Friday, April 17, 2015


“It’s a 4.5 Liter engine with a 325 pound-foot torque, at 7400 rpm and a 3.81 displacement puts this car ahead of any other…”and attention deficit took over. The backdrop of a car showroom and the voice of a salesman is sweet harmony to imagination.

Yes, I wondered, we can certainly measure the volumetrics of the car engine in precise detail. We can measure most anything on the planet with exquisite precision.

From ancient time when Eratosthenes was able to measure the circumference of the earth to within a few stadia (plural for stadium), man has been on this quest to quantify then qualify through measurement anything that exists on earth, from ether to the rock of Gibraltar. Time has allowed us to gather more and more measuring tools. From ancient times when the distance between the earth and the sun, aptly named Astronomical Unit = approximately 93 million miles, took many failures of measurement from Aristarchus to Kepler, finally it was Christiaan Huygens who determined that it was equal to 24,000 earth radii, man’s quest to measure never wavered. 

We came to find out that the Cesium radiation period determines that "The second is the duration of 9,192,631,770 periods of the radiation corresponding to the transition between the two hyperfine levels of the ground state of the caesium-133 atom." And using this information, humans devised the Atomic clock. Time linearity was harnessed. Progress! 
We can measure the very large galaxies millions of light years away through cosmological red shifts to the miniscule cellular interiors and thence to the absurdly minute small atoms within, with tunneling microscopes. We can smash protons and electrons together to reveal the approximate behavior of the “big bang.” We can approximate the energy of the Higgs boson (the God Particle) at 125 GeV based on mathematical calculations after the smash. And Einstein who could imagine the Spooky entanglements mathematically decades ago was experimentally proven correct!

Image of Saturn surface from the Voyager

Satellites hover and tell us our positions within inches and we send a spacecraft hurtling past into into the interstellar space, named "Voyager." Human ingenuity is Amazing! 

When it comes to humans, measuring humans, we have been even more curious; the developing fetus on a 3-dimensional sonogram lays out features of the baby vividly and from birth starting with the APGAR score to the baby’s height and weight to blood pressure and red cell volume, from intraocular pressure to intra-arterial pressure, from the speed of electrical impulse generation in the brain and its impact on the synapse to the beat generation from the Purkinjee fibers to the myocardial cell contraction, almost everything is measured and quantified. We measure salts, hormones, enzymes and other sediments including circulating tumor cells in the blood. We tie behavior to psycho-neuro-chemicals in the brain. We measure the change in ratios of various elements from health to disease. We check and check and recheck to stay healthy. We graph circadian rhythms and everything from circulation in clogged arteries to emotional volatility, to cancer and throw them all in the stress-me basket. Indeed we have arrived at our purgatory! 
Today, however we have a seismic shift in our thinking as we find a new pleasure in measuring the genes and their mutations that cause loss or gain of genetic function. Some of us have come to realize that genes are motivated by nature primarily and through nurture secondarily in equal measure. We have learnt that miRNAs and methylation processes constantly modulate gene function via external pressures. Oh yes, we can measure the human milieu quite well. Essentially down to what makes us tick. We can outline functional paths within our brain, the moment life begins and even have the audacity for perpetuating a lack of responsibility, to subsume our behavior to the function of a gene code. We can map the brain yet remain searching for the elusive mind, just like we have the body but always are on the look out for the soul? Ah yes, we are the Lewis and Clark muddling through the forests, not figuratively but metaphorically, of digital 1s and 0s and calling it the new dawn!

And the new sheriff in town wants to measure something else. His particular penchant is trying to measure a different metric; the human emotion. He seems to think if we can measure the happiness and quality of that happiness or sadness then we would have measure of performance just like the 10 point numerical scale of pain. Yet what he fails to recognize is the vice within the 10-point pain scale. Is my 5 point pain as a stoic equal to your 5-point volatile emotional pain? If the answer is yes then I guess the metric is valid. If the answer is no then we better go barking up a different tree. What do you think? Where is the threshold? Some qualifiers are definitely needed, “oh but that would make it so difficult!” Whether we use the numerical scale or the Wong-Baker FACES pain scale the answer would be the same. The thinking goes…if we can tie emotions to a scale and the scale to value then we can tie cost to value and voila, problem of costs in healthcare will be solved. The bureaucrats crackle their knuckles as their salivary drools thicken. Does the smile mean happiness and does a frown mean anger, always?

