DISTRACTIONS of Majoring in Minors

I recently visited the Vasa Museum in Stockholm, Sweden. The three hundred year old warship sits majestically in the middle of this beautiful museum. You can look at it from every angle. The wooden ship is a master craftsman’s envy. The figurines on the transom are alive and tell the fascinating tale of the logic within illogic, of demand and uncertainty, of powerful words that drowned the truth seeking muted voices, of hubris, of inattention, of layered differences between the knowers of truth and the seekers of fame and ideology. In short, Vasa remains a memory to Sweden's famous warrior King Gustavus Adolphus, his ambition of military expansionism, his impulsive desire and the fearful silence of the knowers who deemed Vasa unfit for sea.

Vasa completed its 300 meter maiden voyage in 1628 and at the first hint of a strong breeze displayed its instability due to a high center of gravity and promptly sank to the bottom, lost for 300 years. It was resurrected in 1959 and after carefully organizing 95% of the remains of the warship, Vasa was brought back to its current life and rests in the Vasa Museum in Stockholm, Sweden.

The impetus of the ship-builders was to have the state of the art battle ship with two rows of cannons on either side. Unfortunately there was not enough ballast to keep it righted when the sails filled. 

The desire was craftsmanship, the regal beauty and potential  deadlyforce the vessel could unleash, however not enough measure was taken of its ability to sail. Today Vasa Museum remains the most visited museum in Europe. It is a testament to the folly of majoring in minor thoughts!

Consider the current vogue in medicine where the physician (the determiner of facts, the allocator of resources and the captain of the healthcare ship) is relegated to majoring in the minors! (you know I was going there weren't you?)

Let us consider the following issues:

1.       EMR: The object of EMRs is to create a large data-bank so that errors are minimized in the practice of medicine and additionally duplication of services is limited to reduce costs. A 2-fer! How could anyone ignore the virtue behind this logic? Well, and that is a deep one, there are many hurdles to overcome. Learning the EMR system takes time, but that is of no concern to the makers of the system (who gain from it), after all it is the responsibility of the physician. Okay, moving on, the information is to be entered close to the time of the encounter so that memory does not waiver, but then the sacred patient-physician contact is minimized by the doctor’s constant attention on the computer screen to prevent errors that can mislead the reader with incoherent information (both to the detriment of the patient and the physician). That sacred faith and the personal trust gets lodged somewhere between distrust and lack of faith. Right about there the 14% placebo effect of the comforting hand on the shoulder benefit is drowned in the sea of digital ink. Physicians spend between 40-50% of their time in “charting” while the nurses spend 50-60% of their time doing the same on the hospital units. Who takes care of the patients during that timeThe answer should not surprise you.

2.       Reimbursements for services rendered: the Medical Revenue Cycle is alive and well, thanks to the insurer models of denial of coverage and denial of payments because of lack of documentation. 11% of all medical bill submissions by physicians, hospitals get denied automatically via the software algorithms built into the large main frames of the insurers. While the Blues, the Aetna(s) and the United(s) cleanup with soaring revenues and net incomes showering their managers with huge bonuses. Meanwhile it notoriously takes the physician 6-10 weeks to collect payments from these insurers. Besides the declining present value of the money, the doctor has to keep his office afloat before he can recover the payments. (S)he at times has to take bridge loans for stability. The doctor now has to master the issue of medical reimbursement by dealing with the insurers. (S)he spends time discussing the merits of care with someone at the insurer level who may not even have a high school diploma but is using guidelines to deny care!

3.       There is also a push for physicians to enter whole-heartedly into the Social Media realm and converse with their patients. The voices are getting strong and these voices seem to take a one-better attitude against those that do not interact through the social media by calling them out. Is that the right mode for a patient-physician interaction? Is this another minor activity that the doctor will be forced to major in? Given the HIPAA laws there are optional pitfalls, sinkholes and avalanches that await the unguarded word of a physician in the digital realm. You be careful out there doc!

 Statistics: 50% of scientific medical studies are not reproducible (false, biased, improperly done or statistically manipulated)! That statement must give us pause. Physicians rely on a properly done study to determine its need in governance of their patient's care. Currently with the fudged data, biased output, conflicted interests of publish or perish, the scientific offerings are limited and it is up to the physician to major in the biostatistics to weed out the right from wrong, the good from the bad, even though both may appear the same.  This simplified .pdf book would serve everyone involved in medicine well “Know Your Chances" by Woloshin, Schwartz, Welch Complete book in pdf via @Medicalskeptic (my thanks). It would behoove us doctors to acquire this knowledge for knowledge's sake anyway.

