Thursday, December 26, 2013


I had a strange dream…

The phantasmagoria of the passing green fields riddled with picket fences and cows grazing the fields pass by at blinding speed. As I hurtled on the autobahn it was hardly the illusion of what sanity is made of. On and on the whoosh of the beautiful fancy passed me by at speeds that seemed unreal that all images stood still momentarily and then with the blink of an eye were gone. And as surely as the speeds tested the Mach number a sudden stop on a country mile brought images of the cows wearing bells clanking their way across the road as the traffic came to a dead stop. The calm within the storm.

The fields stretched far into the distance and there before me was a spectacular image of a beautiful rendering of a castle perched high atop a mountain with sweeping vistas of tall trees. 

Was it an illusion? painter’s imagination? Or was it a work of art? Or was it reality?

The castle stood quietly in its cloaked splendor a midst the floating mist of moisture laden clouds, which kissed it gently and with each stroke uncovered more of its majesty. This was the Schloss Neuschwanstein. The beautiful architectural rendering of what has been considered the imagination of a deranged mind. King Ludwig II of the House of Wittelsbach was declared insane for spending the family fortunes in building castles and bringing it to ruin. The “Mad King of Bavaria” was declared insane and deposed. Three days later on 13 June 1886 his body was found in a shallow lake near Munich along with the body of his psychiatrist.

The beautiful castle still stands in all its grandeur. It rises majestically as its turrets prick the clouds trying to shed the truth about its creator. Was King Ludwig II crazy? If he was why is this endearing legacy in the form of such architectural splendor a draw of fancy of every child and adult in the land and across the globe. Some call it architectural fallacy. Some just shake their heads in incredulity, while others shake their heads in awe. But my dream ends there and as I awaken from this strange corpus of mystified wonder, fresh questions arise.

What is mentally insane? Is it the argument about squandering wealth? Was the “Mad King of Bavaria” mad because he loved the architectural challenge of creating such masterpiece as the Schloss Neuschwanstein? Was the dwindling fortunes of a family, the force that invoked the insanity declaration? Was his drowning a suicide or as some now claim it was a murder because of memory-recalled anecdotal evidence that seems to suggest of such a travesty? Whatever caused his demise, it leaves lingering doubts of what was the intent. If you were to venture into the castle’s interior you would find the trappings of a voracious reader fully ensconced in a perfectly royal “reading throne” next to the royal bed overlooking the Bavarian countryside. 

The tapestries adorning the walls and the rich texture of thought that seems to inhabit every piece of the furniture in the finished rooms suggest great concert between idea and perfection. The Swan room another fancy of the deposed King suggests his predilection to the beauty of the swans. He loved the image of a swan and everything in the room speaks of it. Was this idiocy, madness or a mind in love with the beauty in nature? If one looks critically at today, some girls are fascinated with princesses, and dress in their make believe land of holding court or some boys swing a 42 inch wooden stick and envision themselves in the trappings of a Yankee stadium galloping across the diamond after hitting the home run to the applause of thousands. Yes we all have dreams, but wherein lies this insanity that doomed the King?

Today the proliferating morass of psychiatric diagnoses fills a 991 page Diagnostics and Statistical Manual of Mental Disorders DSM-V book. The most common childhood diagnoses of ADHD and ADD now seem to afflict a large and significant number of adolescents in the U.S. and through the developed countries. Anytime a child is hard for the “busy parent” he or she is rendered as a “case” and stuffed with pills to keep him or her from invading the “calm and quiet” of the parents or teachers who have grown to have a depleting content of patience. In fact the increasing diagnosis is a boon for the mental health and the pharmaceutical industry. A pill and all is quiet for the parent or the teacher to indulge in their fancy. Is that a parental insanity escalated to levels of self-absorption that their mechanics of finding solitude be based on prescribed medication? So where is the true sense of sanity? Is there one? Is the person who fiddles in his pocket to make sure that his car keys are still there, the makings of an obsessive compulsive disorder, therefore a psychiatric conundrum? Is the perfect crease on a pair of pants an obsession in need of a pill? Is the parent’s desire for a successful child a fancy worth putting the weight of adulthood on him or her thus depriving that child of his or her “childhood-ness” an insane proposition invoked by the parent? Where does one or for that matter “who” who can draw the line between the thoughts of a wild imagination and the carefully controlled and constructed mindset of sanctified order?

Mental health issues stemming from “neuro-chemical imbalance” are widely appropriated to  a certain population because of their non-conformist behaviors but do these rise to the level of the challenges such as the shock, the stress, the horror of a war in the form of PTSD that need an understanding ear, a steady emotion and potential short term use of medication. When the flights of fancy of an imaginative soul are deemed insanity to prevent cost overruns, or invasion of “quiet time” then something is truly insane.

Do you brush your teeth every morning and before going to bed every night? Is that a ritual of good habit or a compulsion? Do you watch with intense disdain when someone sneezes into their cupped hands rather than in the crook of their elbow? Do you wear gloves to touch all doors, railings, banisters in public places or yearn for a tap with running water to wash your hands afterwards, or look for the ever-present bottle of Purell nearby to ward off the microscopic evils that might rob you of your health? Do you shake hands with people? You see where I am going with this? I once came across a famous female doctor who walked with her hands behind her back. She looked like a duck at times with the arch in her back as her rear end trailed behind. What were the metrics of her “saneness?”  

