A thought is like cotton – it can be processed hundreds of times and each time it becomes more refined.

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We are the world

It is a momentous week – world leaders are getting together for the UN Summit week, Pope is visiting NYC, and Autumn is finally arriving. For me personally, this is momentous because I remember being excited about the UN Millenium Goals and now I get to witness the reveal of the Global Goals!

What is different between then and now? Well, I am older, the UN week is still the world attention holder, but the goals have become much bolder! The new goals are fantastic because they push the limits of the nations’ leaders to achieve these goals. More importantly, they include topics that were left to the wayside the last time – responsible consumption & production, life below water & on land. I am enthralled as I think about being part of a generation that can witness the achievements of these goals. Of course, the obvious caveat is that many of these goals are closely dependent on the mothers of all goals: peace & justice – leadership from strong institutions.

UN Global Goals

As you notice in this pictograph, peace & justice are listed as goal #16, while the plan is completed by the goal of creating global partnerships. This is such a vital distinction because the success of achieving these goals is soundly dependent upon our ability as humanity to unite for peace and justice. One cannot be achieved without the other –

“Peace without justice is tyranny” – William Allen White

When we listen to the news on the radio or peruse through a magazine or the lonely newspaper – everyone notices the headlines. Based on today’s AP News headlines, I created word cloud (helped by worditout.com). Of course the usual common words are predominant – day of the week, politics, Congress, news; however we should take notice of the following words: Syria, US, military, combat, Russian, injured, war, missions, flee. We seldom come across words like peace, happiness, camaraderie, partnership.

WOrd Cloud

It is clear that the state of our world is not adequately depicted here. I recognize the commonly accepted explanation that unhappy news sells while happiness does not ignite a fire. However, we should ask ourselves whether each of us is truly doing our part in cultivating a community that is inclusive and tolerant of differences but not injustice. We need stability to achieve all the goals outlined above – and stability is achieved only in areas where justice prevails. Each continent of our world is affected by instability. The Global Conflict Tracker is a tool produced by the Council on Foreign Relations, and take a look at their prediction of conflicts for 2015:

Conflict map

To the folks who believe that nations should focus on their individual priorities – think about this: is there any denying now that conflicts on one continent are affecting the interests of all? We are no longer the citizens of individual countries – we are global citizens. When the dividing lines of mother nature’s geography do not amount to any effectiveness, why do we still allow political and religious lines to divide us? If we are to achieve the goals of zero poverty, zero hunger, we need to educate our next generation. If we are to achieve educational goals, we need safe places for our children to study, eat, live, and prosper. These children will look to us to provide by example – the example of peace, justice, industry, and acceptance.

Reading furnishes the mind only with materials of knowledge. It is thinking that makes what we read ours. – John Locke

Does each of us have to go out to a warn torn corner of the world? No. We need to find the opportunities in our own towns and cities to promote each of these goals. Work as a mentor or teacher, help build a community garden, urge your companies to invest in the local resources to decrease unemployment, donate materials to build food pantries & home, and most importantly, bring awareness!

The world is round – a globe – thus our efforts of achieving these goals should be global!

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Atlas Shrugged

“I am a doctor…a doctor. I went to medical school, not computer or business school.”

Does that sound familiar?

Of course it does! As a newly minted attending, I can say that I have heard those words from my former attendings and my colleagues during residency. We have to understand that those words mask a growing sense of frustration, apprehension, and sadness. They are reacting to the perception that the skills they spent decades on perfecting are less valuable in the eyes of the payers. At this time, the doctors think their ability of checking boxes and responding to electronic alerts is significantly more valued than their ability to coach a patient through surviving cancer or taking their medications everyday.

Everyone likes the feeling of belonging, of using their skills for good. If you asked a pastry chef to spend half his time billing his customers rather than creating a cake that rivals the beauty of famous paintings, I assure you the chef would quit that job. (Fortunately, they could move into Brooklyn and open another gourmet Bake shop! :-) )

Now, imagine the frustration of a physician asked to rush through a patient visit, only to spend more time completing notes and clicking more check boxes. Those lost moments are precious for patients and physicians. There is a thread that ties a patient and physician together – it is made of mutual respect, appreciation, understanding of values, and most importantly time. Today that essential thread is a little thinner. A part of humanism is simply lost in the hustle between patients. There is increasing recognition that healthcare provider burnout and stress is surreptitiously plaguing our healthcare industry. We see the effects on the looming/anticipated physician workforce shortage.

You may wonder – is the solution to simply increase patient time visits? I am not sure that would singularly resolve the qualms of modern day patient care.

