Sunday, September 30, 2012

The Gossamer of Failth




The gathering storm looms over medicine. The clouds are turgid with the darkness of human thought. The winds of change are strong as they rattle the shutters while the windows grunt and the whole house of health shudders.

The vortex nearby touches down and in its finite warp captures the patient and the doctor and lifts them in its frenzy to spit them out in far away places. The anger of division meanwhile boils and bubbles. The distance between here and there is farther then the eye can see. The purpose is alienation.

“Doctor, what do you think I should do?” cries the patient. She is shielded only by the warmth of her family and friends, but now seeks shelter in the comforts of another being’s ability. She confides in his knowledge, his care, his desire to seek the ultimate help and his concern for another human’s distress. While he looks at the ravages of nature’s wrath upon a human being and thinks this could be him and captures every essence of what can be done and should be done to come to bear in helping this patient. He volunteers himself, his comfort, his knowledge, his waking moments and most times his resting moments to come up with a plan to thwart the disease that lurks.

“This is what I think we should do.” Replies the doctor after much thought, capturing in that moment all the knowledge that has come to fore on his shoulders to help his fellow human, live through the storm.

“But the insurance is denying this treatment.” She cries, the tears of anger and frustration welling up and threatening to cascade. Her cry seems to inquire, when did another party step into this decision making process? When did the “I think…” of the physician turn into a conspiracy of personal desire. Each individual is an entity that lives by the rule of his/her own double helix. Each is different and each merits an individual mandate of individuation. One size does not fit all, or so as we know from the fields of genetics, neuro-psychobiology, psychotherapy and nurtured life. Whereas for one a simple “no” can be considered a blow to the solar plexus while to another it is a challenge to be undertaken. The field of psychiatry has taken blows from the insurance industry, the latter expecting to cure age-old ailments of the mind in three to seven easy steps. Imagine undoing the riddles of the mature forty or fifty-year-old brain that has been seeded with strong neural pathways from overuse and expect to break from them with words such as, “that is not the way for you to think.” The psychotherapist has to gain the trust of the patient before the latter allows him or herself to be shown a different path. That takes time. Similarly the established bridge between a physician and patient has to happen before the full benefit of therapy can be reaped by both; that of a healthy being rid of the illness.

“So you really think this is the right path. Even the internet says that this treatment has less then a 50-50 chance to work.” She looks down not meeting his eyes.

“You are unique in your own individuality. My plan is based on what I know about you and about this tumor biology.” He answers trying to peer into her eyes. For fear and distrust leads to lack of faith and there he knows no medicine will be powerful enough to wash away this ordeal. It is the limbic connection he seeks that must exist between the physician and his or her patient where true healing resides. The trust feeds into the faith, which bleeds into the self-regenerating spirit. Someone is helping me help myself.

“But I won’t be able to pay for it!” She cries.

“We’ll work it out. There are options available to us. I’ll make some calls.” The doctor says, comforting her. The connection between the two remains firm and she lets go of her reservations. From those words and his eyes, she feels that he will take her to where she wants to go. He feels equally indebted to carry out his promise.

The bond of trust has been established. The faith of words has challenged. And the humanness of living will serve as guides for both.

The gulf that is now widening between the physician and the patient is still bridgeable if the dividers would leave medicine alone, any further and the bridges will not be able to span the divide. The cost of care is alarming in of itself mostly because of the third blind party that shells out the money. It deprives some, of quality care under the guise of unnecessary while it fills pockets of the overseers. It creates a wider gulf in the practice of medicine. It creates an environment whereby the patient distrusts the physician’s motive and in so doing hurts himself or herself due to the disconnect. The dance between the patient and physician follows in lockstep to the beat of a given therapeutic course suggested. Should they lose the rhythm and start stepping on each other’s toes with abandon, all form, grace and function is lost.

The physician is like the deep-sea diver, diving as an instructor with a student. If the oxygen mask accidentally gets disconnected and the student panics, the instructor is there to calm him and restore the continuity, even through all the arm-thrashing and panic. Without that one on one trust all hope and more often life is lost to the ravages of the stormy seas.

Medical care is a joint stewardship between the patient and the physician. It is akin to a mountain climber who anchored through his anchoring lines and pitons can help a slipping climber by lending a hand. If the connection between the two is weak, there is no impetus to support others for fear of self. On the other hand if the anchor of the one giving help is weak then lending support brings both of them down to certain doom. 

