Saturday, January 24, 2015

LESS IS MORE


Robert Browning could not have been more direct in using those words when he described the painter Andrea del Sarto’s obsession with his unfaithful wife Lucrezia to the detriment of his painting career. "Carelessly passing with your robes afloat,— Yet do much less, so much less, Someone says,
(I know his name, no matter)—so much less! Well, less is more, Lucrezia: I am judged."
Yes indeed! Less is more. It is so in human affairs of every walk in every life. Shakespeare also in his infinite wisdom said through Polonius “Brevity is the soul of wit, and tediousness the limbs and outward flourishes…” and it behooves us to consider them in our daily affairs.



Less is More

Too many words take away from the immediacy of a well-crafted story. Too many in supply and profit of their hope spend a litany of words to try to invoke need, want and desire in another or something. They do not realize better can be accomplished with a few choice ones.

We choose to do more in medicine as well. The cause of this effect “or rather the cause of this defect, for this effect defective comes by cause:” merely remains unseen through the eyes  “purged thick amber and plum-tree gum” of those who remain blinded to the cause yet steeled against the effect.

Less is More

Indeed if we were to limit the diagnostics that have made us take steps forward in curing cancers and burgeoning the legions of cancer survivors in the millions, one might think that a stitch in time does save nine later, we might arrive at a different universe. So here careful diligence of the real “less” helps in the more. But this does not mean that each x-ray should be followed by a CT scan for confirmation and then an MRI ordered for confirming the confirmation or a PET scan for overall reducing the p-value further to limit ambiguity.  Yet we must all know, there is never a 100% in the 100% offered. Similarly a chemical profile does not have to be done daily to see trends by watching the milligrams per deciliter rise and fall within the laboratory range. Above all do no Harm! Repetition and injudicious use are all harmful in ways we cannot fully fathom.

Less is More

If less medicine was offered through various outlets and vendors, prescriptions and over the counter, acquiescing to demand for instant cures and for allaying anxiety then there would be fewer “superbugs,” lesser resistance to antibiotics and fewer people walking the streets in states of perpetual depression.



Less is More

Triplet regimens in chemotherapeutic regimens had similar outcomes as doublet regimens in lung cancer therapy. Less here was equal in response but more in lesser side effects. Now however with personalized medicine, we might arrive at a single “silver bullet.” A form of that bullet was attempted in the 80s and 90s via the chemosensitivity assays by Sidney Salmon, MD and Larry Weisenthal, MD, PhD. Those were heady times like the ones we are in nowadays. Soon nano-wires and nano-dots made of gold and impregnated with appropriate fluorescent antibodies and “sniffer” devices will diagnose the beginnings of maladies and swarming molecules of antibodies will swoop down and commit murder on those blinded wayward cancerous and other excited cells. And soon we might be able to convert the wayward cells into compliant ones and rehabilitate them back into the society of trillions. But until then, less is more.



Less is More

Maybe we need a longer umbilical cord between the anxiety-riddled patient who has been thrown into the fear-mongered world of journalism gone stupid. “No Mr. So, there is no need for antibiotics for your sore throat, it is viral in nature and antibiotics do not work against viruses,” might be the appropriately expressed sentiment. To allay anxiety with words is one thing, but for the pharmaceutical drumbeat of “you need this…call your doctor” or provider immediately (as it is fashionable to label the physician) is what feeds the one-eyed monster of this fetish.

Less is More

Regulatory fiat in medicine that forces physicians into mock compliance by taking away their eyeballs from the patient and forcing the sight upon useless paperwork, meaningless-metrics, dotting the “I”s and crossing the “t”s, filling in glossary-based jargon into digital records to keep the mandate-makers happy and the revenue floating in to keep the business of medicine from folding, there is little time to do what doctors are wont to do, like for instance care for a patient. Definitely here, less is more!!

More is less!

More hurts! More pains! More diminishes! More subjugates! More creates more calamities for the future. More hurts us all in a myriad of ways. More back surgeries hurt when not indicated. More knee surgeries do the same. More chemicals ingested lead to a plethora of ailments. More diagnoses without relevance in psychiatry are a detriment to individual health. All medications are chemicals. So more is harmful!


Time to reign in these words  and thoughts in search of brevity.

Wednesday, January 21, 2015

"POLLY WANTS A CRACKER!"

I saw a feral cat the other day, dodging and weaving her way between the bushes. A quick lunge here and a slow retreat there and her day was spent to live another day, to meet another male, to make kittens and spread her progeny around to roam other grounds. Fascinating to that in juxtaposition was the lone parrot housed in a gilded cage looking at the cat through the all glass window. He jumped from paw to paw squawking his meme, “Polly wants a cracker.”

