Saturday, April 30, 2016



See that word up there in the headline? It has the overbearing overhang like a bushy eye-browed, heavyset red-faced teacher hanging over the desk, peering down at you with menacing eyes. Foreboding to say the least. But there is some truth in it. It conjures up wild images of ideology, anger and destruction. Doesn't it? Our first thoughts move oceans away into dark corners of the world where grim faces beset with hatred fill clean slates with squiggles of confusion and ill-willed determination.

Now look at what happens in an idealized world of civility. The daily ritual of a mother and father speaking to a preteen, telling her about the vagaries of human nature, of where not to go for fear of danger, of when not to go for a similar foreboding. But more than the voice of reason the learning upon which such nurture thrives is the action of the adult. Thus life long Democrats and Republicans are nurtured growing into the temporary space of life and filling more tiny brains with similar ideology. The specter of anger slowly and imperceptibly grows and divisions among humanity take place. So indoctrination is a common thread in the flow of generational information; surreptitiously capricious. But as the doubters are constantly vilified and demonized the indoctrination evolves especially as "evidence" is created for a greater good.

Far be it for me to delve into such a deep topic, yet I have over the years found a perfect corollary in the field of medicine, which is similarly nuanced.

When I was a resident, our main aim was health followed by life must be our focus. No matter the disease, illness, malady we as young physicians were charged with understanding and curing the ills and rendering individual patients with such afflictions healthy. We were told not everyone will survive the ordeal but a concerted all-out effort must be made towards that aim. And we did; breaking the textbook spines, jotting information on note books and coalescing the information to guide the individual patient. Those were heady times. Those were freer times. Those were responsible times.

As time went on, the learned lessons continued but the environment changed, slowly at first and then gaining break-neck speed. The suggestions of what to do and when to do started popping in and out of the medical literature. And as surely as the slow pavlovian reflexes were being developed through a concerted effort in the ivory tower silos, the paradigm of care started to shift.

Everyone started pointing to the cost of healthcare and comparing it with the Western world. Spurious correlations later, almost everyone had agreed that indeed the cost was too high and something had to be done about it. Happy in their numerical discovery, they set out with statistical impertinence to prove their bias, not one of these voices however looked at the factors that were raising the cost of patient care. Not one.

Where does one look to control costs? The finger pointing started and of course the physicians were on the standby to take the blame and reap the maligning. The malignant zeitgeist spread tentacles into the seats of power and congressional beasts rose with booming voices filibustering their way into the mental landscape. And so it was set in stone, temporarily, that all manner of costs in healthcare were borne of the greed and complicity of the human physician. Armies of well-meaning intellectuals rose up in arms to defy such augury. They proclaimed that they for a hefty price of a few extra zeros at the end of 1 would change this abomination. They would bring in the new era of non-human and unbiased mechanisms into place and take away the arbitrariness and self-aware needs of the human and use the mountains of data contained in the Big Data networks as a repository base to change the paradigm. The digital universe of the promised cheap care took hold and many fortunes were made and many lives were destroyed in the process. Yet the constant pounding of the vices of the humans and the virtues of the machines slowly and perceptibly changed the human belief albeit with lingering skepticism. Man was indeed flawed and machines with their unbiased view were more in keeping with the future all ready at hand. The young medical students spent countless hours studying their vocation on computers, barely listening to the lectures given by aging teachers. They used algorithms to answer questions to pass the tests and arrived at the threshold of patient care with little experience. Their “work” was decidedly in favor of arriving at work at 9 O’clock and departing from their “shift” at 5 O’clock to spend their free time, freed of all burdens. While at work they became adept at typing furiously on the computer keyboards to fulfill their contractual obligations with their employer for reimbursements. The game was afoot and the loser in the grand bargain was none other than the vulnerable.

Meanwhile housed in a small cottage in the far rural corner of the middle western state an aging physician sat on the creaky chair holding the hand of a weakened soul, speaking softly about the malady that afflicted the patient and comforting her in how it could be addressed. These were the dying breed of human physicians, cast aside by the runaway train of progress. These few, happy few band of brothers, were determined to hold their ground till their last breath and promised to care for the people of their community that they had lived amongst. The small creaky cottage industry of the dying breed of physicians was being overtaken by the shiny glass and steel buildings of tomorrow where industrial-sized medicine was being processed. In these esthetically beautiful architectural abodes was the circuitry of efficiency. The human physicians, once called "providers" now termed as "scribes," feverishly input information of every encounter and the digital output was almost immediate. Guidelines were printed out for the patient, who walked out with a folio of information that he or she could not decipher, but happy in beholding a meaningless treasure trove of something. Contained within the thousands of repetitive words were the potential seeds of the ill, the affliction, the disease and that made the patients happy. After all it was all about information. Management was based on age and morbidity and if both were immodestly extreme according to the algorithm then a comforting prescription of sedatives and analgesics were contained within the package, if not then a time in the future was mentioned to show up at another shiny building where robotically the malady would be handled. Modern medicine had achieved the pinnacle of human caring. One could assuage a fear from the computer screen by telecommunicating via the computer with an expert. Ah life was so rich!

The powerhouses of venture capitalists and managing partners who owned or shared in the such buildings grew large bank accounts that were off shored to some remote exotic lands. Vacations were planned and more investments were undertaken. The media constantly ran reports of the bane of human doctor’s weaknesses and the virtues of the mechanical unbiased machines that had taken over care under the strict guidelines imposed upon the machines by the experts. Ah the fruits of hard labor were being replicated to scale and enjoyed by the few. Sometime however in their hubris to multiply their fortunes, they made mistakes as exemplified in the Theranos debacle. A lesson worth learning from.

Not to be outdone, the diagnostic version of medical care was also in full bloom. promises of ultra cheap with minimal discomfort diagnostics was in full force. Again money flowed in the billions to satisfy the insatiable appetites of the middle and upper management to reap quick riches. Pharmacies rebranded themselves as care givers and pharmaceutical agencies merged to create incremental advances most times of meaningless values, touted as new discoveries and inventions costing millions but yielding very little in benefits.

The game is afoot and the process is quickly unfolding…where it will end, no one knows.

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