Saturday, May 31, 2014


The universal fall from grace is palpably reminiscent of Shakespearian times about the lawyers. “the first thing we do is kill all the lawyers” was the lament then. Well, no, not that bad really but it’s getting there for the doctors these days.  Nary a day goes by that the front page news does not bemoan the cost of healthcare and then with laser sharp vision of scrutiny and gnashing teeth of “reform” the anger spills over against the doctors.

The demographics are changing. Indeed most industrial countries like the United States, Japan and Europe have the baby-boomer population surging and the productive force of the 39-55 years declining. So much so that the retirees (over 65 years) will represent 20% of the US population in 2030 consuming more than producing. The current healthcare costs are 17% of the US GDP and slated to rise to 20% within the decade. The future is being foretold in the healthcare sector daily as the demand for care outstrips supply of dollars and the cost of that care outstrips everything else. This imbalance gives us all pause to reflect at what is and what might be.

There hangs a tale of two states: I know, I know comparisons are odious, but this is freaky!

China with its double digit growth feels its deflationary pressures as the GDP swoons a bit into low single digits.
Meanwhile due to the rapid expansion of its industry, the smog seems to want to choke the life out of its citizens.
Lung cancer rates are rising at an alarming rate there. But care for those unfortunate languishes within the totalitarian walls of bureaucracy.
No caption needed

This new found economic growth opulence is being balanced by the autocratic rigidity imposed on the doctors. The Chinese doctors are extremely unhappy about the conditions in which they practice medicine. They are dissatisfied with their overall conditions. Only 21 percent wanted their own children to become doctors. Interestingly, this survey showed that fewer than 10 percent of respondents blamed patients, doctors, or hospitals for their problems; the majority (83 percent) blamed “the system” for the tension between doctors and patients.” In a society used to the compelling nature of reliance on the state “from cradle to grave” the aging populace is waking up to the increasing out of pocket cost of healthcare.
They blame the poorly reimbursed, always on the hamster wheel doctors for the woes of their personal economics and blindly attack these physicians physically. Noteworthy there were 17,243 physical attacks on the physicians in 2010 and those numbers are increasing annually.
Chinese Doctors Protest conditions

In spite of the Chinese “deepening” level of reforms undertaken by the politburo in 2009 the conditions have worsened. The Chinese government’s reforms decided to pay the doctors through the agency of the hospitals. (Ah the irony of it all)! “The best way to increase doctors’ salaries is to put money in the hands of the hospitals that hire them; and the best way to do that is to make insurance coverage more comprehensive and liberal.”

The cost of that logic led to the following debacle: “Instead, most patients seek care from specialists in large urban hospital settings. Those hospitals are crowded and doctors have heavy workloads. Rarely are there formal appointments. Instead patients often have to navigate complex assembly-line care marked by long waits in a series of lines – it can take many hours in line to register then take care of prepaying one’s account, see a nurse then see a doctor, have tests performed then await the results, acquire a prescription then, finally, have the prescription filled.´”
Patients wait to enter the University Hospital in China

Meanwhile in the United States the Well Point insurer ostensibly through the aegis of its new found friend and technological associate IBM’s Watson came up with a solution to save around 3% to 4% of cancer treatment costs, which total around $5.4 billion a year for its fully insured business,” by using a $350 incentive per insured to the doctors for guideline-based medical care. In cancer, insurers and health-care providers have been developing treatment protocols—sometimes known as "pathways"—that are supposed to represent the best and most efficient approaches, balancing cost, benefit and side effects. Insurers are then paying doctors according to how well they comply.What they fail to address is, “According to an IMS analysis, average reimbursement for administering cancer drugs is 189% higher in hospital outpatient facilities than in doctors' offices.” Well Point and other insurers have looked at the facts and seem to think perverse incentives such as the $350 offered will help offset the costs in cancer care: “The U.S. spent more on cancer drugs last year—$37 billion, up 19% in five years—than any other category, according to the IMS Institute for Healthcare Informatics, a unit of IMS Health. Overall costs for treating cancer are well over $100 billion annually and mounting steadily, according to researchers at the National Cancer Institute.”

