Sunday, August 20, 2017

UNFULFILLED DREAMS

“My name’s Blurryface and I care what you think”

The tide has turned. Nostalgia comes in waves, crashing on the shores of comfort. Life is different, subtle distinctions arrive at the doorstep every day. Art seems to find itself at the forefront of all that is human endeavor. Society is at a crossroads once again.

What happens from here on is a matter of how we as humans ascribe ourselves the kernel of dignity. Should we crawl or take a step and stand firm? Should we pine about what we want and not plan for what we need? Should we live in the sea of nostalgia crashing and dashing all hope of individuality? Should we go back into the comfort of our caves or should we hunt and gather?Where should we go?


The lyrics above give us a clue of our lives as they are today. Everyone wants to be heard because everyone feels that everyone is being heard. Everyone wants to be successful, because everyone thinks that everyone else is successful. But the lone difference in their thinking of replicating the success is one of being handed over that success. A few hit it and gloat to the excess, others continue on a journey besieged with doubt, insecurity and wanting to be back in the comfort of their mother’s womb. Precious little time is spent articulating the measure that will drive their desire forward. More time is spent complaining about the inequalities than about the effort. More is spent on wayward dreams that have no end than on the reality that sits idly in front, staring. There is less and less to pursue and more and more to march towards laziness, which has given way to a mentally tired brain that seeks the pleasure of the oxytocin, merely by an injection than by hard work and solution creating.

Life now hovers on the next “like” or the next “tweet.” How many likes did one get? And if only a few arrive on the screen, a despondency grows. Depression sets in and people get stressed out. And stress has a way of coming in many forms; displaced anger, a quiet involution into one’s own thoughts, sleeplessness and aloofness.

Yes, once upon a time we dreamed big and worked towards the dream. Today we dream big houses, yachts and jets without picking the dirty clothes off the floor.

In the end success and a better future is not in a nostalgic wave but in the hard work - dedication to a cause and striving towards a goal that matters. It is not about feeling “micro-aggressed” and needing a “space” that matters, it is about satisfaction from dedication and effort. These “wants” and “cries of inequality” are but the childish demands of juveniles that some experts promote to satisfy their own tenured consultancies.

Get out of the rut.
Make a name for yourself through hard work.
Stop “feeling” and start “doing,” for a change.
Wishing won't make it happen.
Stop “caring what others think!” Follow your dream and live it!

Or it will pass you by, filled with regrets and unfulfilled dreams.

Friday, August 11, 2017

QUANTUM TUNNELLING & Other PHENOMENA

Ever hear of quantum tunneling? 



An interesting phenomenon to say the least; proximity invites such a phenomenon, where one packet tunnels into another sphere to change the dynamics of the other, when in the reality Newtonian world of gravity and not gravitational waves, it would never be able to surmount such a barrier. It is like ghosts walking through the walls. Now why is that important? This is the question that must dawn the synaptic flow of every mind. Indeed, as a thought tunnels itself via words to another’s mind, it can change the thinking. And yet when you add the entanglements between different spins of these bits of matter the attachment between concepts, ideas spread and overtake us all even when there is no direct contact between the speaker of the thought and the receiver. A term used in German vocabulary calls it zeitgeist. Such powerful memes spread ethereally or so we are lead to believe.



The mind remains the metaphorical matter of such concepts.  So we floss each other’s ideas with memes that echo from our lips and sometime with subtle actions and with sometimes nary a meaning. The echoes keep coming incessant like the waterfall, crashing and changing the human actions. What is it about us that makes such non-rhyming couplets become music? 

The world changes slowly, imperceptibly hurtling into the abyss of an entropic future where form is glory and substance slowly fades to dissolve. The present seems sometime, to become the dystopian future of the past. Clearly we feel powerless in this game of change and yet we propel inexorably forward towards it with each passing linear moment.

