## Wednesday, April 30, 2014

### A Very Brief History of Medicine

“Medicine is not only a science; it is also an art. It does not consist of compounding pills and plasters; it deals with the very processes of life, which must be understood before they may be guided.”- Paracelsus

At the Museum of Archaeology in Malta, the Sleeping Lady of Malta hails from a time more than 5000 years ago. Was it a decadent time filled with latent cynicism, or a time of great thought and action.

An Egyptian polymath named Imhotep served as the high priest to the sun god Ra and was the chancellor to King Djoser of the Third Dynasty. He extracted medicine from plants and is considered the earliest known physician. He was also “Chancellor of the King of Egypt, Doctor, First in line after the King of Upper Egypt, Administrator of the Great Palace, Hereditary nobleman, High Priest of Heliopolis, Builder, Chief Carpenter, Chief Sculptor, and Maker of Vases in Chief. He was one of only a few commoners ever to be accorded divine status after death.” He was a doctor, an engineer, an architect, a poet and a philosopher. The earliest surgery was performed by him.

During the First Babylonian Dynasty (1069-1046 BC) a “Diagnostic Handbook” written by Ummanu or chief scholar became the definitive medical text as a source for treating all known ailments of that time with bandages, herbs and creams. The text was based on empirical evidence and combined the diagnosis to render a prognosis for the ill. The rational use of symptom complex and examined physical evidence revealed the nature of the illness. If the rendered treatment failed to succeed then exorcism of curses was undertaken as the last resort.

In the 5th century BC the next notable was Hippocrates of Kos (460-370 BC) who is also considered the “Father of Western Medicine” because he categorized illnesses into acute chronic and endemic vs. epidemic. At about the same time in India two tomes were crafted over the next two hundred years one called Chakra and the other named Sushruta that were based on the traditional Ayurveda medicine of the times. During the same time in isolation the Chinese created the The foundational text of Chinese medicine in the Yellow Emperor's Inner Canon, written 5th century to 3rd century BC)

Claudius Galenus (129-216 AD) better known as Galen of Pergamon, a physician, surgeon and a philosopher broke down medicine into different subspecialty disciplines. He was also the first to operate on the brain and the eye. He was a disciplined empiricist who learned from experimenting with animals and advancing his knowledge of anatomy and physiology.

After 400 AD medical research and understanding declined dramatically until the 12th century AD when the first school of medicine “Schola Medica Salernitana,” was built in Salerno in Italy. The medical education was rehabilitated with more systems of school began popping up in other parts of Italy. This was the first time that a graduate from the school were called “Doctor.”

Not until Avicenna (980-1037 AD) was there light shone on medicine. Avicenna wrote two tomes one called the "The Book of Healing" and the other "The Canon of Medicine," both were regarded as the state of the art in thoughts related to medical care for the time.

Philippus Aureolus Theophrastus Bombastus von Hohenheim (1493-1541) also known as Paracelsus, a Swiss German botanist and physician through experimentation. He rejected Galen’s ideas on Medicine but was more in tune with Aristotle’s four elements. His expertise in Botany and knowledge of medical sciences also made him known as the “father of toxicology.”

William Harvey (1578-1657) came along and discovered that heart was the seat of the circulation and dissected the veins and arteries to understand the network within the human body.

The 18th century brought Renaissance to Europe and with it the “germ theory of disease.” Foremost in the field was Louis Pasteur (1822-1895) who along with Ferdinand Cohn and Robert Koch are considered the most important figures in medical microbiology. He developed vaccines for rabies and anthrax and also realized and created a method for “pasteurization of milk,” to prevent disease transmission. Ignaz Semmelweis (181-1865) determined that the high mortality during childbirth was due to unwashed hands and became the springboard for modern hygiene. Public Health measures became notable in disease spread through communities and were the springboard for people like John Snow to determine that Cholera was not air borne but water borne in London.

Sir William Osler (1849-1919), a Canadian physician considered the “Father of Modern Medicine” established a hospital now known as the Johns Hopkins Hospital with three others. He created lecture halls and brought in students to view surgical procedures performed by the physicians.

Medicine was on its way to more discoveries. The ABO blood grouping in early 20th century laid the foundation for safe blood transfusion and Marie Curie’s (1867-1934) discovery of radioactivity laid the foundation for radiation therapy. And in 1953 the greatest modern discovery by Watson and Crick on the x-ray crystallography photos of proteins of Rosalind Franklin herald the era of genetics through the discovery of the DNA.

