HUMANITY

"Love and compassion are necessities not luxuries. Without them humanity cannot survive." -Dalai Lama

It happened the other day at a U.S. International Airport. A man in his flight suit hurrying toward the gate tripped and fell face forward. His Airline cap tumbled a few feet away ahead of him but the rest of him stayed perfectly put together. If you didn't know, you might think he was lying quietly face down. But in a busy airport where there are hundreds of travelers rushing to get somewhere this was not the scene for a quiet slumber.

Most travelers looked as they hurried past and then glanced back for a second look without slowing their pace. A woman hurried past the seeing and avoiding crowd, rushed to the scene  and knelt before the gentleman  to ascertain his physiological functions. Was he breathing?  Does he have a pulse? Is he alive? Did he break a bone? Did he have a seizure?  She could not tell. The pulse was feeble, the breath barely audible. She put her hand on his chest and was immediately reprimanded,

“Move away Ma’am!” A stern voice of authority called out.

“But I am just trying to help. I am a nurse.” She pleaded.

 “No Ma’am you can’t do that.”

“He might be having a heart attack?” She cried desperately trying to help a fellow human being.

“No Ma’am, I wouldn't touch him, if I were you. It might be considered inappropriate.”

“But…!” She flailed her arms as the police man followed by a female associate pulled her off the floor and gently pushed her away. The wall around the “fallen” was now complete, stern faces on top of six-foot frames were stern and still. The nurse looked bewildered. She was trying to be a Good Samaritan, a human with humanity. And the Police were doing their duty.  Somewhere there was a clarion call of the legal eagles: Do not touch. Let the experts take care of the situation rather than face a lawsuit allowing a nurse to take care of the airline captain.

20 minutes to the dot, the wailing siren of the ambulance arrived and the EMT personnel expeditiously transferred the gentleman into the ambulance and with them, the sirens receded into the background.

What happened to the airline pilot is a mystery.

Imagine what has become of us as a people?

Imagine what this regulatory and legal compliance has wrought on us as humans?

Where has the compassion, the human to human connection gone?

A plague has fallen on the house that George (Washington) built!

Let us clean up this mess together!

"My humanity is bound up in yours. For we can only be human together." -Desmond Tutu

OVER/EARLY-DIAGNOSIS

Currently there is an intriguing concept in medicine, especially in oncology, which suggests that physicians have a tendency to over-diagnose. The argument goes that because of the amplified diagnostic abilities we as physicians are able to make diagnosis of a disease such as cancer earlier. And that is projected to be bad thing? A correlated argument forced as causality states that over-utilization of the diagnostic capabilities leads to “harm.”  What would be considered a laudable form of care provided to the patient in terms of early diagnosis, intervention and potential cure from the malady (cancer in this case), the experts go to extreme length, to define that as harm (1).  This “over-diagnosis” in their minds is the same as early diagnosis and therefore by using their statistical correlates it is considered a travesty. Usually the authors of these articles are policy-wonks or involved in policy making. They cite psychological harm as well as physical harm behind the reasoning for their premise. The “psychological” harm is a subjective methodology steeped in questions whose answers are created to evoke emotions. The physical harm cited however is real and are the complications related to the surgical procedure, which unfortunately is the unintended consequence of any surgical intervention.

The question arises whether we as oncologists think that Early diagnosis is the same as Over diagnosis?

The consequence of such a thought process if followed through brings us to the conclusion that we should wait till potential cancer related symptoms become apparent and then intervene, even though as the saying goes, “The cat is out of the bag.” Is that ethical reasoning? What is even more puzzling is the use of lead-time-bias that is being used to further the argument that if intervention is done early and survival is shown to increase that is nothing more than the biology of a slow growing tumor and that the lead time in diagnosis gave the false representation of increased survival. This purported argument has been very strong in the field of uro-oncology especially with the use of the PSA screening methodology. The problem that arises here is that we are nowhere close to determining the aggressiveness of the cancer except by obtaining multiple biopsies and evaluating the Gleason’s score. Arriving at this juncture then, the argument suggests that “Watchful waiting’ would be a good measure rather than subjecting patients to a radical surgical prostatectomy or a brachytherapy +/- external beam radiation therapy as a curative intent. Yet recent studies have shown that upfront intervention saves lives over the “Watchful waiting!” (2)

Given the controversy that surrounds prostate cancer, is watchful waiting the right approach in oncology care for a patient with prostate cancer?

