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!


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!

Friday, November 9, 2012

MOL linked to MOC?

I am rarely stunned by events. Things have to be out of the rare. Things have to ring out past the six-sigma or essentially be confident outliers. You know stuff like the 9/11, shuttle Columbia disaster or the black hole discovery. And then there is this, which caught my eye and raised my eyebrow and a convective invective that echoed in the entire house and possibly hurt the neighbor ears too. This…this veiled atrocity seems to climb the same ladder of incredulity as descending down the stairway to hell.

MOC and the AMA;

Let me preface, before I unveil this declaration in its birthday suit, that the “well-meaning” attendants who hold the keys to our futures are the very people who stand to gain from it. The term Maintenance of Certification or (MOC) must come as no big surprise to the doctors but it is largely ignored by the patients and the very “observant” nitpicking media. Just like the ICD Coding is a multi-million dollar contractual windfall for the American Medical Association or the AMA that has only 16% of physicians as its devoted members. AMA has a loud voice because its executives stand in front of the microphone often and collaborate with their counterparts that serve in the government. But now... now, there is a new movement afoot by the AMA to obtain a fresh stream of dollars from policymakers and a fresh “new blood” of members, via the fiat served on the beleaguered physicians to oversee this bogus certificate maintenance. You see, it is and always has been all about money!

MOC and physician knowledge:

Certification in a Specialty is an accepted event, even though it matters little to the patients at-large and further more matters even littler to actual patient care. I have known absolutely brilliant physicians who have never been certified and likewise, I have known others with multiple certificates who are as “dumb as they come.” (Sorry, I am in the judgment seat on this one). Dr. Stream, president of the American Academy of Family Physicians to his credit, said. "It's a fairly rare patient who really deciphers this information."  Yes Dr. Stream you are correct! The only way it becomes an issue with the public is by “making it an issue” as the ivory-towers are wont to do; splash an anecdote and create a junk-science study to prove the cause-celebre. 

The next question that follows is: does MOC have any bearing on the quality of a physician’s ability?

Answer: Read on...

You shake your head. Let me explain…
Does not the practice of medicine have any meaning that doctors have to take patient-centered time and hard-earned money in the pursuit of satisfying the bureaucracy? Do engineers, lawyers and professors take this form of MOC? Answer: No! Well if esoterica is the wisdom in science then we are all dumb. MOC is nothing more than a chosen format to learn the esoterica with no application to the real-world patient care. Ask any physician. But, not one involved in the system.

ABMS piped in for MOC:

Dr. Kevin Weiss MD MPH, ABMS (American Board of Medical Specialties) President and CEO, states"The public can be confident that physicians who are meeting the requirements of the ABMS MOC program are committed to lifelong learning and ongoing self-evaluation," The vice of this “virtuous” statement does not take into account the Continuing Medical Education or 50 hours of annual CMEs the physician currently has to undertake to keep his or her license valid. So, the question that begs an answer is why the MOC then? Here, then is the argument about which mode of learning is the best form for learning. I say, practical experience on a patient-by-patient basis is the ultimate version. In this version, one has to open the books, read through the current science in the journals and engage fellow physicians for their understanding before undertaking any action on any patient’s behalf for any complex care management. I know of several physicians who open up their surgical books and journals before they go into the operating rooms just to refresh and confirm their thought process. I know of several Oncologist who are constantly fighting the battle of keeping up with the daily barrage of newer cancer discoveries so as to provide the best care to their patients. And I know several physicians with many certificates decorating the walls who stand knock-kneed when a difficult case presents itself.

I say...Follow the Money:

The ABMS lists their nebulous reasons for the MOC on their website: “However, in 2006, ABMS’ 24 Member Boards adopted a new gold standard for re-certification with a continuous ABMS Maintenance of Certification (MOC) program for all specialties. MOC uses evidence-based guidelines and national standards and best practices in combination with customized continuing education so physicians demonstrate their leadership in the national movement for healthcare quality. MOC also requires proof of continuing education and experience in between testing for re-certification.” The gobbledy-gook is well written and anyone challenging this would be considered a truant. But look inside this and you will find that the MOC is nothing more than a continuous stream of extraction of hard-earned wealth in the name of excellence. To grow, every company must find new sources of revenue and don’t for an instance think that the ABMS is not a company/business. In this case as fewer and fewer physicians decide to go for certification the need for finding additional heads to bolster the income of an enterprise becomes great, thus the advent of the MOC. As can be easily noted initially the Certification was a one time event to challenge the physician’s knowledge and then soon thereafter as the dollars rolled in, the drumbeat for a continuum was established and now this! By the way here is the Tax Form 990 filed by ABIM (American Board of Internal Medicine) in 2010:

Revenue Amount
Asset Amount
Asset Range
$50,000,000 or Greater
Income Amount
Income Range
$5,000,000 to $9,999,999

While we are on the subject of money, dare I say that the president of the ABIM received over $1 million in compensation in 2009 and over $800,000 in 2010. Nice reimbursements for bureaucracy, don’t you think?

