to unconsciousness. But man’s task is the exact opposite: to become conscious of the contents that press upward from the unconscious. Neither should he persist in his unconsciousness, nor remain identical with the unconscious elements of his being, thus evading his destiny, which is to create more and more consciousness. As far as we can discern, the sole purpose of human existence is to kindle a light in the darkness of mere being. It may even be assumed that just as the unconscious affects us, so the increase in our consciousness affects the unconscious.”  ~ Carl Jung

The dilemma of this enigma called Healthcare continues to spiral. The direction of that spiral remains unknown. Someday I feel that we are climbing the beanstalk towards the friendly giant and at other times it feels like we are screwing ourselves into the magma of hell.

What is it that we hope to achieve? Coverage for all, is a definitely humanistic motive, but at what cost? That is the moral dilemma, worthy of a solution.

In the meantime, the drumbeat of cost containment and educating the growing society of physicians seems to be taking shape. Now before we get mired into all the minutiae, let me posit the unintended consequence of such a thought. The concept is simplistic, if we teach the students the cost-factors of healthcare then they will be more cognizant of the appropriateness of care delivered. The idea at face value seems very intelligible. So where is that elusive answer? The problem being that by forcing an issue of cost-containment onto the student psyche maybe will unintentionally bias them towards cost rather than care.

Lets talk about the cost of treating cancer. The embedded costs of the newer drugs continue to climb. The rationale for this has an available pieces of information; To bring a single drug to market, between 5000-8000 products are evaluated and then a single drug or none may come out of it. The cost to bring that drug to market for commercial use is estimated at $1,000,000,000.00 (or $1 Billion). This cost is to satisfy the FDA demands for safety, which go far beyond the need, it is a knee-jerk reaction to the old “Thalidomide-disaster." We certainly never want that to happen again, but there are reasonable risk-mitigating strategies in place without the over indulgence of the regulatory burden.

For every sneeze and itch if we are to devise a regulation, proffering “means justifying the end,” the regulators need to know that there are unintended consequences of the same, for instance little, or no more innovation, which would be pathetic, or companies running out of money, just to fulfill those imposed demands, before products can be brought to market – a sad scenario under any circumstance.

The pharmaceutical companies are obviously looking for a return on their investment from the capital placed at risk (the drug may not work as predicted) during the development phase and therein lies the cost. If the use of the drug is in a smaller population (a rare cancer/disease) then the cost of the drug per use will be quite expensive and the reverse is and should be true. However there are a few companies that take advantage of situations and affix a large premium for new discoveries shortchanging themselves by keeping it out of the reach for most.

And associating cost-containment with limiting care would not be advisable. I realize the writers, journalists and some doctors have signed on to this, but they are shortsighted. Caring is by and large a human thing. It defines us. We certainly can communicate with individuals and discuss the ramifications of certain futile care, but restricting care at a predefined age or disease stage for surgical or medical need is a fallacy. It may save money in the short run, but it will surely change the country, for the poorer, in the long run. This runs foul of our own incentives that we propose daily.

We recommend that to live healthy lives, people must exercise, lose weight, eat healthy etc. But now when they do and live longer, they will have run out of options for intervention at the wrong time down that road. Better think through this fellas! You, are one blink away from reaching that milestone yourselves ~whoever and where ever you are.

But then there is another flaw in this complex conundrum; the patient/consumer. You see for this complexity to be simplified, the consumer must also play a part in this real life drama and based on all parameters of this thought experiment, probably as much as 50% effort if not more.

I came across an interesting statement from an associate the other day. He said, that it was amazing to him that most of the workers at his jobsite were frequenting the doctors’ offices for minor complaints. Afflictions such as sore throat, a one-day dry cough, or a minor ache or pain or just simply a “fear-of” illness were a common source of “calling in sick.” Of course there are several issues here, but we will restrict ourselves only to the medically manifest ones.

To tackle the problem, both sides of the equations have to be solved. Consumer empowerment of good personal health will go a long way. Making access easy without repercussions for blatant abuse is the sacred cow that needs to be slaughtered. The physician side of the equation has some disincentives too. The over-diagnostic behavior and over-prescribing is also leading to abuse at the provider level (though I get incensed using the derogatory word "provider"). For instance, recommending a cardiac catherization on a 90-year old male who has a minor surgery for a limited squamous cell skin cancer is imprudent, and similarly subjecting a 75-old female with chronic back discomfort for a MRI runs foul to reality and good prudence. Both are odious in their respective claims.