So we come back to my dream once again. Was the “Mad King of Bavaria” really mad or just indulgent of his fancies of perfection and beauty? Was the drive to depose him the arch purpose of the family or the kingdom to preserve the wealth and power of the family and the kingdom? These are difficult questions, but even more difficult is the premise of a wanton approach to label for selfish desires.

Each one of us comes replete with our own baggage of experiences, some experiences are tortured and others are comforting. It is the composite of this collective that makes us who we are. Where in these realms, is the demarcation line between what is and what is not sane? True the ones that have truly lost all temporal sense of existence need help to function. But here again where is that temporal boundary? When the frontal lobe and its cognitive sense of right and wrong, good and evil, yes and no has departed and the parietal lobe of the brain links action to a constant stream of a circular thought devoid of the temporal constraints then one is compelled to visit the malady with all the tools of rational thought and action to correct the imbalance. But what is sane? This question poses many others in our minds. How we answer these and other such questions might then become the defining path for a society. The pathos and ethos contained within the crucible of humanity might just be the elixir of existence and not the vectors between the sane and insane. For instance some would consider the price of this painting at $117 million, insanity. Would you?

We help others not to add to the ritual and decrees of making more use for the help we have created, but for the true sense of lifting another’s life. We do not add to the plethora of psychiatric diagnoses just to pigeonhole another fellow human into a life-long servitude to drug-promoted-mind-control. We live to better each other’s lives and in that we must rest our laurels. 

Thursday, December 19, 2013


Needless to say that time is the ultimate warrior against life. It is. We, humans live as if the end will be the big giant supernova and that remains a few billion years away. That it would be a big whoosh of collapsing dust into a black hole spreading our dust into the universe through its glorious accretion disk jets. Alas, the vision is sorely in need of revision. The four score years haunt the vessel that inherits the wide eyed immortality thoughts. No, it is a simple and tested hypothesis, observed over millennia and validated in its entirety. Life ends whether in a flash or with a whimper, it ends.

Humans are adept at visualizing grand obscure corridors of endless hallucinatory thoughts, of this or that. You know, like the ones we all have. Buy a lottery ticket and become an instant millionaire, live in palatial homes and travel with the jet setters, eating caviar and drinking aged wine to perfection, whatever that means. Yet we still inhabit the same shell with all its confines and a mind filled with the baggage of experiences. The collected images of the past, embellished through the lens of time, with fancy and incredulity foster and remake the person we are, for better or worse. No wealth or grandeur can escape the shackles of a buried past. We live therefore within ourselves, as us. And no hope will shake the limits of our destiny.

This one fine day, an elderly man with an eye towards perfection and a nose for a tale, held my interest. He was confined to his physical limits from arthritic joints, a stiffness that was pervasive in each movement. Yet he was as real in thought as you or I. He sat quietly without so much as the sound of his breath adding to the noise pollution around. My restlessness in my erect vertical stance leaning against the wall must have breached his sense of comfort at some level.

“Tough day?” he asked.
“Yes a little.” I replied.
“That is life.” He said quietly.

I looked up and smiled at his frail frame affixed in the shiny wheelchair. There was concern on his forehead and in his eyes that were weighted by years of wisdom could perceive through the cataracts of time and infirmity when hurt echoes within another’s silent flesh.

“What is it?” he said and after a pause added, “May I ask?”
“My patient is not doing well.” I replied.
“We are all humans, with limited abilities. Nature has her own sets of rules that defy anything we can think of or consider. We do our best and then let the Grace of God take over. We live and we die, and there hangs a tale. Nothing that is will be, everything will perish with the mind. We just do our best!” Never have words with such simplicity or clarity eased a burden as those did that afternoon. Something ticked. Comprehension! I still remember the echo of those words, expressed with the same lilting inflection as he had said them, so many years ago. Wisdom indeed is the paradise for the open mind of an experienced age.

We look for perfections where hopeless approximations are the rule. We look for science where art would better approximate and vice versa. We are forever looking for “something” other than what we have. Clearly something is wrong or right? That pot of gold at the end of the rainbow is what Leprechauns are made of and 1 in 170 million chance of winning the big bonanza is out of reach for the remaining, yet hope springs eternal to find, to discover, to invent, to redeem, to prosper, to live.

Even with our best intellectually crafted approximations in face of what Nature has in store, we still manage to change the world incrementally in small quantum hops as a different place for all. For better or worse, that is what humans do. We are destined to the limits of our virtues, vices and deeds. We are an interesting species. After all we are the “quintessence of dust” approximating the angels on one hand and the devil on the other. We are constantly bouncing off the firewall of Perfection.

"After all we are all humans doomed to live a life of Hopeless Approximations."

Friday, December 6, 2013


What did meaningful use mean? Wrestling with this concept as an inducement to get paid for a spent cause is hardly the realm of a wonderful idea. And then to wrap it up in the cloak of universal utilitarianism of benefits is another blow to the human intelligence, as if there was any left in this drone milked society of ours today.

They haven’t yet proved it, that the use of EMRs has any beneficial effect on a patient’s health. But what they have proven without prejudice or bias that the imposition of this multi-billion dollar enterprise borne of an inquisitive mind to gather a fully populated big database of who does what to whom at what cost, was a boon to technology, to the middle-service-providing-people through pocket-lined contracts and a bane to the patient and the doctors, for whom it was the next coming since “pet rock.”.

Why the harsh sentiments? Why indeed?

If all you see in the pupil of your physician’s eye is the pixilated glare and flicker when you ask a question, a need has been met. But whose need, you might ask?

