On DISTRACTIONS

“In the event you find yourself distracted, focus!” There is a certain hilarity in that statement, if one allows it to congeal in between the ears. If you are distracted, how do you know you are distracted, since distraction has got you trapped in its realm.

To illustrate that point let me tell you a real happenstance that occurred recently. On a clear day when the blue is all blue and not a spot of moisture hangs in the air, I decided to get three more Instrument Approaches under my belt to keep the currency in my proficiency, current. Tagged with a copilot, of many thousand hours in various Airforce jets and large aluminum bodied airlines, sitting beside me, I donned the “foggles” and off we went severing the surely bonds.

Immediately apparent to anyone inside the aircraft and probably those on the ground looking up, it was clear that I was a bit rusty. It took all of 10 minutes or more to clear those phugoid-oscillations that were human induced and had nothing to do with aircraft aerodynamics and forces of nature. The lesson was quite stark; the moment practice ceases, and the effort becomes an object of striving, it becomes subject to unhealthy distortions. Hence, constant practice makes imagination the object of cognition. Where one can foresee the immediate future to a related input, rather than constantly trying to catch up and overshoot.

As time would have it, the yaw-dampening finally and reluctantly happened and the non-turbulent air we were voluntarily bucking in became non-turbulent. My safety pilot let out a soft sigh, and I heard it loud and clear. No words needed to be said.

But that was not going to be the end of it. I had requested the ATC for a RNAV approach to Runway 31 into KACY and had been granted. Vectoring a long downwind over water was not my favorite thing especially at 2000 feet, but the controller had control. My safety pilot, probably seeing my struggle, suggested I use the Flight Director to make it easier on myself. Hmm…he must really think, I stink at this instrument thing, I thought. So, I pressed the FD button on the Garmin box and the Command bars dutifully popped up on the PFD. I protested a bit, protesting, that using FD is akin to cheating. But, I thought, why not since, the rust was defining itself in large patches. I surmised that flying the Flight Director, would make it easier on me and might impress him a bit. I figured the sharper sense of discomfort would quickly interweave with the bliss of past expertise and render my inadequacy moot. The sense of this relatedness was short-lived, however.

I had the Command Bar pegged to the FD and sailing along towards the final approach fix. I dutifully pulled the Manifold Pressure to 18 inches, RPM was at 2400 and the airspeed slowed to a comfortable soft drone. The aircraft steadily hurtled along the quiet path and I started feeling on top of my game again as the MFD peeled away the blue water behind and dragged in the green below us. Everything seemed whole again. My currency had aligned itself with proficiency. The final approach fix came, and I kept flying the Flight Director, enamored and comforted by the ease of automation. Another mile went by and I realized that I had failed to put the gear down at the final approach fix. Oops, so I did. I heard a distinct throat clearing cough from across the aisle. Damn, I thought this was a terrible exercise in progress. I needed to fix this quick. Mumbling my displeasure at my own actions, I resolved to do be more precise. That expanding idea. The resilient thought. The continuous play of motion in a 3-dimensional universe made all the more real the initial collapse of action. The desire to fix what had been broken ceased upon my nerves and now my multiple thousand hours melted away and I felt I was back in training. A certain drift of scent that emanates from failure hit me square in my nostrils and I realized that the Glide Slope Indicator had drifted down to the lower end in accordance with a required missed approach. Damn! Tracing across over the expansive countryside at race-car speeds without the object of arriving the destination in airline fashion was getting worse by the minute.

“It’s a Missed Approach!” I croaked.
“Yes,” is all my copilot said as I flew over the Runway at 1500 feet.
What happened? Is all I could think about. Common sense and Reason eventually unveiled causality, as they did.
First let me quarry the marble out of this flight and sculpt a Phoenix from it.

Distraction was the all-encompassing natural beast that had membered itself to my mental capacities. The suggestion of using the Flight Director when pushed by itself, will register stability in the Pitch and Roll mode only for the current flight path according to Garmin. If I had pushed other buttons as I should have done when flying the Auto-Pilot, namely the Approach mode button, then the FD would have taken me through the vertical descent as well. Automation has it’s, “If This Then That” moments and linearity of thought and action is what the black boxes seek from the pilot in conducting their affairs. None were apparent here, cobbled together in a ball of a single fixated distraction.

Total dependence on automation without careful monitoring-with-expectation is like tranquilizing oneself with certitudes of hope. Imagination as Cognition means to look at the forecast future from any action undertaken. A cluttered mind fails to register intentions akin to throwing pebbles in a stormy sea. Distractions clutter the mind and simple but necessary actions go unheeded.