The current data-driven analytical mind-set of correlations assumed as causations is behind a lot of these illogical thought processes and is borne of the meaningful use objectives. Unfortunately some of these data analytics give enormous weight to the cost factor in their analysis and tend to forget the individual patient. Scientific literature is replete with such cost-to-care articles especially since the global economic downturn of 2000. A more reasoned approach would be to use hard empiricism borne of a well thought out hypothesis and validated through repeatability before using the power of media blitz.

The Jeremy Bentham utilitarian concept, through the eyes of the epidemiologists has created a tall mountain to climb for the individual with cancer. The defining art of oncology care remains that each patient is an individual who has specific needs and comes with his or her set of co-morbidities that confound the unified pluralistic ideology driven motive of “one size fits all.”

Kant’s “Reason” then must be applied to the medical care we deliver to each individual patient rather than the broad brush strokes of the multitudes that have been sampled into the Bell curve and bounded confines of the 95% Confidence Intervals to yield the biased p-value paradigm of the “truth.”

There is a fine line between menace and utility. Where upon we as physicians must decide how to shape the destiny of oncological care. Soon there will be algorithms that will drive medical care and through the rigors of data crunching a holographic representation of a “healthcare provider” will render the physician moot. When that day comes, let us hope not too soon, age and cost hopefully do not drive utility and need to become the technological menace for humanity.

1.       http://www.kevinmd.com/blog/2013/12/overdiagnosis-health-services-harm.html

2.       http://www.boston.com/lifestyle/health/blogs/daily-dose/2014/03/05/study-fuels-debate-surgery-watchful-waiting-for-early-prostate-cancer/B6lvBw0mkEjzNC1GEv6Z3J/blog.html

2a.  Radical Prostatectomy or Watchful Waiting in Early Prostate Cancer — NEJM http://nej.md/1jWzJ02

Immunological Dreams at #ASCO14

Two things caught my attention: 1) The 5-year survival rate of all cancers has improved from 49% to 68% in the past two decades with more than 19 million cancer survivors expected by 2024 and the knowledge of how to manipulate the immune system against the dreaded disease. We will discuss the latter further.

The hallmark of scientific work seems to have been in the realm of Immunosurveillance and cancer. The thrust of the argument for better control of the malignant tragedy is based on the Adaptive Immunity against cancer.

The knowledge that there are lymphocytic infiltrates found within the cancer milieu is well known for decades. It was realized some 30 years ago in the colorectal cancer domain that those patients who had lymphocytic infiltrates in their cancers did better with stage, disease progression and overall survival. Now with the journey of these lymphocytic infiltrates laid out, actionable sites have become visible for the probing and assault against this deadly scourge.

The adaptive Immunity to be effective has to have two components of T-lymphocytes: The T Helper cells (Th1) and the Cytotoxic T-Cells (CTL). The CTL upon stimulation secrete TNF-α and Interferon-ϒ, both of which have limited immunity. The Regulatory cells are the T-regs that oppose the inflammatory signals via TGF-β and Interleukin to suppress the CTL from further activity in order to limit immune activity and tissue destruction. A balance therefore exists between the T-regs and the Th-cells.

The universal knowledge states that Immunity is based on the “Self” and the “Non-Self.” The T-Cells are programmed to recognize and destroy any foreign invaders. However as a means of checks and balances there is a proviso that allows for some self-control to prevent an all-out attack against the “self” should the invaders be contained. This mechanism is available via control-points also called appropriately “Check-Points.” 

The express function of modern-day immune manipulation against cancer is to unbalance the inhibitory signals to the checkpoints to allow for a full-throated attack against the wayward cancer cells. Meanwhile, not to be outdone, the cancer cells have tricks up their sleeves too and try to fool the Immune T-Cells with their vile secretory expressions of TGF- β and Interleukins along with other co-stimulatory cytokines like CD28, CD137 and OX40 to force the immune cells to lay down their arms in quietude. This fight is worth a few more words.

As the cancer cell invades tissues, it is also invaded by these immune cells. The Immune cells have to recognize the cancer cell surface antigens (Major HistoCompatibility Loci) and then” express their outrage” via their secretory products to limit growth of these invaders. Three mechanistic offenses are launched against the cancer cells:

Retaliation 1: The recruitment of the Th1 and CTLs to gear for a limited response. This is followed by an assessment of the damage against the enemy. If the immunity is weak this is the last signal and the cancer enjoys free reign without any further intervention. In this scenario, for example, therapeutic intervention with Herceptin and Chemotherapy are the mainstay of therapy in breast cancer.