Yet salvaging from this experiment the emerging theme of observational science become evident too. EMRs have filled some classic gaps in the field of “this therefore that” philosophical construct through data mining. But then one would ask, is that not a good thing? Surely that question sends pings of synaptic pleasures through every epidemiologist’s veins in the form of an endorphin glow. But does a win for the individual, the patient that sits patiently on the opposing side of the flickering screen?
Thus far and this from variously sponsored studies from the pros and cons tilting windmill landscapes of contingent data, the answer remains elusive, for the propagandists  to outright, no for the pragmatists!

But lest we forget that there is a larger purpose in the linkage between the patient’s personal data and the unified correlates of big data, and the minions that spend countless hours mining it, one heap of digits at a time, we might miss that hot breath of the fire breathing dragon. And Lo, just as we question, here comes a fleeting wave of “Eureka” heralding the new dawn of discovery. Ah we have arrived at the threshold of a new paradigm. The net to bag the big fish has been cast. The rewards is well nigh at hand. “This might be a paradigm that will change the very essence of humanity,” they claim. We will know what drives what. We will know what genes are the presentiments of a given somatic discontinuity. We will know! We will know! We know! We know!

This new door into the cross-linked informational landscape between phenotype and genotype is the brainchild of big institutions, by cross-referencing a “Phenotype-wide Assay” with the “Genotype-wide Assays” and finding the needles that rule the haystack of diseases, we will, they claim harness the power. Well that is good you would think, right? And in many ways it might be. We might for instance know the multi-tasking genes that commit adultery in the soma and create a conundrum of metabolic disorders, of cancers, of heartaches and depressed human thoughts and even what makes us laugh at a bad joke or cry at a good one. All laudable concepts, all worth the congratulatory accolades! But, and this might be a mini-but, what about the gene drivers and the soma (Lamarckian) drivers within the individual. The interacting forces of these two cross-referenced Morlocks and Eloia might have differing opinions to that viewpoint. No? Might we not be surging in our minds towards a paradigm flawed in reality but gorgeous in concept?

Let us presuppose that a typical phenotype is associated with a specific genotype, that would be great, now modify the genotype and the scourge visited upon the phenotype would vanish. Voila! QED. But not so fast, lest we forget that there are incoming volleys that serve different masters within the cell and thus are automated upon invariant schedules and rise up to demands from different sources, via a supply chain of differing mechanistic pathways and cross-talks, the only rational thought we might be able o entertain is yeah, there is a “probability” that this might be associated with that, since it seems to occur in 60 or 70 or 80% of the populace.

Oh but there goes that probability thing again. This probability thing that garners almost a 100% of medical literature comes face to face with the “Ioannidis’ nightmare,” which shows more than 50% of the studies cannot be replicated due to the false gods of bias.  After all the trust lies at the feet of the curator of that big data... But I digress. Oh hey, why not! Educating the mind is a reasonable rational rewarding thing to do. Sometime as someone clever said, I would rather be an octopus and slap eight people at the same time to jog their thinking in one fell swoop, rather than a shark going after chum.

So have we resolved this matter? For now, maybe not but we might have started thinking about unintentional pathways and byways and alleyways that might pose a burden to those that do not represent the rich majority of specified shared genotype-to-phenotype-magical-shoots-and-ladders-type-approach. Just so you feel inclined to shoot the messenger here, read this one about changing landscape of the statins.

Come on give in a little and explore this concept…

Monday, November 25, 2013


There is something to be said about the sudden and violent break from a smooth flight after, and this is relative to the pilot experience, a brief flirtation with a shudder of imminent stall. This departure from the comforts is an aerodynamic oops. You know the kind when a surgeon cuts a vein accidentally, well not exactly that but pretty close. Both the pilot and the surgeon then sweat it out. They either are able to salvage from that experience and live to tell the tale or go down in flames. Lives can and are lost if experience is short and hubris is long.
So what of this departure?

Imagine a smooth flight back to your home, wherever home is. And the last few minutes as you get into the pattern altitude of your home-base airport on the downwind, you feel the drift from the crosswind. You adjust accordingly, but the drift forces you closer and closer to the runway as you continue on the downwind leg. The runway is now instead of being at the tip of your low wing aircraft, it is actually half way to the fuselage, close! You put another wind correction angle to your downwind and arrest the drift. Happily you feel comforted by the inputs. As you turn base, the aircraft now seems to jet across the approach end of the runway and your field of vision. Ah but you are prepared, you took an extra-long downwind leg just for this very reason as you fought the drift. So now you bank into the wind, but it needs more and more bank angle. You look at your airspeed and it is 1.2 VSo. You hold the bank and as you do, you feel the shudder. “It’s that damn wind shear!” something cries out and just as you realize this at 500 feet above the ground, the aircraft nose falls heavily. You’re instincts tell you, “Pull up! Pull up!” and if you do, all visuals are lost except the momentary rush of trees, or bushes or even flat well-manicured piece of land.

The silent sweat that is pouring down your back is a testimony to your understanding of the well-known aerodynamic limits of any airfoil. Exceeding that limit is a virtual calamity at low altitudes but can be salvaged at higher altitudes provided you have experienced and felt and trained for that knowledge.

The wing has a leading edge and a trailing edge, drawing a line between those two points gives us the chord line. It is this chord line that interacts with the relative wind. 