Looking at Accidents and Incidents related to Approach and Landing Distractions;
1. 72% are acts of Omission,
2. 63% acts of crew lack of coordination
3. 52% from situational awareness and
4. 45% slow reaction.

All of these were in force at that RNAV approach I detailed above. All of them!
And Factors related to such events are:
1. Communications in 50-68%,
2. Head down activity 22% and
3. Response to anticipated Activity or situation 14-19%.

Again, all these factors were also at play in the above scenario. My total abdication of authority to the use of the FD without the anticipated need for additional inputs caused the Missed Approach.


How could it have been better?
1. Sterile Cockpit technique and not heeding to the use of FD during the vectoring phase without briefing myself.
2. Using a Checklist for the type of Approach.
3. Monitoring and scanning all data rather than fixation only on the FD.

Number 3 is of importance since our brains function to the laws of Recency. We are asked to repeat instructions to the ATC for the sole reason, a) we heard the correct instructions and b) we remember to input the instructions correctly in the black boxes. The short-term memory lasts in the short-term memory banks for 15-18 seconds. Repeating the instructions fortify them for a bit longer. Otherwise we resort to “Say again.” In this case the suggestion to use the Flight Director at the “last minute,” was the culprit that brought the entire universe of thoughtful actions to a halt.

We must remember that the human mind is filled with disquieting gaps of the daily life that fill in constant distractions. Achieving the purpose at hand requires clarity of mind and Focus. To keep distractions at bay: Securing a sterile cockpit and using Checklists brings back the required focus.

To illustrate the dangers of said distractions, here are a few facts and real-life examples:

1. A study found that children using cell phones are 43 percent more likely to be hit by a vehicle while crossing the street than children who are not using cell phones.

2. A 25 percent increase in pedestrian injuries among 16- to 19-year-olds over the last few years is being attributed to the increase in cell phone use.

3. Statistics show that texting and driving is three to four times more dangerous than operating under the influence of alcohol or drugs.

4. Two Northwest ­Airlines pilots who flew 150 miles past their destination at Minneapolis while going over schedules using their laptop computers.

5. Teterboro tower controller at a Piper’s departure was “engaged in a bantering personal phone call about a dead cat while directing traffic.” a phone conversation was implicated in the Hudson midair collision between a tour helicopter and a Piper Lance that killed nine people.

A few thoughts to keep in mind:
1. Conversation is a powerful distracter…keep it to a minimum
2. “Head-down tasks” during flying are distracting, especially in IFR conditions and disorienting.
3. Defer all Non-Critical activities.
4. Consider any Interruption as a “Red Flag.”

A SLOW WALK INTO OBSCURITY

 

Of all the temperate reasons for conformity, there is a methodological play at play here. It is slow. It is deliberate. And it started a long time ago. Where that was, exists in some obscure nebula of thought in the mind of in an idealized world human. Perhaps even a physician. But it happened and slowly morphed into a spectacle that one day will reap rewards for its inventor, who will not be alive to see it. These movements when putt in motion take time to evolve and evolving they are

What of this thought? It must have started with the hope of universal love or some sort of a utopian landscape, which only the fecund idle minds can dream of at any given hour. Perhaps it was envy, or perhaps it was desired. Either of those intents would bring us to where we are today. 

To start at the beginning of this modern age, medical care in the United States started to become a big business because the world war two population saw the infirmed limp back onto the shores with grim tales of bombs and bullets. The Baby Boomers, offspring of the “Greatest Generation” growing up with more than their parents ever had and having worked less for it, seemed bitten by the love of everything and anything in excess. Excess, as anyone with a little sense would know leads to some bad pathways in health and life. Needless to say, health became the overwhelming issue of our times.

Those times called for some restraint in out of pocket costs for such excesses. And the Insurance companies took notice of the need to step in. What once was pay as you go and collect from the Insurance later, slowly morphed into Physicians “Accepting Assignments,” to get paid directly by the Insurance Company rather than be beholden to the unreliable insured.

The Insurance companies having immersed directly between the Physician and the Patient and opened their pocketbooks to the demands of the physicians saw an opportunity for command and control. The Top-Line and the Bottom-Line for them, however, had to be controlled. A trial with Health Maintenance Organizations (HMO) seemed not to control their costs. Neither did the PPOs.

The next step in this game of chicken came naturally. The Insurance Companies started adding physicians to their “Networks.” The larger the network, the larger the patient catchment area. It seemed to be a match made in heaven for both the Insurance companies and the physicians. 