In medicine it is not the degrees in front of the name, or the number of articles written, or read or journals subscribed to. It is not in the pinstriped suit or the color of the tie that real care resides. It is not in the P4P, "bundling payments," EMRs, "Demonstration Projects" or other crafty words used as symbolisms, it is in the empathic connection for another human being in need. The luminescence of interpersonal resonance between doctor and patient is bright when not filtered through the veil of impersonal advocacy and imposition of a barrier.

Insurance carriers from any agency, government or private, have little impetus except to restrict, minimize, shrink the outlay of capital so the private companies can make more for their shareholders. For the government, so it can garner more support from the voting public. There is no love lost in individual care by either one, except the need to curb, curtail and crucify.

Personal responsibility on either side of the medical divide is the answer to the most efficient and cheap medical care. The free in freedom is for self-responsibility and not what can be had for free.

The most sacred of all things in caring for an individual or being cared for by another, is trust. We still live by that Gossamer of faith.



Wednesday, September 19, 2012

The Rise of the BORG (Bacterial and Viral Resistance)

"It is always wise to look ahead, but difficult to look further than you can see." ~Sir Winston Churchill


Resistance is Futile

Of all the things that convince me about the future, nothing is so stark, so definite, so telling, and so real than the human hubris. No don’t get me wrong; we live in an environment of self-proclaimed wizards, the same snake-oilmen, quasi-intellectuals who can charm the socks off of anyone. We are the experts that hail from the top of Mount Sinai and yet in that very expertise of existence there is this gnawing, irritating human trait called humanism, or more aptly describes as arrogance, the one that is seduced by the vapors of grandeur, by the deluding sense of perfection, by the lofty sense of perfect knowledge. Oh but I digress into the jungle of human existence.

We exist on this planet with billions of other species. And to be certain there are estimates derived from fossilized records that over a billion species have perished between life and now and that three species go extinct every hour. We are one of those species too but with a short lifespan overall thus far as we hasten towards self-annihilation. True we are the ones gifted with the bipedal motion, the extensions of arms and the dexterity of hands that has culminated in populating this planet with monoliths as high as the Stone Henge, Empire State Building, Khobar Towers and the like and made cities where once water and swamp reigned. Yes we are the quintessence of dust as Shakespeare called us, not because we are great or majestic, but because we have the power of reason and that sprinkle of pixie dust called hubris.

"Look deep into nature, and then you will understand everything better." ~Albert Einstein

And then this:

We must rid mankind of all maladies!

Really?

I mean have we thought this one through at all. Have we reasoned? Have we spent an evening thinking about the entire collective life on this planet as a whole? Have we?

Tuberculosis



Take for example the TB conundrum. We started out with this scourge and found some medicines to combat it. And we were successful. A tincture of Streptomycin and the scourge was no more. Where previously sanatoriums had been constructed to isolate the infected and infirmed till their self-healing or death, now the magic of an injection arrested the continuum of that horrid vigil.



Soon better drugs reigned, like Ethambutol or EMB, Isoniazid or INH and Rifampin or RMP. Each garnered a better share of the TB bug. We all celebrated the onslaught against this vile bacterium that had cost so many lives and we had won. The flag of security had been flown atop the TB gravesite.

But then came the discovery of these clever critters finding little loopholes and infecting humans again. Mathematical Modeling revealed a stark but deafening verdict. TB was undergoing mutations and becoming resistant to our glorified, impenetrable lines of defenses. And that Mathematical Model was verified in real life!

“The rationale for using multiple drugs to treat TB is based on simple probability. The frequency of spontaneous mutations that confer resistance to an individual drug are well known: 1 in 107 for EMB, 1 in 108 for STM and INH, and 1 in 1010 for RMP.”

And not only that, but these little bacterial buggers were becoming more aggressive and thus more deadly in their behavior. What once was a relatively long survival, albeit in the sanatorium, to complete riddance of the TB bacterium now killed humans with impunity within a short span of days.

A study in Los Angeles found that about 6% of cases of MDR-TB were clustered. Multi-drug resistant tuberculosis (MDR-TB) is defined as TB that is resistant at least to INH and RMP. Isolates that are multi-resistant to any other combination of anti-TB drugs but not to INH and RMP are not classed as MDR-TB. Yet the MDR bug had climbed its way into the inner sanctums of inner city!

