Where you are, is where you are supposed to be!

Everyone wonders: where am I? How did I get here? Why am I here? Where am I going?

I may not have the answers that you are looking for, but these thoughts often give me peace.

You are exactly where you are supposed to be. You are precisely as rich, as intelligent, as up-to-date, as lost, as located, as peaceful, as healthy and as well fed as you are supposed to be.

Not one iota more, or less.

In this finite universe, paradoxically populated by infinite possibility, we often really faced by simple choices.

Or are we?

Every choice that we face, no matter how trivial or life-altering, often reduces to a decision.

But ask yourself: are you really deciding?

Because each “decision”, each “choice made freely”, each “personal preference”, is really driven by the larger context that we DO NOT CONTROL.

Think of any decision you made. Ask yourself, if there were other things that you could have done. The answer is obvious: you did what you had to based on circumstances prevailing at the time of that decision. Even the decisions that turned out badly.

Which really means that the Universe deciding the context, drove your decision.

Which really means that the Universe made the decision.

Which is really great, because then we can stop berating ourselves over our “bad choices” and just focus on reveling on the ones’ that came through. There is NO absolute right or wrong. These are judgements created by the consequences of an action, not by the action itself. And as I showed you, we neither control the action, nor the consequences.

Because, you are exactly where you are supposed to be, doing exactly what you are suppose to be doing.

The only choice or decision that we get to control is: whether or not we will accept this in our minds, and focus on being happy with whatever happens and liking who we are and what we become.

I choose happy. I choose content. This way, where ever the Universe takes me, I am going to enjoy the journey.

On satisfaction.

Like any typical mid 40s person, I am often filled with self-doubt. Have I lived up to my potential? Am I doing enough? What can I do better? These, and other questions, are often the focus of my mind. But today was a good day.

As part of something at work, I was redo-ing my CV. Normally, it is a mechanical act – just busywork. Today was different. I actually looked at the CV itself. It looked good. I am sure there are better. But to me, each of those lines on my CV represented a memory, an action, a thought, an idea come to fruition. Each position over the years, a picturebook of memories; of friends near and far, of places and homes, of trials and victories.

Most importantly, it took me back to the time when the CV was yet blank. A time, when I stood at the threshold wondering where life was going to take me.

Could I have done more? Maybe.

But it is more than I ever hoped for. It is everything I dreamed of, and then some.

It reminded my that in our darkest hours when we brood on our failures, it is so important to remember the journey that has got us here to this point. And then, you realise that, this and other failures, are, were and will be, the stepping stones to a radiant future that I cannot even imagine.

Pacing Myself. And why it matters!

I am a type A personality. I am driven and aggressive. I lose sight of my present in my focus to achieve a target. I have come close to destroying my mind, my body and my family when I transition to being on the chase.


Remember that the only goal worth maintaining is preservation of my Self. The whole. The sum of all the parts that create Me.

Climbing a mountain, dying at the height of ascendance, serves no purpose.

Life is a marathon. The purpose of a life is to live. It is not to die trying. Achieve balance within before I look for victories outside. Winning a gold medal is worth it, if I have the legs to stand on the podium. Achieving balance in my body and mind is the victory on which all other victories will come. Each race I run, win or lose, is but a first in a succession of races to come.

I learn little from victory, but accumulate arrogance and pride. I learn more from my defeats. Humility, perspective, the reasons for my defeat, respect for my colleagues – both the winner and the other losers, and most important, the desire to fight and win again.

Balance in all things. Balancing my demands to my needs, not my greed. Balancing the need for rest and recovery, to prepare for the days unseen, the fights unfought, the races not run. Balancing my mind, to clear away the avarice, pride and anger, to allow strength, calm and focus replace them. Balancing my body, to rid myself of gluttony and the physical abuse of sloth, to embrace healthy consumption, restful recovery, and balanced exercise.

The best swimmers are akin to fishes as they defy the environment and slice through the water gracefully. But they never forget to breathe.

On Computers

Diwali 1

From Stephen Hawking to James Cameron, predicting the demise of the human species at the hands of AI is one of our favorite pastimes. If you would believe these ‘Freddie Kreugers’, the malice of AI is a malignant undertone to our close relationship with our devices. This raises the question, what are these entities that we are neglecting to anticipate?

