INTUITION

Cognitive Science and Acquired Intelligence

It was a cold day, I remember that vividly. The wind carried the cold in waves and crashed it upon the exposed skin like tiny little needle pricks. The flags flapped themselves into an edge-ripping frenzy and nary a person strolled the sidewalks. The smoke from chimney tops came out in horizontal streaks dissipating into the blue. It was also my first entry into the hallowed halls of the Board of Trustees Meeting of the hospital. After the perfunctory introductions, I was quietly reminded that first year members only listened, this with a broad patronizing smile of “you had better not speak your mind.”

Oh but I did.

“So are we go for the 6^th floor renovation?” The chairman asked.

“Yes we have all the certificates and the appropriate financial backing.” The Secretary answered back.

“Lets move to the issues about the patient complaints.”

“Excuse me…” I interrupted.

“A rather stern look fell, across the room sparing 28 other members, on me.

“Yes, Dr. D?”

“How much is the renovation cost please?”

“It is what…” and the chairman looked at the secretary for answers.

“Eleven million dollars.” The secretary answered.

“And if I may ask, what renovations are being done?”

“The new OB-GYN floor doctor, of course. You mean you didn’t know that?”

“No, I didn’t.” I replied and not to be intimidated, asked the next question against the rising tide of disfavor, “So we are putting eleven million dollars for OB-GYN in our hospital? And what demographics do we have to prove the need. From my perspective the average age of the community in the region is 64 years and the average age of the admitted patient is 70 years. Both cannot replicate the germ cell anymore. So why the expense?”

“We did a thorough analysis Dr. D and the experts in the field have advised us that this will improve patient influx to help the hospital’s bottom line in as short as two years.”

“But…”

“Thank you Dr. D for your input.”

The discussion was over.

(To know the ending of this story you can scroll to the bottom now or enjoy the philosophical debate about intuition and rationalization - Your choice.)

Of Computers and Brains:

Japan's K-Computer

You know for all the computing power of the fastest computing machines that exist including Japan’s K-Computer, which currently has the computational rate of 10.51 PFLOPS (petta floating points per second). And that is fast. Computing with all its power still lacks the intuitive sense, that ephemeral sense, that comes from the many sensory stimuli existing in nature that are received subconsciously, processed in the human brain, and yet never brought up to the conscious level until need arises. Even though Deep Blue beat Gary Kasparov in 1997, it took the computer giant IBM to harness the power of 2 million chess moves per second of evaluation to Kasparov’s 3 per second to beat him 3-1/2 to 2-1/2 score. This was, raw computational power of many-fold over plain genius intuitive power. Imagine the human mind!

Gary Kasparov

Of Newton and Leibniz:

Historically speaking, as Newton’s mechanistic order slowly came into view through his Laws of Gravity in the 1600s, the world changed. The mechanics of the industrial world was off and running. Close at hand was the little known but equally important although not as taciturn as Newton and not as egocentric in his disposition, Gottfried Wilhelm Leibniz. Leibniz was more rooted to a philosophical bent. He arrived at the theory of Monadology where “Monads” were all interconnected and thus everything was attached albeit tenuously to everything else. His counter culture of thought was relegated to the heap of obscurity for two hundred years. His intuitive incline towards the cathedrals of theology was the primary focus of universality in his thinking; that all things are inter-connected.

http://youtu.be/NVRhEGdq9DE

Video: Quantum Physics

Of Quantum Mechanics:

That phenomenon was resurrected later in the 20^th century when the field of Quantum Mechanics came into being. From Einstein, Heisenberg, Pauli to Neils Bohr and his Copenhagen Interpretation to Paul Dirac and John Von Neumann the philosophical masters of physics and mathematics, each labored to theorize and then find proof for the Quantum Theory. What changed and brought forth more flood of thought was the Quantum Entanglement sponsored by EPR paradox (Einstein, Podolsky and Rosen) and later confirmed through experiments.

http://youtu.be/9lOWZ0Wv218  

Video: Quantum Entanglement

Of Quantum Entanglements:

The EPR paradox states: Quantum entanglement is a form of quantum superposition. When a measurement is made and it causes one member of such a pair to take on a definite value (e.g., clockwise spin), the other member of this entangled pair will take on the opposing value at any subsequent time. So Leibniz’s interconnected Monadology espoused via intuition, was based loosely on some theoretical principles without so much as minor proof, and yet came full circle into a full blown, little understood, field of today’s Quantum Dynamics with today's growing “proofiness.”

Of Atoms:

So what is this interconnectedness, you ask? Well I guess besides the Neutrons and Protons, those empty bodies of emerging and dissolving energies the former carry no charge while the latter carry a positive charge and reside in the nucleus of the atom and are surrounded by this nebulous plasma of electrons, in different energy-states, that seem to have long and short reaches of connectedness, what is even more interesting are the electrons that orbit around near and far and never have the same Quantum state. This little gem of information is called the “Pauli’s Exclusion Principle,” which states that two similar electrons cannot share the same Quantum State. So you see, two electrons in the same region exist because they carry different spin states, each one knows the opposing electrons state, and so varying distances of these electrons around individual atoms have interconnectedness through the opposing spins. Fascinating don’t you think? The Yin and Yang of togetherness.

Of Leonardo DaVinci's intuition:

By now you maybe thinking, well where is this taking us, and you are not alone. I am thinking my way through this as you, so patience, dear friend. It is that intuition thing that Leibniz had in mind, that once was shuttered up and only later emerged at a different time, when finally our cognitive senses were able to process the information. (Apparently we humans are only able to understand and process data when that time and understanding is upon us and not before, a perfect example would be Leonardo DaVinci and his scrapbook of ingenious ideas. DaVinci’s Ornithopter that gave rise to the helicopter and so on elucidates this concept~that the 1400s concept was finally realized in the 1900s).