5.       Regulations: The physician office is governed by no less than 38 different federal and State laws, rules and regulatory bodies that can with impunity shut down his/her practice of medicine. A physician is required to know these laws, rules and regulation and ignorance is never an excuse. Another major is needed to discern the legal word behind the regulatory capture of medicine. The fear alone from this is enough to drive anyone insane.

6.       Maintenance of Certification or MOC: This is a product of the private enterprise that assiduously enforces certain demands on the physicians without the clear bounds of verifiable and or validated data. They claim that the MOC process is necessary to determine the knowledge and learning of the physician. These claims are embraced by the hospitals and insurers as a means to weed out physicians from their roster should the physicians be found not in compliance to the MOC standards. There are some very relevant issues in this thinking. If those physicians involved in the MOC process compared with those not undertaking the exercise have similar patient care then how does one better the other? And to boot more than 17,000 physicians have signed a petition to eliminate the new MOC requirements. Most physicians consider MOC to be an unnecessary imposition that actually harms care by usurping physician time away from patients. All this is designed unfortunately to create mistrust in the patient towards his doctor and that leads to despondency and  and with absolutely no known benefits in patient outcomes! 

Just like the Vasa, medicine is replete with the bling of hubris, the shine of pomp and the laurels of asymmetry in thought while the underlying goal of patient care suffers. Might I suggest that the best way forward just maybe a direct patient-physician access without the intermediaries? Or pay as you go or PAYGO! Responsibility on both sides of the aisle as much as the skin in the game like the days of yore!
Healthcare Facts:
1950s = 5% of GDP
1960s = 6% of GDP
2014  = 17% of GDP
If the Trend was allowed to continue the math logic states that the cost would be:
2010s = 11% of GDP not 18% of GDP even with the population growth and demographic change! But somewhere in there by "All the way with LBJ" was inserted the 1965 Medicare Amendment to the Social Security Act and the rest is history! And that 7% of extras in GDP translates to  $17.7trillion x 0.07 = $1.24 trillion of crony pocket change.  Now that is a foreign and abhorrent concept among the elites who wish to partake in other people’s money. Here are some other facts: Direct patient care without the intermediaries will bring the cost of care down, increase the patient outcomes and get rid of this art of majoring in minor activities! It might come as a surprise to the vast enterprise of the “good-intentioned” that medical care is about caring. It is between the patient and his or her physician. Removing the barriers/layers removes the unnecessary burden and gives more stability to the enterprise of caring.

Clearly the healthcare foundational -ballast is grossly under-weighted while the top-heavy self-serving-intermediary-instability continues to increase.

Vasa Replica at the museum

A storm is brewing and history reminds us, with the shaky foundation in place, the first chill of the brisk breeze will surely sink this ship!

Of Mice and Men

A little rain must fall...

We plan. We live. We try to understand.

Somewhere in this universe there is a record-keeping device that ascribes to Steinbeck’s famous quote, “the best laid plans of mice and men oft go awry.” Being George Milton is no solace when you lose a friend Lennie Small to your own hands. It is an act of love albeit a murderous one. Somewhere in that flow of thought, the curse of knowledge comes to mind. You know, like, George understood what would not be; the happiness of a life on the ranch. George could not bear to see Lennie sad or lynched by Curly's mob, so he killed him.

Lennie’s soul must cry out somewhere in this universe of being wronged. Ah compassion of the wrong kind heralded by the slow of mind, by the fast of claimed virtue, by the unwitting and by the rest of the herd seem to fall into their personal trap of emotional comfort. For they seem to think that the act justifies and thus soothes the emotional vein of feeling. Does it? Snuffing a life that can be helped live out some future is a good thing? Justification in the name of empathy is an emotional recoil for reason. “How can you not,” some will say, to ward off future suffering. They forget that the future changes moment to moment. Time lapse photographs of a blooming rose, a fracturing fallen pitcher of milk or the penetration of a bullet through time all change the future. The suffering never goes on. It ends sometime. It ends with time!

How can we in good conscience allow denial of care to a human in need? When did we get bestowed with the rationalization of a George Milton mind? How do we know of what is yet to come? The three days, three months, three years or three decades of a future might through the act of one life change the course of human existence, much like a certain human named Hawking has done. Was Lennie Small in need of protection from his own strength that became his weakness? Was Lennie Small’s simplemindedness nature’s cruel joke or nature’s argument for understanding? Whatever it was, he deserved a better fate! To sit in judgment of a future that is yet to be is to sit and revel in the ultimate hubris a human mind can conjure.