Today we are rushing at breakneck speeds in capturing newer vistas into the human cells and peering into the heart of the atom. We can see the tick and the tock of inner cellular pathways. We can see the interaction of the cellular surface and these pathways. We have learned how various genes create various proteins and how the methylation of various genes can speed up or shut down a gene function. We know about interfering RNAs and how they might alter the color of the iris in an eye.
We understand the microbiome of the intestinal tract and the need for different bacteria to keep us healthy. We have used nanotechnology to create nano-wires and nano-dots to determine the molecular damage created by disease. The merger of man and machine is upon us with neuro-receptors, bionic eyes, motor pathway inhibition, miniature acoustic devices, electrical stimulation of the olfactory centers, bionic arms and legs and exoskeletons to leverage physical abilities. As the old jingle goes, “We have come a long way baby!” The watershed moments are happening daily and encompassing the geometric scale of the Moore’s Law. We are able to create 3D printed organs to replace diseased ones. We are on the move to understand the brain and the farthest frontier of the mind.

Medicine is indeed in a constant state of evolution. It is scaling heights seemed impossible at the turn of the 21st century. What will the next 50 or even 10 years at the rate we are progressing makes tomorrow bright and full of real hope. But the alarm that rings is one of caution. There is a disproportionate focus on costs and through it the laxity on science as well the art of medicine that has brought us to today. Innovation is being stifled. In the name of cost, innovation is being rendered “too expensive” for patients that might benefit them. Medicine must remain an unbridled territory to foster its own timely research. Only then the future we seek shall be seen.

Pioneers and innovators abound with the fast heartbeats of discovery, but what about the doctor, the physician? With the new lust for IBM’s Watson, Is it time to wither away…

He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.- William Osler

## Sunday, April 27, 2014

### There is MAGIC

“All life is an experiment. The more experiments you make the better it is.” Ralph Waldo Emerson

Life is a strange and wondrous experiment. One travel through it weathering the troughs in silence and exclaiming at the top of the lungs on the peaks, but always through it all there are the constant air pockets of negative thoughts that some time manage to coalesce and cause turbulence in words and deeds. But that Saturday afternoon was none of those things. It was quiet and unassuming evening, the gathering dusk and the rolling clouds made it particularly beautiful. The sun peeked in between the clouds and the under bellies of the clouds shimmered with gold.

There was traffic as I waited for my ride on the pavement, when a gentle tug at my coat alerted me to a presence nearby. I looked around and to my surprise found a short Asian fellow looking up at me.

Hmm, I wondered what could he want? Maybe a ride? Some money? What? But he had a crooked smile. One side of his face did not follow the happiness within, probably from the ravages of an untimely stroke, I wondered. He looked straight into my eyes expectantly, but my screen behind my eyes must have remained blank as I looked back at him. I could not place him.

He thrust his left hand forward and not knowing the intent, I took it in mine. His frail and skeletal hands with a paper h thin skin mottled with blemishes from minor traumatic subcutaneous capillary bleeds. He shook my hand with vigor as much as he could muster and then held it. He could see my quizzical expression and some reluctance at this acquaintance.

He looked around and nodded at an approaching lady, about his height and around his age. She walked towards me and her face broke out in a smile also.

“Thank you, thank you, thank you,” she said. At least she could speak. The riddle was about to be solved.
“You,” she said with a strong Japanese accent, “saved our Mikey.”
Mikey, Mikey…the name rattled around in my brain not evoking any signals. I smiled back at them. And then she did something that I had seen someone do a long time ago. She rubbed her chin and put her index finger in her mouth as if in a thought. The genetic code did not lie. I remembered.
Mikey, it turns out was a youngster who had battled and won against testicular cancer.
“How is Mikey?” I asked and she knew that I knew.
“Good,” she said. “Very Good,” she repeated with emphasis. “He is a very important person at the bank now.”
“I am glad.” I said. “Give him my regards. Oh and just to let you know,” I continued, “He saved himself. It was his strength and his will power that helped him.” But she rejected the argument with a wave of her hand. Her mind had been made up.

She spoke for a while and “thanks” hung like a rose in bloom on every sentence. I felt it in my heart. The conversation slowed and then they both just stared at me for a while without an ounce of regret or embarrassment. We stood quietly for a while, they basked in their success at relieving themselves of the burden to thank for their gift they had received and I stood there feeling light on my feet basking in their good wishes.

What a strange feeling of pure joy!

My ride approached and I offered them one to their destination, but she declined. They both waved as I left in the car and turned back to look and found them waving as they were reduced by distance to a size of tiny stick figures and I am sure they could not see through that ether of separation.

Didn't I say, life is a strange and wondrous experiment? It is!

There is magic in spoken words and the good others perceive. There is magic in unspoken actions and handshakes with strangers. There is magic in crooked smiles and paper-thin skin covered fragile hands. There is magic in touch. There is magic in life!

There is magic!