What it will do, if you think through a little deeper, is hamper patient care! With traditional methods of caring for cancer taking a back seat to the modern molecular targeted therapeutics the impetus to use cheaper drugs to make “the whole economic problem go away” will beset the industry with a larger problem of cost control versus patient care! The populace will demand the very best of what is out there in therapy and not getting it will bring with an unforeseen wrath. Meanwhile as time churns and with every turn of the screw the dissatisfaction in the U.S. doctors rises to mirror that of their Chinese counterparts, something will have to give! The conditions are rife with intermediaries reaping large profits and pointing the “blame” fingers at the doctors, for an upset in the marketplace.

The epistemological virtues of thoughts steeped in feckless premise of “throw money at the problem” never achieve the ends they seek. It is often the guileless caught in the cross-hairs of such vacuous punditry. The distractions used as impediments to reason will fall away to a questioning look-back from the hamster-wheel. The Eureka moment will arrive!

Maybe it is time to reconsider this whole process. Maybe doctor-patient relationship should go back to that rather than doctor-EMR-Insurer-government-patient relationship that exists today in the United States. Maybe skin in the game will bring the doctor and patients closer together. Maybe the word “care” will be from “caring” and not from “Medicare.” Maybe a hand on the shoulder will cure faster than an eye on the computer screen and frustration about reimbursements from an invisible employee of a large governmental/insurer organization ever will. And maybe, just maybe we will have the medical profession be the noble profession it once was.

Thursday, May 22, 2014


"The Space Between
The wicked lies we tell
And hope to keep safe from the pain"
 ~Dave Matthews Band

In medicine the contract used to be between the physician and patient. If the patient had a disease X and went to a doctor to get relief from it. The doctor would prescribe a procedure/medication/encouragement Y, the contract was fulfilled when the transaction was completed. Those were simpler times.

Today the space between the physician and the patient is littered with intermediaries. The straight-line of care between the physician and patient has been disrupted. Everyone is an expert trying to angle into the game. This angling increases the gulf between the two parties. The current dictates cover what the physician can or cannot do and what the patient can or cannot receive in terms of care and what the government/insurer  will or will not pay for those services to the physician.

The Complexity of interactions within the Healthcare System of Medical Care
(If unable to view clearly please ask and I will send you a larger .pdf file)

A legion of experts devotes an inordinate amount of time to make itself known and considered useful in maintaining its place as arbiters of such a contract and to fill the space in between. These experts exact a price from the heath-care system and cast aspersions if necessary, on the physicians and when able through tongue and cheek at the patients as well. The emotional contract between the two parties has been reduced to a binary value for the experts to claim the defect in the care rendered using a set of arbitrary and capricious probability assumptions.

The market forces of supply and demand work admirably in business and they also work equally well in health care settings, if allowed. A competent doctor is rewarded with patients seeking his or her help. Yet in today’s climate the patient seeks out those doctors that accept insurance. This sets up a “mill” or an assembly-line of sorts and quality is sacrificed for quantity.  Time is at a premium and eye to eye contact is marginalized. Enter the EMR system, which further alienates. The real understanding of the disease stems not from the cut, copy and pasted 14-paged document for insurance reimbursement but in the single expression of the malady in a patient’s face.  

The multitude of forces that compete within the sphere of the patient physician relationship are increasing daily and advancing their cause to the detriment of the patient-care. Something needs to be done. Something will have to give!

The current zeitgeist circulating the society and reinforced by the governmental and insurance industry is that medical care is a right. Is it? Healthcare costs sky rocket because of overuse of the system. Maybe it is time to reinvent the paradigm of developing the concept of “skin in the game,” and not of, it is ours for free, go get a prescription. Maybe it is time for some hard lessons and education. Maybe it is about lifestyles against chronic illnesses.  Maybe it is about understanding after all.

Dave Matthews Band...Enjoy!