One such delectable moment, where it is hard to pinpoint when this became the de facto principle in the field of medical oncology remains unclear. The use of PFS or Performance Free Survival slowly became the underpinnings of drug benefit in medical oncology. Not only that PFS also became the modus operandi for the FDA to give approvals to drugs that showed a PFS improvement of a miniscule of 4 months but no absolute OS in a small “n” studies.  After many studies failed to show a clear and present improvement in Overall survival or OS in patients, now some are starting to cry foul as drug costs outweigh drug benefits. The cost of cancer medicines seem to climb the ladder of “no worries.” As long as the third party payers pay, well, who really cares? It is the joyous world of memes and meaningless get-rich-quick-and-stick-it-to-others selfies world. It unfortunately realizes the old adage, wherever there is great need and ignorance, predation lives. http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2589085 

Other important measures that have confabulated the mind, if not decimated thought completely is the statistical bent that harrows the medical literature; the issue of “significance!” Using p-values to show significance continues its daily quest to win over the scientific community at large even though fewer “scientists” actually sit down and figure out the reality behind the headlines.

So what of this tunneling issue. Unfortunately, this generation is poised to become the most prolific quantum tunnel-ers in the history of science. We continue on our quest to obfuscate and create new and complex rules in order to hide the real facts under the burden of statistical fiat. Might it be time, now that the “cost-containment” is the zeitgeist of the day and heads are ready to roll? Might we hurtle accidentally into the real reality away from the Matrix? Yet through it all, one might consider that the "Tunnelling" effect just might happen with good information as it readily does the bad version. One can dream, can't one?

Or maybe not! Given the rise of the machines such as IBM’s Watson whose glorified technical abilities will launch science in general and medicine in particular to new heights is nothing better than a Bayesian Trap of a sophisticated yet superficial search engine. A rare but accelerating form of sophistry. For, it is based on the shards of preexisting information and deciphering a new set of rules of the ever changing biology is not currently within the realm of this Artificial Intelligence that uses past data to give reams of mathematical information couched in Confidence Intervals, and probabilities framed upon known knowns. And Quantum Tunelling is becoming a large a factor here as well, petabytes of data notwithstanding. (http://www.cancertherapyadvisor.com/general-oncology/cancer-watson-search-engine-clinician/article/576074/ ) But imagine if you will, where this data resides if quantum tunneling were to happen between what is "good" and "actionable" data with the proliferating snake-oilsmen virtuoso bits? Ah life will get even more interesting as the guardians of the computing gate bow down in worship of this slowly bit-by-bit mutating beast. Such stuff as dreams are made on.

So you see, dear reader, if you are still with me through this Alice’s inspired rabbit hole, the art of the spread of the zeitgeist is more than the gain of wisdom, it is simply regurgitated information couched and spread as knowledge. What is then is nothing more than what information tunnelling makes it to be. The world changes by the memes that control the eyes and ears of humans.

And while “an honest tale spreads best, plainly told,” this one is a complex series of moving parts that humans have lost control of for a while. How should we, or better yet can we control the ever stretching and mind-bending future that seems to lay out before us without us even entertaining a thought. It seems we are propelled by the unseen force of this quantum-packet-magic, ethereal and invisible, to slowly play out like Shakespeare’s fool upon the stage and then be heard of no more. And as Benjamin Franklin might have hinted at, obliquely of the growing act of these agents in the future of his world, “Any fool can criticize, condemn and complain - and most fools do.” We have an ever-burgeoning library of them.



The essence then, must be to use our faculties for their best and think critically for ourselves, lest the rabbit hole leads below into the molten core, where heat vaporizes all.

Monday, August 7, 2017

ANTICIPATION

an·tic·i·pa·tion

anˌtisəˈpāSH(ə)n/
noun
  1. the action of anticipating something; expectation or prediction.

Anticipation is a strange word, come to think of it. Dictionaries describe it as an expectancy of fulfillment of desire. So clearly it is the expectant reward in the future.

Now let me delve into this futuristic feature, briefly, so to speak.