“Only a life lived for others is a life worthwhile.” Albert Einstein

## Wednesday, April 23, 2014

### CHANCE ..is Real

“If it don’t fit, you still must convict!” no I don't think it was this way...
What a wonderful thing chance is! Look around you and you will see a myriad of things that are a matter of nature’s play with chance. Like that beautiful pink rose that shares its DNA between the red and the white roses in the bush, only massaged by the right iRNA. And the African child living near the Sahara that looks up at you with the most beautiful blue eyes that are spellbinding and you wonder; how?
Or the girl that made it to the National Geographic front page, she too had those enchanting eyes that captured the imagination of the world for decades.
Or in the wider circle of humans let us look at chance a little differently; In 1896 Henri Bacquerel found that the uranium enriched crystal caused a “fogging” on the photographic plate in an enclosed bag (without sunlight) revealing to him the nature of radioactive decay, Watson and Crick walking into the lecture hall to listen to Rosalind Franklin about X-Ray Crystallography gave them the intuition of the DNA helix,
Or on September 3, 1928 when Alexander Fleming returned to find a fungus on his dirty dishes that had killed off all staphylococcus bacteria, giving birth to Penicillin, In 1964 Arno Penzias and Robert Wilson discovered that the constant hum from their radio telescope was not bird poop on the radio-telescope but the murmurings of the Big Bang; Or in 1967 Percy Spencer walked in front of a vacuum tube magnetron that made microwaves and found that the chocolate bar in his pocket had melted; And with John Pemberton a pharmacist trying to create a remedy for headache accidentally mixed the cocoa leaf and cocoa nut with carbonated water and lo and behold Cocoa Cola was born. So you see serendipity or chance plays a huge role in the life and times of the human discovery and innovation. Here is a real doozy of a recent serendipitous thought from Franz-Josef Ulm about the physics of urban sprawl . From aerodynamics to medical discoveries to drug development to the tallest skyscraper, the ideas take force from the seedlings of chance that sparks the imagination. The likes of Stephen Hawkings and Albert Einstein have as so many others, had their wanderlust intrigued by that moment of chance inspiring them to the heights, unfathomable by most humans.

The collaborative spirit of chance and insight has advanced life from time immemorial. From the birth of the flint arrowhead to hunt and gather to the quantum bits of digital float in the ether, there is a measure of eureka moment of suddenness that supplants all other things.

Chance is chancy. If you have flipped a coin for more than 10 or a 100 or even (if you had time) a 1000, you would find that there is a longest run of heads or tails mixed into the outcomes.
P(nm)=j=1n/m(1)j+1(p+(njm+1j)(1p))(njmj1)pjm(1p)j1
De Moivre in 1738 calculated the answer to the coin toss experiment and the number of heads as an outcome to the number of tosses. Within that is buried the notion of a run on chance, like the winnings from a Roulette table, or a game of cards or a run on picking the right stocks for a good return on Wall Street. In all this there is no expertise (experts will vociferously argue that there is), but a game of chance that pervades underneath. So within that spectrum of pure chance all probability functions assume a degree of randomness inside the the mathematical equation to arrive at a predictive value. The prediction is just that, a prediction and not a gospel. I have to remind myself of that every day. So should you.

Time has changed though. The latitude of thought now seems to want a different approach in human affairs. Armed with the forced-silliness of force-merger between mathematics and probability mechanics, some have embarked on a rueful journey to use chance in a distorted way. They are force-hiding needles in the haystack that their mechanistic algorithms can find. And then they exclaim “Eureka!”
But these “Eureka(s)” have different modes. These are algorithmic nuances designed to find the deliberately “hidden” chance episode of intent and declare victory through the art of the probable.

You must have heard of the Hazard Ratio that is a time-event analysis and from there at the end the difference between two arms determines the Relative Risk. That is all well and good, it is simple, direct and to the point, no shenanigans here, but when one starts trying to “Fit” the results into the Gaussian Curve for a prediction and then claim that all “norms” should perform within the bounds of the curve, there lies the conundrum of fiat, force and mandate. Simply stated these experts utilize O.J. Simpson attorney’s statement in reverse, “If it don’t fit, you still must convict!”

The word Outliers is a common word in probability and it identifies a subset that does not “Fit” into the perfect Bell Curve. The Bell Curve is designed to capture (two standard deviations from the mean) mostly the 95% of the targeted variables/human subjects. So according to the expert  “probability masters” the 5% who are the outliers are somehow errant in their ways. And this interpretation of chance is now driving these “outliers” into the fold of bad actors, evil-doers or even “killers!” The zeitgeist that pervades wants to force fit all into the commonality of predetermined thought. All thought and action must be comported to the diktat of this time!

By very rare events they mean less than 5% chance of them happening

Maybe someone who is not vested so heavily in the conjured outcomes might find it necessary to consider the magical sprinkles of chance and expose the rottenness that invades reason. The dodgy air of opportunism and profiteering seems to take the lead in today’s pseudo-scholars whose eyes are always on “how will it help my resume/career/advancement/bonus.

Nature continues it’s forwardly drive in the human destiny to evolve the structure to face the environs through Transposons jumping to modify our DNA code. She is a good teacher. We should learn about chance from her. And even though there will be many Archimedes jump out of the bathtub moments in the future, the dark matter of thought unfortunately has found a relic in this crucible of probability and continues to exploit it to its own end!

