## Saturday, January 31, 2015

### QUALITY METRICS, Probability & GOTCHA

Can the bounded asymmetry of thought align itself to the unbounded reality? That is the question. The premise is: "To drive progress, we are focusing on three strategies. The First is incentives, the Second, improving the way care is delivered and the Third, we aim to accelerate the availability of information to guide decision making through Meaningful Use of EMRs." ( here) The verbiage is enticing and any arguments to the contrary makes one look regressive, obstructionist and non-compliant! What could possibly go wrong if we were to reimburse physicians and hospitals for quality and withhold such payments for lack thereof?

Plenty!

First let me tell you up front about the “probability” function. A lot of it is based on assumptions. When we look at small samples and predict the event onto a larger population, there is always a chance that we will be wrong. As noted by John Ionnadis in his 2005 paper that 54% of all studies could not be validated due to the use/abuse of statistical modeling. Sampling has an inherent bias, even if we cite the Bayesian principle (which simply states that the probability of event B is the sum of the conditional probabilities of event B given that event A has or has not occurred). Here we are using conditional probability of independent events.

Here are a few assumptions:
1.       Patients with multiple (more than one) comorbid diseases have a higher chance of complications. eg: a) A diabetic patient with vascular disease and alcohol related fatty/cirrhotic liver has a higher chance of renal dysfunction. b) A neutropenic patient undergoing chemotherapy has a higher chance of infection with other complications related to the chemicals and biologics on top of other chronic conditions such as obesity, kidney disease, heart disease etc. c) An elderly patient with a coronary artery disease, previous myocardial infarctions has a higher chance of arrhythmia, congestive failure and pulmonary edema. 2 + 2 mostly ends up as 3 or 5 due to confounding factors mentioned above.

2.       Younger patients without comorbid diseases have better outcomes due to their resiliency from age. 2 + 2 indeed can amount to 4 in them.

3.       The ratio of the healthy-young to elderly with comorbidities is roughly 3:1. This ratio is skewed, to the extent that the numbers vary regionally and community-wide and can be as low as 4:1 or as high as 2.25:1. A similar ratio feeds its way into the healthcare sector.

4.       Using those simple assumptions let us say that the following ACOs and hospitals exist: a) An ACO tied to a tertiary hospital. b) A rural hospital with limited resources. c) A multi-specialty group with a good reputation with privileges in a secondary hospital.

P = ( Probability # of successful hospital outcomes in total # of hospitals in a group)
# of successful hospital outcomes = x
Total # of hospitals in a group = n
Probability of making the successful outcomes = s
Our formula is: P= s^(x (1-s)^(n-x)

Let us look into the magic of probabilities and statistics. Assuming that the Probability of success in achieving the metrics mandated by CMS = 60% and the probability of missing the metrics is (1 – 60%) 40%. We then further assume that 8 out of the 14 hospitals will achieve this success or 14C8 (Out of 14 choose 8) which than gives us the combinatorial formula using factorization (14!/8!(14! – 8!) = 0.20 or 20%. We are giving higher potential of successful outcomes to a select number of hospitals (n=14) and saying that these hospitals had all the right kinds of resources and the right demographics of fewer patients with comorbidities. Then given all the risks and “paper-pushing-and-game-playing,” 8 out of 14 hospitals have indeed the potential of achieving probable success of 60%. The probability of that successful outcome happening is 20%, in other words even though we give this high likelihood of success, the potential probability of achieving that success is only 20%. OR putting it in numbers: The probability of NOT achieving success by these hospitals is ( 1- 20%) = 80%. (Or 80% of the time you are not going to get paid for services).

It is obvious for anyone to see that given the aging demographics of the United States and the retiring baby boomers that what the government keeps telling us suggests that the ratio will be even more skewed against the successful outcomes, unless humans become robots and an oil and lube job keeps them going until rust settles in from disuse.

Now let us take the first set of hospitals (here we take a larger sample n = 30) mentioned above and the ACO combinations:  a) Given the high risk nature of their patients the probability of achieving success in 15 of the 30 hospitals might dip to 40% hence the probability of successful outcomes goes down to 7.8%!

In the second scenario of rural hospitals (n =30) assume the probability of success is at 50% (the toss of a coin), the probability of successful outcomes now is 14.4%. The rural hospitals with a lesser number of complicated cases will have a better chance of achieving the successful outcome; almost double that of the tertiary hospital.

If you think that is questionable, just go back and review the P4P (Pay for Performance) plans conjured up in the dimly lit confines of the bureaucrats. P4P was abandoned as a result!

And with the third scenario, while it may appear good shows that the secondary hospitals and good reputation ACOs with a 70% probability of success in 15 of the 30 hospitals show a probability of successful outcome in 1.06%!

So where does that leave us?