“There is currently an epidemic of XDR-TB South Africa. The outbreak was first reported as a cluster of 53 patients in a rural hospital in KwaZulu-Natal of whom 52 died. What was particularly worrying was that the mean survival from sputum specimen collection to death was only 16 days and that the majority of patients had never previously received treatment for tuberculosis.”

To be accurate about the Mathematical Model here is a short excerpt to understand the conundrum better:

“A patient with extensive pulmonary TB has approximately 1012 bacteria in his body, and therefore will probably be harboring approximately 105 EMB-resistant bacteria, 104 STM-resistant bacteria, 104 INH-resistant bacteria and 10² RMP-resistant bacteria. Resistance mutations appear spontaneously and independently, so the chances of him harboring a bacterium that is spontaneously resistant to both INH and RMP is 1 in 108 x 1 in 1010 = 1 in 1018, and the chances of him harboring a bacterium that is spontaneously resistant to all four drugs is 1 in 1033. This is, of course, an oversimplification, but it is a useful way of explaining combination therapy.”

So a new barrage of drugs are being crafted and drafted in the battle to circumvent this new abrogation in the paradigm of human thought; that we have control.

Hepatitis B Virus



Just so we don’t get too comfortable with the thought that this is only a single bug. Heck we can smash it in no time. Let me take you into the machinery of the HBV also known as the Hepatitis B Virus.


The gene that encodes the HBV polymerase overlaps with the gene that encodes the viral envelope, and so mutations in the overlapping reading frame can change both proteins.


The HBV is composed of 3400 base pairs and five genes. Each has a specific purpose.



The hepatitis B virus (HBV) is a DNA virus that replicates its genome via an RNA intermediate using reverse transcription. What is interesting is that for its replicative maneuvers, it converts itself into these CCCDNAs or Covalently Closed Circular DNA that is tightly wound together DNA machinery and is impervious to the drugs targeted against the HBV. 

Life Cycle within a human body


So while all viral particles floating around in the blood stream may be rid by the directed therapy, the CCCDNAs residing in the liver tissue by the billions laugh it off in comfort saying “We’ll get you in the end.” The CCCDNA survive to form a large reservoir for replication, reactivation and their own survival in the human body when the selective pressures of therapy are presented.

Hepatitis B Virus


It is important to note that the signs and symptoms from the HBV infection come not from the viral replication but from the Immune response initiated by the body to kill the virus itself. The genetic mutations occur at a glacial pace based on linear time. The rate is 1 nulceotide mutation per year (Mutation Rate = 5*10^-5).



The selection pressures allow the virus to mutate and create quasispecies to live within the liver: It is the constant destruction of the liver cells and the immune response mediated that determines the clinical behavior. “Mathematical modeling showed that the half-life of hepatocytes varies from 30 to 100 days, depending on individuals' immune response.”

The composition of the viral quasispecies evolves over time depending on the selective pressure including, vaccination and antiviral therapy and the host immune response. Escape mutants may then spread in the liver and become the dominant species depending on their fitness (i.e., their capacity to replicate and dominate wild-type strain in the presence of antiviral pressure) and the replication space available for their dissemination in the liver.

PCR Genotyping


The issues of genotyping plague a well-balanced assessment of the HBV quasispecies because of the many pitfalls in the process itself. Yet these are the known methods of determination at present and we have to make the most from them. The dilemma of study is compounded by the dilemma of the limitations of knowledge. Genotyping of the whole virus is tedious but remains the gold standard today. Yet studies continue to use partial genome analysis for reportage that hurts validity and confounds the truth in literature. Besides a single SNP or dual SNP cannot be ascertained by whole genome testing. It has to be done on a SNP by SNP basis with specific endonucleases... so there, now you have the most of it, if not all!


PCR Genotyping Methodology


“(Genotyping relies on either DNA sequencing or hybridization. Sequencing-based methods include standard population-based polymerase chain reaction (PCR), cloning of PCR products, and restriction fragment-length polymorphism analyses. Direct PCR-based DNA sequencing can detect a particular mutant only if it is present ≥20% of the total quasi species pool.61 Cloning can overcome this problem, but analysis of large numbers of clones is required. Viral mutants that constitute as little as 5% of the total population can be detected by restriction fragment-length polymorphism analyses, but separate sets of endonuclease reactions must be designed specifically for each (and known) mutant of interest. These methods are labor intensive, require highly skilled personnel, and are not suitable for high-throughput screening.)”