Alas even Kant at his most vulnerable in his hardened shell of the categorical imperatives would have shied away from such acts of calumny. As I understand Kant’s deontological ethical philosophy, he would believe that an action should be judged by its implications, “Act only according to that maxim which you can at the same time will as universal law.” Would such actions become the universal law?  But hey, forget those philosophical fire-hoses of discretion. This is the brave new world, where anything goes just to “feel good,” or be in the act of “thinking of doing good,” or be involved in the “public good” business.  There is no withholding any assistance from the passions but allowing them to promulgate thoughts and those thoughts into actions that hold hostage an entire society. The hypothetical imperatives have now become the categorical imperatives.

The world has changed stupid, get with the program!
Similarly quality of a human state is a difficult measure. The moment to moment emotional energies that crackle through the brain change the internal and external emotions of the human being. I feel good and the thought of a lost friend kills that feeling. I feel sad and the thought of winning a prize elates me. Measuring such volatility and using that as the parameter of success is tantamount to, perhaps foolhardiness? Must we then ask for everything that is going on in the brain and the mindfulness on a momentary basis? Mustn't we? Or can we compartmentalize, as the experts do writing lengthy treatises?
If value was being judged by a single individual who also happens to have her emotional cake to bake in the measurement, well then all bets should be off. Wouldn't you agree? The multivariate of the "measured" and the "measurer" would be in play and confound answers on a large scale. Yet to a mind indulged with the liquor of metrics none of that matters. Reality is that the "measurer" would have to have their emotive moment to moment state of being, assessed and recorded in parallel too! Maybe the human being is a mathematical model, with limbs tied to the Golden Ratio n’ all and as such can and should be measured for functional efficiency that could be the surrogate to a form of well being? If that's possible?

Speaking of functional efficiency, productivity is one measure that can be allocated to the value of good health, but therein lie the specter of employment, entitlement, vacation time and desire. “I am well,” suddenly takes on a different meaning in different circumstance as does “I am not feeling well.” Speaking from the dais and pontificating the virtues of life before 75 years of age is all well and good, but don’t these high minded priests and priestesses remember what “Said a blade of grass?”  Functional efficiency  is now indeed rooted in a foul jar of expertise!
So what do we do?
How do we measure a human being’s quality? Or for that matter, how do we measure a physician’s work in helping his/her fellow man/woman survive through illness and gain that quality? Oh that one is easy. If the illness is appendicitis, an uncomplicated appendectomy is the answer, unless of course an anomalous artery is nearby or a co-morbid state decides to exert its influence. If it is pneumonia then an antibiotic is mostly curative, unless you develop an allergy to the antibiotic. After all we are all human beings made to order under precise sets of rules and creative force. Aren't we? But what if it is an incurable chronic ailment like diabetes or arthritis or cancer? Is cure the measure? If it is, the best professors in the ivory towers would fail the test. Wouldn't they? They would never admit it though. But let’s just keep that to ourselves.
Scoring value is a difficult thing. A patient recovering from an illness dealt with the news of hospital stay costs would necessarily be disheartened and score low on the “Happy Quality Scale.” Meanwhile a terminally ill patient might have found peace in his or her wretched state and score high. How would that impact the score? A non-compliant patient due to medication cost or lack of access would not be too happy with the world. A compliant patient with dwindling resources would equally not give a smile willingly.
So we arrive at this conundrum of lunacy created by a confederacy of some "very intelligent thinkers” that everything from spit to pee and blood to tears is measurable, hence so should the real quality of emotion. And measuring emotions has value and value is therefore quality and quality can be paid in dollars.

The "turfing" war is about to begin in earnest among well-intentioned physicians!
Therefore if we weight the sampling errors appropriately and place alphas and betas in the equations we would arrive at a formula that will guide the value of therapy as benefit to the patient. Further derivation from that would justify the appropriate reimbursement to the hapless physician. Are there Avogadro's constant or Plank's constants for human beings that can be fitted into our equation to gain that subtle but elusive inference? Not yet! Although the reactive heuristic makes us act as if we do, by latching on to the Confidence Coefficient of 1.96 and with that and the statistical jargon we attempt to prove our hypotheses time and time again, forgetting what the Nobel Laureate Philip Anderson said, "Many good scientist instinctively distrust a measurement which is always on the ragged edge of "statistical significance" and have learned to be very skeptical of marginal statistics."
The new HR-2 MACRA Bill soon to be signed into law, quantifies such actions and emotions- should anyone care to understand, will do the following: Derive risk adjustment calculations, Quality and Outcome metrics, case management, resource use monitoring, interoperability of the EHRs, establish data registries, develop practice assessment checklists, determine the operability of the physician NPIs and their ability to prescribe…and on and on and on, you get the message! Happy navigating the tall grass…
We thus arrive at Kafka's "Nothing alive can be calculated!"

“So the monthly lease on that would be…” I was all ears!

1 comment:

  1. Great post.

    If you haven't seen it you might enjoy the McCloskey article I link to here: