Monday, June 26, 2017


“There is a kind of gaping admiration that would fain roll Shakespeare and Bacon into one, to have a bigger thing to gape at; and a class of men who cannot edit one author without disparaging all others.” ― Robert Louis Stevenson

There is an underlying art in the subjectivity of things colored by the choreography within the mind. Humans such as us have this innate power to put things into numbered or lettered “cubbyholes,” -all things beginning with C should be put in the “C” box and this makes retrieval simple. Ah but therein lies the conditional fallacy of the informal kind.

Let us go where our sophisticated angels fear to tread…

I heard this comment from the podium, “Doctors and Pilots work in the same sphere -of safety, hence they must follow similar practices of education and knowledge improvement on a consistent basis.” On the face of it, it seems quite innocuous and gleaming with factual radiance. But let us look at the basis of this comparison. The pilot works with objects, such as, ailerons or flaps and slats, governed by mechanical arms hoisted to the digital framework of “fly-by-wire” modern aircraft, that make the aircraft fly. A host of digital gremlins can damage the signal to noise ratio and cripple the aircraft, and the only occurrence from such misbehavior is the non-functioning ailerons, flaps and slats. End-result is always the same… a disabled aircraft in need of the pilot’s decision-making process of where to land safely. An Airline Pilot’s six-monthly retraining process is to make sure that the pilot can recognize the fault while in a simulator and make appropriate decisions when faced with such an emergency. The decision to land is mostly a judgement call based on location of the aircraft when disabled, the altitude and its speed. Two real life cases show the human ingenuity of thought. The 1989 Sioux City United Airlines Flight #232 crash is a case in point where human intervention saved 166 lives. The DC10 had lost all hydraulics and hence the ailerons, flaps and slat functions required to change angle of bank and slow down the aircraft respectively. Before and following the event 55 test pilot simulator mock training scenario was not able to do what Captains Al Haynes and Denny Fitch were able to, save lives.

Decision making is an experiential learned process, one that cannot be learned by rote. It takes many years of experience to reach such a level of understanding, as evidenced in the Hudson River crash of the US Airways 1549. The decision to ditch into the Hudson River was memorialized in a movie “Sully” as a heroic decision. How we frame our musings to some extent depends upon our experiences. Ah but for that “ghost in the machine” that keeps us steady, the world would devolve into chaos. As Penfield mused, “There is no good evidence, in spite of new methods, that the brain alone can carry out the work that the mind does.”

It appears that information, knowledge and understanding are three very different things that should not be conflated. Right?

Medical care differs a bit. Although some silly people might push the equitability a bit by saying that the heart is like the aircraft engine and blood is the fuel but they forget that the engine is driven by fuel regulator for thrust but the heart is driven by many more things; emotions, fear, anger, anxiety, stress, flight and joy. Id like to see an aircraft flying on such emotions, wouldn't you? There is more to a heart than meets the fan blades of a jet engine. Conflation? you bet!

Physicians are dogged with information overload in this digital universe. It is important to distinguish the signal from the noise and it appears that only experience is the validator. Attempts at equating tests and retests as proposed by the ABIM/ABMS and the well-meaning quasi intellectual authorities functioning as private entities who tout the benefits of physicians running through the maze of their well-crafted expensive tests, have not and cannot prove the benefit to the physicians or their patients. Yet the inflationary conflation continues unabated and physicians are forced via fiat to comply with meaninglessness.

An experienced physician understands as he or she diligently tries to decipher the pathophysiology behind the ailment and then offers the best salve. Some time he might choose a drug Y when X is called for by statistical methodology, or even drug Z. His wisdom and experience are, the result of many IBM Watson’s functioning in parallel modes with petabytes of CPU power, unequalled.