Obviously for all concerned, to have a “skin” in the game will also prevent abuse and fraud of the system. Unfortunately the fraudsters use today’s technology while the “watchers” use the 20th century version of the same. Personal greed and fraud come from the same branch of human thought. Both are polluted with the same humor of reason. Both destroy humanity.

Asking the people to behave themselves is like asking an average child of four or five to not finger-lick the cake. It won’t happen! The people “getting away with it” have a preconceived bias based on the current societal mores and they can with this bias, keep pulling the levers of fraudulent behavior. After all for them, “what’s good for the goose is good for the gander.” They remember JFK's quote differently, "Ask not what your country can do for you, ask what you can do for your country." The sea change to civility, needs a paradigm shift, the sort that changes discourse. It cannot be done by fiat, governmental or private, it can however be done one on one, through engagement.

I find the shift, taking place in the Social Media between people who have never known each other, never met face to face or heard each other’s voice and yet through the power of words the dialogue is changing us all.

Lets all join in on this most worthy of causes and enchant our selves with human dignity and decency.

From caring comes Courage ~ Lao Tzu

Sunday, March 18, 2012

Of Space and Time

How do we sense?
Within our senses
The loss or gain of time

How do we sense?
Within our senses
The loss or gain of space

Where is the time?
Where is that space?
Where space time is sensed.

What is our sense?
What does it sense?
When time is free of space

How did time
Create the space?
At the beginning of time

How then must we live?
How then does time die?
How then, does space exist?

We march ahead
Banisters grasped
Of that space and time

Where is it all?
When is it all?
What is it all to be?

The raindrop that falls
The leaf that dies
As autumn wind flees

All sense of self
All sense of you
All sense that disappears

Where is this?
When does it exist?
Who counts the to and fro?

Exist we do
Then again, no
No trace, no record, no more

Thursday, March 15, 2012

Medicine in a Storm

All things change, nothing perishes. ~ Ovid

There is something about rain, how it feels on my face, or sounds on the rooftops, and limits the view from inside the car or aircraft windshields. It is the water from the heavens. It is the nature cleanser. But there is a soul cleansing magic in it too. I sit and watch the harsh sunlit view landscape softened by the clouds and the rain, as it has morphed from the Mondrian stark blunt linearity into the soft colorful overtones of a Monet.

There is a literal genesis to this rain in the lift and growth of a sentiment. The violence and attraction of particulate thought and the shearing wretchedness of opposing views that devolve into crackles of lightening, all caught up to define the imbroglio. The build-up of these mental clouds, continue peaking at heights where sight cannot see and the mind cannot comprehend. And then just as the burdens of the weighty moisture laden clouds of thoughts, anger, opposing views and roiled sentiments, all collapse under their own weight, in the form of cleansing the dusty landscape below, creating a paradigm shift of colossal magnitude, the sun peaks again. The cloud dynamics of thought, concept, individuality and collectivism, all conspire to create an anvil capable of inflicting tremendous damage - and rebirth.

Medicine, I fear, is in the throes of this bubbling cauldron of cataclysm.

Imagine yourself in a theater and let that imagination soar…

The theater is alive inside, as the men in stilts outside are crowing about the magic that is to take place within as the actors take their respective place. The stage is set, the dialogue of discontent memorized and the emotive expressions of pain have been practiced. Soon the opposing views that have been rehearsed will be brought to bear before the unsuspecting audience and the clash will begin. The drum roll will announce, reaching a crescendo, the tempo will rise, the decibels increase and the dull thumping Major C will cry, multiple octaves ahead into a sharp, horrifying shriek of despair, damaging the eardrums of sanity. Yes the drama is about to unfold, as the audience sits on the edges of their seats to witness this transmutation of a paradigm. The past, the yesterdays all coalesce into a blur on the stage as the sound of the trumpets announce the First and only Act.