But little did the physicians and patients realize by doing so, they were falling into the distilled trap of command and control and the levers of operations were at the hands of the bureaucrats. The Patients were no longer able to go the physicians of their choice and the physicians would have to refuse to see patients out of network and in most cases not get paid by the patient’s insurer. The Medical Revenue Cycle had begun and delays in payments to the physicians further increasing their frustrations became the norm of the day. READ

https://jedismedicine.blogspot.com/2013/09/the-medical-revenue-cycle.html?spref=tw

The screw turned and the momentum was unceasing in its force. Meanwhile, the population of the United States grew from 260 million to 340 million over a short span of a few decades as the insurers gathered a larger and larger share of patients in their network. That wasn’t enough though. The Insurers had to get the Hospitals to get in on the act as well. Now not only could you not see the physician of your choice but also you could not go to the hospital of your choice. If you did you were penalized with a higher Co-Pay. Meanwhile, the Market Caps of the Medical Insurers increased geometrically and the more the Revenue grew the larger their lobbying efforts grew. The Health Care market kept upping its ante on the GDP blowing through 15% to 19.7% of the United States GDP in a whiz-bang decade. If you saw the Bureau of Labor Statistics graph related to the rise of healthcare costs and the increase of the administrators, you would come away with the only conclusion that the graph offers.

Out came the fingers, pointing at the doctors. Accusations of greed and blame were aimed at physicians for the rising cost of healthcare. They were accused of ordering unnecessary tests and doing unnecessary surgery. Not only did President Obama state at a press conference: “The doctor may look at the reimbursement system and say to himself, ‘You know what? I make a lot more money if I take this kid’s tonsils out” – doctors faced fines, penalties, and even imprisonment. READ

https://www.wsj.com/articles/SB10001424052970204886304574308472181248330

And the dutiful minions including some Senators started publishing opinions in various newspapers and magazines about this or that doctor's greed and how it was hurting the patients. Admittedly there are a few bad actors in the system, but not everyone is bad. Nary a day goes by when Breaking News is in short supply that an article or mention on television does not visit the healthcare costs and associated physician greed. The constant churn is to burn the derogatory image into the public mind.

The regulatory capture of health care needed, another step to garner better control of the healthcare costs, was required. A be-speckled Judith Faulkner walked in as the benefactor supplying the Electronic Medical Records via the system EPIC. She was a major donor to the then President Obama’s campaign and won the lucrative venture making her a multi-billionaire. Her codes were proprietary hence none of the information could be shared between hospitals and physicians except with the government. The fix was in. - READ

https://www.lubbockonline.com/article/20130525/OPINION/305259922

Physicians had to be controlled. The Insurers were only too happy to comply. Thus, the force of denial of payments and preauthorization for procedures rapidly became an art form. Any expensive diagnostic procedure was subject to scrutiny and denial and any expensive procedure was subject to the same. There were no “sacred cows” of good healthcare. Everything the doctors did was subject to suspicion. The physician compensation based on the “Doctor Data Dump” by CMS (Centers for Medicare and Medicaid Services” in 2017 revealed that only 7% of the $1 Trillion spent in healthcare by CMS was physician’s compensation which included “Fixed and Variable Costs of the physician offices.” The rest of the 93% was for Hospital, Pharmaceutical, Device, and Administration. The Administrative costs were close to 38%. But the eye of the toothy tiger was on the physicians, not where the largesse was being distributed. -  READ

https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Physician-and-Other-Supplier

As the population grew, the Medical Schools graduates' growth stagnated. Thus, was started a hue and cry about the coming, “Doctor Shortage.” Newspapers headlined Armageddon in health care. Meanwhile, the physicians burdened by the daily imposed mandates and reduced “reimbursements” from insurers and associated denials could not keep their offices open. The time was ripe for the Hospitals to acquire these practices and their “built-in” patient load. The hospitals offered initial incentives and then turned the screw on the physicians by hanging the sword of Damocles over their heads, “If this then that!” Or simply put, “if you don’t add this to the diagnostics and add that to the procedure, you will face the pink slip.” The dye was cast. Physicians had become the tools for the Hospitals to extract the largest amount from the Insurers and were now bereft of their own reasonings.