The virus exhibits the following drug resistant mutations referenced below in the Addendum: primary resistance mutations (rtM204I), secondary resistance mutations  (rtL180M with rtM204V) and compensatory mutations (rtV173L)

So after the facts and the implied human hubris, we are left with a rather sobering thought; species are coevolving and each species finds a niche to survive and progress. It is after all in the Darwin’s dictate that, “Survival of the Fittest.” Choosing to ignore such an important message based on aggregated evolutionary evidence is the hallmark of a callous disrespectful self-indulgent human mind. Say it ain’t so!

"All, everything that I understand, I understand only because I love." ~Leo Tolstoy

References:

David HL (November 1970). "Probability Distribution of Drug-Resistant Mutants in Unselected Populations of Mycobacterium tuberculosis". Applied Microbiology 20 (5): 810–14.

Sarah McGregor. "New TB strain could fuel South Africa AIDS toll". Reuters. Retrieved 2006-09-17

http://www.ihlpress.com/pdf%20files/hepdart09_presentations/emergence_prevention_vr/2_locarniniHepDart%20FINAL_SLocarnini_031209_REVISED.pdf

http://www.natap.org/2009/HBV/111109_01.htm

Addendum: (On HBV Drug Resistance)

The available agents currently in use against the HBV:

Interferon alfa-2b INTRON® A Merck/Schering 1991
Lamivudine EPIVIR-HBV® GlaxoSmithKline 1998
Adefovir dipivoxil HEPSERA ™ Gilead Sciences 2002
Entecavir BARACLUDE ™ Bristol-Myers Squibb 2005
Peginterferon alfa-2a PEGASYS® Genentech/Roche 2005
Telbivudine TYZEKA ™ Idenix/Novartis 2006
Tenofovir VIREAD ™ Gilead Sciences 2008

The viral mutations causing resistance over time to antiviral agents:

Interferon alfa-2a  (Intron A) Interferon 1991 None
Lamivudine  (Epivir-HBV) Nucleoside reverse
transcriptase inhibitor 1998 14 - 32% at Year 1;  60 - 70% at year 5
Adefovir (Hepsera) Nucleoside reverse
transcriptase inhibitor 2002 0% at year 1;  29% at year 5
Entecavir (Baraclude) Nucleoside reverse transcriptase inhibitor 2005
1.2% in treatment na├»ve at year 6;  57% in
lamivudine resistant at year 6
Peginterferon alfa-2a (Pegasys) Interferon 2005 None
Telbivudine (Tyzeka) Nucleoside reverse transcriptase inhibitor
2006 25% in HBeAg positive at year 2;  11% in HBeAg negative at year 2
Tenofovir (Viread) Nucleoside Reverse transcriptase inhibitor 2006
0% at year 2; adefovir resistant HBV should be treated with tenofovir and another HBV antiviral




Friday, September 14, 2012

Strange Melodies


They talk of changeable rhythms of the heart, the kind that go from lup-dup to brrrrrp causing untold misery to the patient. Similarly, humans give out signals of love and hate, of anger and peace, of vitriol and quiescence, of joy and despair. We are in a constant stream of rhythmic waves oscillating in the ether, all twisting, mixing and merging. And yet today we don’t see or hear them anymore. The isolation is deafening!


We are losing our sense of connection. Our eyes are forever locked onto the keyboards of ever-diminishing hand held screens. We smile or scowl at these mechanical devices while the world goes by, and Einstein's train slows down while time speeds up. The trees with their collection of birds, or the flowers with their assortment of bees and butterflies are now back in their own Pre-Cambrian domain isolated from the stare of the human eyes~ a colorful world viewed through grey lenses.

And then there is the human race isolating from itself as it devolves all thought and action into the world of glowing screens.

The seven-year old, texts her mother about her plans for the afternoon, while she is in the next room sending a text message to her neighbor. The boyfriend texts a love note to his girlfriend sitting next to him and she giggles in response. The wife texts about the young kids, embroiled in a fight and the father responds with a message to each with a reprimand. Meanwhile the toddler plays with the computer tablet and the infant looks intently to her older sibling, gathering information of what is to come.

What happened to looking into those beautiful baby blues or browns or blacks? What happened to looking through the dark mysterious pools into the soul and realizing the intent? 


