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.

Friday, September 20, 2013


Remember Jean Luc Picard, Captain of USS Enterprise? If you do great, if you don’t you might consider checking out some Star Trek-ology. 

You see, there is logic in the way Gene Roddenberry, the creator of Star Trek approached life, the universe within and the universe around. His logic bears the force of reason, the math of certainty, power of persuasion and has stood the test of time in episode after episode. Remove all sense of emotions, empathy, sympathy and what you have is pure, pristine logic – enter Spock. 

Now combine the two forces of Picard and Spock and you have the spinning drives of the IBM Watson and the nuances of a family practitioner, an Internist or a sub specialist in medicine to make the right decisions for good patient care.

But for the moment, let us reflect on the simplicity of the current forces that have overtaken the inhabitants of this planet; the Eloi and the Morlocks. One cites the magic of their heuristic as the, be all end all, while the other points out to the many cracks and fissures in the conjured up heuristic. The fight that ensues creates enemies that resist ceding valid points because of their anchored viewpoints. As the imbroglio ensues, both lose credibility in pursuing the ends of true science through reason.

Our minds evolve to understand that once fabled logic and its creation may not stand the process of time. Taking hard stands and drawing imaginary lines in the sand are the genesis of hubris. Old science and Reason create a new science.

Our progress in science is one slow methodological step after another. The footprints of those steps are visible, and are sometime transiently hidden behind a trail of vituperative dialog. Simplicity, ever the logic of Reason and Occam’s razo- thin thought, never fails the scrutiny of time. It is mostly robust. Today we thrive on throwing more complexity for the purpose of obfuscating the simple truths.

Is this evolution?
Is this revolution?

Or merely heuristics borne of different mindsets cultivated in the fields of predetermined biased and unverifiable thoughts?

To truly engage, one must leave the door open. One must consider all points of view. One must reason with logic!

As Jean Luc said it many times after logic and reason had danced together, “ENGAGE!”

Wednesday, September 11, 2013


There is no greatness where there is no simplicity, goodness and truth.~ Leo Tolstoy

Andrei Kolmrogov’s Optimal length of an Algorithm and Occam’s razor have a lot in common. Whereas Kolmorogov states that “Among algorithms that decode strings from their descriptions (codes) there exists an optimal one,” Occam believes that the simplest argument among all complex ones is usually closer to the truth.

Now that is interesting in of itself to ponder upon, but there is a better axe to grind, one that would make both these brilliant logicians happy and sated.

The combinatorial forces in this forest of healthcare laws and acts is gathering the enormity of a Typhoon or if you prefer, a tsunami. The incoming is bloating the fears and playing on the hidden fancies of others. The tragicomedy is being written in many dialects, dialog, speeches and in journalistic expanse of the written word. Experts abound in the field of information. Most of that I suggest, is patently useless and self-serving and here is how I have come to that conclusion. It seems to me that the solutions are mostly window dressing for a failed paradigm.

Let’s look at the Medical Care as it is being rendered today.

It is a classic story of the Revenue Cycle cloaked in ambiguities and uncertainties. Revenue Cycle, you  might ask, “What is that?” Having little to do with business, most doctors let alone patient ever think about this.
Let me explain the Revenue Cycle for those inclined to read further, is a cycle of providing services and awaiting revenues to pay off the expenses and deriving the most evil of all, the net income at the end of that cycle.

And why is that news? You ask. Well simply put, where in the world today in a small business , such as convenient stores, gas stations, Apple stores, Microsoft stores, Nine West, Black and White, Macy’s Nordstroms, Lord and Taylor, FAO Schwartz, Staples, Home Depot, Target, Pathmark Grocery stores, Walmart, BJs, Restaurants-any and all can you go and expect goods without paying for them immediately. None, Nada, Zilch! Everywhere you buy goods, you pay before you can haul them off to your home. Right? 

And in some places like, for instance at Dell Computers where the negative cash cycle was in play due to Just in Time production and supply chain distribution, Dell actually got the money up front many weeks prior before the goods were delivered. A nice bonus of cash to play with, invest and raise shareholder equity through their stock price, improve the Market Value of the company and inflate the Market to Book ratios. It happens in the corporate world all the time. But that is not where for the moment, I am not going to go, maybe later.

Let’s get back to the Kolmorogov’s Optimal Algorithm for a moment. The simplest and least complex algorithm that realizes the best outcome is what we are after. In the case of Medicine where there are a multitude of in-between-ers the algorithm is mired in a sea of troubles and all "slings and arrows"are directed at the hapless physician.

