Monday, December 31, 2012

Happy New Year


I opened the door today and there in front was a package. It is after Christmas and today is New year’s Eve to boot. But there it was tied up nicely in a red bow.



It felt light, very light.

I opened the package.

And there was a letter in it.

“Dear JediPD (I know, you know that I know who you are, so we will leave it at that),

Rudolph had a routing by your house, so I asked him to drop this off.”

“Rudolph was here!” I exclaimed, loud enough to catch my own words in mid sentence and lower the pitch and loudness for fear neighbors might raise their collective eyebrows.

The note goes on:

“I have noticed an edge in your words and gently suggest you tweak them, I know in your heart of heart there is a well of good wishes for everyone. So let them show, but not with an edge.”

Had I been so overtly insensitive? Maybe? But then again I thought I was just stating the obvious as it appeared to me. Edge? What edge? Go on…

“Remember it is the good deed and not the spoken word that ultimately survives.”

You can say it again.

“But words hurt.”

Yeah but, sometime one needs to express the obvious, you know!

“I know you feel that you have to express the obvious, but try it delicately.”

Boy can he read my mind!

“So here is the essence of what I am saying.”

Do go on…

“Work hard at what makes you happiest, make others happier, educate them of what knowledge you possess and learn from them what they know.”

Uh huh…

“It is in the mind meld of many ideas that a true thought is born that can change the world. And I agree, this world needs a little help.”

Does it?

“And if you do this well, next year expect a real bonus for your hard work from me. I am expanding my sleigh volume for just such bonuses for many like you. (Plus Rudolph has been building his muscles and his nose now shines like the light on the Polar Express locomotive. Oops, I forgot you don’t have locomotives anymore, do you? It’s the Mag-Lev or some stuff like that.”

We have space shuttles, solid fuels and high bypass turbines baby! No need to worry about cracking the frozen ice on a lake anymore.

“Anyway, think about what I have said. Work hard and the bonuses will come.”

And what would the bonus be?

"The bonus will be something that your heart will desire then, not now. As you know time changes everything!"

Whoa how did he know that? Creepy.

“But if you sit on the sofa all day, playing with the iPad or the video games on your computer, then, I am afraid, your home address might be struck off Rudolph’s roster. But that you already know.”

Pray tell that to others too…while I shut down this computer.

“Anyway, wishing you and your family a Happy Healthy 2013 and beyond and hoping that I can fill your bag of goodies to the hilt commensurate with your hard work.”

Signed:



Santa Claus
2012


Saturday, December 29, 2012

SGR and Physicians



The beast within grows. Its white fangs and long curled talons seem like a caricature in a sci-fi movie, than real life. But there it is, the Gryphon, baring its teeth encrusted beak and its hawkish eyes under the brown and white ruffled feathers that spell dominance. The creature is restless, as its deep-dark eyes dart from side to side.



The SGR seems oddly to fit the image of this beast. Born of a thought for containment, as a dovish sort of benevolent bird, flitting about from tree to tree, it has eaten off the forbidden fruit of procrastination and turned into this giant beast of hawk-like demeanor with a reptilian cold-blooded calculating mind-set.

What is SGR (Sustained Growth Rate) formula after all?

The Medicare Sustainable Growth Rate (SGR) is currently used by the CMS Centers for Medicare and Medicaid Services in the United States to control spending by Medicare on physician services. The SGR was enacted by the Balanced Budget Act of 1997 to amend Section 1848(f) of the Social Security Act and replaced the Medicare Volume Performance Standard (MVPS). CMS previously used MVPS in an attempt to control costs. Generally, this is a method to ensure that the yearly increase in the expense per Medicare beneficiary does not exceed the growth in GDP.



“Every year, the CMS sends a report to the Medicare Payment Advisory Commission, which advises the US Congress on the previous year's total expenditures and the target expenditures. The report also includes a conversion factor that will change the payments for physician services for the next year in order to match the target SGR. If the expenditures for the previous year exceeded the target expenditures, then the conversion factor will decrease payments for the next year. If the expenditures were less than expected, the conversion factor would increase the payments to physicians for the next year.”

The four factors involved in these calculations include:

               1. The estimated percentage change in fees for physicians’ services.
               2. The estimated percentage change in the average number of Medicare fee-for-service beneficiaries.
               3. The estimated 10-year average annual percentage change in real GDP per capita.
               4. The estimated percentage change in expenditures due to changes in law or regulations.

As one can guess, given this oddly figured attempt to control healthcare costs, the physicians are being used as the “sacrificial lambs.” While on one side there is a “push” to invest in conforming to regulatory requirements and added jungle of complexity, which any kindergarten student will tell you, adds to the costs of care, the other side is hell-bent on “you can’t raise prices!”  The only thing close to reality would be telling McDonald Restaurants to have seating for hundred customers in each restaurant and hire 20 extra employees to service the stations and oh but you (McDonald) cannot raise the prices of hamburgers. Hmm…



And here is a real world personal example: When I first started practicing medicine, I had one employee. She was the front-office and did everything else except practice medicine. Then as time expanded and as needs grew, my office expanded the workforce to two and then three and before, I had a chance to realize it, I had 10 workers staffing a one-physician facility. There was a billing person, a coder, an insurance pre-qualifier, two nurses, a chart filer, a front office receptionist, an office manager and two laboratory technicians. Not to mention other contractors for computer services, OSHA regulatory compliance, COLA and CLIA regulatory compliances. So all in all, keeping this large workforce to continue providing healthcare services required a larger revenue stream. The SGR creators on the other hand remained distant and oblivious to the external forces enacted by the congressional experts that were constantly shaping and adding the streams of burden on a physician’s abilities. The simple act of comprehension seemed oddly absent in the mix of these “experts.” The one hand continues to harvest “nothing” while the other hand continues to “seed” something; simultaneity of complex idiocy.