Of Interconnectedness:

On the other hand rational exuberance has also claimed the spotlight and still does in the macro world, the apple still falls on the head and creates a headache. The less understood Quantum Mechanics splits a single photon across two slits and gives us a different headache of confusion because of the Heisenberg’s Uncertainty Principle, you know the sort that states that the act of observation changes the particle into a wave and vice-versa, so the results are what you wish them to be. Get a grip on that if you can. Brian Cox explains the Pauli Exclusion Principle and the interconnectedness in the universe:

 http://youtu.be/Mn4I-f34cTI 

So even though the scaffolding of the visible universe, based on rational reasoning, obeys the Laws of Gravity set in motion by Newton, underneath in the microscopic world, intuition plays a part in a conceptual exercise of Quantum Mechanics that although little understood has experimental/mathematical proof of its “certainty.”

Of Intuition and Rationalization: 

The premise, thus being that both Intuition and Rationale are at play in this vast universe of understanding, while the latter is easily understood the former is a nebulous concept in the mind. One doesn’t trump the other but, and here I am going on a limb, maybe complements. This tautological cascading thought has its genesis on a hunch, an intuition. We are exploring that hunch, aren’t we?

So how does that work in humans? Intuition is a “feeling” you know something like, I have a feeling that something is about to happen. Where does that feeling come from? Where is the genesis? Is that just plain fear? Or is it the collective sensory input from the millions of bits of information gathered by our sensory systems and placed quietly in our subconscious for calculation and when completed, it coalesces, the composition is arrived at in that cauldron of bubbling information, and the message is sent to the conscious mind for action.  So should we pay a lot of attention to intuition then? And is this at the expense of rationalization?

Of Gut Feelings:

It turns out most of our instinctual responses are the primary “off the cuff” responses. These responses although appear to be quick, un-thought through, out of the blue remarks they all seem to have a genesis in some rudimentary or collective insight. But here is the problem with this intuitive leap; sometimes it might be based on some false assumptions too. For instance, you want to invest some of your savings in a company and the last record in your mind is a newscast about company-A that was touted to be the next coming of Apple. And somewhere in the recent past you might have discussed that with a friend. Given that data, on the fateful day those thought remnants come flooding down the decision making tree and the quick, response is “my gut tells me…”

Or in another scenario, you might have walked down the aisle at a grocery store and seen some merchandise that you felt would be the next greatest thing for humanity and intrigued, you looked at the box for the name of the company that created it. The moment stuck in your brain and finally overflowed on the day you wanted to part with your money. These decisions although may seem irrational are still based on a modicum of previous experience. They may not have been properly vetted yet but there they are, ripe for the picking. This same principle has caused some companies to end up losing great deals of money on a product that was borne out of hubristic, un-vetted, irrational concepts to begin with and then to prove the decision-makers were on the right track (Ego battling the Super-ego) they spent more capital to market and in the end the entire fortune of the company was lost. It might be the right brain vetting the left brain dictates or vice-versa. But fortunes do run awry from time to time when the hemispheres clash.

So what with this intuition? Is it to be avoided? Is it irrational? Well, no? Intuition is based on a collective experience registered in the mind, remember? The sudden decision called as “intuition” is a result of “suddenness” of action and not the hidden analyzed and thought-through processes. The process as we have come to realize is the slow bubble that happens in the far reaches of the brain collecting and collating information and then through synaptic fiat, the molded concept finds its way into the pre-frontal cortex of the brain and voila a decision is made.

Of To Err is Human:

There is no bias in the intuitive expression. It is naked, dramatic and holistic. Intuition is also not based on emotions. Fear, anger, desire or happiness play no significance in the articulated thought within the conscious mind. Intuition draws from the well of experience and from the spring of underlying subconscious rationalization equally. However the caveat is if more thought is given to the intuitive resources, then explicit and conscious “wishful-thinking” can ruin the advantage of the intuitive thought by using rationalized modeling via limited experiential reserves – a rationalized intuition, so to speak and that can sink the entire enterprise. All your senses say NO! and you commit to a YES only based on a recent dubious experience (The weight of the recency of thought and experience out-weighs the entire reference). Thus the quote, “To err is human.”

Okay, so I am back there in the Netherlands of decision-making. Do we resort to intuition or not? And the ultimate answer still might surprise you.

Of Time, Data, Intuition and Decision:

It appears that when the information is sketchy and arbitrary with instability of thought then intuition plays a larger role in the quick decisions. Such intuitive based decisions under circumstances of unformed, misinformed and uninformed information turn out to last. The constraint of this instability resides in the time scale of data acquisition and the reliability of that data. Or simply put, getting data quickly that is large but sketchy makes the mind use its levers of past experiences and subtle nuances of living into developing the intuitive basis for a decision.

But before we run away with this probability, it is important to know that rational decisions made through analyses also are durable. The difference being that those analysis based decision outcomes occur when the information is verified, the databases are durable and all of that has been accrued and vetted over a longer period of time. Khatri and Alvin state, “ Use of intuitive synthesis was found to be positively related to organizational performance in an unstable environment, but negatively related to it in a stable environment.” In other words when the data and time are limited, go with your intuition and when you have a large volume of verified information go with that.

http://youtu.be/7QrzuqExYlA

Video: John Lennon’s Intuition

Of Assumptions and how they arise:

Okay so we have a reasonable assumption of intuition and rationality, or so I think. But peeling the layer of that intuition, one finds that axioms (or assumptions) also arise from a collective of previous experiences or as Barnard states, “consist of the mass of facts, patterns, concepts, techniques, abstractions and generally what we call formal knowledge or beliefs, which are increased on our minds.” If we were to use the finite regress of the circumstances, then it would appear, the scatter of the colors from a prism tracing back to the point of light is the right metaphor, thus the colorful penumbra of experiences glow backwards into a single point of light, as a uniform directive of an assumption forms, a thought is realized and we call it “intuition.” 