Actually it paints an interesting picture. Even if we were to double the successful outcomes probability in each case it would still be less than 50%. So here is where that leads us…

If less than 50% are able to play the game and get rewarded for it, then what happens to the rest who cannot? How many will survive without getting paid for services? Something to think about!

Remember the arcades where a quarter will get you a prize if you can steer the picker-upper claws to pick the prize from a large collection of soft teddy-bears and the like and drop it into the basket for you to collect. The only problem is that the picker-upper claws are loose and dangle as they slide over any of the colorful furry toy animals. So you spend and spend but never get a prize. The risk reward appears against the establishment, yet the truth is the consumer gets hosed into spending a lot more than the prize is worth and still never gets any.

We see the same gotcha thought process, only that a few will be able to manipulate their numbers to meet the required demands, but not for long. The evidence is plain to see when it comes to the ACOs how more than half of them shut down because they were unable to make any revenue to keep the doors open. Taking the lead from that concept what could possible go wrong to the entire healthcare system? The agenda to limit expense will be successful, to the extent that monies will not be doled out as mandates and checkpoints will guard the outflow. Success will be writ large in the obedient media. "Money has been saved!" will cry the headlines, and the demise of the scores of shuttered facilities will be ignored by the pundits. Yet with such outcomes the answer will also lie in the liberties of the human element. People who spend their lives acquiring knowledge to better their craft in caring for patients, I feel will find alternate sources of managing their patients and as Denials of Services (DoS) becomes the game du-jour, more patients will run away from the game. The bureaucrats will then come to the table, in order to keep their monopoly, by liberalizing the criteria and a new game will begin for the gullible.

So that leads me to another question. Is the attempt to make people (in this case doctors and hospitals) work to the bone but not claim any remuneration the underlying philosophy? Is hard work related reward now considered greed?  Times are a-changing! Aren't they?

What might happen if we look into the future further? Is the new model to create fewer entities that are able to “play the game” with the government mandates and the rest of the many to forfeit ability? Those that do play well will be glorified and those that don’t will be vilified. In the end the choices will narrow to a few. And with fewer vying for rewards comes better controls and less reasoned critical thinking.

Sounds harsh?

O' I imagine I will be skewered by some experts for being naive and a fool and I admit, I am both. But maybe constructive criticism will open a dialog and some eyes.

Think again!

## Wednesday, January 28, 2015

### A SEA OF TROUBLES

Between the Wall and Bayonets
I derived that analogy from the old saying, “between a rock and a hard place.” In this case the Wall is not an unmoving stillness but like the front lines of the warriors of the past with shields advancing against a sea of arrows towards the bayonets. The bayonets are also mounted in the arms of the warriors hurtling in space on the backs of their steed collapsing the distance between.

Ah, in between those two movable targets sits the lonely physician. No, I want to make it clear this is not a boo hoo story of the poor physician. It is not and yet something tells me, it might be…read on.
“Choosing Wisely” as most of you might have heard is the latest version of a collective mindset that sits in the ivory tower and tries to control the mind and movement of the rational-decision-making-reason-based management advocates called doctors. What exactly is this “Choosing Wisely?” (www.Chossingwisely.org)

Ok folks gather around the camp fire and we can let our demons fly.

“Choosing Wisely” is purportedly an “Evidence Based Medicine” guideline format to spell out what supposedly works and what does not in the management of the patient. “The Choosing Wisely campaign was created by the ABIM Foundation to challenge medical specialty organizations to create a list of tests or procedures that can be used to "spark discussion" between patients and physicians regarding the utility of the tests.,, Choosing Wisely recommendations should not be used to establish coverage decisions or exclusions. Rather, they are meant to spur conversation about what is appropriate and necessary treatment. As each patient situation is unique, providers and patients should use the recommendations as guidelines to determine an appropriate treatment plan together.” That is what the ABIM Foundation pundits say. But upon further review as most have done, it appears to have other motives behind it. “Why 'Choosing Wisely' Won't Protect You in a Lawsuit.” William Sullivan, DO, JD points out that Section 5001(c) of the Deficit Reduction Act, the stated purpose of the list was to reduce healthcare expenditures under the Social Security Act.” And furthermore he states that “There are more than 2500 guidelines related to diseases and thousands more guidelines related to treatment of diseases, according to a review of the National Guideline Clearinghouse. Clinical practice guidelines may be used by either party in a medical malpractice lawsuit… It is therefore important to use clinical practice guidelines as outlines of general care that may change based on current medical research, and not as stringent datasets that necessarily define the standard of care.”

Herein we have another dilemma the lawyers can therefore successfully call these guidelines if you choose to follow as not the standards of care. Then we are left with, who will the jury believe, the articulate artist in the pinstripe suit or the fearful-chin-buried-in-the-neck doctor?

Here is another caveat that we as doctors may not realize, if the Insurance Company refuses to reimburse for services rendered outside of those that are considered “Chosen Wisely” and some harm was alleged, the lawyer can use the denial of payment as a testimony against good practice of medicine and sway the jury right or wrong against the physician. See how the wall moves towards the bayonets?

