These are OUR CHILDREN

"Children are the hands by which we take hold of heaven." -Henry Ward Beecher

When I was five years old, I wanted to read a book. I did that when I was six. The title escapes me but it was something in the vein of “Fuss meets Muss” or possibly like that.  At 9, I wanted to write a story and have it in print. I accomplished that at 11, the writing part that is, but a friendly rejection from the Reader’s Digest all but crushed my hopes for authorship. Imagine the lofty dreams of the youth.

And then somewhere there between the solace of parental guidance and the emergence of hormonal defiance, I wanted to be an Astrophysicist.  I don’t exactly know the motivation for that but I was struck with that fancy. Forget the earth, I actually was interested in the universe and how it ticks. In the end however, I settled for the more down to earth vocation, as a physician. This decision was layered upon me through the premature winter from the loss of a parent and the desire to quell death; the ultimate victor. There must be a way to stop the scourge? I thought. But most of my friends suggested that everything that was to be discovered had already been discovered, from the lunar surface to the genome within, everything. Anything could be laid out in paper and ink. Signed sealed and delivered. I had other ideas though, mostly unfulfilled dreams.

"Children are the living messages we send to a time we will not see." - John W. Whitehead

After many thousands of patients that I have cared for, have potentially saved many from the untimely frost of disease and provided comfort to the many souls in despair, I now realize what might have been.

The pre-teen who dreams of going to the moon, to explore new worlds, but never can take the step into his teenage years, is a tragedy. A dream quashed. A desire ruffled. A life snuffed. A teenager, who dreams of creating a business to employ thousands of people and change the world but is never able to spend the first dollar, is a travesty. A 12 year old who dreams of building a skyscraper, for that matters to him so that hundreds will live and grow within the walls, never is able to lay a single brick, is a society’s great loss. A 13 year old who walks lightly in her steps propelled by the desire to harness the digital world and create the next big internet of things never writes the first letter of the code and a 14 year old who looks up and sees possibilities in the flight of an aircraft; the potential of a faster cheaper and more efficient flight never leaves the surely bonds, are the untold catastrophes of our times. These are all dreams that litter our universe’s soul, emptied out of their promises today, for they belong to those little minds that were forced to abandon their dreams and forfeit their lives to the mad schemes of the inhuman adults.

(WARNING: some images from Peshawar, Pakistan are GRAPHIC!)

And I wonder what if my dreams had also become ethereal springs of the soul hopelessly flailing through the winds of time. The only marks left were the bloodied footsteps. What would have happened?

I would not have gone on to become a physician. I would not have had the privilege of helping countless human beings, bringing comfort and health to them. Some of them would not have fathered or mothered children of their own. Some would not have gone on to become influential in society. Others would not have seen the smiles on their grandchildren.  Maybe the postman who continued to deliver the mail might not have saved an elderly man who fell in the street and who might not have survived or the teacher who sparked the imagination of the young one who would grow up to spawn a new industry. One never knows the consequential dominoes that fall from an erased image in a photograph. My own nuclear or extended family would not exist, if I would not have.

"The soul is healed by being with children."

Then, there is the massacre of 132 children that happened in Peshawar, Pakistan and all those diminished lives, wishes and dreams come to the fore, just as the Newtown, Connecticut tragedy brought the feelings of dread and foreboding when a deranged young man took the lives of 20 children. Both equal in magnitude in destruction of unrealized lives and of vaporized dreams. This shameless, cowardly act rekindled the feeling of hate for inhuman actions. Inhuman because that is what they are, under any guise or pretext. The word “hate” by any other name would not fulfill the emotion against such horror. What breed of man can descend to such reprehensible acts? What mind of man can contemplate such an atrocity and then go so far as to commit it? What verse in their religion can deem this an altruistic cause? None within humanity's dictionary.

These are our children!