I think the solution is still to be discovered. In thinking of the solution, my eighth-grade physics project comes to mind – the task was to create an insulation system for an egg so that when it is dropped from the 2nd floor, the impact forces are disbursed and the egg remains intact. So, imagine a patient’s values being the center egg, the expertise of primary care and sub-specialty physicians being the bubble wrap immediately surrounding the egg, and the skills of the interdisciplinary clinic team being the box and package filling that help the egg bounce on impact. Without any of these materials, the egg is bound to crack, and thus we are bound to betray the values of our patient. In order to come up with the solution, we need to recognize that each of the healthcare providers involved have skills that are interdependent.

The team as a whole has to provide for the patient. A physician cannot solely manage the patient, the EHR, the electronic tasks, the prior-authorizations, the billing, all the while screening the patient for cancer and depression. The physician’s abilities will falter and patient care will suffer from the fall. A physician needs time to reflect on the patient’s concerns and read between the lines of patient’s questions. And, we can’t simply require physicians to partner with non-physician providers to complete these tasks, especially when as a society we provide limited resources for that joint venture. Patient Centered medical homes and Advanced Primary Care models are moves in the right direction. However, we do not have the complete solution. I suspect that the solution of the future will be amenable to the needs of the patients and healthcare providers alike.

As we navigate the sea of healthcare delivery, it is important to realize that our paths maybe uncertain but our motivation should be united. For the healthcare leaders of the world, this is the most opportune time to be innovative because small progress will lead to great achievements.

Thought is the wind, Knowledge the sail, and Mankind the vessel. – Augustus Hare

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To the Future Chief Residents…from a former Chief Resident.

It is the end of yet another year, another training, and another phase – Chief Resident Year or as some like to refer it to as “Chiefdom.” This has been one of the most rewarding and trying years in my training for many reasons. First and foremost, the trust that is bestowed upon a Chief Resident is truly remarkable. We are asked to mentor the residents, lead the changes and foresee pitfalls of innovations in the curriculum, educate students, staff the hospital & clinics, and most off all be the person that others can count upon.

I learnt that there are three glass balls in the air at all times: the interests of the residency program, the residents, and the patients. And as chiefs, we need to find the perfect pattern to juggle them and keep them from falling. There will be times when one ball is beginning to descend too low but vigilance can help restore the cycle.

There is no such thing as a “perfect schedule.” We labored over the resident schedules. Spent multiple weeks and countless hours daily on the scheduling of residents. And just when we thought we had perfected the schedule, it was not long before an error was identified. I learnt that perfection is not feasible, but striving to resolve the problem that occurs is very doable. Errors are made frequently – acknowledging and working to resolve them earns more respect from our colleagues and juniors than perfection.

As a manager we gain knowledge about confidential projects and conflicts, whether that involves residents, medical students, attendings, or the institution. Maintaining this confidentiality is the responsibility of a leader and showcases the character of a chief resident. It is a responsibility that is not to be taken lightly.

Working with others is not easy. We are always taught to “play nice in the sand box” but not really taught what to do when conflicts arise. And believe me, conflicts will arise and difference of opinions will be voiced. Our reaction to them is judged as much as our involvement or instigation of the conflict. After making mistakes and learning from those of others, I offer these words: take a deep breath in, write down your initial reaction, then destroy the paper. Come back a few hours later (if time is of the essence, a few mins later) and think about it – remember that it is our task to resolve the conflict in the most respectful manner. I can’t say that I always practiced this, but when I did, it helped me navigate a challenging course.

Looking back at this year, I was lucky to have wonderful co-chiefs and program leadership, who have helped me grow both personally and professionally. This was a once-in-a-lifetime opportunity, and I am very thankful for it. To the future chiefs, I only wish you the best and hope you enjoy this year as much as I did.  To the residents (and graduates) of our program, I am very excited to be your colleague and proud to work beside you as we strive to make a difference in our patients’ lives.


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Summer’s Arrival and Our Departures!

So, summer 2015 has arrived and it is a wonderful beginning! Each Summer, I am excited about traveling, basking in the sun, and eating delicious local food. And this summer is promising to be just amazing. So check out the story of my latest Departure, and stay tuned for the Top 5 Hot Spots in each of the cities we traveled!

Vacationland, aka Maine!

We landed and saw that our rental car plate read “Vacationland” and we LOVED the sound of that! The winter had been long, at times pleasant, but still quite harsh by most standards. So, we decided to go further North to celebrate the beginning of summer – Maine! True to all accounts, it is a beautiful state with wonderful food, friendly people, and a corner of the ocean! V & I had 4 days to introduce ourselves to Maine – 2 in Portland and 2 in Kennebunk Port. We had such an amazing time, that it is difficult to narrow down to our top 5 spots for Portland & Kennebunk Port, but not impossible. Here we go:

Eventide Oyster Co. (Portland, ME) 

When I think of Maine, I think of lobsters! And when I think of Lobster Rolls, I think of Portland! And now, I think of Eventide. This little restaurant on Middle Street is surrounded by super hipster & edgy restaurants. I like my lobster rolls to be well seasoned, more than just mayo & lemon, and this place does it right. The lobster meat is served in delicious non-traditional butter rolls, reminds of the the dough in pork buns!  The portions could be slightly bigger but the sides we ordered completed the meal nicely.  Definitely try the cole slaw and bbq cauliflower – yes, they barbecued their cauliflower perfectly!