While the Congress and the Executive branches have been reviewing the burgeoning “big” data based on a falsified premise, and believing in it’s virtues they have nevertheless continued to “kick the can down the road.” Already in arrears for -27.4% over the past decade, there is very little “stomach” to stomach the potential “backlash” from the physician and patient advocacy groups. Both will lose a large number of care-givers and care-needy numbers. And if the new movement of rising numbers of “hospitalists” (physicians employed by the hospitals to render inpatient care) is a comfort to society, the SGR follows the physician wherever he goes and that brings the hospital revenues under scrutiny and potential pressure. The AHA lobbyist are already at it, spinning their intellectual wheels to find the cure for this contagion. And the beat goes on...

The vitriol continues about the “rich doctors” and their lifestyles of big houses  and expensive cars, as the clarion call to rally the masses in support of the impending cuts continues. Yet even this weary class-envy seems not to bring in the desired angst from the populace, for they fear a loss of “something” for themselves. The “warfare” against physicians continues while the public “servants” fly around under Rolls Royce powered jets from halls of congress to their districts and are wined and dined by corporate magnates to enforce the cuts so that larger portions of the insurance premiums become the incremental added share-value. Ah! But I digress!

So here we are delaying the inevitability based on the faulty premise to begin with. Yet this delay diverts the consequences from now to the future where the pain will be greater and survivability not insured. This persistent delay will rear its ugly head as a rampant inflation of a dislocated reality where healthcare will suffer at the alter of fewer physicians and many “compliance czars” that mete out the marginalized healthcare.



Ron Shinkman of Fierce Health Finance states,
“As a result, doctors are facing a 27.5 percent cut in payments for the care they provide--the accumulation of a decade of cost deficits that have never been addressed. It's a deeply ludicrous cut and will never happen, but it exists solely because of past inaction.
Meanwhile, as the Affordable Care Act takes greater hold in 2014 and the years after, there is likely going to be more pressure to keep the healthcare cost curve down. If Massachusetts, the ACA's original home, is any guide, inflation is going to move up from its current historical lows pretty quickly.
A variety of health policy experts have noted the SGR tug-of-war has kept the physician community from focusing on properly implementing reform.”


US Federal Debt ~ Projected


United States Public Debt



Let us briefly cast our view on the world of finance, it is akin to the “doc-fixes” that have been implemented over the past ten years. There is no appetite for risk. No appetite for new beginnings, just the same old “kick the can,” experience. The Non-risk takers have ensconced themselves and now lord over the risk-takers. “Nothing can be done that rattles any person,” is the rallying cry. The political correctness sting is on. And what this begets is a future that follows. Greece is a perfect example of this glorified pervasive European dysfunction that seems so desirous in the United States. Greece is only a “Nein!” away (no more free Euros from the working class) from devolving into anarchy and chaos, followed closely by Spain and then Italy. A US debt to the tune of $16, 337,000,000,000.00 where almost $950,000,000,000 are paid out as interest annually is 104% of the GDP (Gross Domestic Product). And should you desire to know, Greece is at 178.4%. Spain is at 90.4% and although that might be comforting to some, it is also wiser to know that Brazil and Mexico both defaulted with debts to GDP ratios of 50%.


The Greek Debt to GDP


Greece GDP



Getting back to the Mediscare called SGR formula, the essence of this ensuing debacle lies squarely on the inefficiencies of a bureaucracy that allows for exploitation by the bad elements in society, A payment formula based more on the “lobbyists-determinant” rather than the actual cost and a “ivory-tower” controlled by the non-risk-takers who manage the levers of control, compare and contrast.

Are there inefficiencies in healthcare? Yes!
Are there better methods of delivery of healthcare? Yes!
Are there efficiencies that can be exploited to benefit the system? Yes!

The one-word answers exist in the Risk-Taker realm but not in the exploiting bookish world of “experts.” Just like an economist (Nobel Laureate or not) who has never balanced a checkbook will never know the levers that govern the real world. The consequence of an action is never contemplated by these rarified few. An expert high up in this “high-up” world of  “do this…” has no concept of how medicine is really practiced or for that matter how the world really works or the costs that are incurred and what will be the rip-tide consequences of that "do this..." They just sit and profess…

Ignoring these precarious risks, with vacant eyes, of the beast that lurks is forbearance of what is to come.

Meanwhile the fangs and talons get bigger and bigger and the tail whips and whips hungrier and hungrier...


References:

SGR Formula
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SustainableGRatesConFact/index.html?redirect=/SustainableGRatesConFact/

Medicare Volume Performance Standard (MVPS)
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SustainableGRatesConFact/downloads/sgr2010f.pdf

Medicare beneficiary expense and the GDP
http://blogs.wsj.com/health/2008/07/10/why-medicare-pay-cuts-for-doctors-will-be-back/

SGR and the “Cliff” ~ Ron Shinkman
SGR faces its own fiscal cliff - FierceHealthFinance - Health Finance, Healthcare Finance http://www.fiercehealthfinance.com/story/sgr-faces-its-own-fiscal-cliff/2012-12-11#ixzz2GSwwKnpC

The Sovereign Debt Crisis: A modern Greek tragedy (Federal Reserve Bank of Saint Louis)
http://www.stlouisfed.org/publications/cb/articles/?id=2264

Sunday, December 23, 2012

T'was the Night Before Christmas


The Silence of the night
Has, many voices
The night before
Has, many days.