Imagine, if you can, the horrific moments of this carnage. The wide eyed children rushing across the aisles in panic, jumping over others paralyzed with fear as the bullets sprayed away life. A child searching for his eyeglasses as the mayhem broke loose and an 11-year old apprehensive with confusion and fear, ducking under the seat as a bullet tore into him. The clamor and cacophony of life that still must resonate of this ghastly past within those bullet ridden walls and the blinding automatic fire-burst of death that echos in the minds of those who lived and then the turmoil of internal traumatic silence. This shakes the foundation of our being where every nucleus within every cell of the body shudders in pain. What makes a human devolve into such inhumanity?

A human being ceases to be one when they usurp the life of another, under the pretext of religion, wealth or existential differences. When one destroys the desires and dreams of another no amount of justification can soothe the pain. A human being without humanity is no different than a predatory animal without a higher brain function. Such function that thinks before it acts and then acts not for the benefit of man but to the detriment of mankind. But taking the lives of children? That is the abysmal poisoned well of inhumanity! These murderers must be a new kind of soulless, bottomless pits of psychopathy that deface humanity.  To what God do they pray? To what future do they ascribe?

For the sake of Our Children...!

GAMIFICATION OF MEDICAL EDUCATION

Sometime things take you by surprise. And like embers glowing steadily the logic and thought ignite the spark into a fire. That is exactly what happened when I read this article from the British Medical Journal about Gamification of Graduate Medical Education (1).

I thought well, this seems like a nice idea to enhance education. I read the article and came away with a different impression than was sought by the Authors. “We named our software Kaizen-Internal Medicine (Kaizen-IM). Kaizen, a Japanese word from the quality improvement literature, signifies the need for continuous daily advancement, a concept analogous to the principle of lifelong learning we seek to inculcate in our residents.” Whereas they sought to prove that a Kaizen-IM modelling technique helped ensure educational learning, reading through the article I came away with the tortured use of statistics to prove what they set out to prove. “Analyses focused on acceptance, use, determination of factors associated with loss of players (attrition) and retention of knowledge. Because traditional tests of normality such as the Kolmogorov–Smirnov test, the Anderson–Darling test and the Shapiro–Wilk test are subject to low power, particularly when the sample size is small, continuous outcome measures were graphically assessed for normality by investigating the distributional form of the outcomes using histograms. When normality assumptions were not met, the appropriate rank-based Wilcoxon test was used.”

But here is where it struck a chord and the tumbled notes all fell in a crash of dissonance. “We used the conceptual frameworks of user-centered design and situational relevance to achieve meaningful gamification, including connecting with users in multiple ways and aligning our ‘game’ with our residents’ backgrounds and interests in furthering their education.”

Now why would that bother my internals? Learning by rote in medicine is akin to getting ready for a Multiple Choice Q and A. Now hold on, you power-jockeys of the esteemed elite schools! Think about Medicine as a holistic mechanism for caring for the patient, not as a yes and no binary form of interaction. I need a new paragraph to start that thought, so hold on…

The sheet of paper in front of you has many inked marks on it as the proctor tells you “Start!” And away you go answering all the questions within the bounds of the allotted time. Some, you skip and some you hesitantly answer “C” as a hedge against the limited information in your brain. By the time you are done, the mental exhaustion is replete with multiple rivulets of sweat pouring down your back. You pass your answer sheet back to the examiner and with one last look back at it, you figure, Okay that’s done! Three months later you get a passing grade and you go celebrating till the wee hours of the morning. Loaded with congratulations, inebriated from the slaps on your back and feeling immune to the vicissitudes of mortal life. Ah yes, another conquered!

