Friday, January 31, 2014


Maybe for the USAF, but Not for little Guys!

            Dancing at the edge of an active volcano or leaping from tall buildings with your feet tied to a string involves the same sense of self as a pilot who ventures over a populated suburb buzzing his girlfriend’s house. What makes them tick? I set about exploring this with a true pilot of pilots. A man named Johnny.

            Ten minutes into a flight with Johnny once, I heard the engine hesitate. That gets one’s attention, since there are no gas stations in the sky. I looked over at Johnny, whose eyes were skimming over the instruments acknowledging the responses as he tweaked and prodded the controls- quite the man in his domain. I found us climbing slowly and turning as he did and six minutes later we were back at the airport that we had left recently. After an uneventful landing, Johnny climbed out and proceeded to the mechanic asking him to check and replace a plug or a magneto.

            Now you could be sitting in your armchair reading this and think so what? There was nothing spectacular about that incident. My point exactly! In the company of such a great aviator an emergency was not made a spectacle, it was merely a successful outcome.

            Johnny is a practical man and having him mull over theories is asking the impossible. But I figured I’d get him when he came in for a flight physical.  

“Johnny don’t you see, it was your experience and aircraft knowledge that induced you to land when you lost the plug?”
“Yes but anyone would do the same, that is second nature,” he replied in a slightly tremulous 78 year old voice.
“It may be second nature to you but to most it could be a catastrophe and who knows how many pilots have died as a result of what we experienced because they panicked or did not take appropriate action.”
“So what is this Flying Delta stuff you keep talking about?” he asked. I had him cornered.

            The first time I had reflected upon this theoretical argument was when I was flying with another flight instructor in his Bonanza. A small blob of oil grew steadily to opacify half of the windshield. Even leaning to his left the pilot ignored the urgency of the oil leak. He kept pressing the ignore button in his brain. Geez man! I thought, CFI or not I was taking control. I asked him to put his gear down, cut the electrical load and find an airport nearby. He doggedly flew us to the home base and while we taxied to the hanger, a trail of oil stain followed. Only when he shut the engine down did the flood of dark oil cover the hanger floor. Later it was determined that the prop governor had failed. Here was a 2000-hour pilot ignoring reality.

             Johnny sat there shaking his head while the vein on his forehead visibly throbbed. He grumbled a disappointment as I pressed on with the commercial airline pilot story. With 12000 hours of flight time, this pilot whom I had the luxury of instructing in his newly acquired single engine Mooney should have been a no-brainer. This man flies left seat and his first officer finds all the charts, tunes the radios and communicates while he monitors the auto-pilot. But this was a safety seminar and there were no first officers on board. Under the “hood” and deprived of the outside visual cues he masterfully set the plane up for the initial approach fix and shifted in his seat- a sign of his clear dominance in the field of aviation. I allowed him the momentary self-indulgence. Then the ‘see if you can handle this,’ spirit of the flight instructor rose and swooped down to pull the circuit breaker for the radio tuned to the ILS. As expected the cross hairs of the localizer and the glide slope remained fixated and my efficient pilot kept flying the plane comfortable in his experience. We flew along at 2000 feet right over the airport. After a few minutes, I asked him how the flight was progressing. He looked at the instruments and nodded- pleased. Moments later he flung his “hood” off and a stream of mild invectives spewed. “Gosh darned it! How could I ever? Damned!” I looked at him as his face changed colors shades of red. Exiting the aircraft he complained of a headache and wished not to pursue the flight any further. A tarnished ego had come down with the ‘flu’.
 “And these tales relate to the ‘Delta theory of yours?” typical Johnny.
“Yes of course,” I said, “don’t you see the relationship?”
“Okay?” He muttered under his breath, more a question than an acknowledgement.
“Consider the Flying Delta,” I asserted, “As a triangle with the point facing side ways. Imagine a flight before it occurs. Place all the preflight actions on the left side or the base of the triangle. Any breakdown of this scenario can and should require abandonment of the flight. True?” I asked.

The Flying Delta

“Yes, but...”
“Johnny, the discussion is about the middle of the triangle, the self.”
“Okay.” He growled.