Ah Chance, why do you so torture us now within our limited self-serving viewpoints even though we are so “refined” in our thinking and wholesome in our being?

I can see a better science out there, unmolested, unvarnished and real! I have seen it in the history books. I have seen it in it's tried, tested, validated and verified form. It is there for the asking. It is there for the understanding.

IT IS THERE!

## Friday, April 18, 2014

### Commoditization of MEDICINE

It dawned upon me, the importance of a name. Unlike Shakespeare who deemed that a “Rose by any other name would smell as sweet,” I beg to differ, not about the smell but about our perception of the rose, if we called it, say a “skunk.”
There is more to a name than meets the eye.

Doctors have long been called “doctors” because they were in Latin considered Church fathers, educators, advisers and scholars. Hmm sounds like a lot of hats to wear, doesn't it? But think about that for a while and you will find truth in it. Doctors do, advise, they are learned in the arts and science of medicine, they educate against unhealthy behaviors. Similarly the word “Physician” in Latin holds court as the natural science and art of healing, something more in line with being a doctor.

But recently the word in the politically correct world does not smell as sweet; it is “Provider!” Now why would anyone shy away from the word, doctor or physician that has been in use since the days of Hippocrates and Osler to this one coined by the elite? There must be something to it. For what’s in a name, you might ask?  Ah! But there is power in it. It (the name “doctor”) has long been immortalized in prose and poetry, in annals and tomes, in sickness and in health, in life and death and in any form of ritual or ceremony. Oh yes the word “doctor” has a significance that none other have. It is not the station or the pulpit but the knowledge and the critical thinking that goes with the art and science of medicine. That art, my dear friends cannot be replicated in the IBM Watson or the Star Trek Holographic guiding image of the future.

So then, why did the elite change the term doctor into provider?

To answer that question, we have to look at the word, “Commodity.” Commodity is a marketable item. It satisfies the “needs” and the “wants,” or “demands” if you will, of the populace. Since the commoditized product is not differentiated enough, the demand is great and the margins (or profits) are low. Hence the commodities that people cannot do without are bandied about in the market in greater supply to meet the demands. These commodities can be “hard” (mined) or “soft” (grown).  Examples of commodities include staples such as milk, wheat, corn, soy beans etc. You get the message.

Why does something become a commodity? Well, if the product differentiation is lost in either its function or functionality and is easily available in the marketplace, that product has been commoditized.  Lo and behold, the word Commodity was first brought into the lexicon by none other than the French, who have a penchant for socialistic ideals.

To commoditize, one has to mass produce the product or has to reduce the value by creating competing products that are less differentiated. Debasement of any product in the market is the first and the unkindest cut of all in a marketplace. Vilify the product, demonize the brand or hurl baseless invective by flooding the airwaves and you change the value proposition of the consumer.

Okay, so those who have followed the trend can easily see where I am going with it. Here are the nine factors in the making of a commodity:

ONE
1.       Debase the name. But the long tradition of what the words “doctors” and “physician” represent are difficult to eliminate from the mass memory. So the elite take a swipe and gradually change the title to “Provider.” Ah it is catchy and they use that in various media, oozing slowly into the mindset of the populace. As time goes on the “provider” term starts to take on the nurses and then the home care givers, the technicians, the transporters and the house-keepers. Everyone who might have an iota of influence in being involved in a hospital, private clinic or in a university, is a “provider.” When everyone becomes a provider then everyone in the eyes of the beholder has similar value.  You ask, “who’s my provider?” The answer might surprise you.  And surely as I write this, I find that a certain expert elite named, Ezeke Emanuel, MD of University of Pennsylvania as stated that 80% of all medical care can be provided by Nurses, Physician Assistants, or Nurse Practitioners.  And they are now making noise for equal pay for services they render with less education- so much for cost control here… http://content.healthaffairs.org/content/29/5/893.full Huh? Really? Oh but wait, the NPs, PAs and others are rallying behind that cause because they get to be “doctor-providers.” And many wear the white coats and hang their stethoscopes around their necks as they arrive. (And I am not going to make a disclaimer or a politically correct statement here either). http://www.thedailybeast.com/articles/2013/05/27/nurse-practitioners-playing-doctor-more-often.html

Are they up for the challenge?

