Friday, August 28, 2015


What if I am wrong and everyone else is right? How will I reconcile my thoughts to the reality? Indeed what if I am right and everyone else is wrong? What do I do?

These scenarios play out in our lives daily. Risk mitigation strategies are nothing more than links of multiple “What ifs!”  The actuarial data creates the template and probability thrashes out through the Bayesian lens, numbers that speak to the risks. All is contained. All is accounted for. All is measured.

Is it?

Yet, yet the blood curdling thought turns black the phantasmagoria of the colorful dream when the “What if” chimes in. And it does, if one does not swim in the lake of delusions.

Let me take you on a short aviation encounter of the real kind…

Flying as we all know has known risks. The fatality rate of commercial operators as in Airlines and General Aviation is a miniscule 0.42 per 1,000,000 passenger miles travelled while Auto accident related fatality rates are 3.4 per 1,000,000 passenger miles travelled or 10 fold more. So neither modes of travel are exempt from risk. And if you carry this thought forward, it seems that the drive to the airport is almost 10 times more hazardous than the flight itself.

Since we are inclined to toast the virtues of aviation and link them to the nearby disciplines of medicine and in some cases of business, let us carry this heavy ball and chain further. I commented while delivering a lecture on Aviation Safety, “What if things don’t go the way you anticipate?” There was silence. “What if you run out of fuel in the air?” A hand arose from the rear of the room. “You wouldn’t let that happen!” the voice claimed.

“What if the High Pressure turned into a Low Pressure area and you were faced with head winds instead of tail winds as calculated in your trip planning?” Again the hand raised, “Set the plane down at a nearby field, anticipate the potential based on the speed, fuel and distance calculations.”
What if you are over a mountainous terrain?” I countered. This time there was silence. Inspiration hit the back of the mind that had been responding, “Set the plane down before the mountainous region, fuel up again and then continue the journey.”

“What if there were no airports within a 50 mile radius?” Stumped? Not really, the Phoenician hand rose again, “You have to anticipate that when you begin your journey!” She was right again!
Having found one listener who was engaged, I switched tack, “What if you lose engine power on take-off at 400 feet?” A hand rose across the sea of heads, this time from the back again but the other side of the room, “Go back to the airport!” The baiting was over and the opening I had been waiting for had arrived.

“If you make a turn back to the airport below 700 feet universally that is a no, no! As you turn you lose the vertical component of lift and the potential for stall and spin is extremely high. So the only option is to land straight ahead or 30 degrees left or right of the departure end of the runway wherever there is an open field.” I paused and a few heads nodded. “This brings me to another question, what do you think the main reasons are for doing a traffic pattern at a non-towered airport?” More hands raised, a cacophony of, “See other aircraft in the pattern, arriving and departing and any potential hazards on the airfield itself, such a waste of time, waste of fuel, totally unnecessary” were the main thrusts. “What about using the traffic pattern as a means to observe both the departure end and the arrival end of the runway for the potential of what if?” Blank stares greeted me on that. “What if you lose an engine on departure from the same airport and having surveyed the field on arrival, knowing the terrain surrounding the airport, one can safely figure out a location to set down the aircraft and walk away from potential of harm.” The bulbs of inspiration and understanding lit up. Hey that makes sense was the general brightness that illuminated the attendees.

What if, is a game of chance and played by those that seek not to rely on luck but on mitigating the potential of risk. In business, the smart money always plays the game. Ever see Shark Tank on TV, it is all about the potential of success vs the potential of Risk. The ratio above 1 gains an investment from the Wealthy Sharks while those with an irrational number (fraction) go home. The Sharks look for fiscal trends of the business, the emotional needs and the desires of the public at large, the investment costs and their Return on Investment (ROI) through acquisition of part of the business. Sharp, shrewd and uncannily business wise!

In medicine too doctors continually play the game in their minds and when discussing cases with colleagues. What if I give this medicine, how would the heart react to it and what would that do to the kidney function and how would that affect the lungs. Or this chemotherapy or biologic therapy harms the heart x% of times and the benefits are y%, if the y% exceeds the x% substantially then it’s a go otherwise search for another option. Oh by the way, if you didn’t know this, here is a clue, the practice of medicine is every bit art as it is science. Don’t let the pundits and experts fool you otherwise, they for the most part sit and push papers.

Life is a game of chance and not as the current cookbooks concocted in the ivory tower realms of population medicine purport. Each human is unique and each human has a unique genetic signature that determines a different response than what might have worked within the 2 standard deviations of the normal distribution curve for the majority. My genetic signature is as unique as yours, like East and West and never the twain shall meet in health nor in disease manifestation nor in the response to similar treatment. We are a unique species conceived of a 25,000 gene product built on the foundation of a four nucleic acid code. Now that is impressive in terms of uncanny diversity within a 7 billion population spread across the globe!

Technology can crunch numbers faster than the human mind! Yes, but what if a 50% benefit based on a 95% Confidence Interval is the metric utilized to treat an individual that has a completely different set of genomic signature and does not comport to the “landmark study” being used as the template for treatment? What if the numbers in the medical study were derived from a subset of population that does not equate to the region from whence this patient came? What if the “large” data set of a 1000 patient in that study is a very small subset of a larger population that does not represent the whole even within the 95% Confidence interval and even after the Bayesian rules have been brought into play, but skews it downwards to an alpha of 10 or more in reality? What if we are wrong in using population statistics to govern the health of individuals? What if?

"What if" scenarios are thought experiments without real consequences. These are designed solely to appoint a guardian of luck as you travel across your chosen path. Humans have the uncanny ability of using this argument and making appropriate decisions as they wade through the murky waters of chance.

What if you are right and they are wrong? What if…

Sunday, August 23, 2015

THE "1s" & THE "0s"

"...the touch of the hand  and the sound of the voice Live on in the soul always" -Spencer Free

It was the faintest of voices calling my name, half hesitant, half deliberate and all desirous to communicate. I remembered the face but the name had slipped a long time ago. I smiled, too embarrassed to hide my ignorance and blurted out into a higher than normal pitched hello. Loudness does not hide ignorance, neither does changing subjects. She said, “You don’t remember me do you?”

She was in her seventies, carried herself with dignity, dressed well and had her grey hair cut perfectly to her face. She introduced herself to me as I mumbled my apologies. “You know,” she said in her mild mannered voice, “It sure is nice to see you again.” It had been a long time since I had seen Betty. She took my hand in hers with a smile of gratitude.

