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!