The Revenue Cycle in Medicine runs something like this in any doctor’s office. Go ahead, check it out!
Patient Referral Acceptance à Patient Registration à Patient Intake Process à  Insurance Eligibility à Pre Authorization Process à Patient Care Rendered à Claims Submitted à Patient Claims Status à Coordination of benefits à Denial  Received à Denial Management à Follow-up Tracking of Claims à Medicare Claims Remitted à Remittance Posted on patient à  If Medicare 20% submission to Second (third party eg. Aetna, United etc.) à Claims Status à Coordination of Benefits à Follow-up tracking of Claims à Remittance à Remittance Posted à Patient billed for remainder à Reminders à Payments Received à Posted to Account.

That my friends, is the Revenue Cycle Management a physician’s office is compelled to do. In the process there is an automatic 12% denial rate from Medicare for improper coding. There is a strong bias towards RAC (audits) from Medicare which is not included in the above Cycle but occurs frequently and disposes off a physician and his staff time without compensation, but mostly in lost income.

And here is the other kicker that very few physicians are aware of. The Present Value of the future payments. The Revenue Cycle can take as little as 6-8 weeks and as much as 3-6 months. The delay in payments gives the insurer additional revenues, remember that Dell negative Cash cycle) for balancing their balance sheets and paying out before the end of fiscal year to draw attention to costs from the Congress. While the Non-Medicare delay their payouts to help their Cash Flow Statements for potential  M & A activity, stock price escalation by showing increased earnings per share due to delay in Accounts payable etc.

Meanwhile as the fiscal year ends and the Administrative Costs of Medicare and Medicaid go up, the blame game starts against the physicians and Fraud and Abuse is charged with ample display of such in the news segments. 

The total recovered so far is less than $30, 000,000,000.00 vs. the total healthcare costs ramping up at 2,600,000,000,000.00 and that equates to 1.65%. Removing Fraud is a laudable effort but equating fraud to the entire field of medicine and its practitioners in the eyes of the public is a disservice to the 850,050 physicians with a national ratio of 1 physician to every 350 patients and a shortage of nurses is a travesty, wouldn't you say?

Now let us set up a hypothetical scenario of a new paradigm, where, and I will quote an oft stated phrase, “there is skin in the game for both the patient and physician!” The middle meddling wealth accumulating meddlers that have created a man-cave for themselves and are enjoying the fruits of the doctor's labors will come to a halt (with a lot of threats, anger, vilification, etc).

Here the Revenue Cycle does not exist. Patient Referral Acceptance à Patient Registration à Services rendered à Patient Payment à Payments Recorded.  Here the patient is paying for services and expects the best offered by the physician that he or she has contracted with and the physician renders the best possible treatment for the best outcome, knowing that to remain the patient’s physician he or she must provide the best care. It becomes a mano-a-mano decision making and care.

The patient sends the bill to the insurance company that he or she has contracted and paid premiums  and for that the insurance company wants to retain the patient for future premiums and pays the required invoice submitted directly to the patient. Patients today have no clue,as to how the reimbursement cycle turns under the aegis of the bureaucracy. 

But some would say, what about the ones that cannot afford the care. What about them? Believe me charity in the U.S. is the heart of her people. No one has ever gone without care in this land of the free and no one ever will. A safety net of Medicaid, Indigent care will pay for those without means.  But the majority of the people will be spared the nonsense of the Revenue Cycle Management that is causing more and more physicians to shut their offices and run for the hills. The truth is that of the $1 that is billed for service, 30 cents are never collected by the physician's office and the remaining 70 cents are used to pay the expenses (Malpractice premiums, office space rental, mortgage, office staff salaries, pension and benefits, equipment costs, service contracts, education for self and employees) and what is left over is meager and paltry for the time, expense, effort and psyche expended! 

So you might wonder where Kolmorogov and the Occam’s Razor come in. Well Look at the simplified Algo and you will see the answer for Optimal Care!

Friday, September 6, 2013


"O God, I could be bounded in a nutshell, and count myself a
king of infinite space—were it not that I have bad dreams." ~ Shakespeare

No Beauty in Truth?

I got lost the other day, and realizing that my smart-phone had GPS tracking software, I quickly reigned in my options and was back on my merry way. 

For me this was a success story of augmented reality in a box. A truer statement never expressed, in those sense of the words, about innovation and progress. Yes, I hummed to myself, “we have come a long way baby.”