“How are you?” I asked, trying mightily to carry the communication forward. “I am fine, thanks to you!” she said. And just like that her history tumbled across the screen of my mind.

It had been a long day and I was on my way home and a vascular surgeon friend called. His voice was shaky and his sentences incomplete conveyed the angst. “Are you around?” He asked. “Listen,” he ignored my answer because it was lost amidst his anxious words. “I have a bleeder in here and I need some help.” With those words, I made a quick exit off the freeway and was back at the hospital. The oozing operating site, the saturated dressings and the pinging machines signifying danger filled the recovery room. The nurses immune to the sounds carried about their work with efficiency and measured pace only their flushed faces depicted the anguish within. We spent the evening and most of the night summoning blood products and other pharmaceuticals to contain the bleeding. Just after midnight, the blood pressure stabilized and the intravascular clotting mechanism abated. The elements stabilized and the acidity and elemental imbalance seem to correct partially. She opened her eyes and responded to questions. It was time to find a place to rest.

The storm however continued for her for two more days, the collapsing pressures, the replaced blood products and their own complicating tincture of illness magnified by the blossoming viral infection that she had arrived in the hospital with, unbeknownst to the surgeon. Life took hold and no matter how hard the undiscovered country’s reaper tried to extract the fighting spirit from this lady, she held fast. Four days after she was well enough to enter the post-surgical floor and ten days later, she was on her way home. She and I had many chats by her bedside. She was a woman of faith. She was lady with a prodigious sense of quiet strength. She had an amazing sense of understanding while I droned on about what had happened and how her strength had saved her own life. She listened gratefully, but never interjected her thoughts or questioned what was being said. She had Grace.

And here she stood all 5 feet 3 inches of her frame, complete with her independence, courage and the gift of undeniable strength. “I am so glad to see you again.” She said, “I have been meaning to thank you for helping me through during the difficult time. You saved my life and I will forever be grateful.”

“No, no!” I protested, “It was your strength and courage that got you through.” She closed her eyes and quietly said, “I know better doctor.” With that she smiled gave me a hug. Such human Grace!

Touching a soul as she touched mine gives warmth and comfort beyond all measure. It is a human treasure of gifting love and friendship. It is that rare thing called “the human touch!”

And then without warning in that shrinking open space between humans, she confided her fears, “You know doctor, it is not the same as it used to be.” I knew where the conversation was leading, but held my tongue. “The doctors don’t have time for patients anymore. They are constantly being harassed by their staff to take phone calls, figure out the billing codes, all the while their eyes are glued to the computer screen. Even their questions and answers are echoes off the screen. They are so harried that they rarely look at you. It feels like we are all numbers in the marketplace.” Her face reddened a bit, she paused then the apologies tumbled, “I don’t mean to sound disparaging, but I do miss those days of being comforted, of a hand on the shoulder, of a kind word. I miss telling my doctors about my family now, because they cut it short anyway. I only tell them what I think they want to hear sometime.”

Confessions such as these must make us wonder what we have wrought. There lies the bleeding ghost of humanity, all vapor and cloud, immersed within the confines of a hard fought intellect. An intellect that caters to the demands of its vices and none of the humanity’s virtues, cold and icy to the touch of the probing fingers of past thought, it is huddled in a warm embrace with the devil in the numbers. A society so adrift and rudderless in the vast measureless oceans of space where gravity fears to tread that all manners of vision seem arbitrary and capricious.

One human living or dying is but a “1” or “0” respectively in the emotionless graphic curve, “0s” are meaningless to the “1s” that live for the optimization of rules for the many. The “0” has but no measure, no distinction, it is the past erased, it has ceased to exist. The “1” has but a mis-measured sense of time advocating the non-value of the “0” not wanting to know that the “zeroness” will be upon him or her who is pontificating, soon.

In the end it is about humanity, how we live with one another and not about the things that we desire momentarily. After all a human touch will always be more powerful than the brand new digital wonder on one’s wrist. ! Speak about the many disenchanted souls filling their stomachs with antidepressants as they fill their minds with “nothingness.”  The mind of man does through the body of time conjure up concepts that are tuned to certain interests. Those concepts that ultimately succeed over time are most in tune with the commonest of sense and the basics of humanity.

Thursday, August 6, 2015


Or…the philosophical Neuro-babble of scientism!

This whole thing about digital is getting “curiouser and curiouser” by the day. When you throw in the barrage of hyperbole, the whole mix is a labyrinthine network of chaos. Facts and opinions merge into a single syllabic “wow” from the pedantic crowd that consumes latte with every breath.

So this next coming of the “sliced bread” is the digital what’s what that will take us into the 22nd Century. Hey but the 21st Century just began, so can we give this 0-100 in nanoseconds to the future a bit of a rest?

Artificial Intelligence (AI) will be the in thing, they say. Who, you might ask? Those in love with their abilities to discern the future, that is! Those that hide in dark closets and code and decode the subject of life but may not have lived it yet or never will from within the confines of their dark rooms. “Too abstract for you, this is?” as Yoda would ask.

I will take my cues from the functional Magnetic Resonance Imaging and from the perch of the Single Positron Emission Computerized Tomographic reveal. Why? Read on… it might make sense. In an abstract sort of way, it does to me.

The human mind is a rich diverse group of billions of neurons (brain cells) that converse electrically, collude, recruit and develop denatured protein memories within. The more the force of thought resident on a particular path, the more delineated the path. Imagine a path less traveled like the jungle infested forest facing Prince Phillip before he can kiss Snow White. However, if the same path is well traveled, minus the evil vain-queen-witch, it becomes a paved highway over time from travel. This paving is a function of experiential gains. The plasticity in the brain of pruning (or hacking away if you prefer as in the case of Prince Phillip to see his lost love) is a daily function of the brain. Oh yes, doesn’t matter how old or young you are, pruning makes the world go around from 0 to 100+ years. The thoughts become the actions and lo and behold our world changes. But how do or can we register those thoughts and from that create the epistemic nature of the action? And if we can, can we then objectify the precursor to any action or behavior? Ah dear readers, there is the slope that provides us with equal measure of frills, thrills and spills.

