THE WORDS

What is the intent?

What do they say?

Why the force

Why the fray?

Whom do they fear

Why do they scare?


Some churn

Others burn

Some play

Others slay

Sharpened edges

Blunted.


In metaphors

Hide, the flourish

In adjectives, intent.

Magnificent splendor

Wide open vistas

Wretched topography

Stakes in the ground, all bent.


Like calculus in a pebble

Strewn across

A muddy bottom

Holding memories

Deaf and mute

For another

To recreate, new vision.


Words indeed

Impeccably said

Artfully fashioned

Carefully articulated

Speak volumes

Of something,

Of nothing,

Of anything.


They speak

Of love

And togetherness

Of hate

And separation

Of deceit

And loss

Of innocence.

The force

Of a vowel

Changes the intent;

But the yielding quiet

Mutes any defense.


The eagle soars

Held down by a string

Widening the gyre

Till felled from exhaustion.

Anger spent.


That vainglorious beast

Perpetuating myths

of Indescribable events

Imagined briefly

To Ego's bent.


Yet all is waste

All for self

T'ill self is no more

Wasted time

Time Spent.

Washed away, listless

Second sweeps the face

Words injure

Mortality endures

Emotions inured

Life ends.

Time moves

Cycle begins

Hollowed thoughts

Words spent

Same intent.

LIVES IN THE BALANCE

Clearly we are advancing human thought, most people would say. They would also extoll the virtues of love and feeling in the same paragraph if not as dangling participles. These are the many who add split infinitives just to (really) get into our minds. Metrics they claim are the virtue beyond all virtues. As if value has the same meaning as price. It is extolled in Yasmina Reza’s “Art” when a newly crowned wealthy man seeks eloquence through his acquisitions; a white canvas. The humor aside, it is telling about acquisitions; When “Scream” bids out as a mega-million winning lottery. The sham continues. Faces change but the human constance remains.

We ascribe relevance through irrelevance, as in value for price and intellect for wealth, although in the latter case it is certainly possible. Let us look at simpler model of understanding.

Education.

How do we test a person’s education status?

By the number of degrees he or she holds. The higher the education, the more intellect is perceived. The MD, PhD degrees hold a lot of gravitas or used to in the past. Today degrees are as easy as buying a piece of paper, since “No (one) can be left behind.”

And that brings us to how do we test?

There are expert “test takers” in our midst. Some have gone through the steep ladder of degree acquisitions by knowing and learning the art of passing tests. In fact schools teach the art of test passing and higher scores just so they can get grants from the Feds. Teachers teach the answers to the questions and student learn by rote of things they have absolutely no understanding. Test Prep schools compress the phenomenon even further to “enrich” the student’s mind with jargon filled answers that he or she will regurgitate when the doors are closed, the bell rings and the multiple choice questions are placed in front of her. “Yes, I know the answer to that, its “C!” By golly what a smart lass!

I remember a very smart test taker with degrees filling his pockets threatening to tear a hole in them. He was considered smart, very smart, actually intelligent or shall we say, brilliant. Ask him any question and he would answer, what are my choices? Given the “knowledge” he had acquired, one day he was faced with covering the Intensive Care Unit overnight without a backup resident. It was him and a slew of midnight nurses. Fortunately one of those nurses had years of practical experience. Lo and behold as midnight struck and the bells started clamoring, blood pressures started falling, oxygen levels bottomed, pulse-rates skyrocketed, sodium levels tanked and Potassium levels jumped, his eyes glazed over, muscles became flaccid and a strange thing happened. The resident was found wearing fear in the corner of the room without his booties, shaking from head to toe, fearful of  making any decision. The alert nurse calmed down the nerves of this poor bloke and slowly and steadily she helped with the answers to the horror that faced the clock’s hour face. The resident slept for the last two hours before sunrise in the corner in the Intensive Care with his head in his hands, buried behind his eyeballs in dreams of something or somewhere.

The trauma might have been excessive for him that night, because he resigned his staff position and went home to daddy and mommy. two years later he was working as a in-house Medical Director for a medical firm, barking orders about this and that.

Just as I said earlier, there is a gulf between “value” and “price,” there is difference between “test taking” and experiencing reality. Schools and teachers nowadays prepare little students and adult ones to “pass” a given test for selfish reasons; funding, advancement and tenure. Little students don’t know any better. So they learn what comes their way. The growing neural density, thirsty for information sponges nonsense as knowledge and a future of mediocrity is born.

This nonsense continues even at high levels of “education.” The certification process for physicians through the ABIM is a good case in point. I remember being at a conference in New York at a fancy hotel, where a fairly large room had been set up for breakfast before the educational seminar began. Sitting besides a luminary physician who held a significant power among physician intellectuals. The topic of re-certification came up and I heard him bemoan the fact that he was taking the re-certification exam a third time in three years. “The questions are so esoteric and stupid and have nothing to do with my specialty,” he exclaimed to nodding heads. And when you dig deep (as the saying goes) it is all about raising the "revenues" and the "net asset value."

There are lives in the balance all around us. Every action we take has some ripple effect. Physicians have this burden to bear, the hardest. The practical knowledge of experiential reference and learning daily on the job makes for a wealth of understanding, yet it is being discounted in favor of top-down guidelines based on population medicine.

it is worth remembering that all knowledge is not wisdom, only the applied version need apply there. Just as a child who understands the meaning of the word “lift” and “drag” will become a safer aviator. A child who understands resistance works to reduce it will work it out to deliver more electrical power at the business end of the wire, a physician who understands anatomy and physiology is better able to fix a pathology.