Two equally disparate categorical inputs that seem to be conflated are the terms “Value” and “Metrics.” What has value to do with metrics. Simple as any statistician worth his “variable bias” will tell you that if one weights “value” numerically, then value becomes an easy tool to determine “benefit.” Ah, and therein lies the obfuscation. Who determines the weight of the underlying value? That question is answered by the experts, taking a sample of the population in 100s or even 1000s and then inflating the results to meet the expectations of the 1,000,000s. And there lies the ruminants of the inverse relationship of population medicine and individual care. Determine what treatment works in a simple majority of a few hundred or a few thousand and equate that treatment as the de-facto therapy for the individual across a population of 7 billion+. Some may respond, and the treatment is hailed as a success. Some wont, but the policy die are cast and there is an impossibility in going back, especially when reimbursements are predicated on the boxes checked and “T”s crossed.

A book called “Made to Stick” is an interesting volume to read. It carefully punches the right code to pluck the heart strings of the mental construct. Our arguments are based on inference and analogy from mathematical and statistical fields into subjective domain. An anecdote is used to bring to bear the entire burden of a constricting mandate. A limited number of people’s dietary needs are conflated with health and thence inflated to represent the whole society forcing a policy enactment which ultimately harms the millions… The Food Pyramid is a classic example of such wrongheaded behavioral mandates. The 60% Carbohydrate need per day has resulted in Obesity the world over and cost billions if not trillions of dollars in healthcare costs. Yet we don’t hear about that, since the pyramid is now a “plate.” The art form of such conflated attributes has been perfected to a science where art and science live in the same sphere cobbled together by data-scientists whose very job depends on this burgeoning volume of useless rhetoric.

Might I suggest that we allow a smidgen of thought, a grain of truth, a tincture of critical thinking in our youth so they may address this ensuing societal debacle. Wonder if Shakespeare would have changed his statement to “Kill all the Lawyers, epidemiologists and Statisticians,” if he had known of their existence?

Although the list of subjects in the conflation bucket are overwhelmingly beyond the reach of a short post, I must mention the endless conflation of correlation with causation. That one takes the cake, so to speak. The epidemiologists have found a new religion and have added thousands if not millions into their enclave to figure out how to use the “p-values,” “T-tests” and other statistical fiats to promote this conflation-riddled “correlation is equal to causation” agenda driving science and reason into a dark place, where even Darth Vader would fear to tread.

“But all the colors mix together - to grey. And it breaks her heart. How she wishes it was different.” Dave Matthews Band

Alas, I am, but a single voice.

Monday, June 5, 2017


In thinking back, sliced bread was a pretty good idea. It made for some delicious sandwiches, ask Bluto or Dagwood for that matter. But the greatest ever “sliced bread” for the bureaucratic management tycoons was the slow, methodical, tantalizingly preacher-worthy subservience of the physicians.

Ha, you say, there you go preaching the doldrums of the doctors again. Seriously, stick with me on this one and proof should follow.

Back when free markets reigned and all things were humming, bureaucrats at expensive dinners in fancy restaurants decided they needed to enter in the medical community since it was replete with unfettered tax-payer money. The first element in this strategy was to encourage physicians to participate in insurance. This mechanism, they claimed, would avoid physicians from not receiving their payment if the reimbursement was sent to the patient directly.  As more and more physicians accepted the notions, the insurers figured by simply constricting payments to the physicians was an easy mechanism to reduce their costs. To the hospitals, the curbs brought forth restriction of the “Length of Stay.” Everyone worth his salt, be it the Chief of Staff of a hospital, an MD or the member doctor in the medical staff was trying his/her best to keep those patients from occupying the hospital bed longer than necessary. Each extra day in the hospital was running the deficit cash register into the millions for the government and the private insurer. With back-channel support and intense lobbying efforts, as Aspirin costs skyrocketed for the private insurers and self-paying individuals, a new paradigm was created. Ah yes, they cried in unison, decrease the length of stay and you could be promoted as the most efficient and best physician in the hospital. Why wouldn’t anyone ascribe to that fame and strut the stage for that brief-moment. It was a briefer moment, since the “Average length of stay” for any malady continued to shrink to the point that birthing babies was a 24-hour event and then out went the mother and the child to their family care. Some good did come out of it though, cataract surgery, which had been a week stay in the hospital with sand-bags to keep the head stable turned into a one-hour outpatient ritual. But that was to a large extent the function of innovation, physician dexterity, risk recognition, safety profile of the surgical procedure and not necessarily a bureaucratic policy mandate, done well.