But then you enter the hospital and there lies a frail, weakened human body, a shadow of its formal self as you can see the skin has since loosened off and hanging on the bones with very little musculature support. “What the…?” your words escape between your teeth. The breath from this shadow comes in slow uneasy cadence, yes there is life but it is struggling to maintain its domain within his shell. There is an odor that you have never encountered before. It isn't obnoxious or anything, just a mousey, old cat litter type, wafting through your senses. His eyes open and the whites of the eyes are patchwork of miniature blood vessels and a hazy dull yellow background affixed onto an equally weak sallow complexion as deep pits on a desert floor. There are some spotty blood marks on his arms that lie above the clean white sheets of his recently made bed. His utterances are feeble and devoid of meaning when you ask him questions. He does nod in affirmance and shakes his head slowly in the negative. Suddenly overcome with the complexity of his person, you open his hospital chart and gaze through the lab reports and his diagnostic x-rays. Ah! You think, here it is, the answers to the riddle. This man has “such and such” and with “Mr. So and So, we will get to the bottom of this,” you stride out of the room as fast as you can only to find that the same tests had been done in this gentleman’s previous admission. Now what?

And there fellow journeyman, reader of these words, lies the problem with gamification of medical education. Our entirety of purpose is not in the hospital rooms, but in the confines of the computer glows where we search for meanings, not in the operating theaters but in the virtual operations conducted within the binary logic of a computer console, not with a patient-understanding the look and feel of a disease but in the memory bank tied to a CPU, where a differential diagnosis is within reach and Sutton’s Law is practiced for the ideals of human care to safeguard finance and limit the use of limited resources. When all you need to do is spend that extra moment in spending with the ones with the ill health and recognize through expediency of critical thinking what the problems are and which ones to fix now and those that can be fixed later. It would limit running through the myriads of differential diagnostics (that cost an arm and a leg and in many cases literally) and it would put the resources to better use.

So here we are stuck in the conundrum of do little to save the limited resources but use the tools that expand their use.

Time to rethink!

Time to reevaluate!

And maybe if we do, we will find the answer that is obvious and time-honored…Spend the time with the flesh not with the automated binary logic. Understand the human body and not the logic of a multiple choice. Draft a memory of experiences that will recognize disease and help patients rather than harming them with a “House MD” type approach of “biopsy the brain” when fifty other things yield negative results in a span of one hour.

And about that EMR, there is nothing meaningful about it, except more population-based algorithms!

No, medicine is and will be for the near future be practiced with an art due in part to the humanness of humans and in part to the connectivity between us humans. A discordant approach between the mind-body and clicks leads to de-coherence, which is futile in healing the sick!

1) http://pmj.bmj.com/content/early/2014/11/24/postgradmedj-2013-132486.long

AM I BIASED?

“The gentleman can see a question from all sides without bias. The small man is biased and can see a question only from one side.” - Confucius (c. 551 - c. 479 BC)

Am I biased?

Well, if I am honest with you and above all with myself, I would say, “Of course, absolutely, without a doubt, no if ands or buts about it, 100%!” (After all I do not want to be the small man – my bias there as well). You see, bias is our blind spot, a sort of a functional fixation and the curse of limited knowledge or transparency that remains a continual drag on the strivings of all human beings. This bias is enforced through parochial jargon, tortured reasoning and systematized metaconcepts of dubious integrity.

But if I am not honest about it, I would say, “Of course not. I am an expert!”

Seriously, think about this for a minute. Bias is a natural predilection to the plight of the human brain. It shimmers over every spoken word, caresses every thought with the prejudice of past experience and the phantasmagoria that is added on to that past; a bouillabaisse of ideas, thoughts and actions. The spry and tasty tart ultimately gets embalmed within the tea and toast-lost in translation.

Words that bump against the word bias include; prejudice, intent, inclination, tendency, bent, disposition, proclivity, predilection, slant, leaning, preference, bigotry and preconception. Just reading them one gets the message, loud and clear.