Time to think and comprehend what is real and what could be in the as yet fictional future.

A little rain must fall in everyone’s life. Humanity calls for giving shelter, not the gun to blow off Lennie Small’s head!

MEDICAL RESIDENCY

A few years ago a group of recent medical graduates came to our house for dinner. An exciting conversation of their hopes and dreams followed. What would they do and where would they go in search of fulfilling their dreams. One wanted to go and serve in the rural areas with a large backyard where he could be “one with nature” and when duty called he would step into his home/office and care for the patient. Another wanted to follow in his father’s footsteps, become a sub-specialist and regale the specialty with new knowledge through discovery. A third quiet and more subdued graduate sulked in the background, not willing to express her desires.

As the dinner progressed the graduate magnetized towards the rural bent stated, “I don’t get it,” he said, “Why do I have to go see another surgical procedure?” He put his fork down with an emphasis. “You see one, you do one and you teach one!” There was a momentary silence. As a host, I asked, “don’t you think an aggregated knowledge would make for better decision making?” He fired back immediately, “Repetition is not necessarily the best education.” Not exactly true, but as a host, I volunteered,  “But more exposure leads to more information and that becomes a sort of experiential reference to draw upon, don’t you think?”

Ah but for the infinite regress of a mental intent...

 “A cholecystectomy is a cholecystectomy!” he stated with a smirk. “Fair enough,” I replied, “but each individual is different and each gall bladder therefore is different. You might find one gallbladder fixed from chronic inflammation to other tissues, another might be filled with stones, still another might have a nidus of gall bladder cancer in it stuck to the liver and so on, how can one know how to deal with all those contingencies?” He remained quiet for a moment and then not to be held down with a technicality suggested, “when you go in (operate) that is when you find the problem and you deal with what you find. The procedure of going in is the same!” This young Turk had a lot to learn and maybe he would in due course of his residency, only time would tell.

The sulking violet meanwhile quietly listened to the exchange and the cloud over her head seemed to darken. I asked her what was bothering her and she replied, “I wouldn't know what to do!” she said haltingly in veiled terror. “What do you mean?” I asked. “In the ER for instant a patient with abdominal pain, you cannot open the text book to look through all the differential diagnoses, how would one go about determining the diagnosis and the right treatment?” Ah, I thought from the bullish to the bearish the entire spectrum was covered here. “That is why you have the residency program to help you sort out the problems. It gives you the confidence based on the knowledge you accumulate from your peers, experienced nurses and attending physicians. That is the purpose for the residency, to help put the didactic into the practical format. Medicine is difficult both in the expanse of its knowledge-base and in its practice. The sorting and weeding out of what is right and wrong, is done early on in the residency to help gain confidence in one’s ability and in proper management of a patient’s illness when you embark on the life-long journey of being a doctor.” That might have sounded pompous, but it had the elements of truth in it. She sighed unconvinced and her head went back into the thoughtful repose. She would benefit from the experience of the residency “baptism under fire!” I thought. They had no idea what kind of an immediate future they were up against. Yet it would come and readiness was all they needed.

The night ended with laughter and fun. As we closed the door behind our departing guests, it struck me how arduous a path it is to becoming a doctor. All these graduates had their hopes and dreams, some had the arrogance of youth and others the timidity and fear of the unknown. Graduation from a medical school is only the first step towards the learning process. Residency is an important bridge between what one knows and how it is utilized. But learning goes on for the lifetime of a physician!

The recent legislation passed in Missouri to cover for the physician shortage is a bit discomfiting. Not only does it speak volumes about the expert policy makers but it broadcasts the potential future. What kind of impact would it have upon the actions of the “fearless” and the “timid” without supervision and their behavioral impact on patient care?

Maybe it will all work out. But in medicine, a lot of maybes can lead to a lot of oops!

A Very Brief History of CANCER

From there to here in cancer care...

Cancer has been around as long as life. The incidence of cancer remains true to the cumulative DNA mutations over the eons. The mutations whether heritable (Darwinian) or acquired (Lamarckian) bestow a similar consequence upon the cell; they subvert its function and give it sustainable powers. It is a disease that does not comport itself to utilitarian essentialism. Each cancer is unique in form, structure, behavior and outcome and requires precise understanding of the levers and cogs that hide within the shadows.