Many ways to Win

“The pointy side of the triangle is where, all the probabilities exist. If all those actions are undertaken, then all probabilities dissolve into one conclusive possibility – that of a well executed safe flight. However, the ‘self’ garners the entire inside of that triangle and can be the weakest link. As in the case of the first person, who denied the existence of oil leak and allowed us to continue towards a dangerous outcome. Although the probabilities were many, the outcome of landing safely was mostly an element of luck. And how many times can you bank on luck?  Now, place yourself in that situation?” I asked. Johnny’s frown deepened across his brow with that rhetorical question.

The many probabilities morph into one possibility

“And,” he paused with a hint of skepticism, “what about the second story?” I could see him grudgingly cross over the mental divide.

“The outcome in the pilot’s mind was predestined.” I replied.

“So you theorize that all flights begin with multiple probabilities and the outcome is one of the possible outcomes. If that were true wouldn't there be more incidents or accidents then there are?” Bingo!
“Johnny most times we walk away from the flight with a nagging feeling that something was not just right. This self-critical nature allows for successful outcomes. The eventual outcome remains the final arbiter of all probabilities. History teaches. This is how we learn. The problem is some of us are not self critical and learn to repeat mistakes.”

Pocketing his medical certificate with a smirk on his face, he walked out of the office with, “Keep it up doc.” The gold seal of approval had anointed my theory.

            I sit back and wonder at how one mandates common sense. As a pilot the rules of the game appear strangely different vs. as a doctor. Filtering out the medical risks according to the FAA guidelines is easy given the set of guidelines. As a pilot however you have to know who out there behind the flight controls could pose a threat in spite of a valid medical.

            I encourage pilots with their hanger stories to get a feeling for their risk taking habits. Pilots love to talk. Let them open their mouths and you will hear their minds. So I listen. Sometimes it is the catch phrase like “buzzing” “low level flight” “had a little” or a VFR pilot venturing, “I flew in the clouds for the first time” without instructions. I tell them about Johnny and use him as a benchmark, hoping they may learn. We educate pilots. FAR 61.53 encourages self monitoring. A pilot must desist from flying in case of ‘any change in the airman’s medical, mental, or emotional condition that would affect the validity of his/her medical certificate. Only the most egregious cases need be considered, others mostly need education. Above all, it is the self, the psychologically intact, self, the cognizant self, the aware of risks self, the in tune with ability and capability self – in other words a healthy self. So you see, the probabilities that once appear in magnitudes of plenty always boil down to the one possibility and that ultimately becomes the eventuality.

            So careful in your differential risks, weigh the odds,  and then weigh them some more, mitigate as many risks before you do anything critical. And remember there is always one that you may have not considered that might become the eventuality. Prepare for it.

           Its true in all walks of life, in every field of science and art. Go ahead check it out and make your day!

 The Flying Delta: “Computers as theater” by Brenda Laurel published by Addison Wesley Publishing Company 1993

Article previously published in the FAA Medical Bulletin 2004

Friday, January 24, 2014


When I was young, I remember writing an essay about a “Tempest in a teapot.” The story, I wrote, escapes me but the title remains.

The temporal despondency that exists in our society today seems to long for the next calamity, even if there isn't one. So we create it. Fear is a loathing demand encumbered by a few to create the “double, double boil and trouble, fire burn and caldron bubble” for the rest of us.

The enigma that saturates our fabric seems to arise of an evolutionary process of desire; the desire to live on the edge of disaster. Maybe the art  of science and the science of art have morphed into each other and the calamity that exists is none other than the one that we imagine.

The daily dose of what will kill us comes naturally to the guardians of the expressed words. The media moguls troll the world in search of disasters and pick out anecdotal images of grief, trying to invoke our sentiments on an hour by hour basis. Something has gone terribly wrong. Even our entertainment has reached a spiral downwards and the end spins at the bottom scraping the floor looking for futility, horror and disasters in what has become known as “Reality TV.” We long to communicate but in 140 characters. We long to see others but in digital photographs. We long for affirmations but as" thumbs up" or "likes." We are drifting slowly away mired in the chaos of our own little teapots.