Friday, May 16, 2014


"Conformity is the jailer of freedom and the enemy of growth." President John F. Kennedy

It is a curious fact that the man who propounded the idea of utilitarian ism, his body “Auto-icon” sits in the University College of London as a stark reminder of “The Greatest Happiness Principle.” The Principle stems from “the greatest happiness of the greatest number that is the measure of right and wrong.”  Seems that utilitarianism is good and anything but is wrong. This utilitarian concept is steeped in the ideals of conformity and brings with it the kinds of vapors that mute the innovative spirit. But close to his death even Jeremy Bentham was all but utilitarian in thought. Planning his “Auto icon” was a creative gesture that breaks with the utilitarian concept of conformity. After all it brought Jeremy the greatest creative pleasure to realize that his mummified head and his skeleton stuffed with hay would become his greatest pleasure before his death and a lasting presence.

Does conformity bring in the best out of human beings? That question is being answered tongue in cheek by conformity seeking experts all over the globe. It seems that these conformity-seekers might have misplaced the term collaboration with conformity. Since collaboration is the new buzz-word in business, it does not seem to fall too far from conformity. Consequently the merger has evolved over time into what is now known as “Group think.” That a universally accepted view should drown out outliers and become the defining thought for all. So the answer seems to be yes.

"The opposite of courage is not cowardice but conformity." - Jim Hightower

Society continues to evolve along those lines of redistributive purposing, whether it is wealth, property or ideas. The symptom complex of this conformity model is laid out in the education system where a universalization of the curriculum is in play. The current education system is nothing more than a format of conformity. Every child is taught the same stuff by the teachers who are taught the same stuff. Pretty soon if one extends the thought further this concept leads to a marginalized human intellect, or more appropriately termed a state of constant mediocrity.

A similar view is being forced down the medical care throat. This concept is governed by the “Guidelines” that are now reaching the tipping point of becoming mandates. A quote from the recent article in Scientific American caught my eye: "At best, these guidelines are recommendations based on scientific studies with results that pertain to the average among us. They do not adequately incorporate the personal differences and preferences of each of us as individuals. Furthermore, while these recommendations are based on clinical science, rarely is the science complete or incontrovertible. Hence, the recommendations are consensus statements reflecting the perspectives of those charged with the production of the guideline." Let us do a thought experiment here for a moment; If all maladies are governed through the auspices of guidelines then where is the magic of Art in medicine and where is the individuality of the patient being treated. A guideline form of medical care ultimately draws out and macerates any wisdom of finding a better way, a quicker way, a better treatment model or a more compassionate form of healing the sick. If all humans were equal in their physical states (as in robots) then a grease job here and an oil can there would work perfectly. Given the push and the tug today the Bentham’s “Greatest Happiness Principle” is being applied to all forms and norms of society. The codification of thought is being pursued at breakneck speed to usher in the era of a utilitarian medicine in a box that is made to resonate with the increasingly distracted populace. But John Rawl’s “Difference Principle,” which advocated that high productivity of some, gain advantages for all even the most disadvantaged, is thrown to the wind.

Conformity harkens the murky nature of a uniformity of thought and action. Compliance with conformity is the single biggest arbiter of modern day thinking and brings with it the torrents of “group-think.” It marginalizes and in some cases punishes a minority opinion. It suppresses excellence. Conformity brings in a mediocrity governed by the few. Conformity does not bring with it the “Ideal Splash” that Worthington so idealized.
It brings in carefully picked and chosen ideal splashes only to promote the point of view. These conformity seekers fail to recognize that the imperfections, which assimilate within the human genome may not be imperfections after all but the genesis of greatness; the creative sparks and the innovative fuel that have always defined real progress in world history.

"Diversity: The art of thinking independently together." - Malcolm Forbes

Yet in clear contrast to conformity, all the voiced viewpoints of the conformity advocates continue to express the benefits of diversity, unfortunately only in words. Those two points of view therefore become blatantly at odds with each other. Although they claim that seeking diversity of thought is a good goal, yet the formalization of conformity as the underlying principle of current thought and action virtually destroys the diversity argument.