There are several layers that bear witness to this anticipatory reward or outcome. Assume you have just crossed the hold short line and are turning onto the runway for a takeoff. The anticipation here is the act of pushing the throttle to the wall and the slow (sometime fast with afterburners), but progressively increasing acceleration that forces your back into the leather seat (assuming your aircraft seat has Corinthian leather) and watching the scenery accelerate away from you as the needle threads its way to the (blue line in twins) and VSO1.3 in the single four or six banger and you anticipate the loss of the rumbling noise and the bumpy turbulence of the wheels on the runway to give way to smoothness and vagaries of the wind and weather. Ah! Your mind cries, “what an exhilaration!” It happens to me each time sitting in Seat 10F, 20F or 30A of a commercial jet too; that moment when the surely bonds of earth do not chain me or the lumbering megaton piece of Aluminum to gravity and the quiet roar of the jet engine turns into a whine and smoothness takes over. Ah what a feeling!

So where is the lesson in all this?




Glad, you asked. Here it is! At liftoff, there must be a certain anticipation of dread that must be encountered as well.

What ifs?

What if the engine should quit on takeoff? What then? Many an accident has taken the life of the non-curious pilot. What if, is therefore anticipatory. Of not a reward or the thrill of it but the ignominy of the workings of a gremlin (or your last mechanic or you in inadequate preflight). If you anticipate such an eventuality that gremlins do exist, then you are prepared for the outcome. Landing straight or 30 degree bearing left or right of the flight path below 700feet on a takeoff, on a single runway airfield, or reversal of course above 1000 feet. And you must have anticipated where to land on previous takeoffs where to safely set the aircraft down in case of such an “anomaly” (as NASA would call it). In fact, it behooves us, as pilots to look for safe landing zones (at your airport) while entering the traffic pattern. Have you checked for them? In fact, this should be a routine at any airfield. The 45-degree angling into downwind has its rewards, accept them eagerly.

Anticipation is common to most pilots as it must be to all. For instance, if you bank the aircraft left or right, there is a loss of the vertical component of lift, isn’t it? That leads to a dropped altitude, hence the accompanying action to the bank is a slight pull on the stick (or yoke) to maintain altitude. But if there is no thrust (as in engine power failure) the lift component degradation is more significant. Try finding out that altitude loss at higher altitudes with your instructor- and a wind-milling prop. Maneuvers practiced at altitude and in controlled environment bring the calm needed when things go “clink.” That will serve you well in a real calamity.

Oh, and I might as well mention this while I am at it. For those trained as Instrument Pilots (As I believe all pilots should be for safety reasons alone) entering the clouds the first time on any flight should alert one to review the status of all instrument functionalities (In addition to a thorough prior preflight check on the ground). The Attitude indicator, Airspeed indicator, the Altimeter etc. Those gauges are all we have when the electronic or mechanical gremlin tickles its personal fancy to mess with your $200 hamburger flight. If those beautiful TV screens fail, you are left with the basics as well. Learn to use them well! Scan the steam gauges and the data on the glass; constantly. 

Pilots, Repeat after me, ”Attitude, Altitude, VSI, Airspeed, HIS/Gyro Heading Indicator, Turn Coordinator” Got it? For Glass lovers, same stuff, different format.



And sometime other non-discrimatory gremlins can cloud the view as happened in this F-16 crash at Whittman Field at Oshkosh, WI in 2011 when the canopy got clouded due to depressurization-environmental issues and the pilot went 300 feet beyond the threshold for a $5 million oops!

So, anticipation is the desirous word for that deliciousness, or not, yet to come. Some events might not have the same charm to them as others, but they are all events worthy of note. It is always the prepared (anticipatory) pilot who learns to enjoy and weather all outcomes equally with a similar measure of quiet aptitude, attitude and decision-making.

“Live Long (Fly Long) and Prosper” as Spock might have said.


Sunday, July 2, 2017

HEALTHCARE COSTS AND LONGEVITY

RECONCILE

rec·on·cile
ˈrekənˌsīl/
verb
make (one account) consistent with another,

In business, the act of reconciliation of revenue and expenses is done on a periodic and timely manner. In medicine this is perhaps never done. Each silo stands on its own foundation and power structure, so much so that it becomes an entity to itself. Legions of intellectuals then profit from their fame by using just the right amount of information to fold their personal needs.