When the lab’s ears
Have flopped shut
And the cat’s
Meow is a purr
The dark landscape
Is a tumult~
Of houses and hills,
Of vacant roads
And snow-flakes in still.
Merry Christmas to all
All will be well!

When lights are dimmed
And life dreams
Of elves and sleighs
Of cookies and milk
A painful cry leaves
An ache in its wake
And the bleary eyes
Shake off the fog.
The need is great!




Beneath bright lights
The watchful eye
Governs the landscape,
Ache is identified
And the pain is released.
The eye discerns
as the ears monitor
and the brain weighs
All is well.
Merry Christmas
You will be well!



The doctor reaches
To leave and catch a wink
But the morning
Has broken.
More lives need a rescue,
More hearts need a mend
The Night is not yet done
Humanity still needs a link.
Merry Christmas to all
All will be well! 

Thursday, December 20, 2012

A Brief History of Medicine (1965-2012)


The Changed Paradigm

President Johnson signing the Medicare Act 1965


The United States transitioned from a 1000+ year-old model of fee for service to a third party payer model. In 1965, Congress created Medicare under Title XVIII of the Social Security Act to provide health insurance to people age 65 and older, regardless of income and younger people with disabilities. The purpose for this transition was to create a safety net for the retired individuals to have healthcare when their individual resources were fixed and no new source of revenue was available to them. It was a great boon for the elderly. The payment model was quite simple: after the physician interaction, a form was submitted to the CMS Medicare by the patient and within six weeks the money was processed and the patient paid directly. The public viewed it, massaged by the relentless media, as a transition from a horse drawn buggy to riding the Mercedes.



Medicare Assignments

Soon the polity decided that if the physicians participated in accepting assignments, they would be paid a small premium over the normal costs as a bonus and all payments would then be sent directly to the physicians. This had a two-fold advantage for both the patient and the physician. The patient did not have to outlay for the initial bill and the physician under most circumstances did not have to wait for the patient to be paid in order to receive his or her remunerations. The physicians lined up in droves and those that didn’t the market forces forced them into the fray eventually. After all the population was not getting any younger.

The time value of money was definitely on the government and the patient’s side since the six-week and sometimes more delay in payment due to processing delays, favored the two entities and not the physician who had already expended work and energy some time ago. Why quibble about minor things?

ICD codes and Denials

Lo and behold as things became complicated with the ICD coding promulgated by the Government and created by the AMA at a cost of millions to the taxpayers, to use as measurable metrics, the decisions regarding payment of legitimate expenses for rendered care resulted in an automatic 12% denial. This denial was willy-nilly and reasoned as poor interface of paper submission. If the physician office who was the direct recipient of the monies was not on top of perfect paper submissions with the right “ps” and “qs” a denial would be generated by the central (Medicare) and peripheral (Non-Medicare Insurers) planners. The interface between the patient and physician remained at the health level but the cost of that care was now directed towards the government and third party insurance. And if the physician’s office with its burgeoning staff, to accommodate the bureaucracy, was equally incompetent and limited in knowledge of processing the claims, then the physician suffered an economic blow that became apparent to him or her at the end of the year (since physicians by their very nature are not business people). Once the bulb of understanding was lit, it was already too late, further claims resubmission could not be processed because of the 90-day resubmission rule at the Insurer level. So the dragnet of financial squeeze was in place.

Electronic Submissions of Claims

Along came the digital age and every office had to now perforce of mandate employ the digital mode of claim transmission. Well as you might have guessed the initial processing was quicker with a 3-4 week return on the claim. Suddenly the denial rate increased many fold because of the missed “.” and “,” in the generated claims report. Additionally quasi rules of payments were conjured up based on soft “evidentiary” rule-making. This resulted in denials for “appropriateness of care.” The once reasoned arguments for reimbursements now became unreasonable. Given the electronic submission of data, an automatic audit was created to evaluate “appropriateness of care.” Never mind the complexity of the care given, if there were too many high-complexity claim submissions a report was generated to chastise the physician and ultimately used as a denial of services or better yet there was a demand for return of payments via automatic Audits.

As the utilization of the services increased, due in part to an aging populace and because of the multiple co-morbid states represented on the ICD coding method, the healthcare spending rose dramatically, climbing first to12% and then up to 17% of GDP in 2010. With one eye on payments and the other on the spiraling costs, the Insurance audits increased in frequency and more and more human resources were employed in the game of “I did!” against “you did not!”

Alarms and Bells of all shapes and sizes rang out loud and clear that this was an unsustainable progression of events and that something needed to be done to harness this wild and intemperate healthcare beast.

Medicaid, Municipalities, Bankruptcies and Employers.

The model promised and promulgated by the central planners was to provide Universal Healthcare but in conceiving of this largesse they failed to take into account the costs that would be incurred. The states already whimpering in their own financial straits were looking at their own fiscal cliffs of insolvencies and many decided they did not want to partake in the management of the ever-increasing Medicaid eligible individuals because it would collapse them into bankruptcy. A large gaping hole yawned ahead of this conceived healthcare agenda. Physicians, reeling from the non-payment and low-payment model of Medicaid reimbursement cancelled their participation in the Medicaid services, leaving several thousands of the low-income people under the Medicaid rolls without caregivers. (The cost of care delivery exceeded the reimbursements ~an untenable situation for private practitioners). This impact was felt at the state and municipality level who were left without money and a bloated bag of IOUs. However they paid themselves handsomely all the same.  In fact four municipalities in California alone declared bankruptcy due to unsustainable costs of rendering services and paying for their own heath benefits and those of its employees. The Universal Coverage model was fast becoming a forced reality with ultimately the Federal Government will end up undertaking the care of the Medicaid eligible individuals. (Not to mention the employers who shun healthcare subsidy for their employees and agree to pay $2000 fine to save $12000 in premium coverage for the same would result in a sea of uninsured individuals, filling the Medicaid rolls). The burgeoning rosters of people needing medical help and little available provisions of care for the same became a dilemma where something had to be done. The falconer was losing sight of the falcon.