Can a written word express the real meaning of what is felt? If not, then is the society losing its sense of feeling? Is this the reason why so many are bereft of emotions and qualify for a stake in the sand-box of the sociopath field? Are we losing our humanity?

There is a story in every eye that blinks, in every lip that curls and every fist that uncurls. There is a tale to be heard, like those camp fireside chats of hobgoblins, of dragons, of swords and archery, of love, of kindness and treachery. There is where we behold the delicious terror through the wide-eyed story-teller’s concocted emotions and display. A quick hand gesture after a moment of silence is enough to draw beaker-filled nerve stimulants into the nerve-endings to make every muscle twitch.  None of that can be simulated on the little screen that glows. Yet we are blinded by the rage of the tiny blinking screens. We are oblivious to each other’s nuanced emotions. If it isn’t seen on the screen maybe it does not exist. But it does. It does! The whole beautiful overarching canopy of wonderful sights and sounds, they exist. I promise you, they do! Just take the time to see them.


What will become of us? Ever think it through. Will we lose the sense of touch, and smell? Will we eventually become the animated robotic versions of our former selves? We have become the HALs of yesterday and are on target to become the WATSONs of tomorrow, with more unnecessary information loaded within, but without the essence of the deep knowledge and understanding to utilize it with deliberate efficiency. We seem to be moving into the realm of a society that augurs anger and laughter to the flash on the tiny screen. We seem to be losing the sense of touch and feel. Maybe, I plead to my inner sense of hope, that the pendulum has swung as far as it can go and now has nowhere to go, but come back to the center. Maybe? Just maybe?

We need to listen to the strange melodies of each other’s nature. We need to hear the sounds of our inner beings. We need to connect to the symphony of the human spirit. We need to connect with each other through the rhythm of our souls.

We need to talk to one another, see each other and hold together, for the world is a lonely place!

We need to talk!

"Hi there, Hows it going?"
"Great!"
"Any plans for the evening?"
"Yeah. I'm going to tell a story to the kids."
"Bravo! may I come?"
"Sure."

Lets Listen... For you never know what you might hear and learn...

Sunday, September 9, 2012

Medicine and the Nash Equilibrium

Sand-pile Experiment


Stability of a system relies heavily on risk mitigation strategies; these evanescent little fingers that plug the holes of a universal breakdown are but band-aids of sorts, because risk mitigation strategies are based on observable risks only. The Bak–Tang–Wiesenfeld sandpile model is a dynamic system that displays self-organized self-criticality. The system is one sand particle away from a collapse.

Therein lies the problem.



Medicine has gone through its own risk mitigation for a long time. Every hole in the human behavior that potentially could lead to the fall of man is being plugged, band-aided or in some cases spackled over. Medicine has survived many upheavals in the past and it has done so by the artful, careful, considerate and thoughtful understanding by the doctor scientists of the past. Simmelweis utilized the art of hand washing to prevent obstetrical deaths. John Snow an Englishman was the first to show water contamination as the cause of Cholera that was causing 3 million deaths per year in the 1800s. Sabin and Salk used the vaccine to prevent further Poliomyelitis catastrophes in 1952. These are examples of the risk mitigation strategies that have heaped significant rewards for humanity.

As medicine improved humanity’s lot, a desire to help everyone ensued. The grand cathedral of safety was built to help elderly retirees. Medicare was created, as a safety net for the elderly in 1965. It was a monumental success. The price to get the benefit from the system was to pay into the safety net via taxes while a person was employed in the work force, deriving an income and then when a “fixed income” status was reached upon retirement, that money would help defray the cost of their care. On paper, it seemed, a laudable and a well-choreographed scheme. It was designed as a “Pay now Reap Later” concept. Another large gaping hole had been plugged for the senior citizens of the U.S. and many nations who promulgated the same policy. It was a tactical approach to a practical matter.