Scientists are tripping over in the philosophical realm of neurobiology and neuro-functional anatomy with a multitude of hardware to peer into the moment by moment of each firing neuron to simulate brain function. Indeed, they claim, we may be able to pocket your mind into an iPod one day, Moore’s Law be damned! But there are a few roaches I see in that prospect. For instance, let us take the most admired one called fMRI or (functional Magnetic Resonance Imaging) as a means of deciphering the brain’s activities. You must have seen the glossy images of colored tripped brains of individuals in response to some stimulation or behavior or action? I am sure you have. If you haven’t here are a few images to re-polish that paradigm…

What happens with an fMRI anyway? My simplistic viewpoint, and it is simplistic, is that when a stimulus is provoked, say an image of something to provoke a reaction from the individual’s brain, there is increase in energy output from select recruited neurons that identify the site of activity, eg. Temporal lobe or the occipital lobe where vision and memory merge and if an action is desired  then the Parietal lobe comes into play, but through it all the cognitive orders of action thru assimilation of the diverse stored data banks come mostly from the prefrontal cortex (herein called the decision maker). Are you with me thus far? Okay, so the color infuses into the brain images and voila! According to these experts, we have identified the active components of the brain. Repeat that experiment many times and average out the response, create a Bayesian apriori bank of information and then create a p-value of 0.05 or 95% Confidently Bounded Interval (CI) as the threshold and if the firing neurons cross that threshold, the computer registers the data with plethoric hues. The stronger the p-value of 0.05 or 95% Confidently Bounded Interval (CI) as the threshold and if the firing neurons cross that threshold, the computer registers the data with plethoric hues. The stronger the p-value less than 0.04, 0.03, 0.02…0.0001 the higher the coloring labels just like the weather maps go from a light green for drizzle to a magenta within red color for humongous storms based on radar reflectivity. Is that all good so far? Ok so now let us look at how that activity is determined within the fMRI.

fMRI machines use something called BOLD or Blood Oxygen Level Dependent a mechanism promoted by Seiji Ogawa. The idea being that brain activity would require nutrients in the form of sugar and that will necessitate need for oxygen to create the ATP (Adenosine Triphosphate) to liberate a phosphate group to create energy for the brain cellular activity. And that is how the fMRI was born. Two inherent conflicts arise when viewed from this simplistic viewpoint:

One, if energy is used immediately for the activity, then there should be an immediate deficit recorded in the deoxyhemoglobin (hemoglobin that binds with oxygen and the “de” represents removal of oxygen for delivery to tissues) and

Two, the BOLD activity takes place about 5 seconds after the evoked stimulation and response (Why the delay-or representation of a flat line on the BOLD scale?).

The fMRI machines construct the brain image into 3-D pixels called voxels, (Consider “Volumized-pixels”) each about 5cm in size. The complete activity of the brain at any instant can be recorded using a 3-D grid of 60 x 60 x 30 voxels. These machines register information every second of the 3 minute session creating 30 million plus data points. Indeed when we look at a picture, any picture placed in front of us many thoughts creep into our minds and through the act of parallel processing the information presented and that bound within our personal experiential data banks, the individual response is elicited.

In other words, my response to a green grassy knoll might elicit a desire to hit a golf ball, yours might want to lie down in the sun with a book to read. So the p-value thus used as threshold tends to negate the true experiential responses that do not climb above the artificial alpha of threshold so placed as the arbiter of reality. So, then what exactly does fMRI tell us? The simple answer is “some measured brain activity based on delayed oxygen utility to different parts of the brain” that we are trying mightily to cubby-hole into “cause and effect.”  Does that debunk the mounds of fMRI data flowing through the neuro-scientific literature? Not exactly, but it does bring into question the current vogue of misrepresentation and somewhat blind acceptance.

Now let me launch into the SPECT scan rage of the season that keeps giving us brain images like laundry detergent boxes of different colors. What exactly is SPECT? It is imaging of a single photon emission released by the neuron due to increased oxygen entry within the cell. This single photonic emission when pulsed together via a computer program and again based on the threshold of an arbitrarily placed p-value gives us beautiful red, green, blue and magenta images of areas differentiated by those areas depleted in oxygenation activity and those turgid with a surfeit of the same element. The difference is that the fMRI is a computerized tomographic image (slices put together by a computer algorithm) versus SPECT, which is a 3 dimensional planar radio-nucleotide imaging format. (Radio-nucleotide is essentially a material that joins with a specific cellular target (oxygen in this case) and emits a gamma emission (radiation) for the detector to detect and the computer to assimilate into a 3-D image). The difference is obvious but the human endeavored legion of stories as to “cause and effect” multiply exponentially. Some go as far as delineating sexual, aggressive, criminal, sociopathic behaviors on such images and the laity buys it “hook, line and sinker” as the next greatest thing since sliced bread.

Now let us take this whole house of cards worth of information and stoke the beast of Artificial Intelligence. All I can say is it will take a long time to match the equivalence of the human brain. I say that because of the data from Harris Georgiou a neuroscientist who in using the voxels concept in fMRI has determined: “that a typical voxel corresponds to roughly three million neurons, each with several thousand connections with its neighbors. However, the current state-of-the-art neuromorphic chips contain a million artificial neurons each with only 256 connections.” Thus the parallel function within the brain occurs at a much higher structural and functional level given that there are, as previously mentioned, our brains are operating about 50 tasks at once. Imagine the division of labor, concept enhancement or reduction, sensing, feeling, importing and exporting information, comprehension etc. the task of the brain is immense and it’s power needs are a mere 20 watts! Now that is some Bang for the Buck!

This study in Science by Hilbert and Lopez tells us of our accomplishments and what might remain under the dusty future ( ) concludes: We estimated the world’s technological capacity to store, communicate, and compute information, tracking 60 analog and digital technologies during the period from 1986 to 2007. In 2007, humankind was able to store 2.9 × 1020 optimally compressed bytes, communicate almost 2 × 1021 bytes, and carry out 6.4 × 1018 instructions per second on general-purpose computers. General-purpose computing capacity grew at an annual rate of 58%. The world’s capacity for bidirectional telecommunication grew at 28% per year, closely followed by the increase in globally stored information (23%). Humankind’s capacity for unidirectional information diffusion through broadcasting channels has experienced comparatively modest annual growth (6%). Telecommunication has been dominated by digital technologies since 1990 (99.9% in digital format in 2007), and the majority of our technological memory has been in digital format since the early 2000s (94% digital in 2007). So if one were to calculate the information storage within the brain given that we have about 100 billion neurons each and each of the neurons has a minimum of 1000 to 10,000 connection which translates to 100 trillion to 1 quadrillion data points or between 100-1000 terabytes of information yield. Due to the continuous increase in actual brain storage of information, now the estimates have reached a staggering 2.5 petabytes or 2500 terabytes. That is some order of magnitude one would say! Compile the memory bank to the connectivity (or "Connectome" as the experts call it to look super-intelligent) and you have a ginormous maze of data flow!