Diversity is not just about color, culture or religion but is the grand dame of innovation, creativity and intellect.
It brings with it the varied opinions and from those a few will shine the brightest light. To look this in the eye, one only has to see that men like Steve Jobs, Bill Gates, Mark Zuckerberg, Jeff Bezos and others were all dropouts from the formalized education system who created and pursued a reality from a vision of their own. Had they been forced to conform, we might not have had an Apple, a Microsoft, a Facebook or Amazon today and the millions of people employed by these great companies.
These explicit confrontational set of facts weigh heavily on the implied particularity that seems to have a defective paradigm. Imagine if you will that the teachers were to force the prodigy by the name of Mozart to learn concepts of engineering or for that matter dance or Newton to learn how to sing and play a piano, what might have been? If the force du jour was directed away from the inner voice of these prodigies where would we be? How would they have coped? Would they have abandoned their future life’s work that advanced civilization?

Something to think about!

The deepest cut of all against the diversity of thought comes in the form of a pill. Today millions of children have been subjugated in their creative desires and in their expression of the inner intellect through the omnipresent diagnosis of ADHD (Attention Deficit Hyperactive Disorder).
A curious child with a wild type intellect whose intelligence does not want to be confined to the ridicule of “Common Core” type subjects is put on Ritalin rather than evaluated for his or her genius in a particular field is a travesty. It is too easy to subjugate the wandering irritable “trouble-maker” mind of a brilliant child with pharmaceuticals rather than assess his or her needs and wants. Albert Einstein comes to mind who was considered a troubled student “who would amount to little.” History differs! This muzzling effort works for the busy parent and also for the hassled teacher. Neither wants disruptive influence in the home or school.

Let us look at our children and their needs rather than what pleases and serves us as adults. Let us look at our patients rather than what pleases the insurers. Let us think diversity of thought rather than expression of “group-think.”

Let us think critically for a moment!
Let us think for ourselves for a change!

The future is ripe for the making!

Monday, May 12, 2014

Near Misses of Great Magnitude

The air has warmed but the breezes are cooler still, the flowers are blooming. The air is saturated with voices of little people and their bigger counterparts. Spring has finally arrived and brought out the families. The fathers are out catching ball with their children amid the squeals of near misses and laughter of greater magnitude. And I look at the time gone by.

I remember a day like today when we as a family had decided on a picnic. As we headed out, the infernal beep of the beeper interrupted our plans. We would have to all bundle up in the car and go to the hospital for me to see a patient before heading to the park. There were groans and moans from the children who had heard of this before. But I insisted this time it would be a short interruption. “It is only a minor issue. It won’t take me more than a minute,” I said, as I hustled out the car. An hour later as I emerged the quiet that I had left my wife with was filled with taciturn children, crying and carrying on. I walked back to the car and said, “Okay are we ready!” in as jovial a voice as I could muster. Only grumpy groans emerged. The enthusiasm had long since vanished.

We drove to the park and the infernal beeper beeped again calling me back to the vicissitudes of life; illness. Someone else needed help. I deposited my family at the park and promised, I’d be only a short while to the restrained anger and glare of my wife and the protesting children.

After what seemed a short 20 minutes which turned into another hour gone by, I arrived back at the park and found my children happily playing catch with a stranger. Someone had taken pity on the two lonely little souls and decided they needed some parenting. My wife was quietly reading a book with one eye on the kids and the other within the pages.  After the introduction to the stranger, who it turned out was a remote neighbor of ours, I thanked him and took over the ball. By now my children, it seemed had had enough and they retired to the shelter of their mother’s arms.

The rest of the evening was a blur between beeps and phone calls. The sly disgust on my children’s faces and the resigned look on my wife’s face completed the day at the park.

As a physician, I know about near misses that have great consequences. As a father I know that the near misses that interrupt a physician’s life have a far greater magnitude effect on a family.

And they call us providers?