Moderate quality evidence is not something that doctors should consider hanging their hats on. Back pain is one of those that afflict a large majority of patients (about 19 million) and the American College of Physicians deems it unnecessary for physicians to do imaging in such cases. Yet 130,000 of patients have cancer and 1900 have spinal vertebral infections. If no X-Rays, CT scan or MRI are ordered, there is a missed diagnosis worth a few million to the plaintiff’s attorney. But here is the trap, articles abound suggesting that doctors order too many CT scans and expose their patients to radiation. There is no give in the opposing bayonets either.

To absolve themselves from any and all litigations related to these guidelines the ABIM foundation, the creators of the “Choosing Wisely” program have disclaimers: “The disclaimers contained in Choosing Wisely guidelines, such as "use of this report is at your own risk" and "the ABIM Foundation ... [is] not liable for any loss, injury, or other damage related to your use of this report…"

On the flip side of doing a test that was suggested as a moderate quality evidence that results in a some harm will automatically enhance the lawyers to seek out the experts from behind the ivory tower walls to shriek and yell as to the need for such a test on the patient thus burying the physician in a sea of troubles from whence he might not be able to practice medicine with reasoning. With one eye on the risk to patient and the other equally focused on “Choosing Wisely” guidelines. So, damned if you do and damned if you don’t! The implied volatility of support from “Choosing Wisely” is a double edged sword of Damocles. It hangs, terrifyingly, until it drops!

And now to the dried fruit approach of bashing the statistical proofs, which are abused in medicine, and draining the water out of them: the statistical methodologies used in scientific articles for majority of the “high impact” journals are unreliable and unverifiable, and bring little solace to the weary physician administering medical care (Ionnadis). When “Choosing Wisely” is based on the shaky foundations of some form of bias, hidden under the shifting sands of “Evidence Based Medicine,” then the rendered care to the vulnerable patient -based on any set of those guidelines is fraught with failure and impeachment.

There is a movement towards statutory guidelines that when followed will protect the physician from litigation. But then not following such guidelines based on physicians intuit and judgment will be subject to penalties and what of the best possible care for the patient?

The squeeze is on! Eat your Wheaties!

“Their understanding
Begins to swell and the approaching tide
Will shortly fill the reasonable shores
That now lie foul and muddy.”
-
Shakespeare

http://www.medscape.com/viewarticle/837399?src=wnl_edit_bom_weekly&uac=17589HT

## Saturday, January 24, 2015

### LESS IS MORE

Robert Browning could not have been more direct in using those words when he described the painter Andrea del Sarto’s obsession with his unfaithful wife Lucrezia to the detriment of his painting career. "Carelessly passing with your robes afloat,— Yet do much less, so much less, Someone says,
(I know his name, no matter)—so much less! Well, less is more, Lucrezia: I am judged."
Yes indeed! Less is more. It is so in human affairs of every walk in every life. Shakespeare also in his infinite wisdom said through Polonius “Brevity is the soul of wit, and tediousness the limbs and outward flourishes…” and it behooves us to consider them in our daily affairs.

Less is More

Too many words take away from the immediacy of a well-crafted story. Too many in supply and profit of their hope spend a litany of words to try to invoke need, want and desire in another or something. They do not realize better can be accomplished with a few choice ones.

We choose to do more in medicine as well. The cause of this effect “or rather the cause of this defect, for this effect defective comes by cause:” merely remains unseen through the eyes  “purged thick amber and plum-tree gum” of those who remain blinded to the cause yet steeled against the effect.

Less is More

Indeed if we were to limit the diagnostics that have made us take steps forward in curing cancers and burgeoning the legions of cancer survivors in the millions, one might think that a stitch in time does save nine later, we might arrive at a different universe. So here careful diligence of the real “less” helps in the more. But this does not mean that each x-ray should be followed by a CT scan for confirmation and then an MRI ordered for confirming the confirmation or a PET scan for overall reducing the p-value further to limit ambiguity.  Yet we must all know, there is never a 100% in the 100% offered. Similarly a chemical profile does not have to be done daily to see trends by watching the milligrams per deciliter rise and fall within the laboratory range. Above all do no Harm! Repetition and injudicious use are all harmful in ways we cannot fully fathom.

Less is More

If less medicine was offered through various outlets and vendors, prescriptions and over the counter, acquiescing to demand for instant cures and for allaying anxiety then there would be fewer “superbugs,” lesser resistance to antibiotics and fewer people walking the streets in states of perpetual depression.