IPAB, P4P and EBM.

The only route to control costs was rationing the expected care, Committees like IPAB and NCAB were established to figure out the appropriateness of care delivery. (This scenario has yet to play out). Not withstanding the demands of the elderly and the poor the scenario seems replete with cost curtailment by acronyms like P4P (pay for performance) and EBM (Evidence Based Medicine). The problems with eaxh of these, remains as to how does one consider performance? The P4P is already being played out, and as all such implied top-down simplicity faces the day of reckoning, the physicians realized that the really sick patients would reduce their (the physicians) performance numbers. So they stopped accepting complicated cases and referred them to the tertiary centers. In time the tertiary centers saw their “health grades” dip due to high costs and poor “performance” and that racked the ivory tower industry to the core. Suddenly articles populated the journals decrying that P4P doesn’t really work and a better system needs to be in place. What was good for the goose was not apparently good for the gander.

As far as the “Evidence Based Medicine” scenario is concerned, it was based on the shifting sands of the word, “Evidence.” In medicine, as in all fast changing fields, today’s evidence is tomorrows “What were we thinking?” that if latched on to, will exact its own pound of flesh.



EMRs.

The metrics for measurable intent was falling apart and along came the EMRs (Electronic Medical Records). The federal government initially enticed the physicians with subsidizing the cost of implementing such hardware and software requirements (you pay now and we will determine “meaningful use” later and reimburse part of your expense) and then lowered the boom by saying that those that did not implement EMR in their offices would be penalized annually on an incremental basis, starting at a 1.0% reduction in their Medicare reimbursements.

SGR and the “Doc Fix.”

The only thing left to tackle by the bureaucrats was the SGR (Sustained Growth Formula) whereby the physicians were being paid for services rendered through the CMS system. The polity seeing the red climbing the financial charts decided that to keep the costs down, the doctors would have to have a cut in their payments. So new formulas were used and to achieve the required cuts in healthcare costs, a 21%, then a 24.7% and finally a 30% cut had to be made to the physician reimbursement to recast the resources to service the millions of newly added individuals to the healthcare roster. The problem here was that using such draconian measures and using them as the sword of Damocles, forced the physicians to bow out of the Medicare system. After all being a physician is still not considered “indentured servitude.” The policy-makers fearful of a backlash from the voters unable to pull the lever, keep kicking the can forward because they can’t stomach losing their privileged seats in the halls of Congress where entitlements are sprinkled everywhere and everything is for free all admixed with a pension that would make CEOs of a large company blush!

Meanwhile the physicians who had private practices initially employing one or two individuals as office staff suddenly found themselves with 10,11 or even 12 members of the staff each fulfilling some regulatory requirement. The cost of rendering care suddenly seemed insurmountable. They had to find alternatives. Many closed their offices; some turned into entrepreneurs, chefs, businessmen and women while others found shelter in hospitals working as hospitalists.

Hospitalists and Outcomes.

Hospitals, too had to remake their image and those that did not venture into the new grid of such forced compliance, or were serving the indigent and poor patient clientele became victims to the financial losses and closed doors. The nonprofit large institutions and most for-profit hospitals were happy because they controlled the physician behavior through their paycheck and rallied large resources to pay their CEOs and CFOs. Many small hospitals merged with larger ones as promises were made and appointments to storied positions meted out to the acquired administrative staff. The consolidation resulted in a safety for the hospitals as 83% of the newly minted doctors out of residency wanted to be on the hospital payroll and forfeit independence to this new form of subjugated practice of medicine. This number a short four years before was at 18%.

Time forces reality to rear its ugly head eventually; a review of the costs suggested that the cost of rendering patient care by the hospitalists and hospitals had, via this model skyrocketed, actually doubled. The AHA lobby along with the patient advocacy groups continued the pressure on the policy-makers not to cut costs to the hospitals. Meanwhile in the dimly-lit rooms astride the large chambers, future is being planned to reduce the salaries of the physicians and base it on productivity. Some will feel the pinch of a pink slip soon. After all something will have to give and it will be the new, expensive employees. A substitution will be needed. Always ratcheting down payments to the new incoming “eager to change the world” doctors, indoctrinated in the cost-conscious, arbitrary “appropriateness of care.”

Back to the Envisioned Future.

From a global perspective given the limited resource of physician and no plans to increase recruitment of younger minds into the medical field, a band aid is being offered by convincing the laity that other “providers” including nurses, physician assistants, and nurse practitioners could function as ancillary physicians and “better” care would be rendered. The experts cite the European and the United Kingdom models. (In UK, five years ago a bill in the parliament was floated to allow nurses to perform major abdominal surgeries ~ it was defeated by one vote). Alas what they don’t include is the 6-month wait for specialists, an equal wait for surgeries, multiple cancellations of surgeries, lack of new life-extending medicines and a medical staff embedded in the bureaucratic morass unable to lift itself from a recliner to render care to the sick. They, the policy-makers also figured that these “providers” would receive a lower reimbursement because of their education and everyone would be covered. Unfortunately the seams of this fabric seem rather frayed. The hue and cry from the public used to “I want it now” over equity will be loud and clear soon.

So what is the answer to this demand and desire for a "controversial" substitution model as the standard bearer for all healthcare in the land.