Discovery:

Back in the 1600 BC the earliest information cataloged on a papyrus, cancer is chronicled as a malady. Bone specimens from mummies have revealed cancer in the bones as chewed out bone fragments. There are spotty viewpoints in isolated silos for a thousand years. No real cogent hypothesis was offered. The deadly disease was taken at face value and left at that for the remainder of the century. Along came Hippocrates in 460-370 BC who posited the “Humoral Theory.”

Within his theory was the dark, evil “Black bile” the harbinger of carcinos or “karkinos” (cancer). With that theory perched on his mind, he lamented in resignation, “There is no cure.” And in those times, there was none, let alone knowledge of how this “beastly tragedy” where posited subsumed life.

Five centuries later Claudius Galenus “Galen” 131-201 AD influenced by the “Humor Theory” used his anatomic skills and known knowledge of medicine as a physician, philosopher and made further strides into the nature of malignancy through the Hippocratic lens of “Humor.” The pervasive sense of nihilism inversely controlled knowledge and treatment of cancer for almost a century and a half thereafter.

Not until 1775 when Sir Percival Pott deduced that chimney sweeps in London contracted scrotal cancer from the soot, did the cause and effect of environment on cancer become known. For the first time a verifiable concrete causality was bared. Something to point a finger at!

Other notables in the field included Rudolf Virchow 1821-1902 a German polymath who viewed cancer tissue under microscopy to determine that it was “a collection of cells derived from other cells.” and repudiated the Hippocratic "Humoral" view of life and disease. The pace quickened. The knowledge advanced. Yet the fear remained.

In 1902 Theodor Boveri a German zoologist in Munich postulated that the centrosome, an “especial organ of cell division” was required in mitosis (cell division) and that aberrant mitosis was the prelude to cancer. He theorized that special check points in the mitotic cycle when mutated could lead to a genetic predisposition towards a malignancy. We were slowly breaching the firewall. We still had a long way to go.

In 1911 Peyton Rous of Johns Hopkins University in Baltimore, Maryland used a cell free filtrate from a chicken sarcoma to cause cancer in a healthy fowl. This transmission was due to a virus named appropriately as the Rouse Sarcoma Virus. Thus the viral etiology of cancer transmission was brought to fore in the field of cancer medicine. We had progressed from soot to a cell free filtrate (virus) as the central cause of this hard to control tragedy. We were peering at the mechanism for the first time.

Yamagiva and Ichikawa in 1915 used the Percival Pott concept to induce skin cancer in rabbits using coal tar and prove chemical carcinogenesis.  And then in 1964 we added tobacco, another vile substance to the growing list of “evil doers!” Chemicals and Viruses ruled the domain of causality in cancer!

"If everyone is thinking alike, then somebody isn't thinking." George Patton

Cancer medicine was to undergo an exponential increase in knowledge flow after the discovery by Watson and Crick of the DNA helix in 1953. Subsequent hypotheses and experimental thrust in understanding cancer was relegated to the study of genetic dysfunction and its relation to disease, more specifically cancer.

In her book “Natural Obsessions” by Natalie Angier the descriptive evidence of how the Weinberg Labs under the tutelage of Robert A. Weinberg discovered the first human oncogene Ras (a promoter gene causing cancer) and the Retinoblastoma (Rb), a tumor suppressor gene is worth a read. The trials and tribulations of discovery and the dogged pursuit all exemplify the enormous grind required in bringing a hypothesis to reality through series of experimentation and validations. Basic science has to toil over experiments and not be reliant on the dubious distinction of transposed conditionality as employed nowadays by the Frequentists. In 1990 another dedicated scientist, Mary Claire King through diligent work discovered the BRCA I and 2 tumor suppressor genes. BRCA 1 and 2 both involved in initiating cancer via mutation triggering malignancies in Breast, Ovaries, Prostate, among other organs. Another door had opened into the nebulous innards of the cancer cell!

There has been a flurry of activity since in the discovery of various cellular pathways and their cell-surface molecules that could incite mischief in extremely well regulated cell machinery through disruption. This disrupting influence can be over-expressions of pro-proliferation molecules for continuous cell growth or suppression of the anti-proliferation molecules akin to a driver using the accelerator without a brake or releasing the brake in neutral gear on a downhill road. There are many known allosteric feed-back loops within the cells that promote and suppress cell activity as well. These discoveries have now taken biology into the realm of epigenetics (study of genetic control by factors outside of the DNA sequence) where small collaborators called micro-RNA, peptides and other proteins have influential impact on the genetic domain to coax the wayward cell.We had arrived at today!