The term “relative” is relative based on how the thrust of the aircraft and its attitude is interacting in relation to the wind. For example, the fighter jet with its after-burners lit will have enough velocity to force a relative wind below its wing surface at near vertical and maintain a lift until it doesn’t. 

However if one were to have unlimited thrust as in the STS Space Shuttle with 5,6 million pound force then one could stay vertical and fly into space. 

You see it is all relative!

A classic example is as a child you might have put your hand out of a travelling car. If you faced the palm of your hand parallel to the ground and slowly changed the angle of the palm in reference to the oncoming air, your hand had a tendency to go up. “Eureka, I’ve found lift” you would think and yell. If you continued changing the angle, a point came where the hand simply was pushed back by the wind. That is as close to knowing the angle of attack function of an airfoil. Once the limits of the relative angle to the wind and the chord line of your hand exceeded, the drag exceeded the lift and push-back was the result. Try it someday, and feel the pressures if you haven’t before.

Angle of Attack is the most ingenious and simplistic measure of this knowledge. In mathematical terms the formula goes something like this: L = (1/2)*dv^2s(CL).
Where L = Lift
d = density
v = velocity
s = surface area of the airfoil
CL = Coefficient of Lift.

Lift, keeps the aircraft up in the air, is essentially helped by only two of these factors. The v in velocity and the CL as in Coefficient of Lift are the modifiers of any such departure from flight. Velocity however is limited in its endeavor to a certain extent since a relative wind change can occur at any speed, altitude and attitude. So that leaves us with the CL. Next question is what is this CL?

Coefficient of Lift expresses the ratio of the lift force to the force produced by the dynamic pressures times the area. It is the complex dependencies of the 3-dimensional airfoil (wing surface) and the air viscosity and compressibility. Below 200 miles per hour the latter has little reference, while the former still plays a part and of course the wing tip "downwash" that reduces the CL. So the measure of each airfoil is then mathematically derived at and gives us its aerodynamic limit. Knowing this helps the pilot in ascertaining where and when the failure might happen and how much margin should he or she give to prevent hat breakdown. 

How does one change the CL on an airfoil? Well my dear Watson, that is easy. Change its shape! How you say? Well you have the ability to deploy flaps that changes the chord line and the therefore its relationship to the relative wind and adding slats as airlines do, that further changes the geometry and increases the margin between stall and safe flight. Next time you fly with a competent instructor, allow him or her to demonstrate the stall characteristics of the airplane.

Stalls: Experience the departure stalls and approach to landing stalls. Consider recovery from a stall with the least loss of altitude. Consider stalling in clean configuration (without flaps and gear deployed)and then just as imminent stall occurs (that buffeting feeling) let the instructor put in the approach flaps and see as the chord line changes to the relative wind, the aircraft goes back to smooth flight without the burbles and shudders, albeit still at a higher angle of attack.

We fly with many different gauges in the aircraft and now with the glass cockpit, we fly with loads of information that keeps pummeling us for our attention. Only one instrument that has the capacity to keep us safe is missing from 95% of all the certified and non-certified general aviation aircraft. You guessed it, it is the Angle of Attack (AOA) instrument. Having this instrument is a simple safety measure that keeps the pilot in the know of when the airfoil capability is being exceeded. Try it out yourself. The AOA indicator will warn you well in advance when the violent break is about to happen. Based on our mathematical derivation, we also know that different airfoils e.g. An F16 wing has a different AOA then a Mooney or a Bonanza, have different critical angles of attack.

So there you have it. Keep the blue skies above you and the green earth below. Land when you want to and fly as often as you can.

Sunday, November 24, 2013


Today, I attempt to answer the question, Is the human mind’s pantheon of self-preservation under the umbrella of Invulnerability and if so, then when does the scaffolding of that mental framework come crashing down to reality?

A difficult question it is to ascertain for sure. But there are some leads into reality that focus our attention on things that go Hmmm each day.

Let us take a child of four for instance, when confronted with the ordeal of disease, he or she responds with little apprehension. And most of the apprehension he or she feels is through the eyes of the parents. Left to their own devices, children do not anticipate hardships, fatality, loss of existence or any such attributes that are allocated to the mental corruption that comes from aging. (forgive my harshness here) adults live in the existential doldrums of disease and disability in their  minds.

But as we age and achieve materialism and through that, confidence we gain the cocky sense of self, there is acquired a certain disdain for death. “Nothing can touch me!” Really? But nature, as we all know has a method to correct any such self-reverence with the minor inconvenience of a non-life threatening ailment. Then and only then, all fears come crashing through. Such is the inspiration of humility.

And then as the skin weathers, the joints creek and memory fails, the certainty of the inevitable visit to the undiscovered country becomes a foregone conclusion and in Shakespeare’s words, “readiness is all.” Life is lived in an expectant mode. Where the fears and reality grip at the tendons each day and make them taut and fragile.

Now imagine if one was to keep that innocent frame of reference and enjoy life as if all the sunshine was there for play, work, harmony with friends and family. Imagine if the only obstacles that were in the way were the mental ones of “don’ts” and “cannots” that were wiped clean. Now imagine the productivity from this exquisite sense of self. This non-impetuous, easily evolving, experiential learning would then become the path to enlightenment. Death and its other feared vicissitudes would not hold the power of a single candle to the glow of the exquisite vulnerability of living for each day.

Ah yes, to think it, achieve it and live it!
Live for each day.
Work hard ~ for in labor lies posterity and the future.
Play hard ~ for in play lies vigor.
Laugh hard ~ for in laughter lies eternal youth.
Eat right ~ for in the proper diet lies purity of each of our inner sanctums.