Take for instance the recent episode of “glibness” and  “I am sorry” from the MIT professor Jonathan Gruber, who admitted that he was prejudiced in his own statements that he made to the policy-makers. He used words that would be acceptable to the Congress to pass the healthcare legislation. He was not concerned about the American people, because they would not understand the complexity of the financial jargon within the document. Clearly Dr. Gruber’s bent was to influence. His preconception about the “stupidity” of the American population was an ideal tabula rasa upon which to imprint his masterpiece. His inclination towards the type of healthcare reform was in keeping with the official mind set, hence his slant was met with equal measure of prejudice within the beltway. Oh, I am not here to pass judgment, as it might seem to some, I am merely making a reference to the recent past events. This particular plaque of concern that reverberates within the chambers of my mind seems to stand out as a beacon of internal bias. “What was he thinking?” One might ask. The problem deeply imbedded in that “thinking” based on conjecture alone, would be the sweet, penetrating, sickly but fleeting taste of the praise from his audience.

Biases stem from reconstructed experiences. They are difficult to remove. For example, my bias to trust individuals implicitly was severely violated and thus trust comes to me with difficulty. The verification process takes time and is tedious and I am learning to employ it in full embrace.

Bias has many faces: optimistic, pessimistic, attribution, selection and a catalog full of them can be found in books, yet all seem to stem from a personal prejudice. Color bias is easy to see. Ask a child what color she likes (even in that statement, I am biased by using she, because as a society we are fighting the bias of the male dominated gender) and she will say, pink, red or blue. Ask an adult the same question and they will hesitate to answer (thinking about all the ramifications in this politically correct word not to offend others with different color likings). We might call this the “Compassionate bias.”

Optimistic bias is the mother lode of all biases in the human mind. We survive, because of our instincts to survive. Our optimism sees the future and dresses the present accordingly. There is perpetuity of hope over experience in most times, even to the detriment of the exposed reality. Tali Sharot a neuro biologist points out, 

“The capacity to envision the future relies partly on the hippocampus, a brain structure that is crucial to memory…directing our thoughts of the future toward the positive is a result of our frontal cortex's communicating with subcortical regions deep in our brain.” 

So, deep in the cognition factory of our brain, the neurons in our hippocampus faithfully encode the required information that is processed via the emotional amygdala and then rationed through the pre-frontal cortex (rostral anterior cingulate cortex). We are fed with information, we process it through the filters of our experience and the cognitive output matches our inherent bias, in other words.

Now here is a conundrum worth mentioning in full disclosure; my introspection of realizing there is a bias within me also predisposes me to think that there is a similar bias in everyone else. This meta-bias that permeates in the thinking process creates the dynamics of the “Prisoner’s Dilemma within the Game Theory.” In fact all contracts between entities are based on some form of internal bias.

Moving quietly to the scientific world, one finds an equal rudderless boat adrift in the ocean of bias. The boat is being pulled and pushed by the ebb and flow of currents divined by human thought. Interestingly in spite of the bias behind any experiment the rudderless boat continues to move and as it does, so does society as a whole changes. Our current love for all things internet is transferring a monstrous new 1,826 petabytes of digital jargon and creating 5 exabytes of new data daily (here ). That is an enormous amount of data/information. Manipulation of cherry-picked data analysis can offer a whole host of literary/financial/scientific rewards through monetization in the short term, even though in the long term these outputs are meaningless. But this world that has transformed itself from tomorrow to today to now, the future has become immaterial. Such short-term biases have brought the economies of many nations to their knees. The current account deficits and the rising national debt of $18 Trillion in the United States, is inconceivable to foster future growth and wealth. Meanwhile the spenders create charts and graphs and tables to persuade the laity about the rosy future and the savers worry and worry. The Keynesian door remains ajar and capital continues to flow… out.

 Medicine as one of the disciplines that deals strictly with human health is also filling the coffers of that digital realm with equal fervor. Alas most of the data is subject to bias. The professor/scientist/doctor wants to publish about his or her experiment. Everything is funneled through the loose sinews of statistics. If the experiment is not successful (fails) a positive spin describes the benefits. If the experiment is a success, it is raised to the highest bar of recognition. Less than half of the patients achieve similar results as are proffered in the glowing scientific literature. What gives?  Unfortunately when the rigor of caution and careful analysis is undertaken more than 54% of the scientific papers fail validation (under close scrutiny). Yet some still try to persist in their endeavor by claiming the value of the p-value as the determinant of all successes: 