Retaliation 2: In this format, the initial response is followed by ancillary assault via the co-stimulatory APCs and the Checkpoint regulations. PD-, PD-L1,PD-L2, which are “programmed cell death” inhibitors.   Inhibition of these checkpoints asserts limitations on the immune response and allows cancer cell growth. By inhibiting the inhibitors, the immune attack continues. The PD-, PD-L1,PD-L2 molecules fit the cell receptor sites on the CTLs and abrogate their ability to fight. Anti PD-1, PD-L1 and PD-L2 antibodies therefore allow a new breed of T-Cells to invade along with their co-stimulatory cytokines such as TNF- α and the Interleukins to play havoc with the inflammatory phenomenon and thus destroy the cancerous invaders. Checkpoint inhibitors and Monoclonal antibodies directed against the tumor cell expressed proteins are the mainstay in this approach. Disease such as Melanoma, Non-Small Cell Lung Cancer and Colorectal cancer has been successfully treated with this form of immune modulation.

Retaliation 3: Inactivation of the TGF-Beta and the Interleukins. The cancer cells co-opt the protein expression and inactivate the inflammatory signaling secretions. Again the Checkpoint inhibitors and Monoclonal Antibodies along with other conventional measures can be used with impunity against the cancer.

Would you agree that the knowledge of immune function activity in and around the cancer has meaningful repercussions in our battle against this disease? We have yet to determine the EMT (Epithelial Mesenchymal Transition) effect on Immune modulation and that may hold more answers in the future. Is that a concept worth exploring?

Checkpoints: Initial phase= CTLA-4 (Iplimumab-binds to APC via CD28), Secondary phase when cytokines have been released then PD-1(expressed by  T-cells, NK cells), PD-L1 (APCs and Epithelial cells), PD-L2 ligands inhibit CTL activity, (Melanoma, NSCLC, CRC) LAG-3

Antibodies against Checkpoints and in development: Iplimumab CTLA-4, Nivolumab PD-1, PD-L1(BMS-936559, PD-L2 (AMP-224, LAG3 (IMP321.

Speaking about MoAbs, Ibrutinib against the Bruton Tyrosine Kinase against CLL is a big story that we can discuss in the future.

References:

Scott N. Mueller, PD-L1 has distinct functions in hematopoietic and nonhematopoietic cells in regulating T cell responses during chronic infection in mice J Clin Invest. 2010;120(7):2508–2515.

Shoba Amarnath The PDL1-PD1 Axis Converts Human TH1 Cells into Regulatory T Cells. Sci Transl Med 30 November 2011: Vol. 3, Issue 111, p. 111ra120

Sharpe AH, Wherry EJ, Ahmed R, Freeman GJ. The function of programmed cell death 1 and its ligands in regulating autoimmunity and infection. Nat Immunol. 2007;8(3):239–245.

http://jedismedicine.blogspot.com/search?q=PD-1

Ahmed Tarhini, Earnest Lo, David, Minor.  Releasing the Brake on the Immune System: Ipilimumab in Melanoma and Other Tumors. Cancer Biother Radiopharm. Dec 2010; 25(6): 601–613. Article online: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3011989/

THEREIN HANGS A TALE

The universal fall from grace is palpably reminiscent of Shakespearian times about the lawyers. “the first thing we do is kill all the lawyers” was the lament then. Well, no, not that bad really but it’s getting there for the doctors these days.  Nary a day goes by that the front page news does not bemoan the cost of healthcare and then with laser sharp vision of scrutiny and gnashing teeth of “reform” the anger spills over against the doctors.

The demographics are changing. Indeed most industrial countries like the United States, Japan and Europe have the baby-boomer population surging and the productive force of the 39-55 years declining. So much so that the retirees (over 65 years) will represent 20% of the US population in 2030 consuming more than producing. The current healthcare costs are 17% of the US GDP and slated to rise to 20% within the decade. The future is being foretold in the healthcare sector daily as the demand for care outstrips supply of dollars and the cost of that care outstrips everything else. This imbalance gives us all pause to reflect at what is and what might be.

There hangs a tale of two states: I know, I know comparisons are odious, but this is freaky!

China with its double digit growth feels its deflationary pressures as the GDP swoons a bit into low single digits.

Meanwhile due to the rapid expansion of its industry, the smog seems to want to choke the life out of its citizens.

Lung cancer rates are rising at an alarming rate there. But care for those unfortunate languishes within the totalitarian walls of bureaucracy.