Think Critically as always!

Sunday, November 10, 2013


From Consumerism to Outcome-ism and beyond where the sun is not allowed to shine.

The world is about to be turned upside down, or it might already have. So let us look at the word consumerism. I surmise the dictionary does not lie;

con·sum·er·ism n “the protection of the rights and interests of consumers, especially with regard to price, quality, and safety.”

Now what in those words is derogatory against the consumer…? “Nothing,” I presume you would say. But as the high and mighty would suggest, it is bad. Medicine intended for consumers in the form of consumerism is bad, very bad. So they in their infinite wisdom or lack thereof have suggested and now promulgated, that we go to “outcome-ism.”

Oh that is just terrific. Remember the debacle in the making with the “Pay for Performance,” or P4P as those google-eyed with the idea seem to want. Ah yes that is exactly what this Outcome-ism is.

Now if only we were just viewers then P4P would work wonders

out`come`ism n “the exploitation of the physicians and their patients for monetary restraints.”

“So what?” You might say. Well, my dear Watson, did you ever hear of the fact that there might be some smart doctors on the other side who can win this fiscal battle easily. For instance, stop seeing patients with co-morbidities, reduce exposure to patients in the Intensive Care Units, crop and prop the healthy and make them your followers and leave the ones that need the most help out to the secondary and tertiary care centers so as to reduce the shrill of this tenor of outcome-ism from closing the doors to their practice of medicine. And if not that, then just leave medicine to others! Oh yes did I forget to mention that doctor practices are ever-increasingly shuttering the doors, as are the hospitals in the name of what some Kool-Aid drinkers would say, “quality.” A little disclaimer must follow: The share of the economy devoted to health care increased from 7.2 percent in 1970 to 17.9 percent in 2009 and 2010. In 2010, the U.S. spent $2.6 trillion on health care, an average of $8,402 per person. 

At 17.9% of GDP the healthcare costs should be reduced. Yes indeed! But the mechanism is not to add more layers of middle-management bureaucracy that have nothing more to do with medicine but to extract that all mighty dollar for their own needs. Oh yes, if do not know this little fact, then here is the enlightenment for you: The administrative costs in medicine (read CEOs, CFOs, CTOs, CMOs, COOs, CIOs) have increased by 3000% -yes you read that correctly, while the physician income since 1975 has increased below COLI. But that trifle fact is a mere irritant to be massaged out of the equation. Just for the "ding"of it all from NEJM old article: In 1999, health administration costs totaled at least $294.3 billion in the United States,or $1,059 per capita, as compared with $307 per capita in Canada (If comparisons with Canada are not found to be odious). And should you get testy on this subject here is another Revenue and Cost of Goods associated Profit Margin for the Hospital and the Doctor: Medicare pays on average$18,000 for a total hip replacement – $16,336 to the hospital and $1,446 to the surgeon. Why if you must understand the strings a bit further, here is a quote from Forbes: $360 billion spent annually for administrative costs as estimated by the Centers for Medicare & Medicaid Services (CMS), and the fact that 85 percent of excess administrative overhead can be attributed to the insurance system. Administrative costs for physicians are in the range of 25-30 percent of practice revenues and insurance-related costs are 15 percent of revenues, according to a National Academy of Social Insurance report for The Robert Wood Johnson Foundation. 
And the spending outlays from the U.S. Government will increase: Federal health spending is projected to grow from 5.6% of Gross Domestic Product (GDP) in 2011 to about 9.4% of GDP by 2035.

The Reason Health Care Is So Expensive: Insurance Companies

So what should we do about it. The most simple of all equations is to, putting it in simplistic terms, "let all parties have a skin in the game!" You know the old thing called "Self-Responsibility," that thing. Oh I know the worthy wordy wild crowd will say, "heartless thug"to that and what about the poor people who have no coverage and pretty soon they will write a heart wrenching article about a homeless person who died because he could not have access and then pull in some arbitrary facts from the "Big Data Corporation" (BDC) and create a compelling article that will stamp itself on all those "feeling hearts." But slow down there a moment cowboy, think critically for a moment. If those that can pay and get reimbursed from their insurance companies as in the old days continue to do so and those that cannot can be subsidized by the government and private concerns this in itself will really cut the price of care down by at least 50% if not more. And lets not forget the Tort Reform (the one that keeps the lawyers restless and paying more than $2000 to the Congressional Trial Lawyers lobby per lawyer annually) that will reduce the unnecessary diagnostics by a simple measure of 30-50% of all (CYA) diagnostic costs. The doctor will have to prove his worth in caring for the patient and not the reimbursement schemes while tied to the flicker of a glowing screen, the patient will have to think twice before running to the doctor for simple ailments of colds and sniffles that cure themselves and in the end the 17.9% of GDP will shrink significantly to reduce the Federal Debt, the $1 Trillion annual interest payment on that $17 Trillion debt and the dollar will strengthen, the future inflationary pressures will decrease and the FED will be forced to stop printing money even for the Dollar as a global currency reserve (FED balance sheet running around $3.7 Trillion. (I might be off by a few billions). Ah yes a win-win for all!

The overarching meaning in the Central Planning Committees subtlety is “we the government want not to pay the doctors for your needs and we will decide if your needs are truly needs! We were once, “of the people, for the people and by the people,” but lately we grown smarter and better and “you the people (know nothing), we the government (Know everything and are INefficient-but you don't know what that means)!”