Maybe some answers in the next discussion.





References:

UK model of Healthcare under NHS

Patient Harm under NHS

General Practioners complain about patient harm.

Total projected cost of PPACA

PPACA cost and options for Employers

Medicare Law 1965

Bankruptcy in Municipalities across US

EMR Mandate

Medicare Assignments

The Rise in the number of Hospitalists


Tuesday, December 18, 2012

And Innocence Weeps


H
ey it's me 
I'm saddened 
by the day 
More pictures
More blanks 
More stares.

Hey it's me
It's lonely
Out here
They say
They care
But their eyes
Just stare.

Hey it's me
I'm smiling
No one sees
Everyone ignores
No one cares
Not even you.

Hey it's me
I'm crying
For love
I'm crying
For hope
I'm crying
No one sees
They are lost
In their belief.

Hey it's me
Look at me
Am I a worm
That sleeps
Or a leaf
That sails
In a breeze
To places
Unseen?

Hey it's me
Look at me
I'm dying
Help me
I'm dying
But you won't
Will you?

Hey it's me!
Am I a twig
With dried intuition
And frail
Existence
Eager to snap?

Hey it's me
Look at me!
Hey It's me!
Look at me!
Hey!
It's me...
Do you see me?




And Innocence Weeps!

Ralph wept for the end of innocence, the darkness of man’s heart, and the fall through the air of the true, wise friend called Piggy. ~ Lord of the Flies

Thursday, December 13, 2012

EMR


Ever have those little things buzzing around in your brain, bothering you. You can’t catch them, because, they are imaginary and you can’t even swat at them because…well, they are imaginary. So this one fine day I made a visit to a friend of mine who was the greatest-ever advocate for the Electronic Medical Records. He would go on and on about the benefits. “Oh,” he would say, “look at all the savings in time management. You can carve out specific times for certain ailments, for follow-ups, for meetings and incorporate all the latest articles and merge them with the patient record as a qualifier for what you are proposing as therapy. I mean,” he was almost deliriously out of breath, ”the benefits are endless!” He would exclaim. Thats when the buzzing got loud.



Happily, over time, he had moved from a DOS based system to a Windows one and now had the latest greatest Windows System 7 installed in his Gigabyte filled humming hardware. The multi-screen filled with beautiful landscapes as displays glowed next to his chair behind the desk. The surface software demon however was one that was “specific” to his specialty and even with the whiff of human passage, it geared up for information, displaying a form to be filled with a blinking cursor prompting the next move. He is an Otolaryngologist by trade and a very good one. So his software was specific to the organs that he dealt with.



His office was, as all physician offices are, littered with journals, copied articles and books; a cascading reverie of knowledge. He sat peering around columns of books at me as I sat on the opposing side. His features were not quite as ecstatic as before, but still jovial. He wasn’t quite as bouncy as before, kind of glued to his comfortable chair. Age maybe had allowed the tug of gravity to play a larger role in his life, I wouldn’t tell. But that joy of life he once had, had dissipated some over the past few years.

“So how’s it going?” I asked.
“Good.” He replied flatly and without further elaboration.

And then the floodgates of bottled frustration opened.

“You know this damn thing.” He pointed to the computer, “I spend ten minutes with the patient and then I have to spend twenty on this nonsense. I have to make sure that all the appropriate “Ts” are crossed. That damn default always is so easy, it populates all the lines perfectly, but then one can miss important information. My typing skills are two finger typing and it takes quite a long time to enter the data. I then have to look over at the end of the day over all the charts and re-review them for errors before I electronically sign off on them. So much for expediency! I spend more time with my $60,000 computer mistress then with the patient’s I want to help.” His exasperation filtered out. He continued, “I used to finish work and head home around 7PM, now I am stuck here till 9PM looking over for potential mistakes.”



“But, I thought you loved this EMR stuff?” I inquired.
“I guess, I loved the idea of it.” He was solemn.


“What about the Dictation Software?” I asked.
“Oh that. Well that is another story. All I can say is that there, their and they’re are all the same to a software and can create a bigger mess to untangle late at night.” I guessed he had already played around with it.



There was a moment of awkward silence as if I, the guest, had overstepped the fragile bounds.

“You know this very nice kid who had gotten in the field of ENT five years ago got himself in hot water somehow and the Medical Board revoked his license because he had clicked the default button that had populated the record and in there was a GYN examination that he of course would not have done. The Board decreed that his records were incomplete and fraudulent!" he said with just a touch of a sweat-bead on his brow,  "Now that scares the bejeekus out of me.” He said, his hands now wringing the sweat out of the imaginary ball of clothing. “Unfortunately he... the kid, had used a generic cheap version of the software as his EMR base.” He fell silent for a moment. “But just imagine!” he said, his voice a little louder, “Just imagine the frailty of our profession in all this. Just…Imagine!” His eyes were fixed at me but he was looking at some far off place through me.

We both sat in silence. Mine was stunned at the news and his was stunned at the recall of it all.



“And to further add insult to my injury,” he blurted out, “I had to hire an agency that I have to pay a $1000, for me to get the “meaningful-use” dollars back from Medicare. That agency is one of the approved agencies by the government.” Out of the $60,000 that I spent on this EMR system, $44,000 will be returned to me over three years, provided I can prove to Medicare that the EMR use is appropriate. He fell quiet a moment. “Meanwhile the public is told that we are getting thousands of dollars from the government for free. I am sure everyone else in the field, gets mocked out by patients and business people alike for being on the government dole! What have we gotten ourselves into?” He shrugged his shoulders, “Hell of a way to lose the PR battle in the public/patient court of opinion and income.”