With that introduction of the macabre sense of today let me introduce the medicine world that has drank from the same cup, the wisdom of exploitation. Medicine is in the throes of a change, but it is not in the glow and luster of the latest gadgets that tell you your heart rate, your electrocardiogram or your blood alcohol level on the fly, neither is it the promise of checking your cholesterol, urinary metabolites or electrolytes in your blood stream by blinking your eyelids, nor is it the future of nano-sensors transmitting information about likely mutated genomic structure within our DNA that will result in disease on a second by second basis to alert and warn you of the impending calamity. No it is none of those; it is the sheer programming of the human mind to constantly fear the unexpected. This fear then draws the populace into a terrible consequential narcissistic continuum of fleeing from the inevitable grim reaper, as if anyone can escape him or her.
Some talk of disruption in medicine, while others hail the future as the ShangriLa of always tethered to the once forbidden fruit of universal knowledge. But what has it brought us, comfort, peace or happiness? Is not the premise of progress to aim for a better life? What defines better life? More access to useless information that creates larger tempests in our own teapots, forever shackled to the ultimate tragedy of nonexistence.
Today in Medicine we do empirical work, that cannot be replicated more than half the times (here), and we never publish the negative data, since that is so un-medicine-like-not-to-show-affirmation-of-desired-premise. We massage data, manipulate numbers and rest our wits on some arcane mathematical symbols all the while playing with the degrees of freedom to arrive at the predestined “truths.” What does that say for us?

Before you think Medicine is the terrible art of what is wrong in the world today, let me suggest that finance, anthropology, chemistry, physics and all other fields including the arts suffer similar fates. You just have to dig a little deeper to find the hidden “nasty precious stone.”

So what is to become of this? Is there a solution?

Of course there is!

The basic argument against this contrived art of the probable lies in, “If something or someone defies common sense, then proper vigilance and replication of their contention must be undertaken independently.” But what if you do not have the necessary scientific/mathematical/statistical tools to challenge the premise? Ah! But if you possess common sense and that sense chirps in your inner ear, listen to it.

So I started with the “Tempest in a Teapot” and it holds true. We are all so focused by the clang and bang of the next disaster approaching that our teapot is always shimmering with wakes of turbulence. But remember it is and always will be our own teapot, which we can steady and from which we can pour our own elixir of life, undisturbed.

Tuesday, January 14, 2014

Pivoting on Pin Heads

Two individuals both bright in their presentation find the luster of success by trampling on another’s grief. Both huddled, for want of a better word, in the realm of a self-imposed totalitarian-styled narcissism
I came across them through their words and the words left me wanting for air. From those words, one can see that both have no difficulty of expression. Both find refuge in exploiting the right words for the intent in their meaning. Both seem remarkably astute in their discipline of what they wish for the reader to read. So when I read their words, it was an indictment of their intent and purpose.

Mentioning a brave and open person like Lisa Adams whose courage and bravery in fighting the tentacles of a wretched disease in the same flow and context as resource consumption is a travesty,

Yes, this world has changed from the compassionate comforts to the hard realities of fiscal constraints. We see time in terms of money. We see life in terms of money. We see work in terms of money. In fact money seems to govern every aspect of life. Money, it seems governs our lives, thoughts and actions. This stark reality only comes to face its own sets of demons when confronted with the likes of Lisa Adams @AdamsLisa who has led the charge in breast cancer advocacy since facing her illness and has inspired hundreds and thousands of others through her quest.

The “Hope” we have often heard about is the very essence of everyone’s existence. It is the measure of our respect for life. It is the measure of what we see as our future. This same hope is now being reduced to metrics that measure money. Comforting someone in the throes of an illness with euphemisms and sultry inconsequential words, all the while purposing the one object foremost on the bureaucratic mind is a testimony of how far and how deep we as a society have sunk.

And there are many like the Bill and Emma Kellers of the world, who see the world through their own eyes of cost-repair in a money-dominated minded society (here). Forgetting in the process that there are hopes and dreams of individuals other than their own, they cite personal stories to invoke emotions and passion in the current vogue of “Made to Stick” mantra that everyone seems to aspire. They miss the forest for the trees!

Jody Schoger @Jodyms is a wonderful writer, a disciplined and gifted advocate for patients, well-versed in the disease manifestation of breast cancer who lays out clear examples of the many weaknesses in the Keller arguments in her blog (here).which should be taken seriously. 