So who loses in the end? All.

“All are pun-ish-ed!”

“What me Worry?”

Monday, October 14, 2013


What does that mean? Everywhere I look, the same words taunt me as if the very essence of medicine has been non-patient centric. As if the world has been operating on the mean, self-centered, narcissistic reward-finding jollies. Oh and we forget that it was patient-centricism that helped raise the cancer survival rate over 56%, create the biomechanical limbs, parts of the eye, ears, nose, a heart, a hand, a kidney or a lung, transplanted or through sheer brilliance created from stem cells riding up the scaffolding, curing tuberculosis, vaccinating Polio out of existence, extending life in the most dire circumstances of a diseased imperil, or helping replace diminishing hormones of a diseased organ, or keeping the heart ticking when the sludge of excess clogs the supply arteries to it, or keeping the lungs breathing when the sacs are rigid and have lost all expansion, or survive and thrive after the many other human ailments that result from the wrath of the whips and scorns of time. And this they claim was done for the ulterior motive of self-service?

And yet every dialog now begins with the same two hyphenated words; “patient-centric.” Those that regurgitate these words, mumble to themselves, for deep inside they realize in these politically correct times, not repeating the mantra is akin to a target for blame, vilification and demonizing. The articles written by "experts" all suggest that diagnostic and therapeutic decisions should be done with the patients. Up until now, do they really think that it has not been that way? Every test requested is recommended for a purpose of patient care and every treatment offered is determined based on the best potential outcome with the patient's knowledge and consent. Is that not "Patient-Centric?"

Lets face it if you just look at the Lung Cancer survival rates for Stage IV disease, the Europeans (the countries we want to emulate for cost measures) have it at 7-8% while in the US the data shows 14-15%, Is that not patient centered decision making. If the patient wants to fight the disease and the odds, ours is a purpose of defining the fight and the potential of success and failure. If we as physicians don't do that, then we fail our patients and the legal system is ready with its whips and scorns to pounce on us. If all Stage IV Lung Cancer patients were sent to hospice immediately then the survival rate would be ?%? There is a new definition of medical care being implanted in the minds of newly graduated physicians and patients. The media blasts the use of medical care for the very old and infirm and suggests that we are robbing the future of the youth. But under the same breath these very people are mortgaging our and our progeny's future with printed money and a $17 Trillion debt that bears a $1 Trillion interest payment every year.It appears as a pick and choose policy. True the Healthcare expenditure is 15.6% of the GDP and it has to be reigned in. But there are easier, simpler models that can do that. If we can only get these experts that are super-specialized in minor nuance of the economy and cannot see the forest for the trees, out of the way. Unless there is "skin in the game" from all the stakeholders, costs will run rampant. That is the very nature of the beast that feeds on the dilution of facts to enrich its own core. We as a nation of innovators and entrepreneurs have come to espouse new and wonderful discoveries and that comes at a steep cost. The US with its expensive care, which by the way is mostly accounted for by the hospital expenses, the pharmaceutical companies and Device manufacturers, lives on the edge of discovery. The latter two are responsible for the success against diseases like HIV/AIDS across the globe, diabetes management, cancer biologic and targeted therapies and the list continues to proliferate. All this comes at a cost. We can stop all tthat and live with what we have, too. But are we prepared for that? Even if we are, shutting down the engine of Research and Development hurts the future in incalculable ways. And thus, we  cannot have it both ways.

But before we scoff it off, Menafn has a warning...

...according to the National Health Council based in Washington, DC,incurable and ongoing, chronic disease affects approximately 133 million Americans, representing 45% of the total population. By 2020,that number is projected to grow to an estimated 157 million, with 81 million having multiple conditions.

More than 75% of all health care costs are due to chronic conditions according to the United States Center for Disease Control (CDC). Four of the five most expensive health conditions (based on total healthcare spending in a given year in the United States) are chronic conditions -- heart disease, cancer, mental disorders, and pulmonary conditions."

  Are we ready for that? Maybe we should foster "Personal Responsibility" for our health, rather than a dependency, to limit this scourge of "chronic disease epidemic." That national recognition will depreciate the cost of care dramatically in less then a decade.

Front page covers, large glossy ads and even cheap shots at health care litter the field. But I digress. And man can I...

Meanwhile in the storm of this new form of medicine that rages, the only real ill wind that blows, I see, comes from the rising gale of denials of service by the zombies, of denials of diagnostics, of denials of therapy, of everything but what they claim modern medicine is!

 Oh woe!

And that IS Patient-Centric?

“See what a scourge is laid upon your fate that heaven finds means to kill your joys with love…”

A strange kind of love this is, …full of sound and fury…signifying NOTHING!”

Somethings just need to be said.

Let the rotten eggs and tomatoes rain.

Sunday, October 6, 2013


People say, he took the easy way out. But these callous remarks are thoughtless and without empathy, in my opinion. Creativity, intellect and demanding hard work does sometime exact revenge. And this revenge comes in many forms. It can be tied to alcoholism, drug abuse or down right depression. But then one might ask, “How can someone with such talent, intellect and promise succumb to that?”