The diametrically opposing forces are armed to the teeth, while the audience sweats into a frenzy of ignorant inaction, shaking their nervous legs and twitching their itchy noses. What to do? What to do? Cries abound from the stage and whispers amongst the inimical audience turn into a slow rumble of murmurs of discontent. The pull and charm of the edifice that piped the crowd into the theater with the salve of entertainment and smiles of frolic seem false as the tempest from whence new beginnings arise clocks its hour. 

The actors will die off, killed by the poisoned swords of anger and deceit or by the apothecary of self-denial and unsheltered refuge of this rage, and slings and arrows of misfortune will rain down upon all with uncanny accuracy.

 The harsh deluge of this act will once again drown out the whimper and voices of rationalized fears and give way to a fresh start.

This chaos will end. 

The many arrows of hope amongst the countless ones of despair will find their mark and a new dawn will break. The arrows of hope will come from the audience of this theater. They will prescribe for a new set, a new stage and new league of actors.

 It is the hope I have. It is the thought that kindles my spirit. It is the song that resonates within my soul. It is all that is left for that vaunted new beginning. It may be all that is left of what we call medicine today. The tomorrows hold the key to what the new paradigm will be. Lets make sure it is a good one.

Can we then shape the future of medicine? You ask. Maybe. The future will deploy itself at the appointed hour of the appointed day, as the new cast of characters will fill in onto the stage. They will rehearse and memorize their lines once again. The play will begin at its destined beginning.

For, such is the calumny of the human endeavor, it shapes and is reshaped by the ideas and desires of the mind.

Ah the rain is upon us, I can feel the wetness on my skin. The hushed sound of rainfall on the trees is everywhere.  The blur blinds to wash anew the landscape of thought and action. A new vista is set to unfold. The theaters will remain the same, only the signs and the avenues will change. That within, is changing even though at a glacial pace. It is the requisite of thousands of years of a very slow process and it is in this upheaval of that change that the audience sets its eyes and ears upon. Ah, I can hear the thunder and as each flash of lightening loses distance in time to the reverberating sound.. 1000 and 1…1000 and 2…1000 and 3…

It might be the empowerment of the self, that little lonely, independent self that changes the face of medicine, or it might be a combination of educators, educating people about self-governance and the knowledgeable literati moving steadfast as the pioneers, into the field of understanding and ultimately undertaking rituals of personal responsibility and good health, forging the future for the new humanity. Whatever the refraction from the crystal ball, the bright colors will light the future.

Let your face feel the soft dampening drops of heavenly moisture. Let it sound off the rooftops and blur the view of the windshields, for a new dawn is upon us, ready for the forging to our intent.

We know what we are, but know not what we may be. ~ William Shakespeare

Saturday, March 10, 2012


Between Rocks and the Hard Place

I lost perspective the other day. I did. I started down this path and it forked quite suddenly. Both trails looked the same except one path appeared to have more shade from the trees and the occasional wild yellow flower that bloomed underneath the canopy of the tree shade, which made it all the more pleasant. The other one was barren with spiny rocks that jutted onto the path and I would have to avoid them and be cognizant of their presence every step of the way. My journey could be long or short, I didn’t know, but there was this thought emergence that no matter what, I could always cross over if I had to, if I wanted to. Yet if this was the easy route, why should I not take it? And why even think about the crossover?

The path unwound in front of me and soon the shaded canopy got denser and denser, the sun filtering through the trees, tried as it might, could do little to penetrate the thicket. Meanwhile the darkness that continued to gather brought in the buzz of the mosquitoes and calling screams of hoo-hoo to eek-eek to hwaah-hwaah all merged into a cacophony of a dissonance that burdened my ears. The mosquitoes with their unrelenting zeal shot onto my exposed arms like darts and drew their elixir of survival, leaving behind red angry welts and the prickly branches of the flower bushes scratched the exposed skin and left long bloody streaks. Meanwhile, I walked on remaining psychologically oblivious to this terror, imagining the implied soft cotton balls of comfort, while feeling only the minor irritation of discomfort. No this beautiful path of certainty with its beautiful foliage could not but bring only the most wonderful of sensations onto my person. I continued along the road and soon, I became aware of the thought-feel dislocation that had penetrated my brain. There was a crucial de-linking and as it happened, the fit and feel of the stings and scratches became abundantly clear as to their intent on my body, I could no longer avoid the wrath of this surrounding beauty. I was dying at the hands of this glorious paradise.