Refraction in infinite regress backwards

That assumption, referred to above, becomes a hypothesis and is subsequently challenged by an experiment. Positive or negative proofiness is achieved and a rule or law of concept thereby achieved. QED! 

Janus

Intuition and Rationalization are the two faces of the same god, like Janus who looks at the past and the future at the same time and determines from the beginnings and the transitions, the present.

And the Rest of the Story:

Okay, now the story; whether you arrived via a shortcut or through the meanderings of my brain, here is the rest of the story.

Two years after the structure was built, here were the results. The Bed Occupancy Rate for the new floor over two year period was 69% and that was composed of 78% non-paying patients. The ROI was negative (colored in the magenta -way past the red). I realize some might say that the hospital is providing care to those who need it and that is true, yet to take loans and issue bonds to create an edifice that is now saddled with a loss makes for an interesting intellectual exercise in fiscal decision-making (the purpose of this exercise). So this complex act of biased rationalization against the simple act of intuitive questioning tells a huge story of reasoning. Whatever the eventual financial outcome is not the premise of this story, but the thought process behind the action. Oh and lest I forget, my questioning was never entered into the “minutes of the Board meeting.” Oh well, Cest la vie!

Doubt

There is something in Hamlet that resides in all of us; it is the human condition of doubt and uncertainty. However, we wish to guild our lives with the opposite confines of certainty yet in the deeper registers of our being, we know that, that is impossible. For certainty is the death of all doubt and imagination.

Find out the cause of this effect,

Or rather say, the cause of this defect,

For this effect defective comes by cause.

This innate desire of certainty perpetuates the fraud on our senses and creates the illusion of control.

There is nothing either good or bad, but thinking makes it so.

This elusive of all mythic creatures, this nebulous of all nebulae, this sentient of all beings, this paragon of all life, this human of all intelligent thought that contrives, manipulates and articulates the essence of its being, this certainty is an orgy of defective complex motives.

Though this be madness, yet there is method in't.

In this virtual dilemma of a self-deluding potion of certainty when the mere whiff of the scent of doubt arises, the drama of untold calamities unfolds. And yet as all such events come to pass, life replays itself again. History repeats. Only the times change. The character remains the same, for within us all, is deeply inbred a calculator of thought and action that perpetuates itself inside the small, invisible helical threads of our being. In this chaos of being there is a method to the madness! We, humans are an anachronistic anathema, a contradiction a mystery.

A dream itself is but a shadow.

The riddle:

Yesterday, then, there was this tiny soul so full of life and love that his eyes were lit with the torch of creativity. Unfortunate in this terrible tale was the constant of a certainty created by the masquerading masses. This one particular certainty was crafted in the most innocent of ways. He the manager, arbitrated his way into a collection of wise and entirely plausible ruminations that spelled certainty. The tiny soul in its most vulnerable of all periods was the recipient of this apothecary science, a science imbued with the essence of observed truth and resolute diction that it had resolved all questions of doubt. The tiny soul took it at face value and submitted itself in full faith to the charm and action of this certainty so as to curtail the ailment that afflicted him. The tiny soul laid bare his essence to fight the crush of the advancing demons with the help of this magic sword. Alas that was not to be and while many battles were lost, the war was finally won through the essence of the Grace within this tiny soul.

Later as locks opened by the keys of doubt, this certainty became vulnerable. And as more and more doubt pushed its way through the door, imagination heralded the new axioms that this once “certainty” could not answer. The collapsing scaffolds took down the giant façade of certainty and its authors. The Tiny soul remians the proof of that lie!

Perdition catch my soul


But I do love thee!

and when I love thee not,


Chaos is come again.

You see from this montage above that a silver thread of reality weaves its calling card into the fabric of all life and that is the short story before us. The cryptic nature of these words will in the darkness and quiet of moments reveal the depth of their meaning within. Stay close dear friend, stay close, something is about to stir.

Doubt is not a pleasant condition but certainty is an absurd one. ~ Voltaire

Can we then come to a state of understanding, when confronted with the facts, that the certainty that we hold as truth is a wretched lie? Can we forgive the years of roiled, toiling the suburbs of self-deluding certainty in the face of such defining evidence? Can we? And in as much as I would like to say, no, because of the time spent, the answer is yes. Yes! We must!

You see the polemic discord in the brain although fractures the frame of reference, the fissure so created can be salved and remolded to another such certainty. For we as humans learn to latch on for dear life, like batons in a relay race, onto such frail and nebulous clouds of "being right!" Imagine you believed that the Halley’s comet was bringing the doomsday message for the earth and instead of taking the poison you accidentally drank the red wine that put you into a deep slumber. When you awoke from this disconcerting sleep and found your hands could feel your face and the eyes could behold your visage in a mirror and the rest of you was, well, the rest of you; intact in its imperfection, then the psychological ramifications came drifting down the sky as giant parachutes of boxes of all shapes and sizes filled with new paradigms to behold and claim as your own. Maybe a new belief in another comet, a meteor or even a newly named galaxy would vindicate your thinking as the next great cosmological event to graze history, afford change or even annihilate mankind. Yes we do hold onto beliefs even when we are confronted with contradictory facts and as we do, our rhetoric increases, the voices are raised to a higher decibel and the anger and frustration oozes out. For we are right! We are certain, even when we are wrong about being right!