And then I happen to see a man wearing a “Google-Glass” walking his dog in the park and talking to himself. His dog would occasionally lift his ear and then with what seemed a dismayed disdain, let it flop down. The man kept on talking as he wrinkled and unwrinkled his brow in concentration and pretty soon the dog was barking at a bird, pulling at his leash and bounding for the bird; a frolicking methodology to get his master to drop the invisible mode of communication. NOw let me say, there is definitely a place for Google-Glass in the science, medical and engineering world of reviewing aggregated data in a snap shot for decision making, but for a steady means of communication? 

So here we are in this world of Augmented Reality (AR) and being immersed in it faster then the frog going in for a slow boil. We have plenty of these ARs to flit away the time in distraction and purposelessness. No time to think about much or anything, just react to the digital construct and live outside of the real.

Where are we going? ~ Brace yourself boys and girls, here it comes...

Answering the question leads us to many open-ended dead ends. You see, the more detached we are to our reality, the more immersed we become in this virtual world. And oh, yes the creators are hard at work to create the perfect world of symbiosis between a vegetative-reactive brain and modern marvel of the virtual. And they are out there, constructing an ever better, more enhanced mousetrap for our eyes and ears and other senses. Eye tracking software for the marketers to determine what you see and what "gets you," is a tool to check your internal desires that even you might not know about. 

We might then just become a vessel emoting ourselves into the void of virtual reality till time limit constraints come into play. You can see why fewer youth interact with each other, nowadays, even while they are together? To each his or her smart phone screen flicker.

Some don’t even know how to communicate with another person in the flesh. But they make great one-syllable graphic comments on messaging.

You might conjure up an image of me as a Luddite and an anti-progress person - and you are certainly entitled to it. But let me remind you that I owned the Apple IIe with a serial number of 0001234 once upon a time, and the Apple IIc, the Lisa, the Newton, the Compaq hand held, the many shades of iPods, iPads, the iPhones, the HPs, the Dells, Compaqs, an experimental HUD for a general aviation aircraft, a miniature ADHRS eye-mount display, a HITS loaded iPad PFD/MFD and scores of other gadgets and gizmos -  just sayin. So I am fairly well versed in the nuance of the digital shadows. So, where that has lead me is this recognition about communicating with another human being, not through the impersonal digits but through the viable dialog of thought between two people. This I believe is the crux of life.

“Our greatest freedom is the freedom to choose our attitude.” ~ Viktor Frankl

One day when they placed the EMR in front of me, I realized that my eye-to-eye days were coming to an end and my communication with my patients would deteriorate as a result. I am right about that. Ask others, whose heads are buried in the minutia of lab results and diagnostics, but their hands have barely touched the skin or eyes seen behind the black pools of angst.

What if, you could remove the photons of light from the ambient world and augment them with artificial digital photons on the retina? (That is already here, by the way in the form of Eye-Tap) The initial Oohs and Aahs will subside and then what? Where will our humanity be? Today we castigate people for their lack of compassion and try to adjust that socio-pathic behavior by saying that empathy can be mimicked by learning the meme. But is that what we are after? Are we not crushing the pillar of humanity and replacing it with what we have growing at a rapid and escalating pace, the cold, non-breathing, hard and inanimate form of inhumanity? The seduction, that is, is fairly powerful. But in its shiny glory this love of all tech, also empties the brain of critical thought and plugs in thoughtlessness and the unfeeling sense of nothingness. Is it no wonder there are so many suicides. At the threshold of such technological marvels then, why is there so much depression, so little love and so much need to satisfy each and every desire, whim and want and yet even after all that, there is so much- emptiness?

Where we are headed is an anti-human world of robotic existence. The existential question then is will we survive in this virtual world of Augmented Reality? The answers are few and may not be what we imagine, because what we are seeing is augmented, every photograph is color-accentuated, every actor is air-brushed, every scene is other-worldly and of course all games are now “reality-based.” The teenager now can gut another, riddle the bodies with bullets and throw mass explosives onto cities to commit genocide, all in the name of a game. But is that not changing and rewiring the youthful, non-discriminating, impressionable mind? I say it is. One has to see the recent tragedies vested upon us in the past few years by youths who have lost all sense of living and are now killing others because they are bored! (Here: )

"What we achieve inwardly, will change outer reality." Plutarch

So the other day, I asked my self, “When did reality lose its beauty?” and “what is happening to us?” I am still searching for the answer to the first and for the second, it is staring us in the face. 

"Being human is given, but keeping our humanity is a choice." 