No caption needed

This new found economic growth opulence is being balanced by the autocratic rigidity imposed on the doctors. The Chinese doctors are extremely unhappy about the conditions in which they practice medicine. They are dissatisfied with their overall conditions. “Only 21 percent wanted their own children to become doctors. Interestingly, this survey showed that fewer than 10 percent of respondents blamed patients, doctors, or hospitals for their problems; the majority (83 percent) blamed “the system” for the tension between doctors and patients.” In a society used to the compelling nature of reliance on the state “from cradle to grave” the aging populace is waking up to the increasing out of pocket cost of healthcare.

They blame the poorly reimbursed, always on the hamster wheel doctors for the woes of their personal economics and blindly attack these physicians physically. Noteworthy there were 17,243 physical attacks on the physicians in 2010 and those numbers are increasing annually.

Chinese Doctors Protest conditions

In spite of the Chinese “deepening” level of reforms undertaken by the politburo in 2009 the conditions have worsened. The Chinese government’s reforms decided to pay the doctors through the agency of the hospitals. (Ah the irony of it all)! “The best way to increase doctors’ salaries is to put money in the hands of the hospitals that hire them; and the best way to do that is to make insurance coverage more comprehensive and liberal.”

The cost of that logic led to the following debacle: “Instead, most patients seek care from specialists in large urban hospital settings. Those hospitals are crowded and doctors have heavy workloads. Rarely are there formal appointments. Instead patients often have to navigate complex assembly-line care marked by long waits in a series of lines – it can take many hours in line to register then take care of prepaying one’s account, see a nurse then see a doctor, have tests performed then await the results, acquire a prescription then, finally, have the prescription filled.´”

Patients wait to enter the University Hospital in China

Meanwhile in the United States the Well Point insurer ostensibly through the aegis of its new found friend and technological associate IBM’s Watson came up with a solution to “save around 3% to 4% of cancer treatment costs, which total around $5.4 billion a year for its fully insured business,” by using a $350 incentive per insured to the doctors for guideline-based medical care. “In cancer, insurers and health-care providers have been developing treatment protocols—sometimes known as "pathways"—that are supposed to represent the best and most efficient approaches, balancing cost, benefit and side effects. Insurers are then paying doctors according to how well they comply.” What they fail to address is, “According to an IMS analysis, average reimbursement for administering cancer drugs is 189% higher in hospital outpatient facilities than in doctors' offices.” Well Point and other insurers have looked at the facts and seem to think perverse incentives such as the $350 offered will help offset the costs in cancer care: “The U.S. spent more on cancer drugs last year—$37 billion, up 19% in five years—than any other category, according to the IMS Institute for Healthcare Informatics, a unit of IMS Health. Overall costs for treating cancer are well over $100 billion annually and mounting steadily, according to researchers at the National Cancer Institute.”

What it will do, if you think through a little deeper, is hamper patient care! With traditional methods of caring for cancer taking a back seat to the modern molecular targeted therapeutics the impetus to use cheaper drugs to make “the whole economic problem go away” will beset the industry with a larger problem of cost control versus patient care! The populace will demand the very best of what is out there in therapy and not getting it will bring with an unforeseen wrath. Meanwhile as time churns and with every turn of the screw the dissatisfaction in the U.S. doctors rises to mirror that of their Chinese counterparts, something will have to give! The conditions are rife with intermediaries reaping large profits and pointing the “blame” fingers at the doctors, for an upset in the marketplace.

The epistemological virtues of thoughts steeped in feckless premise of “throw money at the problem” never achieve the ends they seek. It is often the guileless caught in the cross-hairs of such vacuous punditry. The distractions used as impediments to reason will fall away to a questioning look-back from the hamster-wheel. The Eureka moment will arrive!

Maybe it is time to reconsider this whole process. Maybe doctor-patient relationship should go back to that rather than doctor-EMR-Insurer-government-patient relationship that exists today in the United States. Maybe skin in the game will bring the doctor and patients closer together. Maybe the word “care” will be from “caring” and not from “Medicare.” Maybe a hand on the shoulder will cure faster than an eye on the computer screen and frustration about reimbursements from an invisible employee of a large governmental/insurer organization ever will. And maybe, just maybe we will have the medical profession be the noble profession it once was.

http://healthaffairs.org/blog/2014/05/27/chinese-doctors-in-crisis-discontented-and-in-danger/?utm_source=rss&utm_medium=rss&utm_campaign=chinese-doctors-in-crisis-discontented-and-in-danger

http://online.wsj.com/articles/insurer-to-reward-cancer-doctors-for-adhering-to-regimens-1401220033?tesla=y&mg=reno64-wsj&url=http://online.wsj.com/article/SB10001424052702304587704579588170876612100.html

THE SPACE BETWEEN...