“Here we adapt estimation methods from the genomics community to the problem of estimating the rate of false positives in the medical literature using reported P-values as the data. We then collect P-values from the abstracts of all 77,430 papers published in The Lancet, The Journal of the American Medical Association, The New England Journal of Medicine, The British Medical Journal, and The American Journal of Epidemiology between 2000 and 2010.” ---( here )

In a society that massages the numbers and clothes them in words, selects the perfect scenario, applies the arbitrary values and changes the necessary variables, the output from the digital interface will be anything but unpleasant; a boon for the doers and a bane for the followers. We are being governed by the bias of some to the detriment of the many in small and large ways. It is up to us to recognize and critically manage such misinformation overloaded biases.

“Our headstrong passions shut the door of our souls against God.´ - Confucius (c. 551 - c. 479 BC)

"ABIM has Lost its Way"

“ABIM has lost its way.”

-so said Charles Cutler, MD the former Board of Regents of the American College of Physicians.

Now you rarely come across such a glaring comment from someone who has been a shepherd in guiding medicine and medical care.

The monologue started and the ugly facts started to show up on the screen one by one and as time marched on, they got uglier. I will share some of those with you. Oh, before I forget, let me say this was at a debate between the aforementioned Charles Cutler, MD and Richard Baron, MD the President and CEO of ABIM (American Board of Internal Medicine), held by the Pennsylvania Medical Society on December 2, 2014 in Philadelphia. I was there.

Dr. Baron started his protagonist “Maintenance of Certification” (MOC) viewpoint by visiting the history of medicine and the importance of education, from circa 1600s to the present, trying to tie in the time-honored need for physician education. He mentioned that in the 1980s when it was voluntary almost no one engaged in the process. But then it obviously became involuntary/mandatory through fiat, coercion, forced hospital and insurance buy-in!

He then cited MOC “studies” that confirmed the need for the MOC-process as a means to improve physician knowledge; namely make physicians better doctors in improving patient care. His fifteen minutes were laced with a mix of “Here is history and thus the need and MOC is the perfect tool.”

http://youtu.be/1H8NOCcHpw4

Dr. Cutler the antagonist to Dr. Baron’s point of view, started by visiting the revenue stream of the ABIM.

As Dr. Baron watched as his hand slumped on his pad and his eyes gazed at the floor. A lot was going to be revealed, he worried. Dr. Cutler meanwhile quiet and charming always holding a genuine smile on his face,  showed evidence of the ABIM-largess derived from the onerous MOC and showed how it was being used to pay high salaries to the Board of Directors of the ABIM. Dr. Cutler cited extravagant spending by the ABIM (its Foundation) to purchase a $2.3 million town-home in Philadelphia and paid taxes on the town-home annually.

He showed that the Board had meetings that were held at the Four Seasons Hotel, a few blocks away from the ABIM headquarters in Philadelphia with a luxury Mercedes Benz limousine parked in front of the majestic entrance ready to cater to the travel needs of the guests.

 Dr. Cutler revealed the salary of the previous President Christine Cassel, MD and associated other incomes from various agencies totaling $1.2 million a year, much to the growing dismay of the slightly reddened persona of Dr. Baron.

Dr. Cutler also mentioned other non-MD members of the ABIM staff who worked as assistant to the President making salaries in excess of $600,000.

But the dagger in the heart was that there was no real evidentiary proof that the MOC process itself has changed patient care except through tortured articles from the conflicted ABIM authors who had published their articles in journals that, well, kind of are subservient and beholden to the ABIM.