After all that, here is the crux of the neuro-babble matter. AI is a long ways away from mimicking the human brain. True, that IBM’s “Big Blue” can beat Kasparov in the game of chess and Watson can beat the Jeopardy champion, but can it tell the difference of an infant’s crying need between a diaper change and hunger or a cuddle, like a mother can? Didn’t think so! So those stories of computers becoming doctors are highly exaggerated in my opinion. Maybe someday we as humans will have computer chips installed to enhance our memories, cognitive skills etc. but even then the primary base of operation will remain with the human brain – add to, not in lieu of.

So in the end, thus far we can make lots of assumptions about what the brain is doing, but really we don’t have a clue. We appear smart with all the purported calculations and the probability assumptions and yet the main ingredient of “humanness” remains lacking from that large metal box filled with CPUs.

The quantification of uncertainty is a philosophical conundrum as much as it is a mathematical maze. Yet through it all in keeping the scion of truth from imploding, ambiguity has to be given its due share in the process of scientific discovery. One without the other implies abject ignorance.

Medical Research once considered the paragon of statistical research methodology is creaking under the weight of this mathematical jargon. The literature is getting burdened with “ambiguity proofed” positive results through statistical fiat that imply little progress in understanding. Thus ensuring that the “native hue of resolution is sicklied o’er with the pale cast of thought…”

On a more human level… “Have a great day!” (Let Watson figure that out!)  

Monday, July 27, 2015


They ask, sometime in pure ignorance and oft times with incredulity, “why is cancer care so expensive?”

The rabbit hole is deep and dark, but if you shine the light, you can see the trail of the smoking caterpillar. 

Some try to create cost algorithm based on survival benefit of a drug on cancer care, others are trying to legislate lower costs, while still others reach out for subsidies from the eternal fountain of taxpayer wealth. Life in these United States is indeed interesting.

While searching for a gradient to seek the fissures of thought, let me break it down by category:

Drug development: The claim is that bringing a new drug to market is valued at $2.6 Billion (of which $1.2 Billion are time costs). ① 
Incurred in this cost is the old premise that of the 5000 drugs tested only one enters the market, showing benefit in the petri dish, mouse model and then through human Phase I and II trials leading to FDA approval. That $1.4 billion in actual expense is amortized over the next 7 years of patent protection with a certain Return on Investment or ROI for the risk undertaken by the company. There are quite a few “wrong-headed methodologies” in use there. ② However not all costs are related to drug development, some are purely annual price increases to keep up with the earnings per share (EPS).

Insurers: The Cost to insurers is defrayed easily by the price of the premiums. In essence for all the talk of “Risk Mitigation” from the insurers, there is little risk involved, except the agency risk of losing a bonus for the managers should the benchmark of the stock price not reach the intended target. Overall unless you happen to take some real wild risks like AIG with Credit Default Swaps and the like, your chance as an insurer of an extremal event is nigh impossible. ③ Meanwhile as the money trail indicates that the Insurers paid $102 million to lobby the congress to tweak the Obamacare and in return the Health Care Index has risen by 305% over the past three years! Stupendous Returns eh?

Supply and Demand: If a drug is developed for a condition that afflicts only a few souls, it is given an orphan drug status. The price of the drug development will always be high to amortize the drug development costs. But a drug for an affliction of the masses should not be that expensive. The case in point is a company named Dendreon and their drug product Provenge used for Prostate Cancer. The Provenge cost was $93,000 per treatment and enhanced survival by only 4 months led to the eventual decline in the fortunes of that company into a bankruptcy. ④ 

The fault line in this exceedingly pure appearing surface had been discovered. But there were two important lessons from that case; one, the concept of using immunity against malignancies and two, careful how you price the product with limited benefit. Careful of the faint light that beckons, like a mirage, and then dies. 

Oncologists in delivery of care: Much is made of the physician who uses the expensive medicine for his or her own benefit. Fortunately except in a select few unfortunate cases, the majority of the physicians use cancer drugs based on the data they have for the fullest benefit to their patients. This might appear a heresy to the journalists since it does not follow their narrative, but based on talking with my colleagues, the foregoing is a fact. The problem in most cases is the transparency of the drug cost itself. We as oncologists offer treatment on the basis of the best benefit against the malignancy and not necessarily based on cost to benefit ratio. We are after all doctors and not businessmen or women. Our purpose is to heal. And therein is the crux of the matter. Big Pharma and Biotech companies know our ethos and price their products according to their cost plus ROIs. Unfortunately more often than not the “studies” being quoted are based on a low “n” and tortured statistics based on assumptions that carry their argument. The studies are touted as the next best thing since sliced bread! ⑤. The fault may not fall too far from the physicians either at times when more expensive drugs are used where cheaper ones would suffice. The human dignity is best served through truth.

Mini-incrementalism:  There are very few large leaps in oncology patient care, more of the medical literature litters the landscape with mini-incrementalism in benefits through the tortured use of Progression Free Survival or PFS. Unfortunately half of those studies cannot be verified or validated. The purpose in some cases is a continuous source of incremental revenue. This is by far the most destructive force in medicine today. Read here on...PFS

800lb Gorilla: The Insurer-Lobbyist-Expert-Middling-Manager remains the big culprit. Realizing that from 1970 to 2009 physician population increased minimally  less than 5% in spite of the total population of the United States that grew to 320 million, the administrators however grew by over 3000% according to the Bureau of Labor Statistics (BLS).

To apply the Supply – Demand metrics to the oncology dilemma is akin to creating a skin in the game for the two main entities concerned; the patient and the physician. If the patient cannot afford the medication then the volume will dry up and the cost of the product will of necessity go down as long as the intermediaries are not in the process of processing these payments and extracting their bounty. Already China rejected the patent for Solvadi ($84,000 drug against Hepatitis C) India and France successfully negotiated the cost at 70% less. But in truth if one looks at the cost of the Hepatitis C infection, its complications and overall health costs of are for the illness, the cost of Solvadi is actually a fraction of that expense ⑥. Using mandated price controls however is a top-down measure that governments and policy makers use in an attempt to control price and show how they are working for the public benefit. Alas price controls never achieve their objective of cost reduction but in effect becomes the force du jour for control of care and higher prices.

We have come a long way baby! True. But where we are going is not that long. At this rate it will be a long hard winter soon and the chilling frost will last a very long time. 


Saturday, July 18, 2015


What drives you is the same as what motivates you? Provocative, yes, but that statement needs an answer in your own silence.

We have long been stretched across the mountainous range of incentives; the higher the peak the better the result is the dogma. But is that true?