My medical oncology training and years of experiential reference has seen the world view change when observed through differing set of lenses. What once was is no longer. What was considered prudent has gained notoriety. What once we reveled now we revile. What once we took for compassion now we take as misguided idiosyncrasy. “Change” seems to have taken a path oft-traveled. If medicine is not about, healing, comfort, curative intent, and education, then we are truly adrift as people.

True, the term "Hope" has different meaning to different people. But ultimately it morphs into the cortex of each of our own being. Respect for that "hope" is what makes us human.

Times do change, but human emotions remain the same. The clock ticks and the second flies by, but history of that second should always be considered. If the Kellers and their pontificating kin have their sway we will morph into an even more intolerant society, where any weakness be it disability, infirmity or illness will become a societal burden, a consummation devoutly to be rid  and we know what happened with that way of thinking.

Sunday, January 12, 2014

REGRESSION and the fallacy of Analytic Predictions

Lately I have been watching people, a singularly interesting time-occupier. And what have I learnt? A lot of things! Whereas the mores of the society in general are degenerating at a pace far exceeding other epochs in human history, the current goings on seem to be tied to the Gordon Moore’s law, only we are talking deviating brain activity rather than the chip transistors. It seems that humans have a tendency to go into the outlier territory once in a great while and then like the Foucault’s Pendulum regress back to the center. At least, I am hoping that will be the case this time too.

Regress? Why on earth would going back to the center mean regression? Oh that is an infinite jest of the language. Let me explain both sides of the y-intercept and the standard deviations to make a believer out of myself and hopefully you. The former is more at hand than the latter, for you might laugh out loud (LOL?).
Okay, here is the gist of the matter. We draw lines to predict the future. The trend is the trajectory and any future spot out there is the future. Through the lens of our crafty mathematical genius we are able to affix a point and time in the future and predict that that will be the case. We are not always right you know. For instance 1984 did not happen in 1984 but in 2014. The future immersive technology forecast in 2001 is showing legs in 2014. 

HAL-9000 has appeared in the rudimentary form of IBM’s Watson and both are equally ominous in information load and both are intimidating to the human counterparts and both will have streaming consequences on the human linear time.

As long as we don’t give Watson a 100- year rechargeable battery with a sidewinder, we will be okay on, when to pull the plug. Oh, but I digress…

Back to regression.

Lets see. What we need are a few sets of numbers that are metrics of measurement for anything. IQ, EQ, OQ or for that matter DQ (dumb quotient). We place those numbers in a column and find the mean (average)-belonging to the independent (x) variable. Then we have another variable set of numbers as metrics for another measurement, say achievement (the dependent (y) variable). We do the same for this set of numbers and find the mean. The two sets: the independent set measures the IQ or equivalent and the dependent variable measures the achievement are needed to create a linear regression of sorts and in the end an answer of whether the achievement has any effect on achievement. And if they do we can prognosticate based on the standard deviations if the IQ is 185 what would be the equivalent achievement of that individual. Seems easy, doesn't it? Read on, if you are so inclined.

y = mx + c is the same as y' = b0 + b1(x)

The how part is kind of easy. Take each independent variable and subtract the mean, then square the result. we will use the following notations for the variables:

xi = Independent variable.
= Independent variable mean
yi = dependent variable.
= Dependent variable mean.
Ʃ = Sum of

On the other side take the dependent variable and subtract the mean also and now multiply the un-squared independent subtracted variables from the mean to the dependent subtracted from the mean.
Ʃ(xi-x’)(yi-y’). That then becomes the numerator and the denominator is the squared independent variables from the mean. Now the regression line can be drawn from the dependent variable mean and must cross the means of both dependent and independent variables.

b1 = Ʃ(xi-x’)(yi-y’)/Ʃ(xi-x’)^2

The formula for linear regression then is: y'= b0+b1(x) and b0 (the dependent variable intercept) is easily solved as b0 = y’-b1(x)

Simple QED.

But here lies the problem:

We can see that the variances are squared and become the denominator in the equation and the standard deviation is nothing other than the square root of the variances. So all future probabilities have to lie within the realm of these standard deviations. Ah, so here we bring in the old skeleton of the Confidence Interval bounds and the p-values once again. The future probabilities are based on the assumptions that the line will either be in the negative or positive trend and follow the linear pattern along all new measurements and therefore will “likely” fall within the bounds of the standard deviations. These bounds will be +/-2.5% of the edges or in the 95% under the glorious Gaussian curve.