TWO
2.       Next create guidelines to minimize differentiation in what the “Provider” can do. That reduces the underlying principles of the “Art” in medicine and turns everything into a “soft” science. (And I am being nice here the real word is “pseudoscience”).  So elites and experts now create massive amounts of guidelines in how to treat illnesses. But, and you might have guessed it, they forgot the individual patient. You see no two patients are the same and none ever fit into a category or a cubby-hole. The “Unum” is very much alive in the e-Pluribus Unum. Yet the march to dedifferentiate continues at break-neck speed, maiming all and any defiance. http://www.acponline.org/clinical_information/guidelines/guidelines/

THREE
3.       The third arrow to take flight against the doctor is the new art of “Choosing Wisely.” The concept is so convoluted and does not fit good medical care in the majority of patients that at times it appears that some other element, not being mentioned is the driver behind that program. Everyone falls to their knees and prays to the neon gods and those that don’t are taken to task. http://mdredux.blogspot.com/2014/03/is-this-what-abimfs-chossing-wisely-is.html And  … http://www.medpagetoday.com/PublicHealthPolicy/GeneralProfessionalIssues/45286

FOUR
4.       Meanwhile as the commoditization of medicine is in full swing, a constant harping about costs and how the US is far behind other countries in health and survival outcomes is drummed into the spongy brains of non-critical thinking crowds that are busy trying to make ends meet. The graphics are titillating; the charts are colorfully expressing the desires of the experts and the elites, they show; US medicine is subpar and more expensive. But no one, no one looks at the cost drivers. http://publichealthonline.gwu.edu/us-health-care-vs-the-world/
They seem to hone in on the doctors (here they call them “doctors” and not “providers” to complete the image). Meanwhile the drivers of hospital care and the newly discovered pharmaceutical drugs and the latest innovative devices
and the Administrative Costs remain unmentioned. Only the physician is under the magnified scrutiny!

5.
FIVE
On the one hand there is this crush of cost related difficulties and the “fortunes of a great nation is at stake” and the entire fault is laid upon the shoulders of the doctors (er, providers). And as surely as the sun rises, other mandates are drummed up including Electronic Medical Records (EMR). EMRs have created another gulf between the doctor and his or her patient and the value of the doctor through this enforced interaction has further minimized the value of a doctor/physician in the eyes of the patient. However as many have pointed out that EMRs have created larger barriers in medical care and added to the complexity, reduced efficiency and exacerbated the costs (that the experts want to reduce). The drumbeat of progress continues. Oh well! http://www.kevinmd.com/blog/2013/08/sad-state-emrs-harm-good.html