The rest of the story:

A calm sunny August day, breezeless of motion and colorless of change sets the scene. The young professor walked into the laboratory deep in thought. He was smart as they come. He had in his mind constructed a paradigm of truth that was to lead human kind away from the ravages of disease. He had discovered the blithe of the wayward cancer cell and the switch that controlled it. He was on the threshold of announcing his discovery. That night when all the murmurs of the day had gone to sleep, leaving quiet reason to reign instead, he thought through the problem one more time. His mind reeling through the events of the last decade, the painstaking journey of discovery and defeat and the defeat in the discoveries that had gone into the certainty that now manifested in his mind. This was the Holy Grail. This was the pantheon of all human endeavors. This was “it.” He set aside the all-lingering doubts, the subtle nuances of failed experiments until changed values and numbers had proven the cause to be just and certain. He had fortified the logbooks of experimentations into huge piles of material placed in a separate cubicle carefully numbered and labeled as evidence. He kept thinking through the procedures until he had quashed all sense of doubt to its barest minimum presence. He was ready.

After the announcement the next day, a grand celebration was held. There was great pomp and circumstance as many competing entities wished to partake in this manifest glory that would reap huge rewards in helping mankind against the greatest of all scourges. Ah yes, life was at the brink of a glorious dawn of certainty. After all he had saved a young life from the brink of disaster. The experiment had worked as the model predicted.

When all the eyes and ears had gone, after being regaled by the new paradigm, the professor sat back in his hard wooden chair that he preferred, it gave him just enough discomfort, by creating doubt in his actions. A thought emerged and he ran back to the lab. The night and the next few days were lost in the blur of chaos. The doubt that had been cast, that pricking thorn of uncertainty had hit pay dirt. He found the error in his experiment, a miniscule error, a minor infraction of little consequence. He tried to brush it aside. It wouldn’t. The next day, the newspapers were replete with the glory of this new story and his photograph was flashed in every household through the television. He was the wunderkind. He was the new unlikely celebrity. He was called the Einstein of biology, the Galileo of immunology and the Newton of genetics. He was the new face of intellect. He was “it.”

But now what? What to do? What to say? What? The questions would come soon. The experimentation would and could not be replicated and the decade of his work would be tossed aside. Like the “fusion” energy and other such beauties of thought, his work would be carted down into the hall of shame. So now what to do? The scrutiny, my goodness the scrutiny that would follow and the charges and the pain of being that would accompany. What to do?

The once bright and radiant certainty was now soiled and dripped dark with the used oil of doubt. The premature ecstasy of expression was now being governed by the chains of doubt and that left him listless and in despair.

Indeed, what to do?

What should he do?

He unfortunately took a path least traveled by humans. The paradigm now crushed and nothing much to hold on to, he chose “not to be.”

The darkness within the soul cannot be remedied into light if doubt is never allowed to confront that certainty. The ramifications are great. The personal loss is enormous and the ability to gather the remains to restart with a new focus, difficult. Let doubt in. Let certainty remain attached, even if ever so tenuously, to uncertainty. The bonds of that doubt will prevent the collapse of the scaffolding of an enterprise. And unlike Hamlet, it is that “pale cast of thought,” that keeps the imagination going and the ship of state in motion.

And enterprises of great pitch and moment,

With this regard their Currents turn awry,

And lose the name of Action.

The Road Most Traveled: Implied Assumptions

Our thoughts become our words, our words become our actions, our actions become our character, our character becomes our destiny.” ~ Gandhi

Combinatorial Perceptions, the Synapses of Knowledge and Behavior

We go through life with the prism colored and cut to our own internal fancies. I trust what I believe in, don’t you? After all that is the mainstay of the argument of our very existence. The earth will turn and “the sun will come out tomorrow.” This is an innate belief conjured through the lens of historical facts and present day observation. And although we cannot yet pile-on the gravitational force onto the theory of everything – from the factual to the absurd, we know instinctively that the magnets do tend to pull at the iron filings and are in some way involved in repelling the MagLev high-speed trains.

Unlike when we fall from a height, it is the feeling of the heaviness of our mass that we feel that is the culprit, rather than the gravitational tug on that mass, because we don’t feel that force, so to speak. We can reconcile this in our minds through the implicit assumption now and the explicit proofs of science later. 

Something like, “I think this now and it makes sense and about that theoretical business, well I’ll deal with it later.” When it is all said and done, the “now” implicitly climbs the vaunted throne of knowledge. The “then” becomes the esoteric and governs during those heady discussions of material and forces of science. I mean seriously, this concept, that the reason why a chair holds me up is because of the small yet powerful (weak) Van der Waal forces otherwise, I would go through it like goo and as a matter of fact right through to the other side of the planet, brings in some circumspection and doubt. Here the chair holds me, and that, is an explicit conviction while the Van der Waal forces is the implied esoterica. 

But let me not get carried away here.

Our world keeps turning over a new thought, a new science and those that live in it develop the axioms for their survival. These implied concepts may never be proven but in or minds we surely believe in their sacrosanct definition and existence.

M101 (A trillion star galaxy)

We look outside and there are people, cars and houses out there. We stare out at the moon, the stars and even with Hubbles’ bubbles of exciting galactic images do we ever fully comprehend the light-years of the distant between galaxies. No! Yes, there in lies the security of our existence, only so far as the eye can see and that is the verifiable truth!