However over the years as all powerful and wealthy nations with a declining birth rate experience, the U.S. also fell into this trap, the number of workers started to recede in comparison to the numbers receiving the subsidy. Unfortunately this occurrence seemed to happen at the same time that the FICA paying individuals retirees come of age and started receiving Social Security benefits. The debacle that is, brought light to the fact that the government had been using the FICA tax to build bridges to nowhere and stuff the burgeoning public sector “business” with unnecessary expensive “schemes.” The flow of money was so great, free and limitless, that there was no urgency to keep the funds tied up for future retirees. More and more was promised by the politicians running for their congressional seats and the Senate seats in the United States. They brought federal tax payer capital to their states building large behemoth railway stations named after themselves and grand buildings in various municipalities that still lie vacant collecting dust, accruing cracks for the weeds to take hold. Out of guilt or desire for votes, more and more was promised, with less and less available to keep those promises. A picket fence American dream for all was in site and “cheap” money was bandied about so that a $30,000 earning individual was promised a half a million dollar home on cheap mortgage. While that was going on, some used it as an excuse to speculate and house jump reaping rewards for incurring their risks. But then as all bubbling brooks run out of water, credit froze because of the unraveling of the financial engineering and securitizations. Banks stopped taking the “empty” letters of credit and the whole Ponzi scheme came to a screeching halt taking down millions if not billions of people who were left looking through a dark tunnel. The final grain of sand had fallen on the tip of the sand-pile and the cascading landslide created a devastation that we all behold today.

The Landslide


What did that have to do with Medicine? Well, everything, I think. You see fingers of instability have been sewed into the medical system too. Medicine has become more about money then about care. The unstable probes that have been launched onto the medical landscape over time are about to test the fingers of instability. The, this and that was encouraging doctors to accept Medicare payments in part – up to 80% of total. While the money flow was unrestricted more physicians accepted assignments and patient felt they could and did fill the waiting rooms and Emergency Rooms because they did not have to resolve to pay out of their own pockets. Every cough and sniffle found its way into the halls of the hospitals. Each visit cost thousands (read thousands) of dollars. The physicians in the meantime inundated with the burgeoning rolls of patients added to their practices; managing scheduling, billing and other sundry things to handle the large volume of care delivery. Meanwhile insurance feeling the rising cost, limited bonuses and steady profits started raising the premiums and started a “pre-approval practice” forcing doctors to hire more staff to manage approvals and denials of reimbursements. Medicare and the other Insurance Companies initiated an automatic 10-12% denial policy. If the doctor’s office was not prudent in keeping an eye on fiscal matters or on top of their game in billing strategies, then it was too bad for them. They suffered the financial harm to their own detriment and to the thriving bottom line for the insurers.

Medicare feeling the pinch from the rising costs of healthcare due to the planting of miniature “time-bombs” of regulatory fiat, started the nationwide advertising of “fraud and abuse” and started training elderly Medicare recipients and turning them into “whistleblowers” against people perpetuating such fraud. Soon the multi-trillion dollar industry had it tattooed on the populace’s mind that the entire system of healthcare was a fraud being committed in perpetuity. The doctors were vilified and demonized for ordering too many diagnostics and those expensive therapies that “experts” believed should not be used were vilified in the press. The system devolved to the point that the “well-meaning” politicians decided that if they could show their magnanimity by instituting healthcare for all then they would be the grand designers for the future of humanity. But as all schemes done in anonymity are prone to ride slowly to the top of the mountain with banners, they also come down with an express spirit too. That scheme has approached the peak and the sand pile has collapsed. And that is where we are today.

While these ingredients are on a boil in the cauldron and the steam is rising, the detractors pinch and pull the curtains to keep reality from being visible to the masses. “Ah, this is this and that is that,” they say (in Flounder speak) and all the while the bubbles form and burst and the vile mixture is about to burst and splatter over the landscape.

"John Nash" in the movie "A Beautiful Mind"


John Nash the author of “Nash Equilibrium,” is the subject of “A Beautiful Mind” who suggested that as long as strategies are not changed in midstream the equilibrium of mutual benefit is expected.




Well as we have seen that the experts have continued to apply band-aids to the fingers of instability and now have decided to change strategies midstream for all the people - akin to burrowing a hole on the side of the sand-pile. This one-sided change of strategy has disenfranchised the entire population. The “Mutual benefit” is hardly mutual. If you ask the 270 million people who have borne the rising tide of insurance premiums and those that were supposed to be protected find themselves not being able to find good, or, for that manner any care, the entire system is wrought with something unpalatable. Additionally they, the patients, face rising scrutiny for the physician proposed therapies based not on need but on expense. The turgid torque of this volcano is about to expel an undigested reality and it will smell horrid.

The Real John Nash


Plugging small holes in the dam is a euphemism of thought in risk management without an eye towards the bigger picture. And the bigger picture is a calamity of proportions yet to play out. No, this is not a doom and gloom story, it is an unfortunate series of historical events.