6.      SIX
Springing into contention and not wanting to lose out on the revenue stream a hodge-podge of self-appointed experts are making billions of dollars on the plight of the doctors. The costs of the EMRs are astronomical and are never paid in full. But the makers are enriched. Others who benefit are the “data trolls” who glean (mine) and create nuances of “appropriateness of care” and also find means to kill any attempts to expose their deeds by hiding behind software algorithms. For example, Epic Systems had revenues of $1.2 Billion in 2012 from this meaningful enterprise. http://www.forbes.com/sites/zinamoukheiber/2012/04/18/epic-systems-tough-billionaire/ 7. SEVEN The ongoing onslaught continues in the form of a daily banter about “Bad Doctors” (not providers). There is a daily dose of fraud committed by bad actors in the medical field and some are unfortunately doctors also, but they are demonized in large print to make the point that the nobility in this privileged field is no longer. It makes for good news worthy headlines. It keeps the agenda in full Monty. http://www.pbs.org/newshour/rundown/authorities-charge-94-suspects-with-medicare-fraud/ 8. EIGHT The sound and fury is also enjoyed by the legislature, who in their desire to show the public that they are doing an admirable job in their well-entrenched capacities, want more “heads” on the chopping block. The whips and scorns continue to rain on this once noble profession and nary voice is raised in opposition for fear. Criminalization of doctors remains in full force and escalates daily. Here are three separate insights. 1.http://www.kevinmd.com/blog/2010/06/criminalizing-medicine-lead-doctors.html and 2. http://www.amednews.com/article/20061127/profession/311279975/2/ and this one for sure: 3. “The Criminalization of Medicine: America's War on Doctors (The Praeger Series on Contemporary Health and Living)” First Edition 2007 [Hardcover] by Ronald Libby NINE To boot Medicare just completed their first MD Data Dump and lo and behold it is the talk of the town, nay, the country. Anyone can see who was paid what. But the details of what was the profit in all that is not deciphered. The obvious reason it seems is to incite the rage of the public that is a willing accomplice in the class warfare. The lynching continues through every means available to reach the end. http://www.wzzm13.com/story/news/investigations/13-on-your-side/2014/04/15/database-medicare-payments-doctors/7733935/ When business, politics and medicine converge there are bound to be deleterious consequences. There are! You might be in the ivory tower making the claims, you might be a nobody who has found a fog horn to exclaim, you might be a self-serving individual bleeding the life out of the noble profession for pecuniary gains, you might be a believer in the commoditization of the doctors and medicine as a whole or you might be an intellectual in pursuit of another paper to serve your own needs, whoever you are, know this, there are unintended and deleterious consequences to these actions. One cannot take the “Art” away from medicine and one cannot make decisions on the shifting sands of contrived “evidence” and base all decisions on such contrivances. The Art works hand in hand with the Science. Both flourish together and neither survives without the other. For instance Washing hands with soap and water is better than Purell! But someone is making a boatload on selling Purells. These little bottles are ubiquitous, mandated to keep our hands sanitary. No one wants to appear dirty, right? But through it all the most ancient of life (viruses) continues to spread as it will, because it is ancient and it has learned to survive. One day the virus will have mutated to understand the Purell mechanism, and a new "Improved Purell" will be concoted by someone and the inexorable march of one besting will go on...Meanwhile Simmelweis...But I digress... Does Healthcare need a reform? You bet! We definitely need it! But what kind? And how to implement it? Should it be cost driven? Should it be care driven? Should it be based on arbitrary "Evidence?" Should it require input from Physicians, Economists, Politicians, Public at large? Should it be based on the Economics of Political Science? Should it be based on the Politics of Economic Science? Should it be based on Pseudoscience of Correlation? Should it be based on the Business Model or modeled after a Business? Should it be based on Patient care or Care of a Patient? Should the patient have a stake other than healthcare being free in the care of his or her own health? Should 3rd Party reimbursements be removed thus removing incentive for physicians? Should a direct patient-physician relationship remain private and not doled out into the digital realm? Should Medical care subscribe to the data-mining pseudo-evidence as a surrogate for reality? I mean I could go on... You decide the right question and the answer to it yourself. You are so armed with information! Currently Karl Marx is here in spirit and pounding his chest with pride! ## Saturday, April 12, 2014 ### LISTENING: Encoding and Decoding The other day, I received a call from an old friend whom I had not heard from in ages, 10 years to be exact. “Hi there,” he said. How are you?” I might have detected a snicker in his voice over the telephone. The conversation was the usual, hello and then to the point; he and his wife wanted to meet with me and my wife for dinner. I promised I would text him back about the time and date for dinner. The “snicker” what about the snicker, you ask? I don’t know but I felt it. Okay well maybe because a few years ago after a similar invitation we were asked to loan him a reasonably large sum of money (my perspective) for an enterprise he had embarked upon. Since then, I had not heard from him and never received a call back after my three futile attempts. "The most basic and powerful way to connect to another person is to listen. Just listen. Perhaps the most important thing we ever give each other is our attention.".- Rachel Naomi Remen What was he up to? (my inner voice) Should I even broach the subject with my wife? I can just see her reaction now. “What? No!” How did he put it, “Hi there!” How is that for a reintroduction with a lot of money owed? Maybe, he thought, I would have forgotten that by now and maybe he was trying to reestablish the friendship? Maybe, but not likely! When I introduced the subject of dinner with my wife, her response was predictable. But then that tiny little wrinkle above her nose made me realize her gears in her brain were shifting and a new thought was a runaway process. Like interpersonal communication is a complex process, so is thought and bias and assumptions. What was the code in that telephone call? I really did not know. But my decoding mechanism was in full swing. What was his real intention and what was I thinking was his intention? I could not really tell. My assumptions were based on a past experience from a few years ago, even though a bad one at that. Could I put a positive spin in my own mind and reframe the conversation so that I did not see him as Darth Vader? My wife answered my thoughts almost immediately, “You know Jim might have been through hell in the past ten years. He was after all one of your better friends. So he deserves a friendly night out. We won’t bring up the subject about the money, unless he does, right?” She was clearly more empathetic than I was in my own mind. She opined further, “I can see you are still upset, based on the wringing and un-wringing of your hands.” She put her hand on my shoulder, smiled and said, “Maybe he just wants to say hello and rekindle the friendship. Other than the money issue, there was never a bad word spoken between either of you, Right?” She was right again. And then she said, “Besides how can we know his intent by what he said over the telephone? Meeting him in person is the right thing to do.” She was right of course… (empathy is not sympathy). I call him religious who understands the suffering of others. - Mahatma Ghandi I had been arguing mentally, creating a mountain the size of K2 in my head, all from the shimmering of a mental bias that would not quit chattering inside my head! There might have been nothing further implied, except a renewal of a friendship. As far as the money was concerned, my wife and I had both written it off in our minds. So the only argument that kept nagging at us, was what if he asked for more? Would I be able to say no? My wife answered the question easily, “We can simply tell them the truth that we do not have the financial capacity to honor any further requests.” Truthful and quite simple! It was a darker than usual evening without the moon as we walked into the restaurant. Jim and his wife were already at the table. He reached out with a smile and gave us both a hug. His wife followed his queue, both faces in full bloom. “God it is great to see you both. I was half afraid you might decline.” “Why would we? We are friends after all.” I replied trying my false airs of magnanimity. He was comfortable, loose and kept his focus on both of us, shifting his gaze from one to the other. My internals were warring inside, “here it comes.” Or “here comes something!” But nothing came. We had a pleasant dinner. Soon the incipient breezes of comfort and the past carefree lives we had spent together as friends washed the last ten years of dispute away and all four of us were smiling laughing and crying over jokes, and he is a great joke-ster. Soon the veil of bias and intent gave way to empathy and understanding. The focus from negativity to assimilated positivism, the mental arguments dissipated and the bias oozed out of the circle of friendship, judgment gave way to the meaning of friendship. It was a wonderful reunion! It was time to head back to our homes. Just before we were ready to leave, Jim pulled out an envelope and asked me to open it. In it was a check for an amount far greater than I had given to him. “That is for the loan and the interest on it.” There was a snicker in whose mind? Who was listening and not managing his filters? Was I listening? Or was I bending to the whims of my bias? Was I talking in my own head and not giving “listening” a chance? I was all that and more. My wife deserves the credit for that reunion, as she does in most cases related to social analytic concepts, which come easy to women, I realize. I try not to anymore, but I know I still do and the battle continues to subvert the voice inside. ...but for a chance to LISTEN... as listening is not the same as HEARING... The friendship has moved along at a pace that it would have been without the ten year interruption. Jim was prosperous, is an understatement. He often asks if he can help me in any way. So much for intent! The difficult times seemed to have made him tougher, better, stronger and more productive. He gives us credit all the time, but we all know better. "70% of our time is spent communicating and of that 45% is spent listening and 30% is spent talking." Adler, R. Rosenfeld, L and Proctor, R. (2001) Interplay: the process of interpersonal communication (8th. edition). Fort Worth, TX: Harcourt. "Learning is a result of listening, which in turn leads to even better listening and attentiveness to the other person. In other words, to learn from the child, we must have empathy, and empathy grows as we learn." - Alice Miller. I would venture that 70% of clinical diagnoses would be established without a drop of blood being drawn through effective listening by the physicians! And an equal number of disputes could be resolved through the simple act of using both the ears rather than exercising the might of one tongue! ## Sunday, April 6, 2014 ### The function of x ~ f(x) f(x) It is a beautiful morning. The sun is bright and warm and the sky is azure blue. The breeze lifts the veil of life’s opacity and shows her assets. Ah it is good to be alive. What should one do today? Maybe work in the yard, maybe go for a bike ride, maybe roller-blade on the side-walks and worry new moms cuddle their minors closer to them, or maybe just sit on the grass and read a book. So the “x” in the equation is the beautiful morning and the “f” is the function that I am willing to perform as a result of the “x.” Now that we have it, let us explore how the science world has mutated the norms of their and our thinking. The function of “x” has become over time “x” itself! Let me explain: 1. Take for example the hammer. It is always looking for a nail, otherwise it is mostly useless, wouldn't you say? So if we have this new hammer that we bought for$10 we want to pound some nail somewhere to find utility in it. A similar corollary would be discovering a drug and finding a disease to apply it against to find relief. The problem with both is that we have not really seen a problem but through acquisition of an “x” we want the “f “-related to it. So now we have to throw this drug in meaningful ways at different diseases and through the art of statistical manipulation come up with a tightly bound Gaussian metric and negate the null hypothesis, or simply find proof (you know like the one that proves that the absence of your friend is due to alien abduction and the Alternate true Hypothesis is the absence of your friend is due to the fact that he is on vacation)!  Ah, Ha! We exclaim, lo and behold we have found the cure for disease “y!” But did we? Or is it just the manipulation of the hammer to pound down further something that looks like a nail buried in the wood? The example here would be the “Statins:” Once the charmer that was to cure/prevent all of coronary artery (atherosclerotic) heart disease, Pravachol seems to have morphed into its various iterations and now seems poised to find some inkling in curing or at least besting cancer by improving survival rates. Well, and this is only a minor well, the Patent on the powerful statins in cardiovascular care seem to be coming to a close, so it might be time to find another "f". The “x” looking for an “f” then looking for another "x"?  Other beautifully rendered scientific articles with appropriate graphs and tables seem to pop up every now and then on the unbelievable benefits of Vitamin D. It can cure almost everything or can it? But here is the lasting memory of a fond desire to everyone or anyone who loves chocolate. Chocolate is great for your heart! Okay, I’ll buy that, even if it tastes good! So the current science or pseudo-ness of it is to prove whatever you set out to prove and with probability manipulation of a few numbers and voila, there’s the proof!