But what does that mean??

Clamor for Policy-making:

So what happens when this enterprise fails to catch the policymaker eyes? Well. Create the magic of diversion. State that patient care is suffering because the physicians are not up to date with their knowledge. Publish the information so it gets a media play. “The American Board of Pediatrics has posted members' maintenance of certification online since January 2010.”  This by virtue of its statement suggests that those not participating are somehow deficient. To further the argument, state that this is in the best interest of the larger public good and then do what the bureaucrats do best, ensnare a few up-worldly mobile, self ingratiating and self-serving individuals to create the chutes and ladder game for the physicians who will be bound to this form of indentured behavior. "ABMS has always made available the knowledge of physicians' certification. Now that physicians are engaged in maintenance of certification, it is a very natural next step for that information to be made available to the public,"

Now then, having established a few steps towards this “nirvana” how does one force all the physicians to comply with this “eagerly accepted and anticipated” mandate?

Federation of State Medical Boards (FSMB):

The Board of Medical Examiners of different states are now coalescing behind the Federation of State Board of Medical Examiners who have decided how to enable the validity of the MOC concept by making it a sine qua non to the medical licensure of a practicing physician. “The Federation of State Medical Boards and individual medical and osteopathic boards nationwide are developing new maintenance of licensure requirements, and the FSMB has said those rules will take certification standards into consideration.” The collaborating parties in this joint strike task force will also serve the AMA for its legitimacy. The following statement implies a mountain of evidence between the lines: “The AMA should serve as a central repository of information and resources for physicians about maintenance of certification,” said Colin Edgerton, MD, a Georgia rheumatologist and alternate delegate with the Young Physicians Section. Having such a resource would be a valuable benefit for AMA members, he added.”

The Battle Beyond:

This will be fought hard and long and might end up on some dockets too. The self-serving proponents will vilify the physicians for opposing it and start demonizing them in public by saying these detractors want to practice sub-par medicine and endanger the lives of the vulnerable patients. When they make their case, their information will be provided in a straightforward format with the physician's name, certifying board and "yes" or "no" to whether the physician is meeting MOC standards, said ABMS President and CEO Kevin B. Weiss, MD, MPH. Their motives will be no different then those of any political opponents ~ humiliation and rhetoric. “Starting next year, patients, insurers, credentialing organizations and others will be able to go to an ABMS website to see if a physician is keeping up with maintenance of certification.”

So now as the temperature rises and things burn to a red hot, the power-brokers are collectively signing-up to use the MOC and morph its needs as mandatory towards keeping the privilege of holding a license to practice medicine. The battle Royal is about to begin. All sensors are recording data. Yes movement is afoot. "Something wicked this way comes." We shall see.

When the battle begins, the physicians will only have to show the facts that MOC has no known benefits in patient-care. Yet it will be a long hard fought battle. Invectives will fly and the bruising will hurt the physicians cause some more. The demonizing will capture the eyes and the ears of the public. Even if the physicians win, medicine and medical care will lose some more luster. So what to do? Should we fight this at all? The answer is, as in any case of injustice, a resounding YES!

There are intelligent thoughtful voices out there: Washington State Medical Assn. President Doug Myers, MD, said during reference committee testimony on June 17.
“We don’t want [physicians] to lose their license because they don’t have maintenance of certification,” But, I am sure Dr. Myers knows that the drumbeat in the distance is getting louder.

The nobility will be tarnished some more until nothing but a rusty flagpole will stand where once a gleaming beacon of truth held sway.

We must keep that nobility.

We must, for the sake of the future generation of patients and physicians.

We must for everyone’s sake.

If you don’t believe me, live on!


AMA advised to monitor maintenance of certification and licensure requirements

Friday, November 2, 2012


This is a Guest Post by Noreen Heffernan
I write my own blogs, but this one tugged at my heart strings and I requested the author to allow this inclusion. Hope you all get the same heart wrenching feeling followed by the overarching pride and passion that these words invoked in my heart. 