Street and Co. (Portland, ME)

This is a FANTASTIC restaurant in Portland, ME. If you like seafood, pasta, and dipping artisan bread in the left over sauces – this is the perfect place for you! The aroma is wonderful (if you like the smell of garlic & olive oil roasting) and the ambiance is that of a busy kitchen! The seafood is fantastic – some of the best shrimp linguine (I’m from NYC – I have had shrimp linguine before) and definitely a whole-roasted Branzino that reminded me of Capri, Italy! The dessert is something to make room for – we had the chocolate torte and it was decadent. If you are a non-chocolate lover, perhaps go for something different! Seeing the popularity of the restaurant, reservations are strongly recommended! This is a restaurant that will give the top NYC restaurants a run for their money.

Peak’s Island (Peak’s Island, ME)

Off the coast of Portland are clusters of islands. One of the main ferry stops is Peak’s Island. It is a cute fishing village with make-shift beaches and lilac trees that make you feel at home. It is a great 1/2 day-trip to take if you are in Portland. A visit to Peak’s Island is not complete without a stop for ice-cream at Down Front. The staff is friendly & willing to help you decide from multiple options. Our favs were Wild Maine blueberry and Raspberry Rocky bear. Make sure you take a beach blanket, sunblock, and sunglasses!

White Barn Inn Restaurant (Kennebunkport, ME)

The Restaurant is beautiful, the staff is knowledgeable and courteous, and most importantly the food is delicious! White Barn Inn is known for their ostentatious dinner selection – the chefs are absolutely amazing and their pre-fixe dinner is sure to please. The careful selection of wines and perfectly cooked meats are easy on the palate. There is a live piano player who is talented and creates a wonderful ambiance for dinner! The restaurant is a renovated barn and exudes rustic vibes to keep your experience truly Maine-like. Needless to say, White Barn Inn is among the 1,000 places to see before you die!

Overall, Kennebunkport is the quintessential summer town with rows of shops and art galleries, only interrupted by cute restaurants and novelty ice cream parlors. There are many places to try a bite to eat – one of our favs was Tia’s Topside Restaurant with its waterfront porch and outdoor space heaters – even a brisk night becomes perfect!

Lobster Shack (Cape Elizabeth, ME)

In a few words: DELICIOUS Lobster Rolls by the sea. V & I were visiting Portland Head Lighthouse, and hoping to grab lobster rolls for the well known “Bite into Maine” food truck, alas, they were not present! So, we decided to venture to another light house and find a secret lobster shack, called Lobster Shack! The restaurant is a small casual place with a huge outdoor picnic table area. The lobster rolls were amazing, portion size was large, and view was beautiful. We also tried THE BEST Strawberry Rhubarb Pie ever. I know that they are known for their lobster rolls and as they should be. But if you happen to go on a day when they are serving their strawberry rhubarb pie, please do so!!

Portland, Maine has so much to offer that V & I are sure we have missed things. We cannot wait to visit the other wonders Maine has to offer. This was just the beginning, and what a wonderful introduction to Maine indeed!

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Jhumpa Lahiri’s The Lowland

CT prj-0922-lowland001.jpgDamp & humid air fills my lungs every time I walk out of the airplane and onto the tarmac. It is the first and most cherished sign that I have arrived in India. I have fond memories of my childhood in India, which is probably the reason why I gravitate towards South Asian books & authors. Through these works, I have an opportunity to revisit parts of my own childhood. I hope to build a deeper connection with the land that has given me an identity and perspective different from the “Western” world. But most of all, I look to learn something new about my heritage, my culture, and the history of the land of my ancestors. And Jhumpa Lahiri has always delivered on these requests.

Lahiri’s latest work, Lowland, is a walk down memory lane with exquisite insight into the struggle of the individual and society. The attention to details is a treat! The book is an opportunity to observe the a time of great confusion and opportunity for Indians. The 1960-1970s was a time of revolution, a time of anarchy, but also a time during which this young nation arrived on the world platform. The underlying immigrant story of Lowland is similar to many immigrant stories we hear today – a young man leaves his family behind in India to attain greater education and pursue a career in America. However, she narrates a perspective we are not familiar with – the story of the family left behind, the family struggling to make their normal again, the family that has been changed forever by the opportunities and tragedies of this era. The way in which Lahiri links the lives of 6 individuals within a family and 4 generations is truly amazing.