I looked to one side and there further along, I could see an opening. I walked up to it as my strength seemed to sap down my legs and out through the soles of my feet. The rubber soles of the shoes seem suddenly to become unstitched to the leather and were flapping along as I came up to the opening. There to the right of me, many miles was the gleam of the other road. The forested land between was thick and impassable and directly before the rise to the other road was a body of dark blue water, so deep in its color, that the fathoms defied a crossing. The gulf between sanity and hurt seemed to grow and despair started to commingle within my spirit of adventure.

Oh the beauty of the foliage remained unblemished in the darkness, the unfeeling eye of a camera would project onto the digital plate a most beauteous of scenery that all would imagine as paradise. There would be a lusty desire to come here and get a salvation for the hurried and tortured souls. Yes they would. I could see that clearly and yet the terror of the beauty surrounding me seemed to prick at the very essence of this holistic, natural and delightful view. What to do? Just plod along till I was battered and bruised and maybe spent off of what ever this thing in me there is that keeps me going along this road of life? Or to take arms against this meandering path of innocent terror, where beauty and implied comfort was admixed with the tortuous and painful reality that was rankling my soul and change direction to go back to the other path with its outcrops of spiny, rocks that one could see and avoid? The known. How?

And as surely as I was drowning in this dilemma of doubt, the canopy seemed to disappear, the overhead clouds lowered and a fine mist began to fall. My vision failing from the mist could just make out the convergence of paths ahead. I hurried my pace as my flesh was being eaten and the soles of my feet were raw with the feel of the bone on earth. The pain could no longer be cushioned, by the soft cotton balls of implied ignorance, by the emotional words with implied feelings, or the musical notes and visions of feathered comfort. No, the reality of pain and discomfort was now aglow in and through me. The comforting words, the lilting sounds, the feather-filled pillows of imagination could not keep the harsh truth away.

My breathing was shallow and came in spurts; an ebb and flow of life. My thoughts were only to rid myself of this calumny and even if it took the virtual world of beauty with it at that moment in time it was the right price to pay. I ached for the path of see and avoid, maybe that would have shown the devil and the dust and not the irreverence of the implied virtual beauty with its hidden hell. I wanted the real thing, badly.

The path merged and after a few steps diverged again. The same scenario unfolded before me. To the right was the path, pot-holed without a shade and the sun drenched vista of rocks and what appeared as a mirage of a lake while the other path now showed a comfortable vehicle and a paved road. I could get inside the vehicle and off my torn up feet and blistered skin and let the vehicle take me to where ever the path ended or…

I woke up that morning drenched in sweat. The sun was still lumbering below the horizon and the golden streak had yet to herald a new day to awaken the rooster. I was to meet this patient early in the morning.

“So what do you think doc?” He said.
“It is your choice, you know. All I can say is that the known, best care is the path of some resistance, The chemotherapy has side effects and it will make you sick for a period of time but in the end you have better than 50-50 chance of being alive 10 years from now. The path that you envision has no hard data. So there is not much I can say about that.”
“But you do agree that chemotherapy is a poison?” he asked.
“Oh sure. It is for the cancer cells. But in the process, it kills a percentage of normal cells. Fortunately the normal cells have a faster rate of reduplication and recovery than the cancer cell. That is how we beat cancer” I replied.

“I do want to live, but I don’t want the suffering to go with it.” He murmured.
“I understand. Unfortunately there are no easy roads in life. The easiest ones most times turn out to be the most difficult ones that cause the most pain and suffering.”

Which path would you choose?

Tuesday, March 6, 2012


You ask me if I hurt,
Not in the painful sense!
You ask me if I feel,
Yes in the literal sense!
You ask me if I cry,
Always in the emotional sense!
You ask me if I love, 
Yes with every sense!
There is no time but this,
There is no hurt but this,
There is no love but this!
Do I live in the moment?
I do, in every moment
Do I cry with every hurt?
I am numbed to the tears.
Do I feel every word?
I hear, I do!
Must it be this way?
It must, to heal.
Must we bear the pain?
We must, to endure.
Must we live these emotions?
As the clouds with the rain.
Where are the joys?
They are everywhere.
Unlock your heart,
Untie the knots,
Undo the past,
Live in peace,

Saturday, March 3, 2012


Quite the little ripple it set in my thinking, when I asked the question at a recent fast-food drive thru restaurant,

“Here’s a twenty.” I offered to pay for the food.
“Thank you sir and here is your change.”
“But I thought the total was $12.75?”
“You only gave me back $5.25!”
“Sorry sir, let me see…” She looked at the cash register.
“That is correct, sir.”
“Yes sir?” She did get an A-plus for civility and politeness.
“You mean taking 12.75 out of 20 is 5.25?”
“Let me call my manager.”