Less is More

Triplet regimens in chemotherapeutic regimens had similar outcomes as doublet regimens in lung cancer therapy. Less here was equal in response but more in lesser side effects. Now however with personalized medicine, we might arrive at a single “silver bullet.” A form of that bullet was attempted in the 80s and 90s via the chemosensitivity assays by Sidney Salmon, MD and Larry Weisenthal, MD, PhD. Those were heady times like the ones we are in nowadays. Soon nano-wires and nano-dots made of gold and impregnated with appropriate fluorescent antibodies and “sniffer” devices will diagnose the beginnings of maladies and swarming molecules of antibodies will swoop down and commit murder on those blinded wayward cancerous and other excited cells. And soon we might be able to convert the wayward cells into compliant ones and rehabilitate them back into the society of trillions. But until then, less is more.

Less is More

Maybe we need a longer umbilical cord between the anxiety-riddled patient who has been thrown into the fear-mongered world of journalism gone stupid. “No Mr. So, there is no need for antibiotics for your sore throat, it is viral in nature and antibiotics do not work against viruses,” might be the appropriately expressed sentiment. To allay anxiety with words is one thing, but for the pharmaceutical drumbeat of “you need this…call your doctor” or provider immediately (as it is fashionable to label the physician) is what feeds the one-eyed monster of this fetish.

Less is More

Regulatory fiat in medicine that forces physicians into mock compliance by taking away their eyeballs from the patient and forcing the sight upon useless paperwork, meaningless-metrics, dotting the “I”s and crossing the “t”s, filling in glossary-based jargon into digital records to keep the mandate-makers happy and the revenue floating in to keep the business of medicine from folding, there is little time to do what doctors are wont to do, like for instance care for a patient. Definitely here, less is more!!

More is less!

More hurts! More pains! More diminishes! More subjugates! More creates more calamities for the future. More hurts us all in a myriad of ways. More back surgeries hurt when not indicated. More knee surgeries do the same. More chemicals ingested lead to a plethora of ailments. More diagnoses without relevance in psychiatry are a detriment to individual health. All medications are chemicals. So more is harmful!

Time to reign in these words  and thoughts in search of brevity.

## Wednesday, January 21, 2015

### "POLLY WANTS A CRACKER!"

I saw a feral cat the other day, dodging and weaving her way between the bushes. A quick lunge here and a slow retreat there and her day was spent to live another day, to meet another male, to make kittens and spread her progeny around to roam other grounds. Fascinating to that in juxtaposition was the lone parrot housed in a gilded cage looking at the cat through the all glass window. He jumped from paw to paw squawking his meme, “Polly wants a cracker.”

And it dawned upon me how very diverse the universes of these two beings were. One roamed in search of food and the other repeated the rote and was fed. This deliberation clogged the synapsis of my brain for a while. Maybe Polly was the better of the two, sitting all pretty ensconced in his golden cage without lifting a feather, he was satiated just with his rehearsed mantra? Or was he?

Hmm… this was going to be a difficult deliberation.

There is a river close by and I remembered there was sign near its northern bank, which stated in Red on White, “Do not feed the wild birds. If you do they lose their ability to find food for themselves.” Funny I thought what about the emotionally-packed-willing-to-show-empathy individuals who were out there throwing crumbs at the milling flock of seagulls that cackled around, diving, flying and urging their kin to come and partake in the bounty. Were these good-intentioned people not worried about the seagulls dying because of their temporary actions; of creating dependence, that made them (the crumb-throwing people) feel good in their own minds with nary a look at the winter months to come for the seagulls?

Why then would such a sign be put up? Apparently the ecologists had reasoned that if the birds become dependent on the crumbs, they would not survive when no food was offered.  Drawing from that memory, in Taleb’s world the feral cat like the unfed seagulls would be considered “antifragile” a survivor, and the caged parrot, “fragile” much like the " Black Swan" doomed to the ultimate risk, like the turkey near Thanksgiving Day.

Another thought came reeling in, “Why do they call ‘Wild Type p53’ for the normal functioning p53 gene that is considered, ‘the guardian of the genome’ of the human cell, wild?” …Exactly! You got that, didn't you? If the wild type gets mutated it is no longer wild-type but a mutated version and a mutated p53 gene is the arsenal for the most virulent of cancers in the human body. Google that!

Searching for more clues I came across a fight between the Big Blue and Kasparov. it was a very interesting fight between an algorithm-coached machine and a human being. Kasparov the world recognized champion in Chess then, lost the game to the Big Blue in one of the most human vs. machine experiments ever witnessed. Alan Turing, in spite of his " Christopher" would have been proud. At the time the FIDE chess rating of Kasparov was maybe 2800 and Big Blue’s was around 2900. So then as circumstantiality will have it, my mind wandered into the realm of what if we combined the two; the intuit of man and the parallel-processed linearity of say IBM Watson, Big Blue’s new iteration? We might just get an intelligent and better predictive outcome wouldn't we?