This is a must read book for all those who enjoy an intricate story about family ties and generations, mixed with the Indian flair!

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Gender and the Roles

Gender roles – these words automatically revert me to thinking about the structure of a household. I imagine a 1950’s home with the children are surrounding their father as the wife ensures that the supper is laid out for the family. Take a look:

Gender roles have always been society’s attempt at maintaining the security and happiness of a household by designating responsibility to each member of the family. This has largely been questioned by many organizations and leaders. As we make our way in the 21st century, many of us believe that gender roles are archaic and few of us in the “developed” world apply these principles to daily life.

In an NPR-Morning Edition story, I was surprised to find that we subconsciously apply gender roles! New research has shown that gender roles are not only applied in household or workplaces, but during various levels of education, especially college/graduate education. In a recent database created by Benjamin Schmidt, a professor at Northeastern University, male and female teachers were evaluated by students (total of 14 million reviews!). The resulting text was stratified by gender, meaning that each adjective used to describe a teacher was recorded based upon whether it was used for a female or male professor. The study results can be viewed Here – an interactive chart showing the frequency of adjective use for female or male professors, also stratified by discipline of the student (ie. Philosophy, Fine arts, Economics, etc). As NPR reports, Schmidt found that “men are more likely to be judged on an intelligence scale, while women are more likely to be judged on a nurturing scale.” Through this review, Schmidt did not find a difference between genders for the overall rating of a professor. In a separate 2014 study, Schmidt also contemplates the idea that online-students were likely to rate male professors higher in comparison to female professors. Albeit the n of this study was low (43 students participated), the combination of the two study begs the question whether we subconsciously carry our gender roles with us beyond the boundaries of our home and office?

Since the turn of the century, we have seen the rise of female leaders in all disciplines, so much that perhaps we may elect a female US President within the next decade! In the 1990’s various small studies reviewed children’s perception of gender roles. It would be interesting to return to this field and compare the perception of gender roles among the children of today and 20 years ago.

1950sWhen it relates to medicine, the study of gender roles and perceptions is significantly pertinent. Physicians and patients are uniquely compelled into creating a strong relationship based upon the patient’s trust and confidence in a provider’s ability. If the provider is unable to attain and secure this confidence, the two can suffer from an unsatisfying patient-physician relationship. One can imagine that this influences the ability of a physician to encourage patient compliance, adherence, and satisfaction with treatment plans. As we venture into more complex medical management, the effect of gender roles is more likely to emerge to the surface.

Thus, the conversation continues for another day, year, or decade!

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Picking-up the Pieces

Calm, well-mannered, and overwhelmed. Those are the three words I would use to describe CS. He is the average patient in our Resident Clinic. He has struggled in life – migrated to America with hopes of pursuing a better life, lived away from his children, suffered through the passing away of his wife, witnessed the passing of his brothers, more recently his father, all the while working hard to make ends meet for himself and the family of a close friend who also passed away. CS has always been busy taking care of others. Until, this past May. He suffered a heart attack. He survived.

He is very thankful for it. But the day after his discharge from the hospital was his toughest. He came home to an empty house, and sat at the dining table wondering how does he go about “picking up the pieces” of his life now? It was time for reflection.

In Medicine there are many transitions – patients transition from their homes to the hospital (and back to home), medical students transition to being interns, interns transition into senior residents, and residents transition into attendings’ roles. Each road has many speed bumps along the way. Yet, the transition for patients from hospital to home is probably the single most unnerving experience because the patients are now “on their own.” Some patients receive variable degrees of family and social support, and others have no one to offer support.

Part of the ongoing discussions of Healthcare reform is the idea that patients discharged from the hospital should have close follow-up. As physicians, we focus on the clinical side of this transition – medication reconciliation, follow up of tests or radiology, consultant appointments, and avoidance of further visits. One aspect of transition that we may gloss over is the social support.

Let’s go back to our story with CS – he is grappling with adjusting to life outside of the hospital. When asked, his primary anxiety relates to surviving a life threatening event that can occur again. If I swap places with him, this is very daunting! Also, his limited outside social support is a reason for concern. Limited finances do not grant him financial security during his recovery time. He mentions medications that he needs and appointments he should follow-up, but he does not spend more than few minutes on those details. He is anxious about maintaining life after hospitalization.

In our current primary care set-up, we are not given the time to think about this adjustment, or help our patients find their way during this recovery period. The days when a patient could go home and be cared for by his/her family have significantly changed. Physician focus is narrowed due to time or work-flow constrictions. But the truth is, CS can call his PCP or Pharmacy to clarify medications, but he doesn’t know who will alleviate his anxieties. He doesn’t have a person standing by him through this transition. Primary care is holistic care. And, sometimes it requires us to step-out of the role of the doctor and into that of an advisor and counselor.


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