Monday, September 2, 2013

TO LIVE FOREVER ~ ENTROPY and Attribution Substitution

Whether we swim in the seas of Bentham’s utilitarianism (sacrifice for the good of the many), or John Locke’s forests of natural laws (for the good of the one) or rattle around in Kant’s canyons of rights (for the good of reason), one thing is equally familiar from such trespasses is that the philosophical bent of morality relies on the construct of the human mind and its relation to mortality. There are circuitous paths that devolve within, into productivity, entitlements based on goodness, humility, greed based on badness, yet all such paths ultimately stare at the same fate, death!

So in this entropic climate of living, why has the human train of thought so evolved into this form of attribution substitution away from reality? Everyone is exercising they’re purposed thoughts into productive creation of personal wealth to the detriment of any and all. Yet everyone knows that the common fate lurks closer at each passing second. The finite in the seemingly infinite is the reality and all else is a substitution of that reality.

Oh, I don’t mean to be morbid about the whole thing, but what fascinates me is the human mind in general and how it behaves against the odds. Human life is entropic, a linear progressive chaotic event with only one ending. We might consider freezing, brains, heads, or even whole bodies to resurrect later, but the whiff of the soul once gone can only return in the minds of the Nuevo-riche, pseudo-intellectuals. For them the world will go on forever and if it does not then it must be somebody’s fault.

What then makes us substitute for reality reality for this pie on the land? This collection of “somethings” that eventually is strewn to the wind as “nothings.” What makes people who they are? What makes a tyrant a tyrant and a seemingly benevolent master an ill-begotten hiding in the shadows, monster? For, if all fate is conjured up as blackness or as light, it still remains an “undiscovered country from whose bourn no traveler returns.”

The precept of this underpinning is enormous. It gives some direction, some meaning to life. The enormity is so overwhelming to the most intellectual of all brains, that even it cannot fathom the consequence of such an inevitability, even with all probability projections and all theoretical conjectures laid out, even Einstein bluntly stated, "As I have said so many times, God doesn't play dice with the world." By “world” did he also mean the people that inhabit it? Of course he did! So if the world according to this genius is not to be trivialized with the game of chance, then why do we continue on this path? Humans by nature are survivalists and that is also their detriment. 

We are perpetually rolling the dice in economics, masquerading cleverer and clever themes of minute asymmetries to exploit fortunes and hiding those gains from the necessary taxes to keep society at its best. In medicine we also throw caution to the wind in search of a probability function that points south when all needles say “north.” None of the heretical, probability and correlative massages soothe the reality of what is and how to fix it. But through it all one certain fact remains constant that life will terminate for all and that is a 100% surety. No Confidence Intervals or mean errors or z scores needed here!

 Authors, and so many of them that I have lost count, write about the immortality of the human being. Some conjecture the Von Nuemann’s self-replicating machine what will co-evolve with the human DNA and create a whole new species that will inhabit another planet when we as race start to spill over earth’s capacity, or press the dreaded button and evict ourselves into oblivion. The hubris that is human intelligence has a remarkable capacity of substitution. It substitutes where it meets a dead-end. For in mathematics, which is the language of life, there cannot be an absence of a solution to this conundrum of extinction. For example, Andrew Wiles solved what seemed impossible to solve for many decades; Fermat’s last theorem. And yet every hour 3 species on the planet go extinct and nearly 1.5 billion have laid down themselves as fossils in the sediment on this earth’s mantle, and we continue thinking, and continue to exploit asymmetries for personal gain at all levels.

On the other hand, if we are to comprehend this inevitability, then what are we to do about it?  Charity, real compassion and empathy towards each other would be a good start. And we might stop trying to substitute meaning for reality.

True we are living in the ocean of Biggish Data. Even though we have Femtophotography that takes 1 trillion frames per second and all the data-warehouses will, by 2020, have 8 exabytes of data that is 8,000,000,000,000,000,000,000 bytes. What are we to do about this vast empire of digits, logically and truthfully? What is apparent is the manipulation of a biased selection of this data to prove a personal viewpoint. The heuristics of the limited mind to get ahead is to manipulate the minds of the others to gain access to the legendary place of self-importance. But what happens then? Eventually the ruse is unearthed by a smarter mind and all things revert to the mean, so to speak and life is roughed up just a little in passing.

I come back to the premise of life. The existential preface must consider the inevitable postscript and the potentiality beyond before contemplating action.

Is it right?

Is it just?

Is it good?


Live in Grace.

Live in Harmony.

Live in Peace!

Truth has never been told in better words than these...

"There is special providence in the fall of a sparrow. 
If it be now, 'tis not to come; if it be not to come, 
it will be now; if it be not now, yet it will come—the
readiness is all. 
Since no man, of aught he leaves, knows what is't
to leave betimes, let be."
~ Shakespeare