“Hey, cheer up! Look at all the benefits to the patients!” I said trying to help his mood.



“What benefits? My patients are complaining that I spend more time on the computer that answering their questions.” The only benefit I see is the drug-drug interaction for prescribing medications. That I had available to me as software before all this nonsense was promulgated. I could look at my Palm-Pilot and it would answer with the results in a second. Now I have to fill in five different fields before it will give me the answer and at times I will have to override it because my judgment suggests that is what the patient needs, but the software will honk with all its bells and whistles as if I am doing something wrong. I have become fearful of my own decisions and, this is my own business!”



“There has to be silver lining somewhere.” I interjected.
“When you find one let me know.” He replied.

As I was exiting his office to the half-filled waiting room, he pulled me back by my arm. “You know the Insurers are now demanding to see the EMRs before payments.” Now his eyes were wide expecting answers that I could not provide. “Unfortunately, I don’t know the next move in this chess game.” He looked crestfallen for a moment and then regrouped before his eyes met his patients waiting for him. His smile and demeanor changed and once again the patient-physician wonderland of service, integrity, helpfulness, dedication took over. All was well in his world for those brief moments of communications that were to follow, where he would be rewarded by the wellness of his patients.


 The buzzing just gets louder and louder. "Tinnitus," the expert consultants seem to suggest?
I doubt that. Maybe if the EMRs were an invisible background and truly enhanced the operational efficiency of a medical office... then maybe the buzzing would go away.

The only thing reverberating in my head are these words, “See what a scourge is laid upon your fate…”


Monday, December 10, 2012

Dehydration and Flying (It pays to be a plum than a prune)



This was strange. To a 26 year old, the vistas of the world are full of possibilities. Enchantment at every corner, love at every sight. But this one appeared agitated on a flight that he himself had requested. I attributed it to anxiety, which he promptly denied. He complained of a headache and muscle aches. This was a symptom complex with many probabilities.

Sherlock, I am not. So I landed the plane at a nearby airport down from sixteen thousand feet where we had been cruising for two hours. Remarkably after some Gatorade and a trip to the Restroom he was ready to go, all together in form and function. I was concerned but relented.


Slowly the bulb is lit and understanding burns brighter. In a word the answer was “dehydration.”
70% of the body weight is water based. 87% of that is inside the cell (intracellular). The “functional water” is required for oxygen enrichment and for maintaining the pH balance. Water is vital for blood, digestive juices, sweat and tears. Any discrepancy will lead to complications with delivery of these “humors,” including oxygen to the body cells creating a relative hypoxia. Thus balance leads to optimal health.

Not having which leads to the following complaints: Nausea, thirst, exhaustion, muscle and joint aches, anginal pain, migraine, restlessness and most importantly CNS symptoms like confusion, paranoia and anxiety.

Dehydration can occur as a result of high altitude, excessive exercise, sweating and deprivation.
The balance to maintain optimal body water level is coordinated by the kidneys mostly by concentrating urine. If the water is restricted or lost through vomiting, sweating or diarrhea, the osmotic pressure increases in the blood vessels that draws the water from the cells into the blood vessels. Similarly at altitude where the air pressure is low, the water vapor content is low and compensatory hyperventilation (increased rate of breathing) is a norm there is excess water loss through breathing - the exchange of dry air for moist breath. The shriveled cells slow down their function. The most damaging effect is in the brain. Alcohol at any quantity accentuates this effect, as does smoking. A pilot cannot afford that effect. Especially with the need for advanced decision making required in the cockpit.
Good hydration encourages the following: Increased energy, Reverse cellular damage, Normalization of the pH, Balance blood sugar, Fortify immune system, Better sleep, Clearer mind and Better memory.


Remember in commercial aircraft the pressure altitude at 35,000 feet is about 8,000 feet. This means that our bodies are at the 8,000 foot altitude. Hence the risk of dehydration even while you are sitting in a cramped economy or spread out in the first class, both classes are equally vulnerable to the effects of water loss. You breathe in drier air and breath out moisture laden one!

So what happens with continuous water loss, the blood becomes thicker and therein lies the other conundrum of blood clotting. That, I think we shall leave for another post in the near future.


So drink plenty of water before, during and after flight and at least five 8 oz glasses of water daily for optimal health. If you have to pee, so be it, that is why they have lavatories on commercial aircraft. For general aviation pilots, boys and girls you gotta land or use the indiscretion of the urinal.

Optimal performance is based on optimal health. If you are on your way to a meeting, interview or any business enterprise, it pays to be a plum rather than a prune.

Saturday, December 1, 2012

MEDIOCRITY


"By appreciation we make excellence in others our own property." ~Voltaire

What differentiates between excellence and the rest?



There appears to be a pervasive truth in real life, “good enough” seems to suffice for effort. Does it? What drives us as humans? Or better yet, what prevents us from driving ourselves to achieve the peaks of our potential? Is it need, or want, or something inane, unquantifiable that remains elusive to most?



I met a man a few years ago who had shaped his life to the purpose of his desires. He was learned, quite adept at understanding the nuances of science even though he was not a scientist. He also could rattle off a soliloquy in literature and merge it in off-the-cuff everyday conversation. He knew numbers and could manipulate them to his whim on the back of a napkin and he wasn’t even a mathematician. One could sense his underlying stream of thought was a river that ran deep. His words were chosen effortlessly, perfectly conjugated, impeccable in their expression and deep in their meaning and yet they flowed without any overt contemplation. One could view them in the context of ones own reasoning or the lack of it. Such was the nature of this wise person that it struck me that he must have been educated in some school of great repute once upon a time and that he should have many capital letters and commas after his name.