So this is where we are today. Life has changed. The wheels that turned, the cogs that clicked and the tick, tick, tick of the human brain has slowed in function even below its lowest capacity in some. We are allowing ourselves to be outsourced. Our brains are finding themselves limited in capacity even compared to the thumb-drives with only 128K of memory and that is mostly from disuse, leaving terabytes and terabytes of capacity to fester and die. Such a waste! Hans Moravec would be displeased.

There is the lure of the digital age. It is bright, flashy and absolutely hypnotizing. You carry a computer in your pocket today, the expansive physical dimensions of similar computing power, which, only a decade ago would have broken your back. If I want to read a book (a good thing) I have it in mere seconds wirelessly transferred in all its voluminous glory to my digital pad. If I want to calculate the median, a mean or an average, I just plug in the numbers and voila! The answers are right there. The oohs and aahs are palpable and everyone admires the gadget. But what about this three-pound universe that we house between the ears, called the brain?

Wheeling back to the past (if you will allow me some latitude), on a bright sunny Sunday morning drive, many moons ago, I drove with my kids to go skiing. On the way, I started asking simple arithmetic questions. By the time we had reached our destination the seven and nine year olds were busy adding 3 digit numbers mentally. The project had an incentive of course. The winner would get to go down the black diamond slope. The system had been handicapped for age, by the way. And… the winner would also get points towards the latest computerized gadget –Oops!

That was then, this is now. I see them both looking at the reflective bright screens of their respective smart-phones, when not otherwise occupied. But fortunately both are industrious for their own good. The synaptic frenzy of thought and action is still well developed in their brains, they prod and probe their universes and for that I am grateful.

The world changes and our thoughts are no longer our own. We rely on the gadget in out pockets to answer the basic questions that we used to rattle off without much ado. What then has this borne on civilization? Are we better off? Or are we sinking into the abyss of intellectual oblivion?

Well actually the answer is filled with ambiguity in the form of a yes and a no.

Some use the devices to expand their horizons by making the device do more than it claims. They make the devices create new enterprises. Case in point the “Angry Birds” app, a simplistic game that has garnered a fortune developed by an enterprising young man. Or take the instance of a real rag to riches story in the form of Facebook. Mark Zuckerberg its founder initiated the process of creating an open architecture of the computing platform to allow students at Harvard to socialize. As the movement spread, he was sharp enough and quick enough to adapt to the ensuing change. A quick form of communication with words and photos and the rest as you know is a multi-billion dollar 10-year history.

The ones that have the desire will push the limits into an ever-escalating domain of improving computing architecture, creating new vistas, aligning the right structures and realizing the right content and dreams. From that will spawn new industries; holographic universes, safer materials; more flexible, more pliable, less prone to degradation. There will be a plethora, of biological nano-robotic healthcare materials with brain and muscle enhancing drug and non-medicinal mechanisms, of stem cells that re-grow and replace the damaged ones and organs will reform back to their youthful majesty, of exploiting the sensorium to access more surrounding information and processors embedded within to manipulate that data, of drone surveillance for security (hopefully with safeguards from that Darwinian debt of the Orwellian threat of 1984), of psychic warriors that bring down enemies without firing a single shot. There will be exploitations at the fringe of science where the mathematical limits will be tested and retested until a new breakthrough ensues. There will be a continuum of chaos and revitalization. There will be a brand new day, every day. For that is the nature of the human thing. That is what separates us from our closest ancestors, the monkeys, baboons and orangutans. It is that 0.4% of genetic divergence that compels us to find fire, to use agriculture, to foster challenges, to hail the new dawn. It is what makes us. It is what defines us. We are that quintessential dust of nature, that paragon of all life that vows to wow. We are humans. The possibilities are endless, the sky is the limit, should you choose to rise above the rest.

The ones that don’t will always ask for their managers.