So you see dear reader, the current philosophies of Common Core, test taking principles, guidelines and mandates do not enrich the soul as real “actionable” (I use this word sparingly for fear of retribution) understanding. We must learn to unlearn the idiocy that has been mushed into our spongy brains. We must relearn the basics of understanding. And in the end…

The future will be brighter for all of us. For our children and their children. Lets all vow to stop the tyranny on the children’s and that of the physician’s mind!

IN SEARCH OF H1

Humans are constantly in search of meaning. “What is the meaning of this?” is a common refrain from an adult to a child while “what is the meaning of life,” is a common refrain in the mind of an adult. Somewhere in the what are you doing to what am I doing is our existence. We are constantly moved to making complex theorems while roaming in our mathematical world and are equally fixated with numbers when dealing with complex data. The long standing dilemma still remains much as we would like to shelter our eyes from it bright light, “Why do we exist?” On the other side the statisticians are constantly tweaking their assumptions to make bold predictions.

The world changes with every bit and byte of the unknown.

In 1965 the Medical world changed when Medicare “The Safety Net” for the elderly came into being. Soon thereafter physicians noting that accepting assignment and being paid directly from the Centers for Medicare and Medicaid (CMS) reduced the payment losses. It was the win-win zeitgeist of the era. Soon the aging populace, diagnostic workups and expensive therapies ballooned the projected expenditure for healthcare. With no skin in the game both the patient and the physician became secondary in the scheme of things. The patient wanted everything done (and lawyers made sure they held the doctors to that arbitrariness), the physician complied as the RBRVS rolled in, and both sides enjoyed the benefits. Soon electronics plowed into the mix and coding illness became the essence of care. Hospitals under the DRG realized coding ICD and CPT was a boon for their bottom-lines. The more the numbers of illness coded under each admission the better the payment. Specialty coding industries took seed and blossomed overnight. Experts pouring over the charts, crafting mechanisms to increase reimbursement per length of stay. In fact the lower the length of stay and the more coded maladies the better the scheme worked for the hospitals as well to garner a higher payment.

Realizing the increased outflow of the taxpayer money, the government set out to code the very patient-physician encounter adding “time” for each encounter and “eye-to-eye” contact as a means for payment mechanism. Failing this mechanism the concept of Electronic Medical Records came into being to capture the encounter in “meaningful” ways. The government initially paid 40 cents on every $1 spent by the physician for “going electronic.” This little venture cost the taxpayers close to $60 Billion and untold billions to the physicians and hospitals. Net result was that a few companies like Epic and Cerner with close ties to the government capital got wealthy overnight while silos of information grew without any interoperability between the many available systems. The physicians were now governed by the coding they did, the patient progress note now blossomed into several pages from the original intent of the SOAP as they copied and pasted with little meaning and by the amount of reimbursement that they might receive.

Meanwhile the patients continued to suffer as their physicians were forced into clerical work rather than clinical work. Disappointment and depression set in, in the medical community and physician suicides increased exponentially. The “abuse” of physicians through regulatory fiat dampened the core spirit of the physicians as larger and larger numbers left the physician workforce and a 125,000 physician deficit currently looms by the year 2025. Not to worry though there is a new body of online certified NPs and PAs to handle the excess load.

On the flip side of the healthcare clinical sector was the diagnostic and therapeutic industry under the influence of large publicly traded companies. The former built clinic centers near large densely populated areas to service the diagnostic needs and the latter produced an immense number of studies to prove their minimal incremental new pill was “significantly” better than the last one.

The null Hypothesis (H0 ) was under attack by the armies of statisticians hired by the diagnostic and pharmaceutical industries. H0 seemed not to have any backbone anymore. Any and most every study based on a few “Ns” seemed to defy H0. Nothing, it seemed was better than the new shiny box of pills.

Definition of Null Hypothesis: A type of hypothesis used in statistics that proposes that no statistical significance exists in a set of given observations. The null hypothesis attempts to show that no variation exists between variables, or that a single variable is no different than zero.

Suddenly all the attempted studies became insanely positive. Everything tested against the past, current therapy or a sugar pill was better. The pharmaceutical industry pressed new measurement buttons. The previously targeted Partial Response that advocated a 50% reduction in size of a malignancy as a consequence of therapeutic success, the experts in the industry now were comfortable with a 30% threshold. And the same experts who were content with Overall Survival that determined benefit of treatment X over treatment Y now were happy with the poor man substitute of Performance Free Survival (PFS). The measuring spoon size had shrunk. 

Everyone with a little bit of statistical knowledge jumped into the game. Another industry blossomed overnight. medical experts now abrogated their responsibility about discerning treatment benefits on patient using artificial assumptions to make things right in their “technical papers.” Many a professor’s tenure was made and many experts earned positions in prestigious universities all trying to outdo each other in the search of something called “significance;” The game of finding H1.

The statistical beast H1 had been unmoored, ripping its tightly bound chains and was roaming free in the wild. It tore through the countryside. It ravaged the poor vulnerable populace in its greed. The study of Epidemiology was bastardized and the p-value brought forth significance to everything that had none and meaning, where none existed. Logic it seemed had failed its own set of rules.

The world was spinning at a faster speed getting closer and closer to the Seneca Cliff, as Yeats’ words have come alive with force:

Turning and turning in the widening gyre   

The falcon cannot hear the falconer;

Things fall apart; the centre cannot hold;

Mere anarchy is loosed upon the world,

The blood-dimmed tide is loosed, and everywhere   

The ceremony of innocence is drowned;

The best lack all conviction, while the worst   

Are full of passionate intensity.

The ROMANTIC AGE of MEANINGs

We search for meaning...

In rocks and stones

In waterfalls,

In trees and bushes

With their birds n bees.

In images

Of lightening and rain

And through paintings

Of age old disease.

In war and peace

In anger and death

Through poetry and prose

In the grain of sand.

Peering beneath

In the atom of the cell

To find meaning

In Life itself!