Surgery:

While these discoveries were taking place some stalwarts in medicine were taking note and deciding how best to treat this devastating malady. Overtime these innovators discarded the Hippocratic and Galen nihilism and opted for surgical removal of the cancer to help life along. In 1878 Thomas Beatson realized that removal of the ovaries resulted in a shrinkage of the breast cancer. Twelve years later,William Halstead of Baltimore, Maryland came up with the idea of Radical mastectomy for breast cancer to achieve the R0 state. This was to be later known  as the Halstead procedure.

In 1928 Charles Huggins came to a similar conclusion in men with prostate cancer, removal of the testicles (orchiectomy) resulted in longevity.

From radical Mastectomy and other highly invasive procedures a refinement of thought occurred. What if we could do more with less surgery to prevent future infirmity and disability to the patient? Those “what ifs” were rewarded with the advent of combined approach of limited surgery and radiation therapy. The 1985-90 data showed equivalent survival for radical mastectomy and partial mastectomy combined with radiation therapy. More would be done to determine between those patients that would need radiation after surgery based on the genetic makeup of the cancer itself. Today OncoType DX gene screening arrays help determine the aggressiveness of breast cancer and treatment can be based on select cases. Others gene arrays exist and are in use for lymphomas and prostate cancer. We are currently grappling with the need for intervention and bearing the costs of caring by invoking concepts of “Lead Time Bias” in an effort to reduce potential harm by limiting “early/over diagnosis.” Newer forms of diagnostic tests arrive at the doctor's doorstep everyday to find and weed out this wretched disease and we as doctors use them all. But the constraints of money seem hell bent on controlling further progress. But that will not hold! After all when there was no money the DNA helix was discovered, smallpox vaccine was created out of cowpox and Penicillin grew out of the mold. I am sure the real creators and innovators will find what is needed to carve out a better destiny for the human race against cancer, independent of the regulatory arm twists. Progress in knowledge and understanding will happen, the scale of which only time will tell..

Radiation Therapy:

Radiation therapy started as a low voltage X-Rays (where “X” stood for unknown quantity) after Wilhelm Conrad Roentgen’s discovery of the x-rays in 1896. From those humble beginnings of large penumbras of low voltage radiation therapy to focused conformal radiation therapy of millions of electron voltage tailored to the tumor via Intensity Modulated Radiation therapy (IMRT) to Intraoperative Radiation Therapy IORT to gated modulations based on respiratory movements to the Stereotactic Radiation therapy (Gamma knife/Cyber-knife), the movement has an accelerated pace to provide the maximum tumor cell kill while sparing the normal cells surrounding the cancer. Proton beam therapy a newer more expensive methodology based on the sharp division of Braggs Peak is geared towards a similar methodology as the IMRT and currently used in certain tertiary centers as the radiation therapy of choice with equivalency in results compared to IMRT.

Chemotherapy:

The field of Oncology is the study of cancer and all relevant treatment modalities that will favor the patient. The tools in the field of Medical Oncology started with the advent of World War I. In 1917 the German Army used Mustard Gas against the enemy. The victims showed an absence of white cells in their blood. The modification of the Mustard Gas as nitrogen mustard was then used as treatment in patients with Hodgkin Disease in 1919.  After the bombing of Nagasaki and Hiroshima, in World War II the victims of the bombing showed a complete bone marrow wipe out. With that information, cancer treatment took another step of using radiation therapy to destroy the bone marrow in cancer cases, specifically Lymphomas and used it for Bone Marrow Transplantation as a method of curing the disease. From adversity grew a serendipitous and successful mode of treatment for an un-treatable disease.

Sydney Farber of Boston, Mass used Aminopterin, (DNA inhibitor that competes with the folate binding site of the tetrahydrofolate reductase enzyme) a precursor to Methotrexate in treatment for Acute Lymphoblastic Leukemia in children and achieved excellent results, as a consequence Methotrexate was then used to treat Choriocarcinoma a cancer in the uterus (womb) with gratifying full remissions.

From single drug therapy, a combination of drugs came into vogue to escalate the remissions in cancer. Slow and steady success followed with incremental improvement in remissions and subsequently in overall survival of the cancer patient with these treatments. In treatment of Malignant Lymphoma (DLCBCL) a four drug regimen of  Cyclophosphamide (Alkylating agent), Doxorubicin (DNA intercalator), Oncovin (a Vinca alkaloid that functions as a mitotic inhibitor) and Prednisone (steroid) (CHOP) was used with great success. Even with further modifications and additions of various other chemical agents to CHOP the cure rate remained fixed around the 50%+ range until the advent of Rituximab. When Rituximab was added to (R-CHOP) there was a significant rise in the complete remission rates and subsequent improvement in survival.