What if it doesn't? And, you guessed it...It doesn't all the time at least in the 95% model not to fall within the confines of the curve 5% of the time.

Standard deviation or δ = (square root) √ variance and variance = Ʃ(xi-x’)^2/(n-1)

And of course what is not measured are the humanity's frail and bold outliers on both below and above the line’s trajectory. Yet the consapevole are pleased to report in all sort of blinding studies that bring rapture to journals and books alike is the mathematical proof of what they have extracted from this formula. And off they go trumpeting the wonders of mathematics and the superiority of the science of probability as a testament to the absolute truth and the likely future.

But what of the outliers?

In this world of decay, they need not apply. You see we are now firmly entrenched in the sea of, “what’s good for the pluribus and who gives a damn about the unum.” These outliers are the very ones that can change society with one fell swoop. These are the “renegades” the real innovators, discoverers, creators and master minds. These outliers are also the weak and timid that Hitler once wanted to eradicate. Upon the burdens of these are created the wonders of new innovations to help the many. Upon the weakness of these the brave take charge and remodel the world’s mores. The two sets of outliers now in the throes of discard and destroy, not often but almost always in them lies humanity’s future.

So before you go drawing regression lies and use all sorts of catchy “student t-tests” and “Chi square tests” think also of the Pearson’s Correlational conundrums and then the outliers. Because sometimes the weak interfering correlations can confound the strong result in either extremes of benefits or lack thereof. The intent will find the one that feeds it.

The world and human health along with human behavior is a messy playing field that rarely conforms to the norms as established by the mathematical world. Yes we can make a safe prediction about what the S & P will do tomorrow and be wrong and lose some money or make some but boxing the variables of the multi-trillion human cellular milieu is fraught with errors.

Mathematics is the language of life. But it is also the invention from which evil springs to gloat, goad and destroy. Within the numbers and the formulas, lives the manipulative massage of the intent. As Barbie once famously said, “Math is hard, let’s go shopping!”

Just a thought…

Sunday, January 5, 2014


"Excellence is not an act, but a habit..." ~ Aristotle

And this is all about imagination…!

I saw an electricians wire the new house that was being built. They were busy drilling holes and laying down conduits and threading bundles of wires that seemed to zig this way and zag that way leading to various placements of various sockets and switches. Frequently they would re-drill and change the direction of the wires to bypass plumbing or other hurdles in the way. This went on for a while on a daily basis. Many pathways later the structure got its siding and then one day, the settlers came in and voila there was light and ceremony.

Now many years later an electrician’s truck was back there again. He was trying to snake the old burnt out wires but could not force them by pull or push. “Oh the settling of the house makes it difficult, so I have to drill new holes to create a conduit,” he said as sweat beaded his brow. “But,” he reflected for a moment, “I am not exactly sure what I am going to face.”

And it made me think!

What about this rewiring phenomenon? Why is it difficult? Take the human brain for instance. When the child is growing from infancy to about 5 years the brain expands three times in neuronal connections. With billions of neurons being created and trillions of synaptic connections being established, it is a high stakes game of circumstance and chance. The synapses are clicking and grinding in the motor and sensory cities of imagination and wonder. Everything is new and neuronal dendritic connections seek out and connect to any available or previously connected neuron as flashes of the immediate world images come in through the eyes at blinding speed. "Ah yes that face is my mother’s, she coos and laughs and cuddles and loves me. And that must be my father with the rougher face and occasionally the knitted eyebrow and that younger face must be the brother who cannot help himself from pinching me. And that face filled with kindness and joy must be my grandmother. But what is that furry creature that keeps coming up to sniff at me? Ah they call the furry thing Rex.” These pathways grow exponentially and as “Rex” becomes the dog affectionately called “Rexy” and then “Rexy baby” later new wires have taken hold within the old circuitry. The rough faced creature with the knitted brow becomes dad and the cooing lady becomes the all-important listening, advising, nurturing mom. The notion of school arrives and drives away all feelings of comfort and a new fear and longing initiate new connections. And one day, "love" comes knocking at the door and huge bundles of connection find their awy to the amygdala (the heart of emotions in the brain). As the house of life ages and connections that have not been made over and over seem to fade, faces are recognized held in some crucible of thought matched to an event, but names falter. Lovers like circuits might come and go, but emotions remain, like the steadfast sun, which rises in the east and sets in the west and remains a constant reminder of the passing time, many ideals conceived of logic or illogic fall prey to disuse. The compelling nature of the moment seems to lose its moment and pitch and many a connection are lost.