The questions from the audience that followed were mostly directed at Richard Baron, MD the supporter and beneficiary of the MOC process. His answers were mere deflections, usually “rehearsed talking points” and little else. He alluded to the fact that the $2.3 Million Condominium was for sale if anyone was interested, to a muted chuckle from the crowd. But defended his salary by saying that the organization revenues are $60 million a year and to get someone of caliber to head such an enterprise requires high salaries as all such companies need to do, to attract good managers. Huh? ABIM is supposed to be a 501(c)(3) organization and composed mostly of volunteers. Yet in Dr. Baron’s mind the high salaries are justified. He also pointed out that medicine currently is under significant regulatory pressures and physicians are lashing out at ABIM as a consequence, a nuance only a well-oiled bureaucrat can express. On questions about the ABIM’s need for a secure certification examination relating to the need for closed exam instead of an open book examination, Dr. Baron cited the “psychometricians” as the determinants of the rule, stating that when viewed from the “psychometricians” point of view, there was no difference in the outcomes between “open” and “closed” examinations. Further on the topic of making examination questions available to those physicians who need to assess their personal failings, Dr. Baron pointed out that the questions were made by the “psychometricians” and that ABIM had invested 14% of its revenue to craft the questions “ because it is a very difficult process to ask the right question?” was the answer. But there was no response as to ABIM sharing such information. If you are wondering about psychometricians and what they know...

What is telling is that the MOC process requires physicians to lay bare their patient records to the ABIM and all other personal information including the number of patients being cared for by the physician, in the era of “transparency” and yet the ABIM itself is quite opaquely mum about their data, financial and otherwise. Sort of a one way street, like the Roach Motel! You spend your time completing MOC (that you should be spending with your patients) and your earned income to get this certification process and then forever (professionally) you are embroiled in the imbroglio that robs you of both on an ongoing annual basis. There are no such determinants of knowledge, capability etc. utilized for lawyers, engineers, manufacturers, technicians or any other profession that bar an individual from pursuing a living without a continuum of recertifications. (Restriction of trade comes to mind). Yet ABIM through its tentacles is attempting to make this MOC, Certification and Recertification process, from which they benefit greatly, a necessity and requirement for the physicians. Failing or not pursuing such an endeavor the physicians would find it difficult to practice medicine.

In the quest for elevating human understanding there are infinite large spaces between information and knowledge and between knowledge and understanding. Information is passing. The Certification examination is chock-full of information gathering that has little basis in the understanding that is required in the art of medical decision making. These gulfs that exist are the exploits that ABIM wishes to undertake, yet it succeeds only in arming the regulatory forces that demean the physician, it succeeds only in arming itself as the body of repute from which flow all recognition and laurels but without foundation and thus it fails in pushing the needle of understanding by even a whisker with all its undertakings. Patients are lost in the equation. Maybe there is a better way? Maybe there is a better pursuit? Maybe there is a better understanding among those that seek to improve it, but so far it is sorely lacking for want of serious intellectual desire.

Interestingly mentioned at the meeting was that 71% of the 780 patients surveyed by one practice had no idea about Board Certification. And equally a survey of 600+ Physicians of varying specialties revealed that 97% thought that the MOC process was a waste of time and resource with no benefit to patient care. There is p-value there somewhere that screams against the null.

Speaking of stats, the Distribution Curve with its two tails clearly focuses on the risks (left tail) and benefits (right tail) of every probability assignment. In the case of MOC sponsored by the ABIM the left tail is fatter than an otter and the right tail is slimmer than a nematode. Skewing doesn't change a thing. Neither does changing the information variable, because the understanding of the knowledge remains a virtue of experience, intuit and wisdom.

The Pennsylvania Medical Society is to be commended for bringing up the subject and presenting it to the rank and file members and visitors. The official video is referenced below.

 http://www.pamedsoc.org/MainMenuCategories/Education/MOC/Video-MOC-Debate.html

The frustration on the faces of physicians and bubbling up in every question asked, was palpable, but it did not seem to have any effect on the stony determined face of Richard Baron, MD President and CEO of ABIM.

I guess Dr. Cutler is right about ABIM having lost its way. The question then is, will the ABIM organization under the clutter of new found wealth, plush carpets, regal curtains, regency and gobs of money find its way back?

Only time will tell.

 “We have met the enemy and he is us!”