Risk mitigation with an eye towards the bigger picture causes a more stable scenario. Piling on sand on sand-piles, eventually, will initiate instability that is sure to end in a calumny.




Monday, September 3, 2012

Collapsing the Degrees of Separation


Digital Pen-Pals

"Those friends thou hast, and their adoption tried,
Grapple them unto thy soul with hoops of steel.." ~Hamlet

Adopting the internet carries a reward unlike any other. It brings people into your life that you would have never met nor would you ever have the chance of meeting. A surprising pause in this reflection bleeds into your thought process, just then, “Huh really?” followed by “I never thought of that before.” And neither have the ones who have not intrigued themselves with the idea of forging this connection.

The ancient oak of reason spreads its roots into the bedrock of communication; it grows loftier in the air while its roots slide and anchor onto more rocks for greater support. It is in the art of communication through which humans find comfort and connection.

Business, Marketing and Advertising lend themselves readily to any format to extend reach. If I can get to your eyeballs and through them into your mind, well then, I’ve got you for that moment. The connection is made through words and it is akin to “You had me at hello!” How so? And is it all about eyeballs and sales?



An interesting question at first glance. No! there is more to the "need for this speed" of communication. One makes “digital pen-pals.” Remember in the old days when you sat down and wrote in scripted format, a letter to another living in far away land, expressing and describing what was around you and what was happening to you, sharing stories embellished with adjectives? Yup I do! The letter was a veritable postcard of your life and your imagined life. Upon receiving a reply and filled with equal measure of the same, you imagined the other side in daylight and in moonlight, through your own rose-colored glasses of how the trees glistened in the sun and how the moon colored the moisture soaked flowers in its silvery embrace. Oh yes, you did, because, I remember sending those letters to you and receiving them from you.

The anticipation was always so electric. The 6-degrees of separation had been rooted firmly through that contact. The landmasses had congealed back into the Pangaea of existence.

But now we are collapsing that 6-degrees into even smaller-degrees. We have the Internet.

What about Medicine in the age of the Internet, you might ask?

Medicine lives on a loftier plane. It does, I know. The pace is furious, the time is short, the distractions are plenty and the meaning of each word is incalculable. In each wink a life is saved and in every other, one is lost. Why then should the doctor consider this medium for interaction? Is it another distraction and a waste of time?

Medicine has some implanted fears. These fears are the regulatory bias of seeming control and yet so many loopholes exist to allow communication to happen between unknown “Business Partners” that the only person whose life, liberty and profession is jeopardized by the turn of the screw, is the physician. You know of course the grand design of the HIPAA law. So then why should the doctor use the Internet for communication?

Communicating with patients directly is a wonderful ancient art of healing. Eye to eye, hand on shoulder, heart to heart. But sometimes in the dead of despair a word or two help. A genuine word of comfort gives solace to the tortured soul. However using digital words that can seep into the “clouds” of unencrypted or even encrypted data by collapsing this degree of separation may initiate the juggernaut crying, “felon,” “miscreant,” and all such relevant forms of vilification against the physician. How best not to traverse that minefield?

There is a way. Write and educate.

Doctors can disseminate information via the digital word, the video format and all sorts of moving art available in the digital world. There are several very intelligent and prolific writers in the field like @Jordangrumet, @DoctorWes, @SkepticalScalpel, @Doctor_V of 33 Charts @GregSmithMD @drjohnm and @hjluks amongst other notables. On the patient advocate side there are other remarkable communicators like @jodyms @jackiefox12 @BCsisterhood that come to mind. These and others like them communicate but do not make it the morphine of distraction! 

So let us collapse the degrees of separation, write and enlighten each other, express our thoughts, understand the other’s, interpret through the lens of our own values, see the world through naked eyes and learn from each other, all without identifying specifics of our maladies or of our life and person. It is after all not about the singular person, it is about enriching life!



Yes doctors as well as patients can both benefit from this digital revolution. No, it is not earth-shattering, it is not the greatest of all things for humanity, it is just two minds communicating via a new format. And the more that find each other in this vast jungle of a 7-billion-humanity, life becomes intelligent, innovative thoughts seize reflective moments and the world transforms.

Remember the jingle: “Reach out and touch someone?”

"To mingle friendship far is mingling bloods" ~ Leontis (A Winter's Tale)