"The Space Between
The wicked lies we tell
And hope to keep safe from the pain" ~Dave Matthews Band

In medicine the contract used to be between the physician and patient. If the patient had a disease X and went to a doctor to get relief from it. The doctor would prescribe a procedure/medication/encouragement Y, the contract was fulfilled when the transaction was completed. Those were simpler times.

Today the space between the physician and the patient is littered with intermediaries. The straight-line of care between the physician and patient has been disrupted. Everyone is an expert trying to angle into the game. This angling increases the gulf between the two parties. The current dictates cover what the physician can or cannot do and what the patient can or cannot receive in terms of care and what the government/insurer  will or will not pay for those services to the physician.

The Complexity of interactions within the Healthcare System of Medical Care

(If unable to view clearly please ask and I will send you a larger .pdf file)

A legion of experts devotes an inordinate amount of time to make itself known and considered useful in maintaining its place as arbiters of such a contract and to fill the space in between. These experts exact a price from the heath-care system and cast aspersions if necessary, on the physicians and when able through tongue and cheek at the patients as well. The emotional contract between the two parties has been reduced to a binary value for the experts to claim the defect in the care rendered using a set of arbitrary and capricious probability assumptions.

The market forces of supply and demand work admirably in business and they also work equally well in health care settings, if allowed. A competent doctor is rewarded with patients seeking his or her help. Yet in today’s climate the patient seeks out those doctors that accept insurance. This sets up a “mill” or an assembly-line of sorts and quality is sacrificed for quantity.  Time is at a premium and eye to eye contact is marginalized. Enter the EMR system, which further alienates. The real understanding of the disease stems not from the cut, copy and pasted 14-paged document for insurance reimbursement but in the single expression of the malady in a patient’s face.  

The multitude of forces that compete within the sphere of the patient physician relationship are increasing daily and advancing their cause to the detriment of the patient-care. Something needs to be done. Something will have to give!

The current zeitgeist circulating the society and reinforced by the governmental and insurance industry is that medical care is a right. Is it? Healthcare costs sky rocket because of overuse of the system. Maybe it is time to reinvent the paradigm of developing the concept of “skin in the game,” and not of, it is ours for free, go get a prescription. Maybe it is time for some hard lessons and education. Maybe it is about lifestyles against chronic illnesses.  Maybe it is about understanding after all.

Dave Matthews Band...Enjoy!
http://youtu.be/H67uEgRZs2Y

CONFORMITY

"Conformity is the jailer of freedom and the enemy of growth." President John F. Kennedy

It is a curious fact that the man who propounded the idea of utilitarian ism, his body “Auto-icon” sits in the University College of London as a stark reminder of “The Greatest Happiness Principle.” The Principle stems from “the greatest happiness of the greatest number that is the measure of right and wrong.”  Seems that utilitarianism is good and anything but is wrong. This utilitarian concept is steeped in the ideals of conformity and brings with it the kinds of vapors that mute the innovative spirit. But close to his death even Jeremy Bentham was all but utilitarian in thought. Planning his “Auto icon” was a creative gesture that breaks with the utilitarian concept of conformity. After all it brought Jeremy the greatest creative pleasure to realize that his mummified head and his skeleton stuffed with hay would become his greatest pleasure before his death and a lasting presence.

Does conformity bring in the best out of human beings? That question is being answered tongue in cheek by conformity seeking experts all over the globe. It seems that these conformity-seekers might have misplaced the term collaboration with conformity. Since collaboration is the new buzz-word in business, it does not seem to fall too far from conformity. Consequently the merger has evolved over time into what is now known as “Group think.” That a universally accepted view should drown out outliers and become the defining thought for all. So the answer seems to be yes.

"The opposite of courage is not cowardice but conformity." - Jim Hightower

Society continues to evolve along those lines of redistributive purposing, whether it is wealth, property or ideas. The symptom complex of this conformity model is laid out in the education system where a universalization of the curriculum is in play. The current education system is nothing more than a format of conformity. Every child is taught the same stuff by the teachers who are taught the same stuff. Pretty soon if one extends the thought further this concept leads to a marginalized human intellect, or more appropriately termed a state of constant mediocrity.