http://youtu.be/Mz8P8D8MdNU

In other words, let us combine the feral nature of man and the domesticated algorithm of the computer and lo and behold the outcome in say economic and political forecasting might improve, think Nate Silver. Medical care might improve too. The doctor gets the benefit of the “computer spit” and then adds his or her intuit to qualify or modify those “spit-related-computer-endorsed-actions. But here is the dark abyss in all such actions; the doctor in his or her dependency of the computer spit might and most probably will lose his honed intuit over time, out of sheer laziness, like Polly. The dependency will slowly and inexorably eek out the virtuoso in time. What then? No Beethoven’s 9th symphony, No Mozart’s 40th symphony  , No Newton’s Laws, or Einstein’s relativity, or Feynman’s “O” ring, or Jenner’s Cowpox vaccine, or Fleming’s Penicillin, or Curie’s Radium?

http://youtu.be/1MOAF6qlFjw

I agree with Eric Topol, MD, the Medscape Editor and author in his own right of two published books that change is necessary and that whether or not we like it, it is coming and those who stand by the wayside will either be forced onto it's path or die of irrelevance, but I have a problem with the thought that we should divest ourselves of our intuit and humanity for the sake of a head long dive into the totality of algorithms. Even if we took all of McCullough and Pitts Neurons, you know the kind with multiple inputs and a single output and fed these "neurons" with all of the Library of Congress information, they would not and could not provide the human reasoning. There is that nebulous thing called intuit, after all; the recruitment of the neural energy and the firing of the electrical impulse is a random and inherently human process! A cautious merger between the two might make for a better world. Relevant information gathering fed to the ceramic-chip-brain and then the gleaned output reasoned with before calling it " Care."

Which brings me back to medicine: This, Choosing Wisely-Evidence Based Medicine rhetoric is being designed with the linear regressive models that weigh in costs more (the betas) than care for our patients. Maybe we should be careful of how we interpret and use them. There lurks within such hubris, the fallacy of Composite problem. A total subservience by doctors, is akin to the gilded caged parrot. We need the feral nature of the human mind AND the comprehensive knowledge stored within the algorithm couched databases to articulate and best provide for each other when we are patients! The touch of another human being is far superior in alleviating anxiety and pain then the cold feel of a robotic metal-in-human-skin-like-artificial-hand.

The “out of the blue" Eureka moments are non-linear paradigm-changing events and are the realm of the human brain- the random recruitment and firing.

## Friday, January 16, 2015

### "SEND IN THE CLOWNS"

“Where are the clowns?”
“Quick!”
“Send in the clowns!”
“Don’t bother, they’re here.”

Things are tense nowadays. Everyone has an opinion. And generally it is not a good one. It is full of sound and fury, signifying…frustration. The process is unfolding, it is unlabeled and the contents unknown. Like the tense surface of a water droplet skating across the leaf surface ready to splash at the first prick, this tension mounts as it wobbles, ready to burst open.

I happen to be seated at a café with some acquaintances when one fairly intelligent sort who had uncoupled the chemical bonds in the field of chemistry and used his capacious knowledge to advance the pursuits of a company blurted out, “You doctors have a monopoly in medicine.”

“Say what?”
“Yeah, anyone should be allowed to dispense and care for himself or another as a patient.”
“Say again!”

“Anyone can treat a disease or a malady instead of going to the “doctors!” and he emphasized the word with a certain touch of dark humor. He continued, “Every day you hear about some doctor caught prescribing unnecessary medications, some embezzling money, some causing grievous harm to others, some diagnosing disease where none exists!” He whistled, “I mean I can go on and on about what you doctors are up to. So with that why can’t the ordinary citizen decide what medicine he or she can take and get it from the pharmacy, especially now that we have internet and the same information at the fingertips?” He looked around for a moment then said, “I mean, if the doctor has to look up information on his smartphone or his tablet or the computer screen, every time, I ask him a question without saying two words to me why then, why should I visit him. But Noo,” he dragged at the no to its fullest elastic length that would come out of his pursed lips, “the doctor is busy dotting the “I”s and crossing the “t”s on his computer to get reimbursed while his nurse is telling him to hurry up for the next victim! No time for me! Well, I have news,  I have no time for him”

Interesting monologue, I thought. That came from left field like a sudden slap-burn on the cheek and right after a chicken sandwich laden with mayo. This form of monologue has been circulating in various forms in the social media recently too, drawing a multitude of warriors. These forms tout how doctors are really buffoons and haven’t been taught social media in the medical schools and how some don’t take social media seriously and how they are dinosaurs and Luddites. It is a common theme played out on the cyber-theater near you every moment of every second. And everyone falls in step with fingernails that can draw blood from underneath the white coat.