As artful as these puppeteers are, the long game was their mainstay. Another industry mushroomed: The Nurse Practitioner and the Physician Assistant industry! The growth of the 18-month thinly educated NPs and PAs grew at an astronomical rate. While the graduating medical students climbed out of the medical school with $200,000-$300,000 debt, the “others” came out with almost nothing. Almost to a “T” the experts started calling the Physicians, “Providers.” The logic was inescapable, call the MDs, Pas, NPs, RNFAs “providers” and you create parity and equality in everything; from education to reimbursement. - READ

https://www.bls.gov/ooh/healthcare/nurse-anesthetists-nurse-midwives-and-nurse-practitioners.htm

First the experts allowed the NPs and PAs to do any procedures under the direct supervision of the physicians placing the onus of litigation burden on the physician while everyone else pretty much skated for free. But the NPs and PAs now emboldened with the desire of using the scalpel and the stethoscope but with a limited 1800 hour of knowledge started the push from State to State that they were capable of performing to the same level of expertise as physicians, therefore, they need not be supervised. Many state legislatures having limited information or knowledge wholeheartedly agreed so as to appear sympathetic to the “Needs of the Vulnerable Patients.” The game was afoot. the 1800 hours were being equated to the 20,000 hours of medical school, Internship, Residency, and Fellowship of the physician.

The techies, not to be undersold came up with the idea of “Telemedicine.” The ‘No-Touch” medicine was in full force. Any “Health Care Professional Provider” so desirous was eligible to sit in front of the computer camera and make diagnoses and suggest management with less than half the information needed by doing the age-old, “History and Physical Examination.”  - READ

https://www.healthleadersmedia.com/innovation/4-ways-telemedicine-changing-healthcare

Meanwhile, large corporations added their fuel to the inferno with walk-in clinics manned with Nurses, NPs and Pas to “Practice Medicine” under the umbrella of Pharmacies as in Walgreen, CVS, Walmart, Rite Aid, etc. A 24/7 clinic was available 365 days a year in these facilities. Staying ahead of the crowd, soon newspapers and magazines started touting the “better care” afforded by these “walk-in clinics’ as compared to the crowded doctor’s offices.  -READ

https://www.walgreens.com/pharmacy/schedule-appointment.jsp?frm=clinic#/location

Notwithstanding Telemedicine, the idea of Artificial Intelligence was soon co-opted as the next greatest thing since sliced bread. AI, they said was equal or better than the Physician reading the X-rays, CT scans, and MRIs. Articles jammed the Journals and new Journals had to be created to carry the motherlode of information touting the benefits of coders versus the human. The coding experts and their partners regaled the virtues of AI and that it would displace the Radiologists and soon the Doctor. Marching into the field in lockstep currently, are the Social Media Giants with oodles of money and deep-pocket lobbyists to make a grab for the $3.65 Trillion a year tax-payer expensed in healthcare. - READ

https://www.aamc.org/news-insights/will-artificial-intelligence-replace-doctors

In the end, it boils down to, a little more than “More Earnings” whether by buy-backs or tax-payer funds equals higher Earnings-per-Share (EPS) equals Higher Stock Price equals larger Salaries and Bonuses for the CEOs and their “managers.”

So, what is to become of this downward spiral in healthcare, where quality is being measured by unreliable metrics (the metric-makers are the insiders with a semester of statistics in their background) just to tout a certain profit line?

After all is said, the age-old Direct Patient Care by a physician without any intermediary Insurer to decipher and decide is what should be considered "the appropriateness of care." It seems the best and harkens back to the days when medical care was between the Patient and the Physician. -READ  https://www.statnews.com/2018/09/06/direct-primary-care-doctors-patients/

The patients are getting squeezed in all of this. Suboptimal care because of Insurer/hospital/ governmental expert pressures. Everyone, it seems has an ax to grind in the scheme of things and further it seems the forgotten in all this...is the Patient.

In Direct Care, unhappy patients leave the physician and go elsewhere as in the free-market in the business world, and not be in permanent servitude. The Health Savings Account is a simple mechanism for the patient to pay the doctor bills that are marked down by 70-80% compared to the Insurer prices. Negotiated prices individually by the patients with their physicians further reduces the cost of care. Instead of $14,500 on average Premium for a Family of 4 and a Deductible of $6,500 and a Co-Pay of $50-100 per visit, where the patient does not realize a single penny from the Insurer until he/she had divested a royal sum of $21,000 annually. For that much money, one can pay for catastrophic insurance that actually helps in dire circumstances requiring hospitalization and other expensive care for cancer etc. and the rest can be used for non-threatening illnesses. 

Quite a simple concept really, that the Insurers now fully vested and seeing the large ROIs will never allow to blossom, unless the public says, “'I'm as mad as hell, and I'm not going to take this anymore!”

It’s a slow walk into obscurity or a rise to reason. The choice is ours.