A dividing cancer cell

The other day a man in his fifties walked in with a diagnosis of colon cancer. He had a full head of hair, a sallow complexion, a wide eyes stare and a brain that could eat the mathematical formulae for lunch. He was brilliant. Entirely wrapped in his own world, he would give you logic that would be difficult to disprove ` akin to his simple proof of -1=0 on a napkin. Most people would shy from this kind of a discussion and they did. He worked as an analyst for a mid-sized firm and had oodles of materialistic things. His hands were thin but held a tight grip in a handshake. He was no one’s fool. He asked questions and weighed the answers as one weighs the travel bag before going to the airport -does it meet the measure of an extra $50 or not? In his case the weighing scale was in his beautiful mind and the decision from that weighing was instantaneous. The blue veins on the back of his hands throbbed with the intensity of the hidden arterial pulse of energy. – He would ask a question and then his eye would dilate into large pools of deep blue to intake the response including the full focus of the demeanor of the respondent. He was a human machine of incredible mental prowess, a Holmes, a Mason, a Newton, a Riemann and a Fermat all coalesced together in one. Unfortunately he also was to become a victim to the disciplines of his character and convictions and to the vicissitudes of nature.

“What stage is it doc?”

“Stage four.”

“And the probability of survival?”

“Poor.”

“Quantify that, if you would please.”

“Okay five year survival is 19.2% and that is up from 9.1% in the last decade.”

“What is the Median?”

“Now around 30 months and that is up from 14.2 months.”

“Hmm…” His hand cradles the chin in repose. “So, what is the duration of this chemotherapy?”

“The plan is to give you four months worth and reassess response.”

“So, 4 out of 14 gone.”

“Or 4 out of 30 given today’s therapy.”

“So I have to be 1 out of 5 to live 5 years?”

“Yes.”

“And the odds are 80% against me?”

“Well not exactly.”

“Why not?”

“Simply put, I have 4 out of 5 chance of not surviving 5 years, and I have a 50% chance of living 30 months and a 20% chance of surviving 5-years with the best that you have, correct?”

“That is right. However if you are the 1 then for you it becomes 100%, doesn’t it?””

“Can’t do that to me doc..” he said with a knowing smile.

The interview was over from his perspective. His eyes went to half-mast and he had receded into his cave of comfort. His mind had harkened to the comforts of numbers that balanced, of graphs that correlated, of tables that comported themselves to the linearity of reason. The beautiful mind had gone back to its cave of statistical existence.

The orderly and methodical reasoning was at work. He was in good physical health and everything to look forward to. The decision would be simple. Faced with the odds and the projected albeit anemic benefits for a fifty-year-old the odds calculations would automatically announce the need for that 50%  and that 25% chance of survival, helped along by the strength and character of a firm and resolute mind, rather than the sure and ultimate premature loss of life without such a fight. It may have been his version of loss aversion?

Let me take you to a risk-taker’s short interlude. He knew that he had, had a bad hand in a game of poker, yet he continued, thinking that the next shuffle of the cards would change his fortune. He doubled his gamble to recapture his losses only to lose it again.

Or the market trader that bet five times as much on margin and lost his house, family and a life he had enjoyed. The vile contempt of loss-aversion had bitten again. 

All such behavior nuanced via the delicate tendrils of the assumptions based on a dictates of a past trying to change the future. To escape such a behavior is the balance between reality as it is and what we want it to be. The mind keeps saying “this is true, because I say it s true.” To escape such a firmament of durably wired synapses in our brain is a monumental task requiring great strength and fortitude, and the fundamental understanding of the prejudice that exists within. Once understood, the bonds of these enormous shackles can begin to disintegrate. But not until then! Not until then can we liberate ourselves from the bonds that prevent us, that control us, that also perversely, sometime preserve us. We are wired to be suspicious of all shadows at night, for fear of a hidden predator, or all things that slither in the grass or fins that break the water’s surface. These are predicated on self-preservation and are totally juxtaposed with all other implicit assumptions that follow along. The few good assumptions become admixed with the many gained on the edge of a limb and pretty soon the story of our life’s journey can be predicted onto the future. 

Lack of certainty is precisely what makes conclusions more reliable than the conclusions of those who are certain: because the good scientist will be ready to shift to a different point of view if better elements of evidence, or novel arguments emerge. Therefore certainty is not only something of no use, but is in fact damaging, if we value reliability. ~ Carlo Rovelli

The bright shining paradigmatic ball becomes tarnished.

Months later on a chance meeting, the wife of the patient with stage IV cancer happened to cross the doctor’s path.

“Are you the doctor who spoke with my Joe?”

“I am sorry, who are we talking about?”

“Joe! You know, the man with the advanced cancer who wanted all the statistics and then refused therapy.”

“Oh yes. I am so sorry for your loss.”

“You know he wouldn’t take the treatment because he saw his uncle die of cancer in a miserable state. He did not want that to happen to him.”

“He was a smart man and he calculated his odds carefully to come to his decision.”

“Do you think he could have lived longer?”

What do you say to a question filled with such horror? Do you lie and say, “No” to appease the wails within and salve the wounds of a loss. Or do you say “Yes, there was a better chance for lengthening his survival,” and destroy any sense of peace in this poor soul’s mind that is wreaking with guilt and feelings of loss. Or do you simply, speak the implied truth and say “We may never know,”  - splitting the difference between a lie, a hope and the existent reality. An untimely frost had shuttered the blossoms of that beautiful mind and we will never know what else he may have been capable of doing, much like a Mozart 

or a Ramanujan.