Biologic Response Modifiers:

What is Rituximab?  It is a monoclonal antibody directed against the CD-20 cell surface antigen. Since most lymphoma cells expressed CD-20 on their surface, Rituximab complied, attached itself to the surface and prevented further transmission of signals to the nucleus of the cell to grow. However this was not the first immune modulator by any means, Immune modulators or Biological Response Modifiers had been employed previously. The use of Interferon in melanoma and Chronic Myelogenous Leukemia and Interleukin-2 or IL-2 in both melanoma and Kidney cancer were examples of attempts to modify the immune response against the cancer. Additionally studies utilized programming the Dendritic Cells in the bone marrow to activate the T Killer cells (Lymphocytes) into storming and destroying cancer (prostate) with limited success. Companies such as Dendreon produced a product in that fashion called Provenge that afforded a limited improvement in survival of 4 months to patientwith prostate cancer at a cost of $100,000. Newer attempts at modifying immune behavior is via the Check Point Inhibitors to allow the full scale of immune surveillance unhampered by cancer in throwing another mortar attack against the disease.

Infused with the epistemological experience, both perceived and real, the current focus has gravitated to the Tyrosine Kinases (more on these critters in a different post) as the next targets to control. These are extra and intra-cellular proteins that modify cell behavior through manipulation of the cell signal. Various TK inhibitors include Erbitux (Anti EGFR) and Bevacizumab (Anti VEGF) and Imatinib (Anti  c-Kit or Stem cell Growth Receptor) are in use today and more are in the pipeline of the various biotechnology companies.

The idea is to starve the flow of information (Anti EGFR) or flow of nourishment (Anti VEGF) and now possibly manipulate the epigenetics via the override of the microRNAs to calm or speed-up the genetics into forcing the cell into submission.

The next few years will be a bounty of ideas and actions against Hippocrates’ carcinos. Stay tuned...

(There are many other notables that have meant so much in the field of cancer, unfortunately space does not permit for the historical reference to each).

References:

1.       Sara Gandini Tobacco smoking and cancer: A meta-analysis Epidemiology: International Journal of cancer http://onlinelibrary.wiley.com/doi/10.1002/ijc.23033/full

      

      Galen:
       http://www.nlm.nih.gov/hmd/greek/greek_galen.html

      Sir Percival Pott:
      http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1037746/

      

      Rudolf Virchow:
      http://www.science-of-aging.com/timelines/virchow-pathology-cell-formation.php

      Theodor Boveri:
       http://jcs.biologists.org/content/121/Supplement_1/1.long

      Peyton Rous:
      http://www.nobelprize.org/nobel_prizes/medicine/laureates/1966/rous-bio.html

      Wilhelm Conrad Roentgen:
      http://www.nobelprize.org/nobel_prizes/physics/laureates/1901/rontgen-bio.html

      Sydney Farber:
      http://www.learntoquestion.com/seevak/groups/2007/sites/farber/bio.html

      

The AUDACITY of STATISTICS

...and The False Incredibly inflated (lepto) kurtosis of sap!

"The Important thing is not to stop Questioning"- Albert Einstein

We have tools

We have ghouls

But nowhere are there more fools

Than in the rules

from those who govern the tools!

           In the bias

           That climbs on the shoulders

           To bring plausibility

           Through implied causality,

Where is ignorance?

Where is reality?

Where are all the tools of Reason?

           When did justification

           Fill the void

           And intellect

           Become Treason?

           In the name of Progress!

           For every season

What is it that drives this madness?

What is it that foments this fear?

What is it that stokes this fire?

Of Ignorance laid bare!

           When did this tall sap

           Spawned by the spray of illogic

           Blown through the aperture

           Of a fat tail

           Confined to the deviation of two

           Become logic?

I see

Before me

The making of a genie

Devoid of Bayesian food

That cannot answer a wish

But bloats and floats

Hovers and covers

Behind the mask of We!

           Frailty thy name is true

           Pseudo in your thought

           Mocking in your action

           You always fall from grace

           But never too far

           From the sap

           Where your existence

           Remains tethered in place!

Oh humanity how foolish

Oh reason how devoid

Of life how gray

Of living how perilous

What is to become?

What is to remain?

What is in the end?

But emptiness and blame!

           The logic of a strain

           That grows viral each day

           From this to this

           And that to that

           From tools from ghouls

           That manifest!