So the curious case of rewiring comes to mind. How to rewire the brain?

Indeed how to?

Like the house that is settled, a new hole has to be drilled. The old wiring has to be severed at both ends and withdrawn and new wiring has to take its place. It will require a consistency of effort and a daily workshop of fixing and changing to create the conduit to replenish the memory and since new switches are needed for other receptacles, a new wiring pathway needs to be constructed as well. The old switch is covered over by sheet-rock and now stands behind the armoire. New links are needed to join the switch to the sockets and new sockets are needed in place of the old ones that lie hidden behind sofas and chairs. The house needs work both outside and inside to remain a home for comfort. It needs constant attention like the lawn to rid of the weeds (bad connections) and planting flowers (new connections) fit for each season. The constancy of effort is a ongoing rewiring process. Hypotheses and Spins, like selection bias and statistics of small numbers, both fail to the Occam's Razor of verifiable, repeatable facts. Only a nimble and receptive mind, grows new connections and rewires new circuitry.

Relearning old tricks and new ones is a difficult process in an ossified mind that fails at agility. Like businesses or corporations that fail to see the future often get mired into harnessing old tactics to stay current and are met with customer disdain and ultimate loss of profitability, because they keep trying to force the new wires through the old conduits in a settled enterprise. Relearning needs rewiring and that also needs remaking. (Sears Holding might fit this picture). The agile on the other hand, are adaptable and align themselves to the future by constantly relearning and rewiring the concepts. (Apple seems to fit this one). Along with the concepts they also rework the old façade, “painting, fixing and creating new eye pleasing and sustainable ideas and concepts.”

Rewiring is a constant process, which does not allow settling. Rewiring needs a new outlook every day and that needs an open mind, receptive to changes and desires. Some studies suggest that rewiring a new concept in the brain requires many days of repetition and that is true. The more difficult the doing, the more effort it takes, but once ascribed to the concept of relearning is done. Agility to adapt is all encompassing to align one’s needs with what one desires to accomplish in one’s life.

Go ahead…


Thursday, January 2, 2014


Standing on the shoulders of these giants Bryan Vartabedian ( @Doctor_V ) and Greg Smith ( GregSmithMD ), I can see the relics of the past and the optimism of the future. The year is new. The resolutions are many. Time is always short. Life is filled. So the three words that hover around my mind’s eye are as follows:

1.       Think. Rene Descartes famously said, “Cogito Ergo Sum,” (I think therefore I am) there is much meaning in those words. I have been parsing the word “Think” in my many previously digitized posts but never in full practice. So resolving that conflict, I believe to consider and by consider, one might as well say, to think through the possibilities, all points of view whether they hurt my innate psychology of desire or for that matter enhance the substance of my past experience, will be finding peace in the comforts of my soul.

2.     Reason.  C.S. Lewis once said, “An explanation of cause is not a justification by reason.” and he may have his opinions based on his experiences, my thoughts are more in line with the Dalai Lama’s words, “The ultimate authority must always rest with the individual’s own reason and critical analysis,” Reason, is the base upon which a society exists. Although C.S. Lewis might have invoked his reasoning based on the falsehoods of forced justifications and man’s attempt to justify his immodest action. Yet “Reason” stands out as the only logical expanse of human behavior where time has bestowed thought and comprehension into considering the affairs of man. So reason in my mind is the second pillar of what I consider an important trait of my future existence.

3.      Inspire. Transcendence of any society is organized by those that inspire and lend shoulders of strength for others to stand on and view the future. Inspiring the youth and others to create a better future for us all is a motivation that needs no justification. I find that encouraging others is in itself a virtuous cause. One can only inspire through positivism based on reasonable thinking. The future will unfold as you dream it. So let us all aspire (me especially) to inspire the good to unfold our dreams.

2014 will be a better year.