And it dawned upon me how very diverse the universes of these two beings were. One roamed in search of food and the other repeated the rote and was fed. This deliberation clogged the synapsis of my brain for a while. Maybe Polly was the better of the two, sitting all pretty ensconced in his golden cage without lifting a feather, he was satiated just with his rehearsed mantra? Or was he?

Hmm… this was going to be a difficult deliberation.



There is a river close by and I remembered there was sign near its northern bank, which stated in Red on White, “Do not feed the wild birds. If you do they lose their ability to find food for themselves.” Funny I thought what about the emotionally-packed-willing-to-show-empathy individuals who were out there throwing crumbs at the milling flock of seagulls that cackled around, diving, flying and urging their kin to come and partake in the bounty. Were these good-intentioned people not worried about the seagulls dying because of their temporary actions; of creating dependence, that made them (the crumb-throwing people) feel good in their own minds with nary a look at the winter months to come for the seagulls?



Why then would such a sign be put up? Apparently the ecologists had reasoned that if the birds become dependent on the crumbs, they would not survive when no food was offered.  Drawing from that memory, in Taleb’s world the feral cat like the unfed seagulls would be considered “antifragile” a survivor, and the caged parrot, “fragile” much like the " Black Swan" doomed to the ultimate risk, like the turkey near Thanksgiving Day.

Another thought came reeling in, “Why do they call ‘Wild Type p53’ for the normal functioning p53 gene that is considered, ‘the guardian of the genome’ of the human cell, wild?” …Exactly! You got that, didn't you? If the wild type gets mutated it is no longer wild-type but a mutated version and a mutated p53 gene is the arsenal for the most virulent of cancers in the human body. Google that!

Searching for more clues I came across a fight between the Big Blue and Kasparov. it was a very interesting fight between an algorithm-coached machine and a human being. Kasparov the world recognized champion in Chess then, lost the game to the Big Blue in one of the most human vs. machine experiments ever witnessed. Alan Turing, in spite of his " Christopher" would have been proud. At the time the FIDE chess rating of Kasparov was maybe 2800 and Big Blue’s was around 2900. So then as circumstantiality will have it, my mind wandered into the realm of what if we combined the two; the intuit of man and the parallel-processed linearity of say IBM Watson, Big Blue’s new iteration? We might just get an intelligent and better predictive outcome wouldn't we?

http://youtu.be/Mz8P8D8MdNU

In other words, let us combine the feral nature of man and the domesticated algorithm of the computer and lo and behold the outcome in say economic and political forecasting might improve, think Nate Silver. Medical care might improve too. The doctor gets the benefit of the “computer spit” and then adds his or her intuit to qualify or modify those “spit-related-computer-endorsed-actions. But here is the dark abyss in all such actions; the doctor in his or her dependency of the computer spit might and most probably will lose his honed intuit over time, out of sheer laziness, like Polly. The dependency will slowly and inexorably eek out the virtuoso in time. What then? No Beethoven’s 9th symphony, No Mozart’s 40th symphony  , No Newton’s Laws, or Einstein’s relativity, or Feynman’s “O” ring, or Jenner’s Cowpox vaccine, or Fleming’s Penicillin, or Curie’s Radium?

http://youtu.be/1MOAF6qlFjw

I agree with Eric Topol, MD, the Medscape Editor and author in his own right of two published books that change is necessary and that whether or not we like it, it is coming and those who stand by the wayside will either be forced onto it's path or die of irrelevance, but I have a problem with the thought that we should divest ourselves of our intuit and humanity for the sake of a head long dive into the totality of algorithms. Even if we took all of McCullough and Pitts Neurons, you know the kind with multiple inputs and a single output and fed these "neurons" with all of the Library of Congress information, they would not and could not provide the human reasoning. There is that nebulous thing called intuit, after all; the recruitment of the neural energy and the firing of the electrical impulse is a random and inherently human process! A cautious merger between the two might make for a better world. Relevant information gathering fed to the ceramic-chip-brain and then the gleaned output reasoned with before calling it " Care." 


Which brings me back to medicine: This, Choosing Wisely-Evidence Based Medicine rhetoric is being designed with the linear regressive models that weigh in costs more (the betas) than care for our patients. Maybe we should be careful of how we interpret and use them. There lurks within such hubris, the fallacy of Composite problem. A total subservience by doctors, is akin to the gilded caged parrot. We need the feral nature of the human mind AND the comprehensive knowledge stored within the algorithm couched databases to articulate and best provide for each other when we are patients! The touch of another human being is far superior in alleviating anxiety and pain then the cold feel of a robotic metal-in-human-skin-like-artificial-hand.

The “out of the blue" Eureka moments are non-linear paradigm-changing events and are the realm of the human brain- the random recruitment and firing. 

Ask Archimedes! For that matter ask Turing!

Friday, January 16, 2015

"SEND IN THE CLOWNS"

“Where are the clowns?”
“Quick!”
“Send in the clowns!”
“Don’t bother, they’re here.”