Behavior Theorists will say yes. They as you know have confused the issues of Mice and Men. Pavlov’s old ghost that rewarded with a snack from the correctly recognized trap door vs an electric shock from the wrong one in mice works to do more harm than good in the short and the long run both in mice and men. Mice are synaptically hard-wired to reach a certain destination to receive a reward in forms of food and little else. In men watching the mice, it accentuates their resolve of incentives to potentially enhance productivity.

Incentives are both Intrinsic and Extrinsic. The former have a moral compass attached to them and the latter are more coercive in nature. Or let us just say the difference is between, “what I want to do, vs. what you want me to do.” The misguided mind wishes to enforce the extrinsic incentives to modulate the intrinsic ones and that, time, data and reason suggest is impossible – Edwin Locke (Ref # 1)

The misguided view of such thought is obvious. Pavlov’s conditioning is based on avoidance as much as it is in survival. The human kind mistakes that as increase in productivity causal through rewards. Our weaknesses are revealed under the uncompromising high altitude truths and there we find; rewards that feed desires quickly cause the hunger of understanding to flame out faster and with that exploration and innovation.

What good do incentives do then? Here are a few answers you will hear from the managers who have grown up with the “If this then that” concept of the American way of life.

1.       1. Productivity goes up! Does it? The answer in the short term is it does but then as more productivity is needed to keep the incentive, the quality goes south. The initial incentive creates a temporary phenomenon which fades quickly forcing the manager to go back for more and more of the manna. The classic fallacy that follows is; the initial hypothesis is correct and therefore more incentivizing is needed. The spiraling structure rides the next turn of the screw. Ultimately the train of thought has to reach a destination and it does when the cost per widget equals the profit from that widget and demand equals supply. To the manager who benefits from incentive programs because of his own bonus tied to it, it is always a “self-fulfilling prophecy,” when things go bad from good and he chimes his new incentive program as the panacea for success.

2.     2.   It motivates the producer. Does it? Temporarily, but it also creates a window of discontent from the others in the field who are without the incentives and feel inferior or “left out.” This particular cycle ends viciously in employee rivalry and competing for the finite pool of incentives thus leading to short cuts and loss of real productivity in the intermediate and long term. It is demoralizing to the ones who do not receive the incentives to continue with their daily workload with the same enthusiasm.

3.      3.  It benefits the manager. Yes that it does!

Mimi and Eunice

What bad do incentives do? Plenty!

1.       1. Incentives do not lead to an enduring commitment to any action or any program. Rewards have a similar effect on the human behavior as punishment and both in the end from the individual’s perspective feel like manipulation.

2.       2. Individual gain becomes the name of the game. Call it the Agency problem where the incentivized motivated manager cares only for the short term solution for a long term issue. Example a CEO/CFO who for the sake of a large bonus has to show a rising Stock Price to gain the appropriate stock shares as bonus reward for his actions. His actions might consist of reducing the labor force to reduce expense and thus increase the net income during a decrease in revenue, or he might consider increasing the debt (to offset income tax) and use the debt to buy-back the shares to enhance share value or he might sell a long term promising project for a short term windfall to shore up the assets and the share value through buy-back or report financial problems within the company in arcane hidden parts of the financial reports as “Special Purpose Entities” used by Arthur Anderson, the auditing firm in the classic case of Enron, where realized losses were hidden.

3.     3.   Incentives destroy exploration of causality in dwindling productivity and try to fix it with rewards.

4.      4.  Incentives are thieves of individual intrinsic motivation and desire.

5.      5.  Extrinsic Incentives reduce innovation. (Ref #s 2-5)

Nowhere is there a better example of such promotion of behavioral reward followed by punitive action more visible than in the field of medicine.  The CMS Authority has burdened the physicians with miniscule rewards and heavy penalties to attempt to change physician behavior. The long held Damocles Sword over the physicians called the SGR (Sustainable Growth Rate) formula to pay physicians that kept hinting at a 21% cut in reimbursements was repealed and instead a worse APM (Alternate Payment Model) was adopted that gives the CMS sweeping powers for draconian reduction in payments to physician from the 7 cents per dollar paid to them of the total healthcare costs. The 7 cents are under the most glaring of scrutiny than any in any kind of vocation. Meanwhile the healthcare managers with 5-6 times the average salary of physician, continue to reap the rewards from the Agency Problem by creating surreptitious models that point fingers of blame at the physicians for the escalating healthcare costs. Another example, for instance in this game of sham is the 0.5% reward for following a directive (“Meaningful Use” of EMRs) otherwise a 2% penalty. Likewise promoting ACOs to cut costs through “Less is More” policy saved the CMS over $400 million and rewarded the ACOs with less than 1/10th in return. As the “Pioneer ACO” program fall out shows several of the ACOs disbanded due to belief that such dire cost cutting was leading to poor patient practices and hurting their chances of surviving financially in providing care to their communities.

More recently however the Insuring forces are incentivizing the use of poorly designed pseudo-scientific data to enforce limited screening of diseases like cancer.

Punitive actions are like their twin sister  incentives, neither present a long term viable behavioral modification. They actually lead to demoralization, as Robert W. Baird and Co., Inc., wrote in the 1985 book, Intrinsic Motivation and Self-Determination in Human Behavior“the research has consistently shown that any contingent payment system tends to undermine intrinsic motivation.” The basic effect is the same for a variety of rewards and tasks, although extrinsic motivators are particularly destructive when tied to interesting or complicated tasks.” Incentives like punitive actions perversely affect human behavior; opportunity for exploration, improvement of self, advancing of one’s self image, achieving personal goals and renders obsolete intrinsic motivation."

The last question that remains is, “Do incentives  motivate passion?”

The answer is NOT, as Jonathan Friedman of University of Toronto stated simply, “If they have to bribe me to do it, it must be something I wouldn’t want to do.” So it comes to this final conclusion should anyone care to listen: You cannot force passion into a mind that is closed to it, with rewards! Incentives squelch innovation and real growth.

1.         “Financial Incentives” G. Douglas Jenkins, Jr. in Generalizing from Laboratory to Field          Settings, edited by Edwin A. Locke (Lexington, MA: Lexington Books, 1986.

2.        “Intrinsic and Extrinsic Motivational Orientations: Reward-Induced Changes in Preference for Complexity” Thane S. Pittman, Jolee Emery, and Ann K. Boggiano (Journal of Personality and Social Psychology March 1982).