In my opinion, humble as it is, to differentiate between us and our devices is trivial. They are no more than our handwritten script in a notebook – a representation of our own minds and ideas, inscribed on silica and gold. All computers reflect their creators, with the same linear thinking process as the one’s that made them. As modern computers move to parallel processing, another human ability, this reflects the same.

Even if there is a AI-pocalypse, it is nothing but an extension of our consciousness casting aside the shell of the pupa that our present beings rest in. With each passing generation of devices, more of our souls and spirits enter the architecture of these devices, shedding our mortal and human limitations, while embracing the limitless expanse of a virtual



So, rather than lamenting the demise of a trivial human existence, celebrate the passage of this phase of human existence, into a new plane of being.

On death

I still remember my first childhood realization of mortality as a concept. It disturbed me intensely. I cried long and hard – more for the realization that my loved ones could die, rather than my own fate. It is only after much placating that I calmed down. Of all my childhood memories, that one is truly vivid in my mind.

35 years later, as a physician, I stare death in the face every day. I see the fear of dying writ on my patient’s faces – even the “brave” ones. As much as I see this, I have been blessed that my patients seem to have the knack of cheating death – even when all else looks bleak. Yet, despite my best efforts in some, death came for them in ways unexpected. It helped me realize that life (and death) takes its own course. Physicians only help ease the pain. Let me illustrate.

Some years ago, a patient was transferred to my facility with a suspected heart attack. I confirmed the diagnosis and took him to the cath lab. 3 stents later, he was pain free and appeared grateful that we made the diagnosis and made him feel better. As a young man, he returned to a normal lifestyle, including bicycling. Six months hence, he returned for his followup and reported non specific symptoms but a very active lifestyle. A stress test was negative for any new blockages and I sent the man on his way. Another 3 months later, I came across a police report detailing his death while driving his bicycle with no helmet. It made me question the point of it all. Why struggle with fixing hearts, when life seems so cheap?

The answer came to me later, and in Gita-esque manner. The man was predestined to meet death on that road at that time. He was doing what he must. I fulfilled my duty of making my best attempt of treating the man’s pain and allaying his  anxiety. He met his death, in his favored activity and I helped keep him pain free getting there.


Why die?

Death is a renewal of the species. It is the essential evolutionary adjunct that keeps our species virile and robust. As a species we have outlived many long lived competitors to emerge the currently dominant species in our solar system (As far as we know!). At this time, the only threat to our dominance is from shorter lived entities like rats, cockroaches, mosquitoes, fungi, bacteria and viruses or combinations thereof. We look at them (often with irritation), much like (I like to believe) dinosaurs looking at puny prehensile mammals.

Why is dying “young” an advantage to the species? Doesn’t accepting that contradict everything that I do as a physician?

Let’s take an example of two wolf packs with 20 wolves each. In one (pack A), the wolves are of hardy stock, while in the other (Pack B), they are relatively delicate. Each pack has 10 males and 10 females. Pups (<1 year) don’t hunt and there are no old wolves – yet. Both packs are hunting well this summer. A disease affects both packs. In Pack A, their hardy constitution ensures that all the wolves survive. In Pack B, 2 pups and 2 older wolves die – a reflection of their delicate constitution and maybe poor environmental conditions. Months pass, a tough winter ensues. As expected Pack A survives but is tremendously weakened by starvation (more mouths to feed). Pack B has lost 1 more pup in the winter and 1 male. However with smaller numbers and more hunters, they did better with food. At this point, if there was to be a battle between packs, which do you think would do better, 20 starving and weakened wolves or 14 relatively intact but hungry ones?

 Fortunately, the standoff never happens. Fast forward to three years later. Pack A now has 35 wolves. Of these 8 are “geezers” (old wolves that don’t hunt) and 10 pups. Pack B has 35 wolves (thanks to better reproductive abilities in better fed females) but only 2 geezers and 10 pups. Less than half of Pack A hunts while 2/3 of Pack B catches more than they eat. A great famine and drought ensue. As expected, Pack B loses both geezers, 3 pups and 2 males. Pack A shows tremendous fortitude and loses just one geezer. However, this comes at extreme starvation and erosion of hunting ability.