We got to talking that one lazy afternoon when the sun has crept to the top of the canopy and is just ready to slide down the other side and the shadows barely taint the brightly lit  earth. Our subject of discussion varied from medicine, a subject that he seemed quite familiar with, but he was not a physician, yet he could name some esoteric anatomical parts of the human anatomy and relate their physiological function. He equated the basis of pathology with such simplicity that it would have startled a few academics in medicine. You see when a person looks at disease, the way he did, as normal physiology gone wrong, there isn’t much room for discussion when he arrives at a conclusion. We spoke about the heart and its chambers and he was able to coalesce the argument into rhythm and muscle failure based on blood flow access via the coronary arteries.



We spoke about cancer and he was able to form a picture of the broken down cell function and its relation with its counterparts, its messaging to its neighbors and the deregulation of the communications within.



True he was not conversant in each and every gene that filters good and bad behavior, nor the new found language of the microRNAs or the Histones and their function or Zinc fingers and their effect on protein modulation, but within his arguments, I could see a sense of understanding that required these operands for the whole to function with impunity. The more he spoke about a subject, the more familiarity I was able to beckon within my own reasoning.



And as familiar he was to the landscape of medical science, at my urgings he seemed to go deeper into the cell and then to the strong and weak nuclear forces within the cells and the nature of their behavior.



He spoke of governance based on the rationale that there must be thousands of hits on our well synchronized, capitalized, coordinated life-form via the free-flowing fermions and even some bosons that hit our outsides through Background Cosmic Chatter and from inside us, through the ingested foods grown in a soil that reeks of radium and cesium from the deep fusion machine within the earth’s core. “And yet, lo and behold” he stated with some degree of joy and contemplation that we live fruitful lives through almost ninety years. We must have some mechanism within us to prevent the “wheels from falling off,” he stated and then proceeded quickly into the mismatch gene repair mechanism and thence into a five minute discussion of the p53 gene and its guardianship of the replicating cells.



What struck him, as his emotions would betray every once in a while allowing his passion to soar was the interaction of the protons and electrons within each cell. “After all,” he claimed, “the animate matter is the same as inanimate matter, and each is comprised of the same basic fundamental energy of cohesion?” The questioning nature of the statement wasn’t anything but the rise of cadence in his voice.



 “You see, at the very fundamental level, a disharmony between cellular function would occur should a stray electron come hurtling through space entangled in its fuzzy path to the nucleus of a far away animate object and the pull and push of the nucleus of the fundamental unit of the ATGC within the DNA could be knocked off kilter. A simple variation of the H+ turned into an OH and the A can change to a G that can reformat a specific gene, thus allowing for a disruptive effect on the cell function. “Imagine if you will,” his voice now lowered a few decibels, “a perfectly functioning cell whose mechanism of action via a specific gene has gone awry as a result of this “hit” and now it has to divide to create more of its kind, unless there is a mechanism to stop the cell from dividing with its repository of normal as well as that one specific abnormal gene, the progeny would have the same disrupted function?” His thumb rubbed over his chin and I could tell the wheels were grinding up there in that rarified reasoned mind of his. Some heavy-handed logic!



 “Almost like getting hit by the flu and the virus injects a piece of its DNA into our human DNA with the reverse transcriptase enzyme. I call it a photocopying effect. That little piece of injected DNA may do nothing at all, or it just might strengthen or weaken a neighboring gene and thus change the course of history of one person or a whole subset of the human population.” He grew silent for a moment and then in the same quiet voice he said, “something like the Sickle cell disease that started as a result of the human being coming into contact with Malaria or the Ashkenazi Jewish subset population with the BRCA 1 gene mutated silence of the breast cancer suppressor gene.”



He explored the science of prediction and with a simple but direct blow to the very essence of it, declared that the assumption that grinds the predictive value into numbers is the fudge factor that betrays our lack of reality. Pretty heady, I thought. We skimmed the surface of the ODDS ratio and probability and somewhere in that kernel of discussion we might have hit on Thomas Bayes and what followed was a brief history of the man behind Baysean Logic. Absolutely incredible it seemed, how seamless the conversation was as it bridged between the varied disciplines. It just flowed as a stream, easily circumnavigating the streambed and the rocks beneath.

What do you say to that? Even though I sat stunned in my hard back wooden chair, my mind was alert though my body had slumped under the pressure of his grand yet simple  and mostly verifiable logic. My shoes were moving involuntarily from side to side trying to smooth the wrinkle of my understanding on the tarp that covered the carpet, but this was a wrinkle the size of the Himalayan range.

I thought that hours must have passed with that free-flow of knowledge, yet it was only about forty-five minutes when I looked at my watch. He took a bite of the plum that he had held in his hand gently turning it over and over for the past hour. “Looks like I have wasted enough time. I have to get back to work,” he said. He got up and picked his paint brush and the masking tape and gazed at the corner of the wall next to the window where we had decided that a paint color would be a shade darker then the rest of the room to give the room some “character.”

I finally had the nerve to ask him how he had acquired such knowledge. Painters don't know this much medicine, science, literature? Or do they? 



Amazing insight, I thought, in this fifty-year-old slender man with the wisdom of millions working comfortably as a painter. There was remarkable excellence in this, one seemingly quiet gentle human being who stored a fund of knowledge within, lost on those considered as the “Intellectuals.” His reasoning championed a process of understanding that comes only from a desire to cross the gulf between mediocrity and excellence.

He thought about my question for a while, hesitant to answer it and then said, "I used to be a physician once, now I enjoy the finer things in life! I live with the constant fear of ignorance."

As a parting shot, he looked back before his paintbrush reached the paint...