Things are tense nowadays. Everyone has an opinion. And generally it is not a good one. It is full of sound and fury, signifying…frustration. The process is unfolding, it is unlabeled and the contents unknown. Like the tense surface of a water droplet skating across the leaf surface ready to splash at the first prick, this tension mounts as it wobbles, ready to burst open.

I happen to be seated at a cafĂ© with some acquaintances when one fairly intelligent sort who had uncoupled the chemical bonds in the field of chemistry and used his capacious knowledge to advance the pursuits of a company blurted out, “You doctors have a monopoly in medicine.”

“Say what?”
“Yeah, anyone should be allowed to dispense and care for himself or another as a patient.”
“Say again!”

“Anyone can treat a disease or a malady instead of going to the “doctors!” and he emphasized the word with a certain touch of dark humor. He continued, “Every day you hear about some doctor caught prescribing unnecessary medications, some embezzling money, some causing grievous harm to others, some diagnosing disease where none exists!” He whistled, “I mean I can go on and on about what you doctors are up to. So with that why can’t the ordinary citizen decide what medicine he or she can take and get it from the pharmacy, especially now that we have internet and the same information at the fingertips?” He looked around for a moment then said, “I mean, if the doctor has to look up information on his smartphone or his tablet or the computer screen, every time, I ask him a question without saying two words to me why then, why should I visit him. But Noo,” he dragged at the no to its fullest elastic length that would come out of his pursed lips, “the doctor is busy dotting the “I”s and crossing the “t”s on his computer to get reimbursed while his nurse is telling him to hurry up for the next victim! No time for me! Well, I have news,  I have no time for him”



Interesting monologue, I thought. That came from left field like a sudden slap-burn on the cheek and right after a chicken sandwich laden with mayo. This form of monologue has been circulating in various forms in the social media recently too, drawing a multitude of warriors. These forms tout how doctors are really buffoons and haven’t been taught social media in the medical schools and how some don’t take social media seriously and how they are dinosaurs and Luddites. It is a common theme played out on the cyber-theater near you every moment of every second. And everyone falls in step with fingernails that can draw blood from underneath the white coat.

I thought for a moment and just then an intra-psychic thunderbolt hit my synaptic bundle…
Maybe the road that we as a nation have chosen; to vilify the doctors, by dumping billing data without context, and started on the path to demonize those that have billed more than the norm, patronize them, tell them they don’t have manners, or empathy, that they do unnecessary appendectomies, or that they cause harm by doing too many CT scans, which cause cancer and those who lack the requisite knowledge to differentiate between the need and the want, or lack the know-how of caring, that a computer is better than their intellect and intuit and that the nurses and assistants can deliver similar if not better care, well then what does one expect? It is game over.  The walk-off home run hitter is trotting from third to home base. And through it all, they, the doctors, are made to comply with absolute idiocy of electronic medical records to boost information gathering that harms patients through one size fits all and helps insurers to harm the doctors in return financially. These are people working hard try to comply with various and sundry mandates that are only dreamt of in a bureaucratic philosophy, which take away from the time that should be spent with the patient. The more the number of mandates, the larger the unbridgeable gulf between the patient and the physician grows. And then the blame game ensues, to the tune of billions of dollars being steadily siphoned away by the mandate makers and lobbyists, against the doctors and firmly centered in the crosshairs is guess who? ..the white-coat wearing, stethoscope bearing physician. Who suffers? The Patient mostly, for now. When we have holographic doctors driven by a air-condition-cooled remote IBM Watson sorting out between "cluster-headache" and "migraine," then we shall see.

“Maybe you are right!” I replied to the smart and intelligent hydrogen-carbon-chemistry man.

Huh! You could see him taken aback and speechless. What followed is a tale for another time…

Maybe we have accumulated the requisite number of clowns already. We have done it to ourselves, allowed the insurers to dictate reimbursements, allowed the government to dictate the appropriateness of care based on costs, given the keys to medicine's cabinet to anyone willing to throw a rotten egg, and allowed the middling managers, economists, statisticians, mathematicians, bureaucrats, politicians, even Ravi the taxi driver in New York and Jason the hedge fund manager, the right to decide how medicine should be “practiced.” Meanwhile the elite experts pontificate about how everyone should be treated as patients, or how we have the right to free physical examination (BTW that doesn't work as a form of prevention and now given those costs they are shying away from that too), or how we should not be treated after the age of 75 or that cancer is a good way to die without treatment. I mean, what the heck is going on here?

Geez o’Peez where are we going?

Maybe we are already there.

“Where are the clowns?”
“Quick!”
“Send in the clowns!”

“Don’t bother, they’re here.” 

http://youtu.be/8L6KGuTr9TI


Sunday, January 11, 2015

"OFF WITH THEIR HEADS!"