The winds of change are nothing but the whispers of the mental dictates. We embark on journeys that are predicated on a long ago desire, stifled before but with age fully expressed. Without such a compass we are rudderless in our action. The guidance we seek comes from the long ago, far away memory that fills the chest of our imagination with implied assumptions. The origins of these assumptions are hard-wired into our mental framework. They dictate the cause and manipulate any adverse even explicit instructions to the contrary. Such is our existence, predetermined, focused and ruled by an autocratic frontal lobe dictator that has taught us our rules of governance at the feet of our youthful exuberance along with all the misunderstanding, miscalculated assessment and ignorance or all three.

At best, we nurture the fantasy that knowledge is always cumulative, and therefore concede that future eras will know more than we do. But we ignore or resist the fact that knowledge collapses as often as it accretes, that our own most cherished beliefs might appear patently false to posterity. ~ Kathryn Schultz

Such is life.

His was a journey destined to meet the fork on the road of his life. It was a mental predicate based on an implied assumption gathered from the travails suffered by a loved one that he did not wish to repeat for himself and against all the known potential odds stacked in his favor compared to then, he made a choice based on then without the rules that governed life, now.

The strength of the implied assumptions trump even the most explicit convictions of human endeavor. 

We become the victims of our incessant cerebral chatter. 

We lose the “todays” due in part to our “yesterdays” and in so doing lose walking down a different path to a different future, to a different world.

We will never know which road is better.

Conformity over Originality

Following the Yellow Brick Road to extinction...?

When did we go there? How did we get here? When did we become this? A trailing mass of Dickens characters, lined up with little cups in our hands asking, “Please sir, I want some more?”

Oh yes, doubt as we must this inclination, doubt as we must to protect our inflated egos, doubt that we will to protect the fragile nature of our existence, this much is true; we have succumbed to the disease of mediocrity, insincerity disinformation and dependence.

Our purposes were much larger. Our desires were much greater, our needs much smaller, but now, things have changed. I see it, in the young as they hook the button into the button-holes of their lab coats and sling the almost never used stethoscopes around their necks, constantly “crossing the Ts and dotting the “Is” with their heads buried in their digital divide and one eye on the time-clocks, that life has changed.

There is a clamor about “guidelines” “rules” and “methodologies” that need to be weighed on one side of the scale and the patient’s needs on the other side. The “balance” seems to tip away from the patients, on an ever-increasing sway, even though there are much ballyhooed “patient-centric” discussions that rivet our eyes and fill our ears. The disconnect is real, the gulf is getting wider and the drumbeat of rationalization is getting much more intense, even as the person in the gurney, with question marks gleaming in both eyes, tries to decipher, but fails miserably, of what is going on around him or her.

Haboob over Phoenix

Conformity to a design is like a haboob over thought. In originality, lies the path towards innovation and new ideas. Where did that contemplation go? What happened to the differentiating between multiple diagnoses, when did the understanding cease? When did severity or age become the firewalls to thought? From the kernels of original and diverse thoughts come the grandest of ideas and elaborate innovations that help and spur better thoughts and newer ideas about protecting health. When did the frost of this “new thinking” stop that seed from blossoming? When did we become the “unfeeling, uncaring, punch the clock group?” that just talks about caring. But I digress.

Those that are young feel that age is for the aged. That, that far away 60s and 70s is a traverse across the grand scale that might take eons to cross. No, not so! It all happens in a blink of an eye. Then what happens? Do these young ones turn into beautiful carriages, from their pumpkin mode? Or, faced with mortality will they transform into, like any other pumpkin, shriveled with sallow complexion. Oh, but they need only the Camera-Obscura into themselves, an introspection so to speak, to see “reality” for what it really is and delve into rational thinking.

We feed the desire to live longer, to exercise, to diet and live healthy lives and having done so when ailments come knocking on the door, we wish to turn our backs because there isn’t enough to feed the notion. Yes, living healthy is a prescription to stave off disease and prevention against this imbroglio of healthcare chaos, but when need arises proper care for those in need once considered appropriate is now the abnormal. Oh, I don’t mean keeping a person alive on a respirator for months, or such extremes of inappropriateness, but a patient in her 70s with a diagnosis of lymphoma to be told to go home and die in peace really rattles my cage.

Living life is becoming cost-prohibitive. The social barriers to aging are ever-increasing. Some specialty societies are hiring only the younger doctors right out of schools to enter into palliative-care subspecialty so that the emotional disconnect between existence and time is pursued to its eventual outcome –cost containment. It might be a more civilized version of indoctrination. The dictates of this wonderful, politically correct, benevolent society are feeding the monster of its autophagic demise.

The dual landscape of doctors and patients are mired in these deadly games of impoverished thoughts of conformity. The salvation, then, lies in the originality of thought through knowledge and understanding.

Imagine if we were to live the lifespan of Abraham, as some genetic-engineers predicted a while back, where then would we be? I think the real magic in living is in good health, in avoidance of the vicious whirlwinds of illness by choice and lifestyles. The water-spouts of ever-increasing burdens of high-brow interference is sure to land at the footsteps of every human being alive today. The shifting-sands of this irony will swallow the “human” in humanity. If only we would learn to not be dependent, but be self-sufficient and chart our own destinies. Self-reliance in all aspects of living is the greatest of all liberties, the hallmark of freedom. We must choose to govern our own health. We need to empower ourselves to understand our own bodies. Only with knowledge we can understand how our insides work and with the understanding stave off disease. While the flux of this pull-push continues in medicine, personal enlightenment is the only true road to health. (Please take the time -16 minutes -to see this video ~ very enlightening)

Somehow it is easier to see this from atop the hill between the young and the old. What is happening and what is becoming.