That nagging prickly itch, has always confounded my sense of quiet, when I look at graphs dominating the universe of healthcare disparity among nations. Something is amiss.

Often in the light of day, a graph will present itself by a notable to evoke a sense of something in the observer. That something, is the subject of this discourse.


On the face of it, it does look damning. Wow, one wonders, the United States, the wealthiest of nations spends so much in healthcare and gets back so little in return compared to all the other industrialized nations in the world. Ivory tower experts and politicians have often resorted to using these graphs at their various forums to articulate an idea, a policy or a mandate. The elites choke on their finger-food at the sight of this graph. “How can that be?” they gasp.


So, in the act of this reconciliation, let us also put this graph up. Now this one makes the physician community raise their fists. They may have a point, if one considers this in the realm of expenses alone for just a moment. If you look at the administrative burden imposed on healthcare starting in 1979 one begins to wonder whether the expenses incurred were directly in relation to physician patient care or some other gnarly rudiment of an established order that has wormed its way into medicine? Perhaps there is the invisible Maxwell’s Demon at play here?

Hospitals that are allotted 36% of every Dollar expensed in healthcare seem to have an overtly large fount of administrative costs and that is ever increasing. There are many reasons for that including the Managerial 7-figure salaries but there are arcane policies and mandates rained down from the governmental and policy expert heavens as well. For example, in the modern-day hospital, there are more non-nursing nurses walking around with pads and pencils than there are care-giving ones that get their gloves dirty. There are legions of non-physician infectious disease experts, oncology experts, cardiology experts, Reimbursement experts, Social Service experts, Patient safety experts etc. who walk the floor speaking in hushed voices of technical importance but never lay their finger on the patient.

But you might say, “Ok, the graphs are provocative and I can understand that administrative costs have raised the healthcare expense, but what about the longevity issue?” Yes, my dear Watson (Not the IBM kind) there is a story in that as well and we shall take that slowly and perhaps step by step.

There is a grafted nuance conflating variables that have no need to be cohabitated in a graph unless one wants to write a provocative piece on “correlation.” And lo and behold that is exactly what we get most of the time. Just for a chuckle one might ask the question, “What does longevity have to do with healthcare?” The experts will propound with deep Darth Vader type hiss, “Because death is avoided by good healthcare.” Really? Wouldn’t one think of other reasons just for the sake of an argument? You know, like lifestyle and behavior?


The most ideologically touted reasons for decreased longevity is Maternal mortality, Infant mortality, death by firearms and obesity. Most of the time in that order.


"In the United States the Maternal Mortality numbers are around 12/100,000 live births. In 2015, there were 3,978,497 births thus the total maternal mortality would be: 477 maternal deaths. On the infant mortality side the numbers are 6.1/100,000 and that would translate to 242 deaths in the same year. Total firearm related deaths in 2015 came in at 13,286. Now one might want to keep that in perspective especially with a population of 312,000,000."


Ah some might say that is heartless, “There should be zero deaths, given such a wealthy country! We must avoid all human deaths especially the little babies and vulnerable women.” Yes, I guess we should try to, but humans are humans and not robots, last time I checked.



But that still does not answer the question why the longevity in the US lags other “Industrialized nations.” Does it? So, let us take that discussion a bit further. Using the last bit of “reason” that experts give, let us look at “Obesity.”

Global OBESITY Chart (hi=Redness)