I came across an article in the New England Journal of Medicine recently and it provoked some thoughts that I would like to share with you. http://www.nejm.org/doi/full/10.1056/NEJMp1407373
But before we go to my thoughts let us reflect on these two paragraphs:



“Research suggests that for physicians to play a substantial role in such decision making, there has to be a relatively high level of public trust in the profession's views and leadership. But an examination of U.S. public-opinion data over time and of recent comparative data on public trust in physicians as a group in 29 industrialized countries raises a note of caution about physicians' potential role and influence with the U.S. public.”



And:

“Indeed, the United States is unique among the surveyed countries in that it ranks near the bottom in the public's trust in the country's physicians but near the top in patients' satisfaction with their own medical treatment.”



The Authors then opine and in the same breath contradict themselves:

“Part of the difference may be related to the lack of a universal health care system in the United States. However, the countries near the top of the international trust rankings and those near the bottom have varied coverage systems, so the absence of a universal system seems unlikely to be the dominant factor.”



They go on to segment the population to achieve a meaningful use of their article:

“The United States also differs from most other countries in that U.S. adults from low-income families (defined as families with incomes in the lowest third in each country, which meant having an annual income of less than $30,000 in the United States) are significantly less trusting of physicians and less satisfied with their own medical care than adults not from low-income families“

And then from the double-speak right from the Animal Farm:

“Although non–low-income Americans expressed greater trust in physicians than their low-income counterparts did, when responses were analyzed by income group, the United States still ranked 22nd in trust among the 29 countries. On the flip side, although low-income Americans were less likely than non–low-income Americans to report being completely or very satisfied with their own care, the United States still ranked seventh in satisfaction among low-income adults (ISSP 2011–2013).”



They do grasp the problem meekly:

“We believe that the U.S. political process, with its extensive media coverage, tends to make physician advocacy seem more contentious than it seems in many other countries.”

But then squirt it away with this politically-motivated, correctly-interfaced, seemingly-validated, interlaced through the arbiter of political correctness against the physicians’ diatribe:

“Nevertheless, because the United States is such an outlier, with high patient satisfaction and low overall trust, we believe that the American public's trust in physicians as a group can be increased if the medical profession and its leaders deliberately take visible stands favoring policies that would improve the nation's health and health care, even if doing so might be disadvantageous to some physicians.”

And as always they warn with icy-cold fangs that draw blood and impose fear and humiliation among the physicians with:

“If the medical profession and its leaders cannot raise the level of public trust, they're likely to find that many policy decisions affecting patient care will be made by others, without consideration of their perspective.”





Let us ask these authors the very basic question, "Who are you?" And you find that there is not a single physician among them and not even one that has moved to the dark side of regulatory capture. The degrees they hold; a Sc.D, an M.A., and an M.P.H. The last one of course has the associative epidemiological know how to prove that association is tantamount to causation.

Unfortunately NEJM is complicit in this fine act of political correctness by endorsing such nonsense.

Why for heaven’s sake, can patients be happy with their physician but angry overall? Because the media and the political machinery is constantly yammering away at the costs of healthcare and that physicians are the root cause of that cost. It is 17.9% of the GDP they bellicose, but they never seem to deem it necessary that majority of that is the middling administrative management that derives oodles and oodles of money. If one were to simply seek an answer, one has to look at the 2012 Data Dump by Medicare, which showed that only $77 Billion was in direct payment to the doctors from the $985 Billion expensed and that translates loosely to about 7.78%. Of that, a large part was a direct pass-through for fixed costs, medication and equipment. But no, that would not fit the Elite narrative. No, that absolutely won’t do!




Saturday, January 3, 2015

FATHERLAND...A STORY.

This is a story...of more than a hundred years!


There was once a great big country called Acirema. Over the years it had grown to a large state through enterprise, innovation and hard work.  With the bureaucratic mindset in place and giddy with success the time had come for the country to take even bolder steps to advance the culture and society. The head of state decided that everyone should walk backwards so that people would slow down their rampant desire to overwork and over-consume. And by doing so, they would reap the benefits of their minds better. The prospect was difficult at first, so the state gave bonuses to those who could accomplish the feat first for an hour and the bonuses got higher and higher as one was able to continue on for a day and then days and then months, until it became commonplace. The logic was carefully controlled by a mechanism of news cycles that determined the value of “Walking backwards.” The articles in the magazines were replete with health benefits, longer survival, better communication and more time for meditation. These articles were the fodder for the enabled television and the holographic media. There was a certain intransigence to logic as the megaphones of propriety sounded off in the distance and complete degeneracy of reason took hold.