 I hear drumbeats of “appropriateness of care,” of “cost of life,” “evidence based medicine” and I wonder to myself, “They know not what they do.”

A Dream

I heard old soldiers never die they just fade away. There might be truth in that.

Photo by Sergei Grits/Belarus

The room is strangely quiet. The sound of the busy feet no longer grips the moment. I can hear them, but they are just the echoes of a distant world. The walls look forlorn with plaques of this and that staring back at me. There is a lifetime of work and achievements on these walls, yet they appear dislocated in virtue. Strange!

I hear the door creak and straighten my posture, but it is the muffled breeze from the air conditioner that moves it. There is solemnity in the air and strangely a mixture of wistfulness and bright clarity. The photocopied articles from far away lands lie stacked on one corner of the desk with yellow marker colorings on the printed words demanding attention and signifying value and meaning. Some of the facts contained within maybe the keys to the secret locks that guard the truth in medicine. A microscope sits patiently on the near left corner of the desk, waiting to unearth the mystery of a human tissue and it's component cells. It appears strangely alone, wistful, a sentient being, as does the "In-File" rack that once held charts, also sits empty, in concert with the surroundings. This space and time is out of joint. This view oddly enough has no frame of reference. This then is the death of a dream.

The desk itself is worn, showing it's age. A rash of scratches on the glass blotter, now sit glaring at any discerning eye. Once hidden under books and paper, now, they are clearly visible. These marks hide within their topography the joys, sorrows and frustrations of past adventures in the wild safaris of medical care.  Some of these scratches have remote but distinct memories while others are bereft of a link.

The shelves on the far wall that once contained a plethora of trinkets, photos and other memorabilia from grateful fellow humans now are empty and memory-less. In the far corner a photograph sits atop a table. I remember this one well; a thirty-year old mother holding her baby and smiling from beneath her locks of hair at the photographer and at all others that look back at her photo. She at half her age was a victim to a devastation that we, she and I, thwarted successfully. Memories like that force a smile on my face and there are many in the deep recesses of my mind. Just below on the second shelf is a model of a red Ferrari automobile that a thirty-something brought back from his travels after he fought a battle against the wickedness of nature's cruel joke and won. He loved fast cars, he once said and that he, “would buy me a Ferrari if he lived through this ordeal.” He kept his side of the bargain as I had kept mine. Middle-aged now, he is knocking at the door of the "Boomer" age category with three children of his own.

And then there is this large, red hard cover text-book, stifled between bookends that still clearly shows the dog eared use of the years gone by. The book's spine is somewhat weakened and bowed from use and as it sits there upright in all its enormous majesty, the days of it being regaled are numbered. The content within is dated. The speed of information now proceeds at a pace much different then that of a novel where timeless words like “My name is Ishmael” and “It is a far, far better place” or “to be or not to be” remain burnt into our memories. These words reach and touch some class of neural images that resist change, unlike the words in this large voluminous text book of medicine that need change even before the final editing is complete and much before the printing has even begun in the press.

I sit in the chair behind the desk. It feels familiar. The cushion weakened and lax in just the right places fits my form well. I can feel the missing bolt underneath the right armrest instinctively from old habit. I pull at it and dislodge it from its hold. Very little effort concentrated in just the right place is needed to accomplish that feat. My fingers have mastery over it. I lean back on the chair and it unburdens itself of a familiar creaking sound that I have heard as many times as there are minutes in a week. Strangely the sound is familiar and comforting.

I look across from over the desk and a strange yet familiar movie plays in my head of all the faces that have faced me, looking for answers, some concerned with the news that they least expected and others elated with what they heard. Mostly these are faces of very brave people. The movie plays on and for a moment, I am back in the game, understanding, rationalizing, collating, praying, hoping and devising for that face that holds my attention. It is a battle for and with each and every one of these faces. The war goes on as each battle is fought. Courage is found aplenty but there are no medals of honor, or purple hearts to be worn, victory lies in the time to create memories with the loved ones.  And then as suddenly as it starts, the movie ends. There is the blank wall in front of me once again, the show is over, time to exit the theater.

The eerie silence is broken as a burly gentleman knocks on the door. He has come to help put things in order. My years of memories are being packed, locked away for some distant future where they will hold no sway. These memories are mine alone, hidden in the catacombs of my thoughts and there they will reside. That time has passed. Maybe in the future better ones will replace them, but that is for another time to unfold. Soon the calculators, the financial gurus, the well-intentioned highbrows will swarm in to take over this space for their own. Soon the stethoscope will be a long forgotten relic. Soon apportioned benefits, determined values and expediency in the name of “better” will rule. Soon the blur of “cost” will overrun the value of  “care.” Soon a new dawn will break. Soon. The shirt feels moist against my skin. Strange.

I did not intend for this. But then no one does. There are no Churchill moments, no Babe Ruth smiles, no Patton salutes, just an echo reverberating within my soul and a heavy heart hammering within my chest.

It is the end of a dream.

Since then 'tis centuries; but each

Feels shorter than the day

I first surmised the horses' heads

Were toward eternity. ~ Emily Dickinson

P4P

What a great concept. You work hard and your hard work gets you a reward. An ideal concept, so simple and above reproach, you would think?

The pay part of the first “P” has no ambiguity-laden vices in it. You pay for what you get. Determine the benefit, write the check and the transaction is complete. Also quite simple!