I thought for a moment and just then an intra-psychic thunderbolt hit my synaptic bundle…
Maybe the road that we as a nation have chosen; to vilify the doctors, by dumping billing data without context, and started on the path to demonize those that have billed more than the norm, patronize them, tell them they don’t have manners, or empathy, that they do unnecessary appendectomies, or that they cause harm by doing too many CT scans, which cause cancer and those who lack the requisite knowledge to differentiate between the need and the want, or lack the know-how of caring, that a computer is better than their intellect and intuit and that the nurses and assistants can deliver similar if not better care, well then what does one expect? It is game over.  The walk-off home run hitter is trotting from third to home base. And through it all, they, the doctors, are made to comply with absolute idiocy of electronic medical records to boost information gathering that harms patients through one size fits all and helps insurers to harm the doctors in return financially. These are people working hard try to comply with various and sundry mandates that are only dreamt of in a bureaucratic philosophy, which take away from the time that should be spent with the patient. The more the number of mandates, the larger the unbridgeable gulf between the patient and the physician grows. And then the blame game ensues, to the tune of billions of dollars being steadily siphoned away by the mandate makers and lobbyists, against the doctors and firmly centered in the crosshairs is guess who? ..the white-coat wearing, stethoscope bearing physician. Who suffers? The Patient mostly, for now. When we have holographic doctors driven by a air-condition-cooled remote IBM Watson sorting out between "cluster-headache" and "migraine," then we shall see.

“Maybe you are right!” I replied to the smart and intelligent hydrogen-carbon-chemistry man.

Huh! You could see him taken aback and speechless. What followed is a tale for another time…

Maybe we have accumulated the requisite number of clowns already. We have done it to ourselves, allowed the insurers to dictate reimbursements, allowed the government to dictate the appropriateness of care based on costs, given the keys to medicine's cabinet to anyone willing to throw a rotten egg, and allowed the middling managers, economists, statisticians, mathematicians, bureaucrats, politicians, even Ravi the taxi driver in New York and Jason the hedge fund manager, the right to decide how medicine should be “practiced.” Meanwhile the elite experts pontificate about how everyone should be treated as patients, or how we have the right to free physical examination (BTW that doesn't work as a form of prevention and now given those costs they are shying away from that too), or how we should not be treated after the age of 75 or that cancer is a good way to die without treatment. I mean, what the heck is going on here?

Geez o’Peez where are we going?

“Where are the clowns?”
“Quick!”
“Send in the clowns!”

“Don’t bother, they’re here.”

http://youtu.be/8L6KGuTr9TI

## Sunday, January 11, 2015

I came across an article in the New England Journal of Medicine recently and it provoked some thoughts that I would like to share with you. http://www.nejm.org/doi/full/10.1056/NEJMp1407373
But before we go to my thoughts let us reflect on these two paragraphs:

“Research suggests that for physicians to play a substantial role in such decision making, there has to be a relatively high level of public trust in the profession's views and leadership. But an examination of U.S. public-opinion data over time and of recent comparative data on public trust in physicians as a group in 29 industrialized countries raises a note of caution about physicians' potential role and influence with the U.S. public.”

And:

“Indeed, the United States is unique among the surveyed countries in that it ranks near the bottom in the public's trust in the country's physicians but near the top in patients' satisfaction with their own medical treatment.”

The Authors then opine and in the same breath contradict themselves:

“Part of the difference may be related to the lack of a universal health care system in the United States. However, the countries near the top of the international trust rankings and those near the bottom have varied coverage systems, so the absence of a universal system seems unlikely to be the dominant factor.”

They go on to segment the population to achieve a meaningful use of their article:

“The United States also differs from most other countries in that U.S. adults from low-income families (defined as families with incomes in the lowest third in each country, which meant having an annual income of less than \$30,000 in the United States) are significantly less trusting of physicians and less satisfied with their own medical care than adults not from low-income families“

And then from the double-speak right from the Animal Farm:

“Although non–low-income Americans expressed greater trust in physicians than their low-income counterparts did, when responses were analyzed by income group, the United States still ranked 22nd in trust among the 29 countries. On the flip side, although low-income Americans were less likely than non–low-income Americans to report being completely or very satisfied with their own care, the United States still ranked seventh in satisfaction among low-income adults (ISSP 2011–2013).”

They do grasp the problem meekly:

“We believe that the U.S. political process, with its extensive media coverage, tends to make physician advocacy seem more contentious than it seems in many other countries.”

But then squirt it away with this politically-motivated, correctly-interfaced, seemingly-validated, interlaced through the arbiter of political correctness against the physicians’ diatribe:

“Nevertheless, because the United States is such an outlier, with high patient satisfaction and low overall trust, we believe that the American public's trust in physicians as a group can be increased if the medical profession and its leaders deliberately take visible stands favoring policies that would improve the nation's health and health care, even if doing so might be disadvantageous to some physicians.”

And as always they warn with icy-cold fangs that draw blood and impose fear and humiliation among the physicians with:

“If the medical profession and its leaders cannot raise the level of public trust, they're likely to find that many policy decisions affecting patient care will be made by others, without consideration of their perspective.”