Pretty soon everyone was undertaking the journey to gain the financial windfall from the head of state and his Ministry of Well-being and Reform. The herd mentality blossomed and just like the Colors of Benneton were everywhere for the moment, the limpid pastels of shallow thought showered irrational exuberance into the flag-waving mushed-out minds. The tragedies and accidents from such a mandate on ambulation were conveniently buried deep in the stacks, never to crest in the news. The accidents and loss of life from misadventures by some by falling in gravel pits, open manholes, walking into a street lamp or into oncoming traffic being driven backwards, caused the Steering Committee to mandate that everyone buy a set of “electronic eyes” for the back of their heads. That was their intelligent solution! The contract for the “electronic eyes” was given to the man who had proposed the initial concept of “Walking Backwards” to the head of state. A large order was outsourced to the cheap tech company in Anihc. The orders were delivered soon thereafter and the Steering Committee of the House Body declared it a monumental success. The accident rate decreased minimally and the media rejoiced. The news banners from all services used buzz words like “gravitas,” “meteoric,” “exuberance,”   simultaneously, to show their extreme intellect and know how.  Soon the thrilled adoring population was holding rallies in town squares. Life was a daily affair of worship of words and unquestioned obedience.



Corporations held meetings in large rooms where everyone was facing outward towards the walls with their electronic eyes directed at their CEO, who dutifully looked at the painting of the founder on the wall. All paintings of former CEOs and founders were changed and a set of electronic eyes were painted to conform to the zeitgeist. Photos from these meetings were place- held on front pages of the holographic news sections, on the digital universe and some old-fashion disappearing and appearing prints seen only in the town of Hogsmeade, but in color.

One day the newest member of the Steering Committee was walking backwards in the park carrying his 3 year old child. The child did not have the “electronic eyes” on, since the mandate began after the age of four per state decree. The child asked why daddy was walking “that way?”

“Well…” the father began and then stopped.

“Yes, why am I or are we walking backwards?” And without hesitation the answer erupted in his brain, because that is the law of the land! Indeed, we are followers of the Law! His logical mind followed through. The questioned remained and continue to prick his conscience. By then the human anatomy had morphed and the calf muscles had become fully developed, the buttocks had shriveled and the thigh muscles were grotesquely hypertrophied. The human bodies in Acirema could easily be differentiated from those in the Eporue Empire to the east across the “pond.”

“Daddy,” cried the toddler in his arms, “if we walked where our eyes are, it would be so much easier!”

The Steering Committee member thought about that all night, lying awake in his bed, tossing and turning. What to do? Maybe he would propose a change, but he was afraid for losing his important job. If you did not follow the commandments of the head of state then you were considered dispensable.

At the annual Steering Committee meeting held in the large caverns of the public building that spread over ten blocks, the 10 members started to get seated and the squeals of the chairs being pushed around over shiny marbled floor reflecting the enormous crystal chandeliers overhead, echoed across the hallways in all direction magnified by the volume of unused space. Soon the waiters brought the food and with especial dexterity they would pour the wine and serve the food. Being a waiter required special skills, balancing food and wine without “electronic eyes” and walking backwards was a feat in itself and thus the pay was very good. When everyone had been fed and the clink of glass and silverware had ceded to the hum of quiet, the head of state got up. He was a portly man with a bushy waxed mustache that tapered  symmetrically at both ends, like the one on Terry Thomas, an English actor in the movie "Tom Thumb." He puffed through his thin lips that underlined the graying hair of his mustache on delicate “S” shaped pipe periodically exhaling billows of smoke curdling the aseptic air of the room from a small O shaped stab-of-a-mouth.  After a preliminary yet effusive speech on the state of the state that was holographically-projected in front of him that only he could see with special codes n all, and that would later be edited for public consumption, he ended with his usual flair to the thunderous applause that 9 Committee members could muster with reddening palms and the echo chamber effect of the surroundings. As the applause muted to his choreographed palms-down gesture, he asked about the revenue stream for the past year. The Chancellor of Budgetary Advice got up slowly and with his back to the back of the head of state mumbled to no one in particular except the enormous columns around the seated guests and the large inanimate paintings on the walls that the revenue had shrunk by another 20%. “Sir,” he began, “the world seems to be reluctant to take the lead from us at the present, but we are constantly making headway slowly with the hierarchy of the rest of the world body and it appears we might have found a road in.”

“Very well, Mr. Chancellor, I expect the “Blue Economy” that I outlined at the Union of Empires meeting early in spring will excite the outlanders who have weak economies and this measure of incentivizing their lot will bring them into the fold.” He pulled at the cuff of his shirt sleeve from under the finely tailored suit, revealing the gold and diamond studded cuff-links that held together the sleeve against the bulge of his bulbous arms.  The word “Blue” he regurgitated as if clearing his throat was meant as an opposite to the “Red Economy” that the Anihcanc lived by.

“I hope they will see the clear reason, Sir.”

“They will, they will, Chancellor they will, once they see the benefits that we are seeing.” The head of state chortled.