Oh Sandy!

Casino Pier Seaside Heights, NJ

*I would ride the Jet Star as an 8-year-old girl.  The rickety old roller coaster, even at that time, was full of joy and suspense for my little self.

Jet Star at Casino Pier 

*My family would drive up on the beach of Island Beach State park, back in the pre-teen days.  We would grab sandwiches from Wa-Wa and have a picnic on the beach in the evenings.
*As a teenager, I would go to the Seaside Heights beach every summer with my friends.  Sheridan Ave baby!!  Tanning contests, beach chairs set up 12 in a row, and we would walk to the Sawmill to get a slice and a soda for like 2 bucks during long 8-hour beach days.

Boardwalk Seaside Heights

*After prom, we rented hotels in Seaside Heights close enough to smell the ocean air, which would hardly mask the smell of beer. J (Sorry Mom).
*In my 20’s, I worked at the Seaside boardwalk in the summers between college.  I would set up shop at a booth or roam the boardwalk/beach with my friend checking badges.  We would go on rides during off time.  Best job ever!

Ferris Wheel

*JENKS-where we would dance away any problems and then have a slice after closing.
*At 23, after I got engaged, we went to the Surf Club to clink glasses and meet up with friends.
*My bridal shower was across the street from the beach in Point Pleasant.
*I spent most birthdays on the boardwalk of Point Pleasant, having dinner with my friends, drinking Blondies and then we would have one too many at Martell’s Tiki bar.

Seaside Heights Boardwalk

Before Snooki and the cast of Jersey Shore came to town, Seaside Heights wasn’t “big” or “Known” to the world.  We lived our lives and made our memories.  I grew up there.  It is my familiar place.  It is my heart.  No matter what anyone says, it is a wonderful, real place; a place that gave back to me tenfold in the form of fun, friendship, laughter and love.  To see it to see a piece of my heart breaking.

Last night my 3 year old daughter sat on top of the couch and sang “America the Beautiful” It was endearing and hilarious since she didn’t get all of the words right.  I made her sing it again. I needed a laugh.  Ample timing.  Sitting there, amidst all of the disaster and devastation the east coast has faced, particularly my home, that moment felt priceless.  Thank goodness these kids can stay innocent in their minds.  If I can, I need to shelter them from everything right now.  Even with no power, we are able to have sleepover parties in the dark, and have flashlight discos…at least we have our home.  At least we have sweatshirts and socks and hats and gloves.  What about the children and the people that don’t? 

Yesterday I stood in Target behind a family who lost everything.  The mother, with her 3 kids were trying to start a life anew, one piece of clothing at a time.  The 12-year-old daughter was holding a newborn baby who was in a onesie, without pants or socks or a blanket to keep warm.  The 12 year old was in her pajamas, wearing old beat up sneakers on her feet.  She started complaining and her mom took her by the shoulders and said, “We just lost everything.”  

Jet Star in its final resting place

My heart broke.  Outside the store, I asked them if they would take an extra blanket from my car.  They refused.  I circled around the parking lot and gave them all the cash in my wallet.  They nodded took it.  It was only $25 but something is better than nothing.  This is one story!  One!  There are thousands upon thousands of more like that.  We need to help these people.  If you are reading this and have a roof above your head and extra dollars in your pocket, help those who don’t.  Help those who have lost everything.

The Devastation

How do we help?  We open our pockets and hearts.  Nothing is small.  This is what is so wonderful about America.  This is what makes us beautiful.  Instead of spending $25 on Starbucks, buy a blanket and donate it.  Instead of putting away $50 this month, put away $20, and give the rest to the less fortunate.  

The strength of the individual

This is what makes our country strong…different…. And now, as I look at pictures of the place where I grew up, where I created and hold on to all of my memories, my sadness is replaced with motivation.   

The broken Casino Pier

I’m not the only one.  I saw it in the volunteers at Toms River North HS, organizing and sorting donated clothing.  I saw it in the overflow of supplies and donations. I saw it in facebook posts urging people to help, collecting, organizing, donating, and shipping.  I see it everywhere. 

Today, I realized there is more kindness than not. There is more togetherness than not.  There is more support than not. There is more hope than not…

One act at a time, we can do it.  We can rebuild the Shore; the place where so many created so many priceless memories.

And so last night when I listened to my daughter sing, I understood the words more than ever…

“And crown thy good, with brotherhood
From sea to shining sea”