And therein is our story…

When I was a medical student, a taller gentler soul inhabited our classroom. He was gifted, hardworking and driven. He would spend countless days, dissecting muscles and organs to understand human physiology, when all of us were trying to get a shut eye. He spent many hours grating the chemicals to create the aspirin powder, in order to ascertain the whiff of medical drug. “I want to know how?” is what he said one time to his close friend. On the eve of a promising future, we heard that he had put a gun to his head and pulled the trigger. The shivers of fear, discomfort, confusion and internal turmoil spread through the campus. The why was answered as dibs and drabs of information seeped out, he had wanted to top the list of the graduating class. He came in second. Maybe there were “tiger parents” lurking in his midst, we would never know. But society was the poorer for it.

Many years later, while attending to patients in the hospital, I was made aware that a colleague of mine had passed away suddenly. The news blew the wind out of my lungs. He was young, smart and sported an affable smile. He was quick to befriend and equally reaching to put his hand on a troubled shoulder. At his funeral, I learned that he had taken his own life. What had happened? The story follows that he had been troubled with depression from time to time, related to patient care and facing a malpractice suit and a Board of Medical Examiner inquiry, was too much for his constitution.

Fast forward to a recent loss of another colleague, a big, burly, happy-go-lucky kind of a guy, with a beautiful family had decided that a financial loss and the troubles in his medical practice were too much to bear. His patients loved him. The insurers did not. His family adored him. His bankers did not. 

The somewhat older estimates suggest that 28-40 / 100,000 physicians take their lives annually. It roughly translates to about 400. Bring this number into a sharper focus and one finds that this number equates to about 2 average medical college graduates a year. Now bring into focus the total number of practicing U.S. physicians at 850,000, the number is even more significant when you estimate the rate of an average non-physician individual suicide rate is 12.3 / 100,000. So physician suicide rate is almost 3 and ½ times that of the average population. See here ... and here ... .

What gives?

Although many have propounded theories to assuage the mind with statements suggesting that it is linked to a high rate of drug abuse and alcoholism. These theories have been laid to rest since the rate of both drug abuse and alcoholism is not any more in the physician community than in the overall population. Others say this is because of depression, the catchall term.

But why?

Maybe, I might suggest that the depression follows a certain path on which physicians are forced to walk on. The patients, nay the society demands the physician be an empathetic, intelligent, all knowing, healer. That he be infallible in his approach to life. That he must constantly be aware of all that is available in medical literature. That no unintentional harm must come from any of his actions and that he must be a model citizen. He must stand the cold and hard scrutiny of a retrospective analysis from a prospective action meted out in the hot cauldron of a manifest disease. Now, that is more than the weight of an Olympian torch to carry for any human being. But most carry these burdens on a daily basis and if they cannot, they retire, leave for adifferent occupation or become academicians, protected by the glare of the florescent lights and the comforts of collectivism. And that maybe okay for them, for it is their choice, but it does show a frustration and subsequent change from the modeled system.

But before you think that this suicidal intent is a male thing, think again, women physicians are four times as likely to go into a state of depression with suicidal ideation. And any person with a grain of intellect will not callously ascribe that to hormonal imbalance or the like. Women, as men, practicing the art and science of medicine are equally bedeviled by the rigors of this profession.

Now add to the burdens of worrying about reimbursements for their hard work to keep the business of medicine afloat.  Add to that a constant meddling bureaucracy of EMRs, SGRs, P4Ps, MOCs and it takes away the patient-physician interaction- the most rewarding aspect of medical care. The whole game changes and instead of a warm and caring physician attending to a patient, we get a community of physicians who following the procedures,  forced upon them, acting as drones following the guidelines commandments of the few, appear un-involved, distant and callous while the larger society deems them to be greedy and disinterested. 


The birds eye-view of this societal scene, as it is being played out today is a breach of the very foundation of human to human interaction. This subjugation of the intellect, through the rigors of regulations, requirements, an artificial model of payment structure and other arbitrarily imposed terms and conditions is fast encroaching on a terrible discourse that must follow in the near future. Healthcare is indeed a problem for the entire world. The population is graying in the developed world and the needs of the many cannot be met by the work of a few and that number is dwindling rapidly. But the current method sought out in some Big Data dumps with p-value significance is not the remedy by far. In the US alone where 310 million citizens reside a paltry 1 in 350 physician-patient ratio will change to 1 in 400+ very soon and instead of developing the cadre of physicians, we are bent on destroying the nobility in this once noble profession. 

And, lest you take the low road, let me warn you, IT IS NOT ABOUT MONEY! IT IS ABOUT JOB SATISFACTION (The ability to provide good care and take pride in one’s work)!

Maybe it is time to take the foot off the accelerator on this downhill course that will end up in a tragedy we do not want to see. Maybe we need the “skin in the game” for all participants. Maybe we need to see the impact on the physicians and the overall effect it is about to have on everyone’s life in the very near future.
Physician suicide is just the tip of the larger unmet, unseen debacle that is unfolding before us. Maybe we need to think about the future a few quarters in the future, maybe a few years in the future. Maybe, just maybe, we need to think.

Think…for this is my silent language of grief!


Friday, September 27, 2013

MEME MUTATION ~ and the finite bound proof

I remember a 74 year old man who had brought his 6 year old grandson with him for a visit. I noticed that the grandfather was toying with a pencil, twirling it between his fingers of his left hand from the index to the ring finger and back, all in involuntary, unrehearsed and completely disembodied synchrony. On his right sat his little grandson many years younger and many inches shorter who was also involved playing with the Twizzler, wrapping it around his fingers and un-wrapping it between the different fingers of his right hand and occasionally taking a small bite from it. From a distance, it would seem the two actions were disconnected. But the more I looked, the more it became apparent to me that the adoption by the grandson was the unspoken paradigm of his grandfather’s behavior.  There was the missing link however, the father of the grandson and the son of the grandfather, who had to be accounted for if this behavior in some way matched the other two and represented a transferred meme. So I asked if he would be joining us. No, the grandson proffered, dad was a very busy man and at work most waking hours of the day.