“What about our manufacturing status?” The head of state directed his question at the Ministry of Manufacturing and Creativity. “Sir, the manufacturing increased its error rate by 10 fold in the last year and that is still 2 fold lower than the benchmark we established the previous year.”

“Good!” the head of state chuckled. “Now tell me about the Ministry of Health, Ekezuber?”

“Sir,” the wise old member, who was one of the initial architects of the “Backward Society,” had dutifully followed and perpetuated the mandate for the last several years, got up slowly and said, “Our population health has never been better. Our population has diminished by 8%. The older members of our society are no longer living past 75 years, meanwhile the productive members numbers are stable. We are having trouble with procreation and are developing mechanisms to mandate artificial insemination to avoid sexual procreation after appropriate DNA testing is complete. Sexual procreation has been difficult to manage for the positive selection we have hoped for. Besides with the 100% Social Media immersion there is little need for the sexual procreation these days. But going forward, we should have a very strong productive and highly tailored force by the year 2230. Our projections are that Acirema will be, from a health point of view, self-organizing, time-limited, revenue neutral within the next decade. ”

“Very good, Ekezuber! We can always count on your expertise to advance the health and welfare of our society,” The head of state paused for a moment and then with his thumb and index finger poised delicately on his chin said, “we can always increase the marketing budget if you need more incentives to get the right mix of numbers.” He paused a moment and then chimed in as delicately as he could, "You will be 75 years old this year, Am I correct?" "Yes Sir." Ekezuber replied quietly with his eyes squarely on the column in front of him. "Since we value your incredible work and diligence, we might make an exception for you." "Thank you, thank you your excellency, my family will be ever so grateful." Ekezuber could not hold back his delight as a tear rolled down his left cheek.

“Thank you sir! “ Ekezuber replied with an exaggerated diffidence. He let his eyes take in the enormous columns and the 30 foot walls around him and said quietly but self-assuredly for maximum impact, “We are developing a mechanism to eliminate poverty also!” He was going to show his worth to his sovereign.

“Excellent!” the head of state satisfied with the response that reached his ears through the echoes in the chamber. The single clap of his hands thundered through the cavernous room and caught everyone by surprise. He was clearly elated with that news.

“Any other reports from the Steering Committee?” his “electronic eyes” encircled the group.

“Your excellency,” the youngest member of the Committee slowly got up. “I was walking in the park carrying my 3-year old and she asked if we should walk forward? Of course that option I feel is totally ridiculous but thought the humor in that question was worth sharing with the Committee. She said, “if we did, then we would not need the “electronic eyes.” There was silence and then finding some courage he advanced his late night sleepless thoughts, “it might be more productive, less expensive, more efficient and possibly increase the revenue stream in taxation from the productive citizenry.” He let his splayed fingers of his hand brace the shiny mahogany table and ended with, “It might be worth investigating?” His heart hammering inside his chest felt like a unbalanced clothes dryer, he sits down suddenly overcome by the weight of his conviction.

Hark! the state of nature had raised a hand against the nature of state. Silence was deafening, even the ventilation system lost its hum momentarily. Rousseau had challenged Hobbes and something was going to go down, and soon. And came immediate and on cue...

“Might I remind this Committee that no questions against the mandate can ever be entertained? But given this statement, and the way you posed it, I suggest we take a vote whether you should remain a member of this Committee in the future?” If anyone could see his eyes, the pupils had constricted as if the entire bottle of Pilocarpine had been fed them and the lids constricted to slits in real anger that not enough light could reach in. But no one could see any of this in real time. The head of state had spoken.

There was an immediate unanimous vote to remove the offending member and the meeting was formally adjourned and declared a success. The statement was scrubbed by the “scrubbers” that recorded all conversations and declarations of the Committee members, absent any untoward comments by anyone during the meeting. The vacant post would be filled immediately and the 10 members would remain as 10 since the names of the Committee members were never made public in the first place. And the nature of state was never out of peace.



Years later a movie was made by the Anihc movie industry, then the largest in the world, called the “The Fall of the Backward Mandate.” It was a soaring success with millions of viewers lining up in virtual theaters across the world. The “Backward mandate” was used in Schools everywhere as a Business Model Review of how not to do things. Anihc had supplanted Acirema as the world’s greatest power a decade before. The Little Red Book became the bible for all “organized societies.” 

Saturday, December 27, 2014

These are OUR CHILDREN

"Children are the hands by which we take hold of heaven." -Henry Ward Beecher

When I was five years old, I wanted to read a book. I did that when I was six. The title escapes me but it was something in the vein of “Fuss meets Muss” or possibly like that.  At 9, I wanted to write a story and have it in print. I accomplished that at 11, the writing part that is, but a friendly rejection from the Reader’s Digest all but crushed my hopes for authorship. Imagine the lofty dreams of the youth.