3.       “Enemies of Exploration: Self-Initiated Versus Other-Initiated Learning,” John Condry (Journal of Personality and Social Psychology July 1977).

4.       “Toward a Theory of Task Motivation and Incentives” Edwin A. Locke (Organizational Behavior and Human Performance Volume 3, 1968).

5.       Intrinsic Motivation and Self-Determination in Human Behavior, Edward L. Deci and Richard M. Ryan (New York: Plenum Press, 1985).

Friday, July 10, 2015


Funny thing about asking someone, “What is Intuition?” And you will get different answers. Some will say it is your inner conscience, others will say it is your ability to quickly differentiate while others will opine that it is mindless instantaneous reaction. Of all the answers the last one is intriguing. And it is pretty close to the official definition: “the ability to understand something immediately, without the need for conscious reasoning,” (from the Latin word "Intuir" or knowledge from within) don’t you think?

We function through the day as radiant blossoms or wilted lilies. The modus inspired by what elevates our spirits or weighs down our minds. It might be looking forward to a quiet evening listening to music, thinking about a solution to a pet project or starting a paper due in the math class the next day, a business plan for a customer, or dictating a consultation that involves a large dose of research.  In the more delightful measures of expectations, we dive head long with the Rosseauvian delight. All in! Here the corridors appear as large expectant runways at International Airports and navigating is applied with ease. In the latter each corridor is filled with constrictions to passage and the whole task is laborious and trying. Our ability to circumnavigate the complex jungle of our existence is enhanced through intuition. Intuition protects us, saves us from disasters and lacking it with equal measure can feed us into the lion’s den.

After conducting a “Human Factor and Decision Making” seminar at the FAA Seminar, I was asked to fly with a pilot for a flight review. He was good. All the steep turns, the slow flight, detecting impending stalls and recovery from actual stalls was done with proficiency and thoroughness. He after all had several thousand hours under his belt. Equally his gaze was never fixated. His eyes glanced at all the gauges under the glow and flicker of each instrument. Monitoring the airspeed, the attitude indicator, the Vertical Speed Indicator, the turn coordinator, the wind direction, the aircraft crab angle, the pitch and yaw in the turn, the fuel consumption, the ground-speed, the trim, the radio communication with Air Traffic Control, while my was gaze was outside the windshield to look for other aircraft and he all the while communicating with me about his intentions of what he was doing. All these actions were being performed effortlessly and with a certain command on the phraseology of the spoken sentence and the articulation of the intended thought. This was multitasking at its best. Or was it?

This was the Jeffersonian hand at play; a thoughtful, implicit consent to be governed by the explicit rules of the game. Experiential references carried the day. If you prefer we could term that as “muscle memory.” How do we build that muscle memory? The answer is obvious by practicing the required subset of practical knowledge. One cannot learn this straight from the book. Knowing that reducing power causes changes in the aircraft attitude is one relegated to experience as the acceleration decreases and the plan lurches forward nose down to regain that speed and without a pilot’s input it would reach the speed that would increase the lift and by virtue of aerodynamic laws it would try to climb again and create an unbalanced pitch motion. It goes back to the old mantra of Lift to weight and thrust to drag ratio. So unless you have felt the forces at play while flying the aircraft, you could hold yourself as an aviator in front of a landlubber class of hundreds and fool them, by regurgitating “bookish words.” Sitting in the pilot’s seat for a minute and experiencing the sensations is worth more than the countless hours of learning by rote.

Let us get back to my proficiency seeking pilot in the left seat for the moment. We had accomplished a lot in the almost four hours of flight. No there were no moments of fright in this flight. Everything was a seamless act of coordination and evaluation. This guy was good. We were flying over a beautiful countryside over Tennessee, with fields of green and red rose bushes visible too as cows snacked on grass and empty roads on a workday flew by below, all visible from the side window of my right seat.

We were at 3000 feet and about 10 miles from the nearest airport. I decided to test his one main skill.
I killed the engine!
He looked at me dumbfounded.
I asked, “What is the first thing you are going to do?”
“I will push the mixture, prop and throttle to the max!” he responded.
“Try again!”
“I will check the magnetos!”
“Try again!”
“I will change the fuel tanks and turn on the fuel boost pump!” he said in a husky voice, his face taking on an amber shade of yellow. The push and pull of remote thought and recent encounter danced in a fugue dreamscape; diving in madly then holding back to review, as all the memorization poured out in a linear splash.
“I will change the Transponder to squawk 7700!”
“I will call ATC and declare an Emergency!” His face was now the color of fusion between red and purple.
Meanwhile the aircraft is flying at 165knots and we had lost 500 feet during this discussion. Now the cows seemed concerned too, their mouths frozen in mid mastication. The tiny windmill below shook to the sudden gusty breeze from the west. The moment lingered.
“Well then I give up.” He said as his face slumped. He had abrogated his responsibility in flying the aircraft. “Oh, I would pull out my Pilot Operating Handbook! Is that what you are looking for?”
“Glide Speed.”  I said quietly.
“Pitch to Glide Speed!” I said with a little emphasis. “That should be your first reaction…always. Transferring speed energy into altitude gives you more distance to find a suitable site to land. It also adds to your time to find the potential cause of the engine failure and find a safe landing zone and it diminishes your descent rate flying at L/D max (or maximum lift with the weakest of drag).”
“What do we do now?” he asked
“Land the plane!”
“You mean anywhere?”
“Anywhere, safe!” I answered.

His instincts took over as he gained some altitude, transitioning to glide speed and making all the arrangements to land. He looked at an open pasture and set himself up to land on the green grassy field to his left.

Once he had committed and the safe landing was assured I  restarted the engine at around 700 feet and off we went headed back for the airport, which was now only 4 miles away. In a debriefing later, he acknowledged that had he resorted to glide speed immediately that we would have easily made it to the airport given the winds at 3000 feet.

You cannot learn that kind of knowledge from reading books. If ever he was faced with such a dilemma, he will know what to do without hesitation. Now this will be in his repertoire to execute effortlessly as a routine. After the red blush on his face had waned a bit, he came over during dinner the next night and thanked me for the lesson. “I will never forget that.” he said. The Angel of Reason had visited him overnight. 

That in itself was the best reward!