           The impoverished spirit that makes us less!

Should we not complain?

Should we hide our feelings?

Should we live in disdain?

Should we marshal thoughts

Float them into life's vein
And continue our effaced reeling?

            Or forge the audacity

            Of courage
            Not crying for fear
            Nor living in rear
            And use the limits
            Of Common Sense

            To force life
            Into the future tense!

When love of virtue

Integrity of knowledge

Wisdom of time

And governance of province

Will bring ceremony

To Logic
And free of treason

Life will be whole
And True

Once again
Matched to Reason!

OPPORTUNITY: The WARP and WOOF of it!

The skein of the word opportunity folds within itself a verb for action. Ultimately it is that, which without renders the word impotent. And in many ways man has evolved to create a spectrum of actions that has fashioned the surroundings around him. We build and destroy to build again. We craft and cajole to morph the world in an image broadcast only in one’s mind’s eye.

I have a fascination with the concept of opportunities. It has untold beauty and acres of desolation wrapped up in the warp and woof of it.

From afar the lenticular clouds have grace and stationary beauty but as one comes closer the raw tumult and sheer mayhem within is surprising and distasteful. Therein lies the probable opportunity for harm. Oops, I started on the wrong foot. Let me take that back and start anew, but remember there are opportunities for good as well as bad and it all depends on your psychological bent.

It is the same in the perfectly beautiful shoreline of any coast from a six mile high view but the ragged fractals are even more so mesmerizing and difficult on the ground. The continuous power of the forces that exert their influence is what we as humans must harness to our needs.

The distant beauty has hidden within it the imperfections of a much more ravishing undisturbed and raw state of exquisiteness. The complexity of the fractals rendered to the naked eye, unfolds an elegant repetitive orderliness that astonishes. What is, is, often not what it seems!

Similarly in states of chaos and change there are subtle forces at work. These forces through the heat of friction from differing ideation create a momentum for the mass to gain an alternate vector of energy, which becomes transformational in itself. It is like writing; the initial thought is never the end product! It is a continuum of evolving forces that bend and twist to suit the master. Through words there is intended action and through that action a story unfolds. An opportunity lies dormant in all states of being.

Finding opportunities is for the fecund empty mind that has the capacity to distill its essence. We all see the same, but folded within that visual is the deeply ingrained searchlight of biased preferences. It is in that bias of thought that differing actions reside. This inaction sits and waits, warmed under the boil, ready to reveal itself in time.

All present must go through the sharp focus of the lens of turbulence- the hard work. The force exerted upon it is dislocating, traumatic and painful and yet once through to the future a different dignity beholds.

The trauma of today may become the source of laughter tomorrow. In that trauma, stagnant and unmoving, is the choice to craft a new view of the future. In that momentary frameless discomfort a new life awaits!

The stories abound; of a child with asthma who grows up to be an artist on a wind instrument, a victim of a neurological disease contemplates the itching of the universe, a child with vertigo conquers the fears and becomes a jet jockey, in deafness the most harmonious of harmonies are writ on the parchment. Such realities force upon us the logic of plasticity of the human endeavor. Our accomplishments are foretold sometime in the wails of dismal backgrounds. To some the challenges become daunting to the point of persistent incapacity of thought, habit and character, while to others they create the fabric of the canvas where they grow to paint the brightest colors ever imagined.

Opportunity then is a vision from a distance, a mirage on a hot summer’s day. The craft and mold of it into reality is what the future reveals. Like the first pluck on a guitar string, the possibilities of harmony are endless and then with hard work and dedication, and an open spirit of creativity the possibilities turn into a melody.

So go ahead and pluck that first string and record the first note!

To those that fall from the weakness of their conviction, all I can say is, “buck up, it is your life!”

To those who pick up and move on to higher grounds I say, “You are the inspiration, Thank you!”

COSTS!

A single thought conspired and overwhelmed the synapses of my being the other day: Costs! Everywhere you look nowadays there are diatribes from famous and not so famous, from intellectuals and those who call themselves intellectuals, from business people and those who have never created or operated a business and from politicians. The lingering tormented flame that attracts all these disparate beings also, I fear, will burn them.

1.       “We are running out of money!” well yeah its true! If you spend more than you earn eventually the debt will bankrupt you. No, that concept is on the decline because “experts” proclaim that we cannot run out of money because we are the innovators and the creators (by we, I mean the USA). But dare I ask about the $17.6 Trillion debt? and the $16.8 Trillion of Goods and Services (GDP)  things become a bit fidgety.