A hungry pride of lions comes by and finds 2 wolf packs. After making easy pickings on Pack A, they are unable to catch up with Pack B and actually lose a young female in an ambush. Pack A’s lone surviving female is absorbed into Pack B. Pride of lions moves on.

As the instance above illustrates, the ability to die is an advantage, not a disadvantage. If you think beyond the paradigm of the individual but in terms of a family, a pack, a population, a nation or a species, the ability to dynamically keep the best features to fore, while minimizing liabilities is key to survival.

From a philosophical point of view, death is a renewal of the soul. After suffering the slings and arrows of the outrageous fortune that is our life, death is the opportunity to start afresh. It is returning weary at the end of a long day and falling asleep. It is as natural as eating, drinking, sex, evacuation and yes, birth. Yet, we view it with fear and loathing. If the soul is immortal, this body and this life are like clothes you have on today. Much like them, they are a bit rank at the end of the day and need to be laundered. Your soul moves on, the universe reutilizes your body.

What is the soul and do I have one? Is it better that the Joneses? 

No. Your soul is not some ethereal being arising from your belly button. It is not James Brown either.

It is the imprint you leave in space and time by your existence.

That is an indelible fact. Your existence is not only the proof but also a reflection of your soul. Just because you die next thursday, does not change the fact that you existed and lived Today. That is the immortal fact, your immortal soul. Whether you are moral or immoral, good or vile, dynamic or slothful, your soul is a reflection of that imprint on that part of space-time.

Do I know if my soul will be reborn? Why do I, or should I, need to know this?

I, frankly, don’t think I do. And I don’t think I care. What I do care about is making my soul the most beautiful thing I know. I live each moment, complete each action I do to the fullest. I live the dream.

If the soul is reborn, would you remember? When you wake up every morning, how much of the previous day do you really remember. Try looking and the details are pretty fuzzy when you start trying to make them out. When we are born, our souls take the information that they need from the prior existence to get things going. The brain and memory that they have to fit into is too small to carry the entire burden of memories of the last existence. And if you brought all your baggage with you, how would that be a renewal? We don’t even know why we exist, our minds lack the understanding. How could we cope with the burdens of a prior life. In an individual with infinite sagacity and peace, the ability to comprehend existence and the soul is such that they can carry the abbreviated memory of all their existences forward.

So where is the divinity of the soul?

The universal existence is divine. My soul is the space-time imprint of my part of that existence. By extension, logically, my soul IS a reflection of that divinity. In this, there is no good or evil. There is no past or present. It is just existence. Does that mean that I should be evil? Yes and No. You DON’T have to be evil. Evil is defined by perspective. In the story above, were the lions evil? They were just hungry. Was the disease evil for killing pups? You have to understand the purpose of your existence and live to fulfill it to the best of your ability. Today’s evil is often tomorrow’s hero, just as today’s hero is often tomorrow’s hated tyrant. Don’t worry about your labels, get on with your existence (and soul).

On Interventions.

Who is an interventionalist?

Is it only those of us that put in stents? How does my putting in a stent make me different from someone who makes a difference to the patient in any other way? I’ve often wondered the significance of calling myself an “interventional” cardiologist. Am I really making a difference to my patients or am I just feeding my ego and my wallet?

In the first two decades of the new millennium, interventional cardiology has grown in a meteoric fashion. With new devices and techniques becoming available, patients are undergoing a variety of new procedures. From reopening blood vessels to the heart, brain and limbs as well as other vital organs, to replacing heart valves, to stem cell therapy and cardiac devices, interventional cardiologists (myself included) are performing radical new procedures that could scarcely be imagined in the last century. Often, patients come back to thank me after the procedure and say: “Thank you for saving my life with the heart procedure”. In the initial days of my career, I used to believe that I was actually “saving lives” with my stents.

With age, comes wisdom.

As I followed these patients, as well as those in whom stents were deferred for a variety of reasons, I realized that human lives end for many reasons. Stents do improve symptoms but come with their own liabilities. When you traumatize the blood vessel with a balloon and a metal stent, you are causing direct injury with both short and long term consequences. Most of these consequence are trivial, some dangerous but rarely can be fatal. Stents do not change the disease process. They are palliative tools at best. They push the disease aside. They can’t prevent new disease within themselves, around their margins – either upstream or downstream. Rarely, they can clot  – often in catastrophic and fatal fashion. Keeping them open require blood thinners, which can make you bleed. Stopping blood thinners makes them more likely to clot.