2.
The same experts that prattle on about the symbolic “f” of a certain “x” now bring the two together in another well-advertised episode of “f(x)” by using the self-enriching models of creating such endless hardships of NO utility as the Maintenance Of Certification (MOC) for doctors. The “x” here is the biannual expense of $5000 cash outflow for the doctors to the inflows for the American Board of Medical Specialties and the “f” in this examination is deemed as means for the doctors to be tested for their knowledge and abilities. Huh? Knowledge and abilities tested every 2 years? The makers of this MOC test (x) propound that the public deserves to know that their doctors are knowledgeable. Indeed the doctors have to fulfill the Continuing Medical Education credits of 50 hours per year to maintain their license in the states they practice and that is the “f” of the test of practicing medicine “x.” But these self-serving agencies have now put themselves right in the middle to promote themselves as the arbiters of physician knowledge. What is most interesting is that there is not a single shred of real “EVIDENCE” that the tests that they profess to be the greatest thing since sliced bread for detecting “unknowledgeable” doctors have any proof. But they carefully craft the queries to the willing about how they “felt” the examination helped their knowledge base. So the “x” here is in place in the form of MOC and the revenue stream to the agency and the “f” is grinding out the template of acceptance and acquiescence through enabled doctors (selection bias) who will affirm the “x.” What is not mentioned that the ABIM a branch of ABMS brings in more than$49 million/year and the President of ABIM makes about \$750,000/year. The “f” of this “x” is plain to see, isn’t it?