Balanced to the GDP

To counter that the argument posed by the Federal Reserve is to “Print” money. They have absorbed $4 Trillion of bad mortgages and “bad assets” on their Balance Sheet, so that the financial instruments; banks etc. can strengthen their wretched flailing liquidity ratios. Some day of reckoning will have force the FED to unwind those bad assets into the Main Street market place and when that happens what do you think will follow? Hyperinflation of course! More paper money chasing less goods and services and thus pricing those items will be at record high prices. And meanwhile the politicos to boot want to just “Give, Give, Give” to their constituents so that they themselves can be reelected to the “Bennies hall of fame” –free care, free savings, free pensions. This art of giving has to be combined with some art of taking from the earners and there lies the fly in the ointment. When does a hard-working worker tire of this confiscatory drain?

2.       “Healthcare costs are so high!” Agreed!. Okay now let us dissect that little nugget to its essence of quarks and leptons. 30% of healthcare is directly related to administrative costs. You know the kind that tells you whether you can care for the patient or not based on some obscure guidelines of population medicine correlational science data. The cost of healthcare in the United States based on Dan Munro’s article  in the Forbes was $3.8 Trillion in 2012! If we were to reduce the administrative costs, eliminate most of the intermediaries, between patient and physician,s we could easily eliminate close to $1 Trillion. “Oh No, that cannot be done!” will be the cry from the vested interests of the intermediaries. But real reform is painful and agnostic!

The demographics of the United States is changing; currently 65 and older account for 13.6% and will grow to 20.4% of the population even as the total population also continues to increase at a steady clip. And older Americans have a higher per capita expenditure of healthcare dollars. So do the math.

And as the public funds continue to pay for the healthcare expenses increasingly the problem becomes obvious to anyone with a set of eyes and a brain to go with it! The skinin the game is being coddled by the politically engineered false safety net.

With CMS spending close to $1 Trillion dollars in elderly healthcare, although the agency reports 7-8% in administrative costs some suggest that figure to be in the neighborhood of 30% accounting for all fixed and variable costs. That then brings sustainability into question especially as the labor force shrinks and consumption increases.

Reforms with weak measures and countermeasures will lead to no reduction in expenses:

BTW that cost also includes stuff like RAC Audits, Denials, Authorizations and other bureaucratic misnomers necessary to keep the paper-pushing vogue in vogue.

Merely polishing the old paradigm will not work! Decreasing the burden of unnecessary costs and revisiting the concepts of how to manage as a profitable country would necessitate a reorganization of the hierarchical tall organizational structure into a lean-mean horizontal structure that fosters real innovation and not window-dressed words emanating from silver-spooned mouths.

Tort Reform is not likely when Congress is occupied by the Lawyers and they are shrewed enough to fund their lobbyists with their earned largess. That by the way according to some would eliminate over utilization and duplication of CYA services and reduce the costs by some 2,4%! That percentage translates to $55.6 billion of which $45.6 billion annually is the cost of defensive medicine. 

3.       Business Costs: The cost of doing business, any business- the core of the economy, by any measure has gone up. The Cumulative Regulatory costs in loss of productivity and Employment are huge, Meanwhile “the Regulatory Compliance Costs in 2008 were $1.863 Trillion.

The stranglehold of a regulatory bias, which by its very nature and being, threatens the potential for any future success lays bare the increasing probability of societal failure. Those that love regulations to protect them from the evils of witches, shamans and snake-oil men fail to recognize the risk of such protection.

So the rallying cry from all walks of the expressive, political divide is muted by the facts that exist today. Costs rise not solely as a consequence of inflationary pressures but from all the nuanced politically forged and well-entrenched ideology of excessive, obtrusive and overwhelming managerial interventions. While the initial intent may have been noble and the desire to “do no harm” a desire, the continued extension of reach can only lead to greater harm to the economy.

 In reality human kind has a keen interest in Liberty and with it an accompanying cling to the Instruments of avarice that feed it the safety measures against the risks of risk-taking, innovation and creativity.  Espousing the latter wretchedness on the grounds of finding comfort in a cocoon, sheltered from the many vicissitudes of life itself leads to the ceremony of perilous circumstance, of servitude and a longer term harm to living itself.

Let us remind ourselves that we must control our own individual destinies. We must shape our own individual futures and we must above all cherish the freedom and liberty of being the Unum in ePluribus unum.:

“What light is to the eyes - what air is to the lungs - what love is to the heart, liberty is to the soul of man.” Robert green Ingersoll