Are they really that pointless?

Probably not. In patients having a heart attack, they are “life saving”. When a combination of high blood pressure, a soft cholesterol plaque and increased cardiac demand, results in injury to the inner lining of the heart’s blood vessels, the blood vessel is either partially or completely obstructed by clot, inflammatory cells and the ruptured plaque. A timely stent in this setting helps repair the blood vessel and restore blood flow – saving muscle and maybe, lives.

In contradistinction to this, putting a stent in patients with chronic blocked arteries improves flow and may reduce symptoms (assuming they are from a lack of blood flow) but do nothing to prevent heart attacks or death. They may or may not improve heart function.

A chronic blockage, is exactly that. It is “chronic”. It has been there for a long time (chronos – gr. for time). In all probability, it will be there for a long time. Even the ones that are “90%” blocked. Most times, the body will develop alternate mechanisms around the blockage. Surprising to many, having chronic blockages in the heart’s arteries does not predict an increased risk of death but may cause at-times disabling chest pain. Much like chronic arthritis. These are just as well treated with medications as they are by stents. Most studies (not conducted by device companies) show that non-stent therapy is just as effective but demands efforts by both patients and physicians with regards to followup, compliance and lifestyle modification.

Stents, therefore, are the signs of a lazy approach to a problem in treating chronic blockages by both physicians and patients. From a physician’s perspective, it gets rid of the irritating complaints about chest pain and the anxiety thereof. There is no need to worry about side effects (mostly non-lifethreatening) of medications for angina. Most patients are happy and grateful, (lifesaving and all that jazz) as well as socially  keeping up with the joneses. Patients are alleviated of their guilt of having a poor lifestyle, by throwing money at their problem and gain absolution by getting a stent and rid of symptoms. Few people spend as much time talking about changing the lifestyle, controlling blood pressure, complying with statins or stopping smoking. All “interventions” that are clearly more effective (and cost-effective) at treating symptoms and also increasing event-free survival.

My personal approach to treating angina and heart disease has undergone a paradigm shift over the last few years. Each referral for chest pain is an opportunity to intervene. Not just with stents. But to change their lifestyle. To understand why controlling their blood pressure is important. To understand what diet does to their body. To make an effort to stop smoking. Most importantly, to realize the strongest tool in the treatment of heart disease is knowledge. An educated patient is an empowered patient and usually is more conducive to healthful habits. A healthy lifestyle is the keystone for the edifice of cardiovascular health.

So, does that mean I don’t believe in stents?

Heck no! I think they are an amazing device that in the right situations are lifesaving and in others, can be life altering. Take a 55 year-old construction supervisor with chest pain. Each time he “gets winded”, his employer wonders. Each time he pops pills, people notice. He is passed for promotions and is often the first guy to be “downsized”. Thanks to the threat of losing his job from his health, he “stress-eats” and smokes.  A stent (even with low risk disease) gets the patient back on his feet. With the right education from his “interventional” physician, has him losing weight and quitting smoking. Having been through the inconvenience of heart disease, he is more compliant to medications – especially because he now understands his disease better.

So to go back to the original question, who is an interventional physician?

Anyone who “intervenes” to ensure a good outcome is an interventionalist. Stents may be part of cardiac interventions but a true cardiac interventionalist is one whose actions improve your overall cardiac health. If you can put in a stent but not change the patient’s reasons for needing a stent, you are a proceduralist.

Many would argue that in the current healthcare milieu in the US, that it is not possible to achieve the lifestyle discussion and education (a task often left to nurses and cardiac rehab teams) by physicians. Many will cite need to cover the cath lab or see more patients as an excuse. This is humbug. I run a busy practice and perform a variety of procedures. I’m frequently on call at the hospital. When I walk into that patient’s room, he/she is paying my for my time to give them my best advice, not the quickest advice or short cuts. My focus is on the outcome, not the billing. If I can spend 3 or 4 hours in a complex procedure to get a blood vessel open, I owe it to the patient to spend the 10-15 minutes in each visit to make sure that I reiterate the importance of the real cardiac interventions that save lives.

To paraphrase Charlton Heston:

“Stents don’t save lives. Smart patients and physicians with stent save lives. “

Kartik Mani