A Short Psychology of Intuition:
From William James' two mode Intuitions of "Effortless and Fast or Rational and Analytical to Kahneman's Type and Type II modes of intuition, both embody the visceral mid-brain response and the contemplated neo-cortical revisions. The Type I is ingrained from age-old hunter gatherer fear and flight function to escape beasts and monsters and the Type II is learnt. As Massimo Pigliucci stated in his book Answers for Aristotle,"Moreover, intuitions get better with practice — especially with a lot of practice — because at bottom intuition is about the brain’s ability to pick up on certain recurring patterns; the more we are exposed to a particular domain of activity the more familiar we become with the relevant patterns (medical charts, positions of chess pieces), and the more and faster our brains generate heuristic solutions to the problem we happen to be facing within that domain." Meanwhile causal links that determine our intuition is illustrated by this statement from Kahneman, "You have to think of [your associative memory] as a huge repository of ideas, linked to each other in many ways, including causal links and other links, and activation spreading from ideas to other ideas until a small subset of that enormous network is illuminated, and the subset is what’s happening in the mind at the moment. You’re not conscious of it, you’re conscious of very little of it."  Thus it is all about the coherence of the causal links that are arrived at in the form of intuition. Perceived causality and the reaction to it, after all are the underpinnings of all rational reasoned thoughts. Inadvertently however, there are moments where the fly in the ointment is perceived and the flaw of jumping to conclusions comes into play and overconfidence is the outcome. This overconfidence stems from the coherence of disjointed beliefs and thus can create a major error. The human mind has the capacity and capability to fool itself with wonderful stories built upon a foundation of little or no evidence. Unfortunately, when executing such ill-begotten plans the person subjectively has the same sense of accomplishment as another who has done his or her due diligence. So at times raw intuition is a man with a Janus face holding a double-edged sword!

Intuition is borne of experience. No amount of cognitive rationalizing and reasoning in moments of distress can bring about the right outcome except a brush with that one dose of raw experience. Speaking of comparing medicine and piloting, as most experts tend to do, this is the only intersect between the two; learning from raw experience!

Friday, June 26, 2015


When I was in medical school, the most important person was the patient. Your entire being was focused on the patient. What can I do to resolve this person’s ailment? In fact at one time, I rattled on about the information I had gleaned from the textbook and was babbling along when the professor interrupted, “That is all good, but what does it have to do with this patient?” That broke my train of thought and all I could do was speechlessly stare at him. Today we use terminologies like “Patient centered” and “Patient Centric,” but we fail to actually embody those words. We talk of “listening” as if listening is a new found treasure. We talk about “outcomes” as if previously we were not concerned with the well-being of our patients. We talk about “performance” as if caring for a patient is a function of a metric related athletic score. Medical care has always been about patient’s well-being. Today however the business oriented statisticians are using population medicine inspired data to treat individual patients. The wrongness of this is obvious, yet they, the experts continue to pontificate with “Hazard ratios and p-values” to the eager ears of the uninformed.

In Business parlance there has been a Merger and Acquisition between the business and the medicine mind. The merger was actuated by the "managers" in the two fields without the consent of the voting block in medicine and now that has morphed into an outright acquisition by the business mind with associated divestiture of the medical mind with layoffs and other cost control measures in progress...

When and where did we as physicians go wrong?

In the midst of this dilemma, I decided, I wanted to learn about what makes the entire healthcare system tick? Who was at the till? And what is the motive? I decided to go to a business school. I wanted to learn how business people think? The dean of the university who interviewed me told me that going through the business school would change the way I think!

It did!

I learned that business minds think differently than medical minds, in ways that are inconceivable to one another.

Let me dissect the medical mind first since I have had it for many years and my heart still beats the rhythm of medicine as surely as it conveys the next moment. The medical mind is quite simple and very complex at the same time. Simple because it has a simple ethos; to conquer the malady that afflicts another human; to salve the wound, to soothe and comfort, to help regain what is lost in human functionality, to help live, to help alleviate pain, to heal and to cure. Simple stuff there! Not a lot to think about. Complex because, what ails the individual and how many different maladies can and do create similar symptoms and signs creates mountains of stress. Further, to differentiate between cancer of the lung and to the lung is a whole textbook somewhere ready for the learning. The dilemma proceeds from medication induced damage to illness related ones, from a benign nodule in the lung to a cancer that kills in less than a year, from a cold causing fever to a more sinister disease such as kidney cancer, which sometime only presents as fever and nothing else. These and others footnotes present the conundrum, a physician faces in daily life. To embark on the correct strategy lives the need for appropriate diagnostic work, experiential intuition, much like Sir Arthur Conan Doyle’s Sherlock. “Elementary my dear Watson,” that only comes after the workup has been completed, the correct decision has been arrived at and executed. The constant vigilance of evaluating the benefits to the patient from that decision is a recurring theme in the medical mind. Medicine is true science borne of empiricism in the strictest sense not through the jargon of ratios.

On the converse side in the recent past what I have learnt from the business world is also simple and complex. Simple, that 2+2 = 4 and 4-2=2, these are, you will agree very simple arithmetic concepts. If the revenue is higher than the expense then there will be income, if the expenses are higher than the revenue there will be borrowing to maintain the business until lenders tire of the lending without evidence of higher forecast revenues. If you thought that was all, you would be wrong. There are many complex shenanigans within these simplified concepts that are employed to obfuscate. Difference between cash based and accrual based is a very interesting scenario to visit and learn from. The “Goodwill” category in income statements also poses a nice source of fodder to hide and not hint. But we will let those issues pass for the likes of HBR to contemplate.

My purpose is to look only at the human element in this short treatise. If you look at the “forward looking statements” from CEOs of large corporations you will notice that they always mouth these words, “Our employees are our best assets!” Yet when the net income declines, the first thing these managers do is choke off the employees. Pink slips fly and the “Agency Rule” comes into play so the bonuses at the year end do not suffer. Needless to say the stockholders are happy since the market rewards a rising net income which translates to the Earnings Per Share (EPS), hence the share price rises to meet their expectations. If Net income does not rise with this strategy, then by all means buyback with borrowed money is the order of the day to raise the stock artificially. This short term thinking is evident in most businesses and if you were to look back the past 5 years you might notice the headlines of thousands of workers being fired across the globe and in the U.S. In the latter part of the world there are now 93,000,000+ sitting on their hands without a job. Speaking of stock buybacks, the S and P 500 spent $914 Billion in 2014 in buybacks. Yet thinking of employees as a disposable commodity to beef up the short term quarterly interests for personal benefits has unseen but real consequences in productivity as well. Take for example the difference between Costco and Walmart. The former has loyal well-paid employees that make a decent livelihood at around $43,000 average salary. The latter has a higher turnover rate due to dissatisfaction. The former commands a $21,850 in U.S. operating profit per hour per employee vs. $11,615 at Sam’s Club, a Walmart subsidiary. And if the managers would look at the cause that should light their personal wealth fire; Costco stock price rose 139% and Walmart was up 41%, they would treat their employees as assets and not as expense.  (here:
Blue: Costco Red: Walmart

So this “employees are our assets” is nothing more than  a tired old rhetoric that fits the narrative to exploit the emotions of the employees and the shareholders. A crocodile tear at the right moment when the flash goes off is worth a few front page photos and headlines.