Let us ask these authors the very basic question, "Who are you?" And you find that there is not a single physician among them and not even one that has moved to the dark side of regulatory capture. The degrees they hold; a Sc.D, an M.A., and an M.P.H. The last one of course has the associative epidemiological know how to prove that association is tantamount to causation.

Unfortunately NEJM is complicit in this fine act of political correctness by endorsing such nonsense.

Why for heaven’s sake, can patients be happy with their physician but angry overall? Because the media and the political machinery is constantly yammering away at the costs of healthcare and that physicians are the root cause of that cost. It is 17.9% of the GDP they bellicose, but they never seem to deem it necessary that majority of that is the middling administrative management that derives oodles and oodles of money. If one were to simply seek an answer, one has to look at the 2012 Data Dump by Medicare, which showed that only \$77 Billion was in direct payment to the doctors from the \$985 Billion expensed and that translates loosely to about 7.78%. Of that, a large part was a direct pass-through for fixed costs, medication and equipment. But no, that would not fit the Elite narrative. No, that absolutely won’t do!

## Saturday, January 3, 2015

### FATHERLAND...A STORY.

This is a story...of more than a hundred years!

There was once a great big country called Acirema. Over the years it had grown to a large state through enterprise, innovation and hard work.  With the bureaucratic mindset in place and giddy with success the time had come for the country to take even bolder steps to advance the culture and society. The head of state decided that everyone should walk backwards so that people would slow down their rampant desire to overwork and over-consume. And by doing so, they would reap the benefits of their minds better. The prospect was difficult at first, so the state gave bonuses to those who could accomplish the feat first for an hour and the bonuses got higher and higher as one was able to continue on for a day and then days and then months, until it became commonplace. The logic was carefully controlled by a mechanism of news cycles that determined the value of “Walking backwards.” The articles in the magazines were replete with health benefits, longer survival, better communication and more time for meditation. These articles were the fodder for the enabled television and the holographic media. There was a certain intransigence to logic as the megaphones of propriety sounded off in the distance and complete degeneracy of reason took hold.

Pretty soon everyone was undertaking the journey to gain the financial windfall from the head of state and his Ministry of Well-being and Reform. The herd mentality blossomed and just like the Colors of Benneton were everywhere for the moment, the limpid pastels of shallow thought showered irrational exuberance into the flag-waving mushed-out minds. The tragedies and accidents from such a mandate on ambulation were conveniently buried deep in the stacks, never to crest in the news. The accidents and loss of life from misadventures by some by falling in gravel pits, open manholes, walking into a street lamp or into oncoming traffic being driven backwards, caused the Steering Committee to mandate that everyone buy a set of “electronic eyes” for the back of their heads. That was their intelligent solution! The contract for the “electronic eyes” was given to the man who had proposed the initial concept of “Walking Backwards” to the head of state. A large order was outsourced to the cheap tech company in Anihc. The orders were delivered soon thereafter and the Steering Committee of the House Body declared it a monumental success. The accident rate decreased minimally and the media rejoiced. The news banners from all services used buzz words like “gravitas,” “meteoric,” “exuberance,”   simultaneously, to show their extreme intellect and know how.  Soon the thrilled adoring population was holding rallies in town squares. Life was a daily affair of worship of words and unquestioned obedience.

Corporations held meetings in large rooms where everyone was facing outward towards the walls with their electronic eyes directed at their CEO, who dutifully looked at the painting of the founder on the wall. All paintings of former CEOs and founders were changed and a set of electronic eyes were painted to conform to the zeitgeist. Photos from these meetings were place- held on front pages of the holographic news sections, on the digital universe and some old-fashion disappearing and appearing prints seen only in the town of Hogsmeade, but in color.

One day the newest member of the Steering Committee was walking backwards in the park carrying his 3 year old child. The child did not have the “electronic eyes” on, since the mandate began after the age of four per state decree. The child asked why daddy was walking “that way?”

“Well…” the father began and then stopped.

“Yes, why am I or are we walking backwards?” And without hesitation the answer erupted in his brain, because that is the law of the land! Indeed, we are followers of the Law! His logical mind followed through. The questioned remained and continue to prick his conscience. By then the human anatomy had morphed and the calf muscles had become fully developed, the buttocks had shriveled and the thigh muscles were grotesquely hypertrophied. The human bodies in Acirema could easily be differentiated from those in the Eporue Empire to the east across the “pond.”

“Daddy,” cried the toddler in his arms, “if we walked where our eyes are, it would be so much easier!”

The Steering Committee member thought about that all night, lying awake in his bed, tossing and turning. What to do? Maybe he would propose a change, but he was afraid for losing his important job. If you did not follow the commandments of the head of state then you were considered dispensable.