Now here comes the quasi-deterministic, difficult to interpret non-equitable half of that three-lettered bureaucracy. How in the world do you determine the right-sided “P?” Indeed, How?

In medicine where the recipients of all the benefits of the medical world come in all shapes and sizes, the world of “equating” falls apart at the seams.

In medicine the “performance” is determined by the outcome of the patient. Simplistically speaking if some one comes in with a cold and you prescribe a medicine and the cold, heals itself, then you have performed admirably. Similarly if someone has a broken bone and it is “”plated,” “screwed.” or put in a cast and it heals itself, great you deserve an “A” for effort and oodles of reimbursement. On the other hand if someone has diabetes, a bad heart, poor blood flow in the extremities and after surgery for a minor ailment ends up with an uncontrolled infection due to poor immunity or poor self-care then you as a doctor deserve the bane of all the high-brows that determine policy. There is equal blame to go around in all aspects of those providing care.

So what do you do?

Now here is the other side of it. Physicians being physicians, are not all dumb in their quest to please the world of mega-dictates. As many have found out and determined through the process is that to “turf” the difficult patients to the secondary centers is the right course of action. This, to avoid the difficulties of the management of a oor-health patient and also to avoid the ‘stripe’ on your ever-burgeoning’ report card being formulated by the various Insurance and governmental agencies. Consequently the burden of the secondary centers increased exponentially within a short period of time. These secondary centers got jammed with the so-called “poor-performing” patients and brought down the “grades” of those institutions. And it doesn’t end there. The “secondary institutions” realized the “musical-chairs” scenario and kicked the can down the to the “tertiary centers.” The short straw was passed down-stream.

A while ago, as the story goes, a patient went to his primary care physician, who after thoughtful analysis and reasoning, referred him to a specialist. The specialist seeing the multiple co-morbid states in the patient and the likelihood of extensive time-consuming discussions involving the patient, the insurance company and the family of the patient in the future, referred him to the secondary center. The expert at the secondary center also on the hospital committee for excellence balanced his responsibility by referring the patient to a tertiary center for a “trial-based-treatment” that was not considered, leading the patient back after three months to his primary care physician, who sent the patient back to his first specialist. Given the problems in the case, he (the specialist) elected to decline care and advised other specialists in the area. The patient finally received his treatment and fortunately for him did well. But the lingering aroma of the decision-making process still stinks up the brain.

If you haven’t figured this scheme out by now, the end result was that those smart and adept in this game of “kick-the-can-down-the-road” make out like bandits for their “performance” whilst those saddled with the burden of difficult patients get the short straw.

Equally in the dog house another logical yet flawed concept of disincentives for ‘never-event” coined by the Infectious Disease experts is coming back to roost on the hospital’s nest eggs. The better term here would be NP4PP (No pay for poor performance) Poor performance being considered an “acquired” infection in the hospital. Ludicrous as it seems, it is bloated with the eddies within currents of thought flow from the towers of power. If on admission to the hospital the Emergency Room doctor did not mention there was a possibility of an infection,such as say a subclinical bacterial, parasitic, viral organism, then that is considered "Hospital Acquired." Dumb! you say? Think again. That is the mandate. This is a verisimilitude to the financial disaster engulfing the globe. Pay for stupidity and gaming the system while withholding for innovation and hard work.

Now let me transliterate this situation to a very heady, “Quant-ified” scheme that pervaded the world of finance. The similarities are eerily similar.

In the financial world derivatives are nothing more than leveraged securities of an underlying asset. 

What brought down the financial house of cards was that the “Whiz-kids” decided to bundle up different mortgagees of varying rated-value and placed them in “tranches” and sold them as securities with “first-lien” (the 25%) getting the collateral backing of the assets and the “second-liens” of which there were the 75% ers were unsecured.

 If the entire mortgage backed security was “called” or the tranche was filled with poor asset backed mortgages (You know the people who were earning $30-40,000 per annum and were given mortgages for houses worth $400,000) the poor ‘joe-shmoes” hedge-fund suckered investors would be left holding the bag of worthless paper. 

The scheme worked for a while as all such schemes do. But then someone or all have to take the fall of this “Ponzi-style-scheme.” Now what does this have to do with the P4P for physicians?  Elementary my dear, elementary! Think!

Continue the thinking, dear reader, of sending the difficult patients to the other centers. And as a “bone” so these institutions don’t get wise to you quickly, you throw in a better outcome patient. That is the same as bundling different scenarios in a “tranche,” isn’t it? Eventually, one of two outcomes have to happen; 1. The secondary and tertiary centers become wise and stop the inflow as they realize the worth of their hemorrhaging financial sheets or 2. if they don’t they lose solvency. The second scenario can be averted temporarily by a white knight, who can right the ship with hard decisions and cut the inflow of “poor-performing” patients to balance the sheet. But you might ask what happens to the sick people who need the real help and the expertise? Ah! But the “experts” have promulgated another policy of how to deal with the really sick… (convince the public the art of elegant dying) but that we will leave for another day.

The American College of Physicians Ethics expressed it’s concern: Pay-for-performance initiatives that provide incentives for good performance on a few specific elements of a single disease or condition may lead to neglect of other, potentially more important elements of care for that condition or a co-morbid condition. The elderly patient with multiple chronic conditions is especially vulnerable to this unwanted effect of powerful incentives.

Unintended consequences of well-intentioned self-gratifying enacted concepts without the foresight of seeing the horizon can be devastating. The financial markets have been reeling under the weight of the “well-meaning housing and a white picket fence for all with cheap money” scheme that may take years to deleverage. The quality of life for millions is in shambles, while in medicine the color of the swan is turning black as we speak.