Monday, November 19, 2012

OUTLIERS (Those daring few)


Liberty's Bell

Imagine the outliers, for a moment. Yes they are none so dramatic in nature and none so modest in behavior then the prodigies of the past. My belief is that the 10,000 hour rule will get you into the 2.5% (read on to determine where that comes from) variety but to be a class outlier, well...

Hybridized RNA Outliers hyb-24 and 12


These select few quietly persist in what their inner compass compels them to do. Meanwhile the rest of us model new models and base our models on even newer assumptions. 

The hybridized RNA hyb-24 and hyb-12 are represented in the last two lines of this matrix



The axioms ride upon other axioms, until we have gigantic bag of assumptions.



The question then is, can we, through the modeling process predict who will be an outlier? Can you? I mean lets just think for a moment. Did anyone detect the existence of a DaVinci, a Mozart, an Einstein or even a Hawkings while we are busy crunching numbers? Or are we even thinking of such an existence. 
Srinavasa Ramanujan


Can we predict that a Ramanujan is a 20-year-old mathematical prodigy living in some hut in the remote village of India? You see what I mean. 



When and only when these outliers make their appearance can we say, “Voila there she or he is!” But here the premise is based on the historical data. Can we simply assign the probability that there is such and such a chance of someone of that caliber lurking somewhere in the far reaches of this planet. To that answer, there is maybe a yes, but not a qualified one. Yes someone is predicted to be there at any predicted moment and time, but with a predicted probability that does not quite reach 100%, Ah! and so there is the rub.



Maybe that is why we contemplate our purpose to repurpose our thoughts through the lens of our inner bias.

Well here is a stunning view from the inside of the modeling conundrum. Imagine if you will that there are a 1,000,000 people across the entire globe and you only have the capability of determining the existence, whereabouts and characteristics of a few from that sample of, say 100 or so to enable a verdict about the status of all of them.



Therein lies the mystery, magic and some degree of hedging in the mathematical modeling that seems to wag the dog. The small n represents the larger N with assumptions bracketing the whole. Thus predicting from a small sample the larger truth of a unique uber-gifted solitary individual is indeed a difficult process. And we can Monte Carlo our simulated iterations into the billions and still come up short with the correct answer.

The premise remains that much of the population has a central limit tendency, which means that the large majority congregate to the middle. A deviation on either side of the central limit is called a standard deviation. Thus two standard deviations from the central limit on either side represent around 95% of the entire populace. This is also known as a 2-Sigma determinant. Some in the business have modeled their modus operandi under the 6-Sigma category, which effectively although with a tincture of hubris suggests that their operating mode is perfection of their art. My answer is “Impossible.” For crying out, humans are involved. Perfection is the sanctity of a Singularity!

Singularity


The Gaussian Normal Curve also called the Bell Curve basically indicates that the central “fat” part of the bell represents about 95% of the entire populace. The lips in a 2-dimensional left and right view hold the remainder 2.5% and 2.5% on either side. These 5 % er are the ones we want to look at. Actually the maxed out, intellectually gifted, talented, focused, driven and purposeful few in the extreme limit of the right tail or the 0.000001% sitting on that ledge. Now here lie the drivers of innovation, progress and profundity in life. The rest of the 99.9999% unfortunately are beholden to these few, these great, these wonderful individuals that transform the world. Oh but before we start crying foul, within this 2.5% also lie the mooching “Varmits” who usurp life under the guise of benevolence after all these are the brilliant monsters who use their talents to tear-down, destroy, flatten and annihilate the virtues and benefits of that certain majority within this minority. To this small but saber-rattling destroyers are likes of the Hitlers, Lenins, Saddams, Maos, Gengises and a select few others of the world. But the other world has a selected place for them called, “Hell.”

Outliers on a Box-Plot


So let me continue with the “real” outliers. After all those outliers must be representing the “right tail” or “lip” of the bell curve. That means that the intellect, passion, determination, devotion and single-minded focus of such an individual is a characteristic that is extreme. It is he who goes off on his or her lonely path to sit on the right ledge and contemplate the right horizon.  It is she who ruminates about the next building block that manifests a changed paradigm. Occasionally however, the right tails pull the mean/average towards it and make the rest look good, but for that benefit, they still do not vindicate he or she who truly and richly deserves such accolades.



The reason for this obvious disconnect, is in model after model we try to ascertain the majority. Our purpose is to address the majority of the population. That is where whatever we are selling or determining are located. Learning about the psychological well-being, the earnings, the buying habits, the selling habits, the living habits, the height, weight, the size of the nose the intraocular distance, the color of the iris, the length of the eyelash all are represented by the 95% probability of being accurate which give some vindication to the majority but which also by virtue of use and misuse the outlying few get shoved under the rug and everyone starts singing the Auld Lang zyne upon reaching the probability significance with a 95% surety.

Steve Jobs


And just about then the blue/green narrow-eyed, with a shock of brown hair, tanned-skinned, Uber-intellectual appears and each word, he utters is the gold drop of brilliance. But the self-congratulatory diaspora are too absorbed in their games of chance and deceitful bias. Ah but this brilliance in the isolation of his or her time and space, creates a majesty, quietly drifting away into the horizon and the “Oohs and Ahs” echo follow behind him or her. These are the remembered few. These are the creators. They are the valedictorians of the human class. These are the few that change the planet.

How do we locate this singular, brilliance in this modeling process? How do we look at this wonderful cohort of gifted beings and pick, encourage, support and enhance this one or these few to make the world a better place. It is quite simple…

But then you know that already.

The Right Tail…Live Long and Prosper. For through you, so will the rest of us!