Unfortunately, I feel that same mentality has wormed its way into medicine.

Let us for the moment assume the following; that medicine is a large company and doctors are the main employees. The owners of the “Company,” are the Government and the Insurers, since they dole out the “reimbursements” and the patients are customers. Simple enough! The business mind attracted into the fold of medicine sees the situation in the same context as it does a widget producing manufacturer. The customers (patients) get the widget (care), employees (physicians)are told to work overtime with a lower pay or skimp on the materials (diagnostics and therapeutics) to make the widget, for the sake of the “Company” and if they refuse or if the expenses exceed the desired results are easily discarded from the payroll. Mechanisms of discard include forcing doctors out of hospital staff membership if they don’t comply with onerous requirements of hospital or other private enterprise profitability; MOC (Maintenance of Certification) a continuing annual process of re-certification (for the sake of revenues - more on it below) and Hospitals using sham peer reviews etc. Hospital and Company CEOs are flexing their collective muscles.

Reimbursements to the physicians are easily controlled; previously through the SGR formula and now through newly minted methodologies (MACRA) via ACOs and APMs which, it turns out, are more punitive than the SGR, bu their full impact will not be known till after 2018. These formulations are the work of managers of the government bureaucrats, insurance company executives, elitists that are bounded by bookends of sly and slippery words and lecture from high lecterns, all the while partaking in large grants and salaries. One only has to look at the American Board of Internal Medicine (ABIM) and the revelations by Kurt Eichenwald in the Newsweek articles of how they have fleeced the U.S. physicians (a humiliation of unparalleled proportions that certainly needs further scrutiny). The carrot and stick model used by CMS of giving a 0.5% raise now to follow the preferential business based guidelines to lower costs vs. 2-5% penalties later for not reaching to those arbitrary standards of cost control (as primary endpoint) is the dujour modus operandi. Patient care is implied as the secondary endpoint (for those of you who like reading medical literature) but is never given much credence. The Kahneman and Tversky Loss-aversion behavioral economics are fully applied with prejudice to medicine. The business side of commoditization (and here on YouTube) with “Less is More,” no doubt a business concept, is allowing unsupervised practice by NPs and PAs in some states that are facing physician shortage, akin to: (Hire the underage workers at Foxconn). There lives a beast that will turn Medusa into stone!

The idea of constantly retraining pilots and therefore the physicians is simple but here are a few loose ends; training does not equate to wisdom. One can rattle away concepts without a clear understanding that only comes with layer upon layered experience and critical thinking. I am reminded of my professor and what he said at those times. It is easy to train anyone to do a sequential task of minimal complexity, it is altogether another issue to be able to apply wisdom to the need or want for that task that comes from education and experiential reference. One can be trained in triage for routine care but when human pathos complexity hits as it does most times, repetitive training alone will not do!

Let me bring in the Airline pilot training that all the "experts" are advocating, here for comparison. If any of you remember the Sioux City Iowa crash of United flight #232, it was not the training that helped, but Captain Al Haynes' sheer intuitive brilliance that saved 185 passenger lives. In fact 55 test pilots failed to equal his success in the simulator given identical conditions and having been pre-warned of what was to happen. So a word of caution to those beating the drum of pilot training and equating it to doctor training, it is more than training! A corollary to that crash is the more recent Asiana Airline crash in San Francisco where pilots were trained in Instrument flight by the Autopilot and failed to realize that in case of Instrument Landing System failure they had to hand fly the plane and you guessed it, they couldn't! They were trained to manage the autopilot flight!

The intuition gathered from compiling years of education, knowledge and critical thinking is needed in caring for the patient. So if NPs and PAs desire to practice medicine then they should simply go to medical school, follow through with a residency in training and be ready to take on the medical world. I say welcome to that. Doctors learn daily through human - human interaction. Pathology differs in each individual as does to some extent physiology. No two humans are the same.

Meanwhile guys and gals, ease up on the physicians, if you will. Tone down the demonization! Enough is enough!

Using syllogisms to prove points are constructs of the pseudo-intellectuals. They use the informal fallacy of "post hoc ergo propter hoc" or this happened because of the preceding that! A classic example is:
The cost of medical care goes up
because of greedy doctors
Healthcare costs are rising
The doctors are greedy

This form of modus ponens methodology obfuscates, confuses and destabilizes the noble profession. In fact the very act of forced balancing a model unbalances it. To prove the point there is a daily barrage of wrongdoings highlighted in the media. Lately caring for patient's in pain with painkillers subjects the physician to criminal charge. But since the modus has been broadcast earlier the corresponding asymmetric il-logic must also be true; doctors are bad people. The result; patients are left to deal with their pain by the physicians for fear of over-prescribing allegations and indictments against the doctor.

By now you might have guessed that the business mind differs greatly from the medical mind. It does not discern the effects on the consumer as much as it covets its growth and success, although in the long run, those that survive time, pay attention to the widget creation and customer satisfaction equally. The current business mind however is a short term thinker; the next quarter and the surreptitious mechanisms to inflate the correct numbers to be rewarded for such acts has become an art form. The widget may be of sub-par value but if you say it is great on TV and the Internet through populated bots, it achieves a longer "time value." Enron is a prime example of accounting fraud that destroyed a large number of shareholder savings. LTCM, another entity which exploited small asymmetries in pricing until it took down $4.8 billion in stockholder wealth and needed $3.5 billion in bailout from the Fed.. Also remember the Gremlin and the Chevy Volt in the same context for further illumination of thought. The latter two products (widgets) expose the forced logic of failure with precision. History teaches us but as George Santanaya prophesied, "Those who cannot remember the past are condemned to repeat it."

The business mind is focused on net asset value. They consider the machines, the robots, the buildings, the pencil and paper as assets. Human workers are considered a “Fixed Cost.” Therein lies the greatest misadventures of the business mind meddling in the field of medicine.

The medical mind is focused on human healing, recovery and overall health. The business mind on the next quarterly revenue and net income!

Yes, I did learn to think differently. I see the holes in the dam where the tips of the fingers are visible. How long will it take for these cracks to rupture can only be measured in the “near term!”