“Very well, Mr. Chancellor, I expect the “Blue Economy” that I outlined at the Union of Empires meeting early in spring will excite the outlanders who have weak economies and this measure of incentivizing their lot will bring them into the fold.” He pulled at the cuff of his shirt sleeve from under the finely tailored suit, revealing the gold and diamond studded cuff-links that held together the sleeve against the bulge of his bulbous arms.  The word “Blue” he regurgitated as if clearing his throat was meant as an opposite to the “Red Economy” that the Anihcanc lived by.

“I hope they will see the clear reason, Sir.”

“They will, they will, Chancellor they will, once they see the benefits that we are seeing.” The head of state chortled.

“What about our manufacturing status?” The head of state directed his question at the Ministry of Manufacturing and Creativity. “Sir, the manufacturing increased its error rate by 10 fold in the last year and that is still 2 fold lower than the benchmark we established the previous year.”

“Good!” the head of state chuckled. “Now tell me about the Ministry of Health, Ekezuber?”

“Sir,” the wise old member, who was one of the initial architects of the “Backward Society,” had dutifully followed and perpetuated the mandate for the last several years, got up slowly and said, “Our population health has never been better. Our population has diminished by 8%. The older members of our society are no longer living past 75 years, meanwhile the productive members numbers are stable. We are having trouble with procreation and are developing mechanisms to mandate artificial insemination to avoid sexual procreation after appropriate DNA testing is complete. Sexual procreation has been difficult to manage for the positive selection we have hoped for. Besides with the 100% Social Media immersion there is little need for the sexual procreation these days. But going forward, we should have a very strong productive and highly tailored force by the year 2230. Our projections are that Acirema will be, from a health point of view, self-organizing, time-limited, revenue neutral within the next decade. ”

“Very good, Ekezuber! We can always count on your expertise to advance the health and welfare of our society,” The head of state paused for a moment and then with his thumb and index finger poised delicately on his chin said, “we can always increase the marketing budget if you need more incentives to get the right mix of numbers.” He paused a moment and then chimed in as delicately as he could, "You will be 75 years old this year, Am I correct?" "Yes Sir." Ekezuber replied quietly with his eyes squarely on the column in front of him. "Since we value your incredible work and diligence, we might make an exception for you." "Thank you, thank you your excellency, my family will be ever so grateful." Ekezuber could not hold back his delight as a tear rolled down his left cheek.

“Thank you sir! “ Ekezuber replied with an exaggerated diffidence. He let his eyes take in the enormous columns and the 30 foot walls around him and said quietly but self-assuredly for maximum impact, “We are developing a mechanism to eliminate poverty also!” He was going to show his worth to his sovereign.

“Excellent!” the head of state satisfied with the response that reached his ears through the echoes in the chamber. The single clap of his hands thundered through the cavernous room and caught everyone by surprise. He was clearly elated with that news.

“Any other reports from the Steering Committee?” his “electronic eyes” encircled the group.

“Your excellency,” the youngest member of the Committee slowly got up. “I was walking in the park carrying my 3-year old and she asked if we should walk forward? Of course that option I feel is totally ridiculous but thought the humor in that question was worth sharing with the Committee. She said, “if we did, then we would not need the “electronic eyes.” There was silence and then finding some courage he advanced his late night sleepless thoughts, “it might be more productive, less expensive, more efficient and possibly increase the revenue stream in taxation from the productive citizenry.” He let his splayed fingers of his hand brace the shiny mahogany table and ended with, “It might be worth investigating?” His heart hammering inside his chest felt like a unbalanced clothes dryer, he sits down suddenly overcome by the weight of his conviction.

Hark! the state of nature had raised a hand against the nature of state. Silence was deafening, even the ventilation system lost its hum momentarily. Rousseau had challenged Hobbes and something was going to go down, and soon. And came immediate and on cue...

“Might I remind this Committee that no questions against the mandate can ever be entertained? But given this statement, and the way you posed it, I suggest we take a vote whether you should remain a member of this Committee in the future?” If anyone could see his eyes, the pupils had constricted as if the entire bottle of Pilocarpine had been fed them and the lids constricted to slits in real anger that not enough light could reach in. But no one could see any of this in real time. The head of state had spoken.

There was an immediate unanimous vote to remove the offending member and the meeting was formally adjourned and declared a success. The statement was scrubbed by the “scrubbers” that recorded all conversations and declarations of the Committee members, absent any untoward comments by anyone during the meeting. The vacant post would be filled immediately and the 10 members would remain as 10 since the names of the Committee members were never made public in the first place. And the nature of state was never out of peace.

Years later a movie was made by the Anihc movie industry, then the largest in the world, called the “The Fall of the Backward Mandate.” It was a soaring success with millions of viewers lining up in virtual theaters across the world. The “Backward mandate” was used in Schools everywhere as a Business Model Review of how not to do things. Anihc had supplanted Acirema as the world’s greatest power a decade before. The Little Red Book became the bible for all “organized societies.”