As is well known to most physicians and thinking humans around the world, obesity is a chronic disease state. The metabolic effects of Obesity cause Type II Diabetes Mellitus and many organs to fail, among them, the heart (higher numbers of heart attacks), the brain (Higher numbers of stroke), the kidney (Higher incidence of kidney failure), the eyes (Blindness), Peripheral Arteries (Vascular ischemia gangrene), Immunity (More Infections and risk of septicemia). Perhaps it is time to look at Obesity as the culprit. Wealthy countries have an epidemic of Obesity. The definition of poverty is fluid so one needs to be careful in assessing that particular-variable. For example, in the deserts of Africa and war strewn middle eastern nations Obesity is non-existent because of lack of food and the safety net. Meanwhile in wealthy nations where Food stamps (SNAP) and other such public beneficence is available, obesity is rampant. There is evidence of the association between sedentariness, poor health, obesity, diabetes, other metabolic diseases, and premature death. Thorp et al. state, “There is evidence of the association between sedentariness, poor health, obesity, diabetes, other metabolic diseases, and premature death.”
Thorp  AA, Owen  N, Neuhaus  M, Dunstan  DW. Sedentary behaviors and subsequent health outcomes in adults a systematic review of longitudinal studies, 1996-2011. Am J Prev Med 2011;41:207–215


Another worthwhile thing to mention is the infant birth weight that seems to be diminishing as feelings of "body dysmorphia" syndrome continues to wax (I admit there might be conflation here, it also might be nutritional intake voluntary or involuntary). Doesn't seem to help the infant survival either in the well developed industrialized nations.



If we are to agree that obesity is an epidemic in most wealthy civilized societies then one would construe that longevity is also compromised. Comparing obesity charts, it appears that the United States has a 36% obesity rate (defined as BMI >=30). Sweden on the other hand has an obesity rate of 10%. Now putting the two figures together one can easily make the link between Obesity, Type II Diabetes and shortened life span due to the inherent morbidities. It is not that the US has poor healthcare. It is that a sizable segment of population has chosen a life style of excess food intake and a sedentariness that provokes the “untimely frost.” The CDC makes a case, “The U.S. is one of the wealthiest countries in the world and accordingly has high obesity rates; one-third of the population has obesity plus another third is overweight. The situation is predicted to worsen; rising childhood obesity rates forewarn of worsening statistics.”

A lifestyle choice that brings with untold misery to the human body and shortens longevity is not by any means related in any way to healthcare itself, if one were to use a tincture of reason. Is it?

In “Cool Hand Luke” the Captain states, “What we have here is a failure to Communicate” correctly, methinks.


Tying together Taxes to healthcare and thus longevity is a simpleton’s mechanism to obfuscate the truth it seems. The expert’s wheel barrow with square wheels continues to noisily hurtle down the road and no one questions the wheel or what’s in that barrow? The noise is deafening and all encompassing. The experts maintain in-spite-of the evidence available, “They note the U.S. also has the highest homicide rate, the highest rates for obesity and overweight, and the highest rates of mother and child deaths of all high-income nations.” In their own right, these statements are true but not if one conflates them with the expense of healthcare. The EU citizens pay astronomical taxes via Income Tax, VAT and a host of other consumption variety of taxes. For example, a real tax rate of 57.53%, France topped the list in 2016. In the UK, the 45% top rate of tax kicks in at an income level of around $250,000, while the Outside the G20, the Danish government taxes workers at 60% on all earnings over $60,000. Apparently, the love of the government runs deep in the veins of those European souls. On the U.S. shores, experts and policy-makers conversely, “suggest large inequalities and lack of universal health care are among the reasons the U.S. is falling behind,” without any real evidence or making rational deductions based on the evidence easily available to the curious.


As has been the case and will be for sometime to come, The costs are then shifted at the feet of the physician. And evidence of that comes when a complexity of systems is brought to bear in the form of P4P, PQRS, MACRA, MIPS etc. These are nothing more than attempts at controlling the healthcare costs by squeezing the physicians. But what evades these experts is that physicians make between 7% based on the 2012 Physician Data Dump and 9% based on experts. Or in simplified terms physicians make 7 cents on every dollar spent on healthcare and that includes all the costs of having a medical practice, employees, supplies etc. Or in business terms the fixed and variable costs. The largesse accumulated by the other “providers” is mostly ignored because of the intense lobbying efforts by the Hospital Association, The Insurers, The Pharma, The Pharmacy Benefit Managers, The IT gurus like EPIC and CERNER. Willful blindness seems to work well in the Halls of Power.

At some point, a bit of intellectual reconciliation might be a good idea! Don't you think?

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