And then somewhere there between the solace of parental guidance and the emergence of hormonal defiance, I wanted to be an Astrophysicist.  I don’t exactly know the motivation for that but I was struck with that fancy. Forget the earth, I actually was interested in the universe and how it ticks. In the end however, I settled for the more down to earth vocation, as a physician. This decision was layered upon me through the premature winter from the loss of a parent and the desire to quell death; the ultimate victor. There must be a way to stop the scourge? I thought. But most of my friends suggested that everything that was to be discovered had already been discovered, from the lunar surface to the genome within, everything. Anything could be laid out in paper and ink. Signed sealed and delivered. I had other ideas though, mostly unfulfilled dreams.

"Children are the living messages we send to a time we will not see." - John W. Whitehead

After many thousands of patients that I have cared for, have potentially saved many from the untimely frost of disease and provided comfort to the many souls in despair, I now realize what might have been.

The pre-teen who dreams of going to the moon, to explore new worlds, but never can take the step into his teenage years, is a tragedy. A dream quashed. A desire ruffled. A life snuffed. A teenager, who dreams of creating a business to employ thousands of people and change the world but is never able to spend the first dollar, is a travesty. A 12 year old who dreams of building a skyscraper, for that matters to him so that hundreds will live and grow within the walls, never is able to lay a single brick, is a society’s great loss. A 13 year old who walks lightly in her steps propelled by the desire to harness the digital world and create the next big internet of things never writes the first letter of the code and a 14 year old who looks up and sees possibilities in the flight of an aircraft; the potential of a faster cheaper and more efficient flight never leaves the surely bonds, are the untold catastrophes of our times. These are all dreams that litter our universe’s soul, emptied out of their promises today, for they belong to those little minds that were forced to abandon their dreams and forfeit their lives to the mad schemes of the inhuman adults.

(WARNING: some images from Peshawar, Pakistan are GRAPHIC!)



And I wonder what if my dreams had also become ethereal springs of the soul hopelessly flailing through the winds of time. The only marks left were the bloodied footsteps. What would have happened?



I would not have gone on to become a physician. I would not have had the privilege of helping countless human beings, bringing comfort and health to them. Some of them would not have fathered or mothered children of their own. Some would not have gone on to become influential in society. Others would not have seen the smiles on their grandchildren.  Maybe the postman who continued to deliver the mail might not have saved an elderly man who fell in the street and who might not have survived or the teacher who sparked the imagination of the young one who would grow up to spawn a new industry. One never knows the consequential dominoes that fall from an erased image in a photograph. My own nuclear or extended family would not exist, if I would not have.



"The soul is healed by being with children."

Then, there is the massacre of 132 children that happened in Peshawar, Pakistan and all those diminished lives, wishes and dreams come to the fore, just as the Newtown, Connecticut tragedy brought the feelings of dread and foreboding when a deranged young man took the lives of 20 children. Both equal in magnitude in destruction of unrealized lives and of vaporized dreams. This shameless, cowardly act rekindled the feeling of hate for inhuman actions. Inhuman because that is what they are, under any guise or pretext. The word “hate” by any other name would not fulfill the emotion against such horror. What breed of man can descend to such reprehensible acts? What mind of man can contemplate such an atrocity and then go so far as to commit it? What verse in their religion can deem this an altruistic cause? None within humanity's dictionary.

These are our children!



Imagine, if you can, the horrific moments of this carnage. The wide eyed children rushing across the aisles in panic, jumping over others paralyzed with fear as the bullets sprayed away life. A child searching for his eyeglasses as the mayhem broke loose and an 11-year old apprehensive with confusion and fear, ducking under the seat as a bullet tore into him. The clamor and cacophony of life that still must resonate of this ghastly past within those bullet ridden walls and the blinding automatic fire-burst of death that echos in the minds of those who lived and then the turmoil of internal traumatic silence. This shakes the foundation of our being where every nucleus within every cell of the body shudders in pain. What makes a human devolve into such inhumanity?

A human being ceases to be one when they usurp the life of another, under the pretext of religion, wealth or existential differences. When one destroys the desires and dreams of another no amount of justification can soothe the pain. A human being without humanity is no different than a predatory animal without a higher brain function. Such function that thinks before it acts and then acts not for the benefit of man but to the detriment of mankind. But taking the lives of children? That is the abysmal poisoned well of inhumanity! These murderers must be a new kind of soulless, bottomless pits of psychopathy that deface humanity.  To what God do they pray? To what future do they ascribe?

For the sake of Our Children...!

Sunday, December 21, 2014

GAMIFICATION OF MEDICAL EDUCATION

Sometime things take you by surprise. And like embers glowing steadily the logic and thought ignite the spark into a fire. That is exactly what happened when I read this article from the British Medical Journal about Gamification of Graduate Medical Education (1).