Then came the “reimbursement” issue where a patient could not be readmitted to the hospital within 30 days for a similar diagnosis without an abject rejection of payment from the insurer. Many patients suffered the consequences, due to emergent complications being managed at home without necessary resources. That however was not the thrust of the argument, the managers exploited graphs and power-point slide shows to regale their point of cost reduction without an eyelash in the direction of real harm done to scores of vulnerable patients.

What followed was by changing the paradigm and giving the physicians a new name. The Physicians were turned into “Providers” to reduce the esteem of their years of knowledge into the low subterranean grey of commodity. A rose by any other name still smelled sweet, but it was withering under this growing bureaucratic mushroom cloud. Suddenly, or maybe not so suddenly the integration of the physician elites from top notch universities began taking seats at the table of the government and medical societies where decision making became a collective groupthink. “Yes!” they all cried in unison, medical care in the modern world was stealing a quarter of the GDP, while they sucked up 7-figure incomes, bonuses and exotic travels to far away island retreats to conjure up their next costly mansion, boat or an airplane. These experts compared the U.S. costs to other western democracies and graph upon graph graced the society spawned journals. Everyone cried out that U.S. medicine was raping the nation of its treasure. The variables they used were irrelevant but made for an excellent News Story worthy of television coverage. There was no mention about the Administrative Costs for the middling managers that accounted in some cases for as much as 30-40%. But the busy-bodies were looking for heads to roll under the banner of “Public Good.” Who, to blame?

The finger it seems always points in the direction of the doctors. Yet the U.S. government’s own data revealed that physician payments were only 7.7% of all expenses incurred in medical care via the CMS. The Physician Data Dump by the U.S. Government, to show transparency, revealed; physicians were paid $70 Billion in 2012 out of an estimated $985 Billion in Medicare. Hmm… it doesn’t take a genius to figure out the percentages. Simply divide $70 Billion by 850,000 active physicians and you get $82,352.90 payment per physician. Oh, and just for completeness sake $385m Billion was ascribed to the administrative expenses. Yet the drumbeat about fraud and other rackets continued to keep the think-less vacuous minds engaged with the dog and pony show. “Never you mind, Look over here!” The bureaucratic intellectual honesty seemed the latest oxymoron.

by Charles Kroll

Physicians were jostled around with “This is More” and “That is Egregious.” Soon physician exits from the field of medicine followed, some forced by finance others by fiat and still others by demonization. Meanwhile self-appointed non-practicing physicians assumed power in non-profit agencies (ABIM/ABMS), created to govern the physician’s knowledge and education, costing physicians time away from their patients and money, while these agencies paid their staff of “experts” million dollar salaries from the revenues received. Meanwhile they failed to show an proof that such rigor improved physician care or their patient’s outcomes. The shortages followed suit and the non-physicians were given authority to practice medicine without a medical license in some U.S. states where the shortfall was more intense. These non-physician “Providers” were however exempt from any of the education, training and retraining efforts employed against the physicians. Anecdotal stories proliferated about how wonderful the care was under these non-physicians while simultaneously undermining the physician expertise. “Oh, what a web we weave…”

Where does this end? The answer is quite easy to come by. The new in-training doctors are being indoctrinated with the art of this form of care. Treat an individual through the lens of population medicine. If the one size does not fit all, too bad. We now live in a world so far away from where we started that the past no longer evokes a memory. Perhaps it was in a parallel universe? Who knows?

These policy experts and non-practicing physicians forget that innovation in medicine is not all borne out of a computer statistics and groupthink, which they seem to employ in every decision-making. The eventual price to pay gets steeper and steeper as we go down this rabbit hole. Eventually the masses will realize the folly forced upon them. IT might be too late, but brinks and abysses are relative terms and doing a 180 takes discipline, time and effort. Imagine that huge barge in the Hudson river? Good luck at that!

Currently the bureaucratic managers and their cronies are in full control, extracting large paychecks for their deeds while pointing the fingers of blame elsewhere. The finger of instability in this sand pile is wiggling and I have seen the sand pile shudder.