What was the connection between these two people separated by the gulf of at least two if not three generations? Was this mimicry by the little one of the actions of the bigger one?
The question lends itself to life in general. Families seem to adopt similar behaviors. This form of mimicry is cast through invisible paths of learning. 

Do as I do and not as I say is the real world behavioral edifice of standing on the shoulders of giants.

What is most interesting in all this is the slight twist in the learned process, to suit the individual’s need. Wrapping a Twizzler around sequentially around the fingers on the same hand without help from the other hand to me seems an evolving meme of dexterity. It was a mutation of the meme, so to speak. An evolving concept tied loosely to the original.

Today, life is a constantly evolving metaphor.

Memes rise and fall at breakneck speeds or even at snail-paced speed in a bit by bit progression. The internet has cast aspersions on the slow meme evolution. However, by itself  the internet also cannot hold the evolving meme in the consciousness for long, because of newly minted and competing memes. The slowly evolving ones are more gradual and have a larger impact on society as a whole, while the fast and furious ones die a quick death, the spark, the flame and then embers.

Marketing and Promotions of new products lend themselves to the internet for initial success, but the value propositions contained within the product lend themselves to the sustained promotion. Upon that proposition, the mutating memes of the desires of the populace, the shape and form evolves into progressively differing concepts. A case in point is the success of Apple. The lack of success of the Newton Pad many years before the iPad shows how the consumers never took hold of the Newton concept with the same fervor they took to the iPad concept. In the former advertising was mostly via the print and occasionally the television, our thinking had not digitally evolved as yet, but the iPad glory came into being in full force with the age of rapid dissemination of information through the internet. Once taken hold, the value of the iPad product sustained its appeal, while Apple continue to innovate for the next meme. An adjunct to Apple's story is the not so gloried life cycle of Microsoft, bent on revitalizing the Windows architecture in billions of lines of code and forgetting to change the meme in a see now, do now world inhabited with the ADD disposition.

In Medicine, and you know I was going to go there, there are many memes with good reasoned logic that fail and equally many flawed ones that take hold. During the Galen era, blood-letting was a treatment du jour for almost any ailment, to the point that it may have caused the ultimate death of George Washington, the first President of United States who seemed disposed to a bad case of pneumonia. But in those times, where diagnosis was non-existent due to the lack of common understanding of physiology and reasonable treatment availability, anyone could profess to do the job. The presence of the barber pole is a reminder of the red stripes indicating blood and the pole as the staff to use for a puncture wound and thus the pole was the calling card of the “surgeon.”

Sometime the meme takes on a different mode. A child’s interest in a particular field becomes the enduring journey towards discovery. In that meme there is the constant tug of war between the thought and the environs. Take for instance Andrew Weils,

a British mathematician who spent his life tackling Fermat’s Last Theorem for many decades until he found the proof. And in similar fashion “Tom” Jhang

Yitang Zhang, lecturer in mathematics at the University of New Hampshire

who recently solved the “Two Prime Conjecture,” both of these individuals worked hard at their memes with a constantly evolving thought to come to an understanding that has wowed the world.

The question then arises can a meme be instilled in a brain?

Given the discussion above, if the idea is perceived by a fertile mind and the desire to explore it further is initiated, why then the answer is an unqualified “Yes!” With exponential growth of the billions of neurons establishing trillions of synapses, the capacity to absorb dwarfs the adult capabilities. (sorry dads & grandads)

So, my plea to the mothers and fathers and the grandparents, teach the youth to strive for excellence and shun mediocrity. Install the meme and let them run with it!

Today the rage is Social Media. Everyone and anyone is talking about it. The conversation goes that medical and non-medical people must be in a state of constant communication to advance the cause of healthcare. Is that the right path? Communication is good for learning and teaching but not an employment as the fix-it scheme for any and all ailments. The differing degrees of our genetic pools make us a ocean rather than a thimble-full of water. The differences are both absolute and relative. Hence a similar meme cannot serve the needs of the many. The idea of e-Pluribus Unum comes to mind. Engage bu only to learn and educate.

Having said that, there is a place for Social Media, where it can and does provide some amazing benefits to people with breast cancer as in #BCSM and the #HCSM for Health Care Social Media and #HCLDR for Health Care personnel in a Leadership role. These and other Twitter based hash-tags serve a distinct and unifying purpose in teaching and learning for all. Through these sites, memes are generated by individuals and espoused if valid by most, which then modify and let evolve the original premise. Expressing thoughts and concerns by some and finding others that allay anxieties through rationale is a wholesome and enduring concept.  These Tweet chats are a perpetuating and evolving meme of thought and reason.

Adopting the current vogue may be the entrenched value for the day, but can it endure the rigors of time. The answer depends on the potentiality of mutation of the meme and the perceived value to the people.
I met the father of the grandson a few days later and he too had force-evolved the meme from his father, but in a different manner. He had to sign forms and after completion he flipped the pen and caught it cleanly and twirled it from index to little finger and back, ending with another flip and back in his jacket. Ahem! Almost like a punctuation mark. And I wondered what his son was capable of in the next decade with his gifted abilities?

The finite bound proof is in place.