I thought well, this seems like a nice idea to enhance education. I read the article and came away with a different impression than was sought by the Authors. “We named our software Kaizen-Internal Medicine (Kaizen-IM). Kaizen, a Japanese word from the quality improvement literature, signifies the need for continuous daily advancement, a concept analogous to the principle of lifelong learning we seek to inculcate in our residents.” Whereas they sought to prove that a Kaizen-IM modelling technique helped ensure educational learning, reading through the article I came away with the tortured use of statistics to prove what they set out to prove. “Analyses focused on acceptance, use, determination of factors associated with loss of players (attrition) and retention of knowledge. Because traditional tests of normality such as the Kolmogorov–Smirnov test, the Anderson–Darling test and the Shapiro–Wilk test are subject to low power, particularly when the sample size is small, continuous outcome measures were graphically assessed for normality by investigating the distributional form of the outcomes using histograms. When normality assumptions were not met, the appropriate rank-based Wilcoxon test was used.”

But here is where it struck a chord and the tumbled notes all fell in a crash of dissonance. “We used the conceptual frameworks of user-centered design and situational relevance to achieve meaningful gamification, including connecting with users in multiple ways and aligning our ‘game’ with our residents’ backgrounds and interests in furthering their education.”

Now why would that bother my internals? Learning by rote in medicine is akin to getting ready for a Multiple Choice Q and A. Now hold on, you power-jockeys of the esteemed elite schools! Think about Medicine as a holistic mechanism for caring for the patient, not as a yes and no binary form of interaction. I need a new paragraph to start that thought, so hold on…



The sheet of paper in front of you has many inked marks on it as the proctor tells you “Start!” And away you go answering all the questions within the bounds of the allotted time. Some, you skip and some you hesitantly answer “C” as a hedge against the limited information in your brain. By the time you are done, the mental exhaustion is replete with multiple rivulets of sweat pouring down your back. You pass your answer sheet back to the examiner and with one last look back at it, you figure, Okay that’s done! Three months later you get a passing grade and you go celebrating till the wee hours of the morning. Loaded with congratulations, inebriated from the slaps on your back and feeling immune to the vicissitudes of mortal life. Ah yes, another conquered!



But then you enter the hospital and there lies a frail, weakened human body, a shadow of its formal self as you can see the skin has since loosened off and hanging on the bones with very little musculature support. “What the…?” your words escape between your teeth. The breath from this shadow comes in slow uneasy cadence, yes there is life but it is struggling to maintain its domain within his shell. There is an odor that you have never encountered before. It isn't obnoxious or anything, just a mousey, old cat litter type, wafting through your senses. His eyes open and the whites of the eyes are patchwork of miniature blood vessels and a hazy dull yellow background affixed onto an equally weak sallow complexion as deep pits on a desert floor. There are some spotty blood marks on his arms that lie above the clean white sheets of his recently made bed. His utterances are feeble and devoid of meaning when you ask him questions. He does nod in affirmance and shakes his head slowly in the negative. Suddenly overcome with the complexity of his person, you open his hospital chart and gaze through the lab reports and his diagnostic x-rays. Ah! You think, here it is, the answers to the riddle. This man has “such and such” and with “Mr. So and So, we will get to the bottom of this,” you stride out of the room as fast as you can only to find that the same tests had been done in this gentleman’s previous admission. Now what?

And there fellow journeyman, reader of these words, lies the problem with gamification of medical education. Our entirety of purpose is not in the hospital rooms, but in the confines of the computer glows where we search for meanings, not in the operating theaters but in the virtual operations conducted within the binary logic of a computer console, not with a patient-understanding the look and feel of a disease but in the memory bank tied to a CPU, where a differential diagnosis is within reach and Sutton’s Law is practiced for the ideals of human care to safeguard finance and limit the use of limited resources. When all you need to do is spend that extra moment in spending with the ones with the ill health and recognize through expediency of critical thinking what the problems are and which ones to fix now and those that can be fixed later. It would limit running through the myriads of differential diagnostics (that cost an arm and a leg and in many cases literally) and it would put the resources to better use.



So here we are stuck in the conundrum of do little to save the limited resources but use the tools that expand their use.

Time to rethink!

Time to reevaluate!

And maybe if we do, we will find the answer that is obvious and time-honored…Spend the time with the flesh not with the automated binary logic. Understand the human body and not the logic of a multiple choice. Draft a memory of experiences that will recognize disease and help patients rather than harming them with a “House MD” type approach of “biopsy the brain” when fifty other things yield negative results in a span of one hour.

And about that EMR, there is nothing meaningful about it, except more population-based algorithms!

No, medicine is and will be for the near future be practiced with an art due in part to the humanness of humans and in part to the connectivity between us humans. A discordant approach between the mind-body and clicks leads to de-coherence, which is futile in healing the sick!