3.
Healthcare cost has been the topic of conversation for several years now. Yes, it is spiraling and you know why? Because it is an incentivized system of care. The misplaced responsibility onto the middle man (the Insurers, Medicare, Medicaid) to pay for any and all ailments of the elderly and the indigent. This incentive creates a sense of entitlement. The doctor’s offices and the Emergency Rooms across the country are bursting at the seams with patients who have arrived there with every minor ailment that time can heal. But what is lost in the jungle of honking noses, dried out coughs, red cheeks and low grade fevers are the real medical horrors that have difficulty being seen by the physician. So cost containment is a need. If responsibility is shifted to the patient for a larger portion of payment and the rush to the emergency room will most likely be reduced. But no, the experts have taken a different tack.
They are refusing to reimburse the entity that cares for the sick by denying reimbursements for re-admissions, for infections that become evident during hospitalization claiming them as a result of hospital error and the like. The votes seem to propel the politicians into this circuitous thinking of find the wrong “f” for the “x” all the time. Find the fault with the physicians or providers as the doctors have been demoted to nowadays. These same experts burying their heads in the sand find arcane and clever ways to arrive at reasoning  that we should not be trying to diagnose an illness too soon as it causes unnecessary tests and potential harm. They go against mammography (breast cancer screening and PSA test for prostate cancer suggesting “lead time bias” as the root cause of too many diagnostic errors. They also have determined colonoscopy is an over utilized screening tool. But then studies recently have shown an overall dramatic reduction in colon cancer as a consequence of the screening colonoscopy. They flood the digital and printed ink universe with their version of the “f” (harm) for the “x” (costs). Who is the general populace to believe? The current vogue answer to that question is; the adoring media and its “Made to Stick” format and their "Buy-in." A travesty upon travesty!

EMRs. Now here is an “x” that was contemplated at the political level through the arbitrage of the experts willing to create the hardware and software for self-aggrandizement at a large scale. So they duped the consciousness of the physicians and the general populace into thinking that the Electronic Medical Records would reduce errors and give a better handle over the disease to the doctors. Did it? Simple answer: No! Did it create a gulf between the physician and the patient? Answer: Yes! But for the “f” in this “x” which was done for monetary gains of the companies that got the contracts, it seems that the physician practices are in disarray due to complexities of the EMR and its meaningless use after spending thousands of dollars that they have been refused reimbursements for by the agency. It has created a mound of useless verbiage through “cut and paste” in the medical records that are done to satisfy some arcane rule of the insurer for documentation and the most devastating of all, it has taken the eyes off the “Ball” -the patient. The eye to eye communication no longer exists and the patient drones on about his or her ailment while the doctor is busy trying to fit round pegs in square holes in the arcane digital universe. This paradigm shift in patient-care is uniformly destructive to the field of medicine. The holistic view however of human care is in the understanding of another’s dilemma and then to solve it through knowledge, experiential reference and a pulse on the frailty of the other. It is not as some experts will have you believe that medicine is but a ceramic/silicon away from being dehumanized and perfected.

Kahneman and Tversky famously discovered the utility of the “f” of “x” and not “x” itself. In other words, the relative rise in the utility of one’s wealth as measured by the benefits had a far more meaningful nuance than sitting atop a mound of coins as Uncle Scrooge. You see, the small incremental “f” of “x” have a larger core of happiness in it then a large “x” sitting in a vault that these experts are accumulating on everyone’s dime.
The “f” today is manufactured, sometimes created out of thin air similar to printing money by the FED. The artificiality of this “Goldilocks soft-landing” will have a price to pay in the end. The “x” here unbeknownst to most is the lost asset of many trillions by the middle-class, and the ÿ" here is the white-wash, but that is another story…

Know your “f” of “x” that is...

Live only to accumulate the “x” off of others by a false “f’ prophet and one day not too distant in the future the Lorentz Strange Attractor will have your head for the false "f."

THINK!