A similar view is being forced down the medical care throat. This concept is governed by the “Guidelines” that are now reaching the tipping point of becoming mandates. A quote from the recent article in Scientific American caught my eye: "At best, these guidelines are recommendations based on scientific studies with results that pertain to the average among us. They do not adequately incorporate the personal differences and preferences of each of us as individuals. Furthermore, while these recommendations are based on clinical science, rarely is the science complete or incontrovertible. Hence, the recommendations are consensus statements reflecting the perspectives of those charged with the production of the guideline." Let us do a thought experiment here for a moment; If all maladies are governed through the auspices of guidelines then where is the magic of Art in medicine and where is the individuality of the patient being treated. A guideline form of medical care ultimately draws out and macerates any wisdom of finding a better way, a quicker way, a better treatment model or a more compassionate form of healing the sick. If all humans were equal in their physical states (as in robots) then a grease job here and an oil can there would work perfectly. Given the push and the tug today the Bentham’s “Greatest Happiness Principle” is being applied to all forms and norms of society. The codification of thought is being pursued at breakneck speed to usher in the era of a utilitarian medicine in a box that is made to resonate with the increasingly distracted populace. But John Rawl’s “Difference Principle,” which advocated that high productivity of some, gain advantages for all even the most disadvantaged, is thrown to the wind.

Conformity harkens the murky nature of a uniformity of thought and action. Compliance with conformity is the single biggest arbiter of modern day thinking and brings with it the torrents of “group-think.” It marginalizes and in some cases punishes a minority opinion. It suppresses excellence. Conformity brings in a mediocrity governed by the few. Conformity does not bring with it the “Ideal Splash” that Worthington so idealized.

It brings in carefully picked and chosen ideal splashes only to promote the point of view. These conformity seekers fail to recognize that the imperfections, which assimilate within the human genome may not be imperfections after all but the genesis of greatness; the creative sparks and the innovative fuel that have always defined real progress in world history.

"Diversity: The art of thinking independently together." - Malcolm Forbes

Yet in clear contrast to conformity, all the voiced viewpoints of the conformity advocates continue to express the benefits of diversity, unfortunately only in words. Those two points of view therefore become blatantly at odds with each other. Although they claim that seeking diversity of thought is a good goal, yet the formalization of conformity as the underlying principle of current thought and action virtually destroys the diversity argument.

Diversity is not just about color, culture or religion but is the grand dame of innovation, creativity and intellect.

It brings with it the varied opinions and from those a few will shine the brightest light. To look this in the eye, one only has to see that men like Steve Jobs, Bill Gates, Mark Zuckerberg, Jeff Bezos and others were all dropouts from the formalized education system who created and pursued a reality from a vision of their own. Had they been forced to conform, we might not have had an Apple, a Microsoft, a Facebook or Amazon today and the millions of people employed by these great companies.

These explicit confrontational set of facts weigh heavily on the implied particularity that seems to have a defective paradigm. Imagine if you will that the teachers were to force the prodigy by the name of Mozart to learn concepts of engineering or for that matter dance or Newton to learn how to sing and play a piano, what might have been? If the force du jour was directed away from the inner voice of these prodigies where would we be? How would they have coped? Would they have abandoned their future life’s work that advanced civilization?

Something to think about!

The deepest cut of all against the diversity of thought comes in the form of a pill. Today millions of children have been subjugated in their creative desires and in their expression of the inner intellect through the omnipresent diagnosis of ADHD (Attention Deficit Hyperactive Disorder).

A curious child with a wild type intellect whose intelligence does not want to be confined to the ridicule of “Common Core” type subjects is put on Ritalin rather than evaluated for his or her genius in a particular field is a travesty. It is too easy to subjugate the wandering irritable “trouble-maker” mind of a brilliant child with pharmaceuticals rather than assess his or her needs and wants. Albert Einstein comes to mind who was considered a troubled student “who would amount to little.” History differs! This muzzling effort works for the busy parent and also for the hassled teacher. Neither wants disruptive influence in the home or school.

Let us look at our children and their needs rather than what pleases and serves us as adults. Let us look at our patients rather than what pleases the insurers. Let us think diversity of thought rather than expression of “group-think.”

http://youtu.be/wX78iKhInsc

Let us think critically for a moment!

Let us think for ourselves for a change!

The future is ripe for the making!

Near Misses of Great Magnitude

The air has warmed but the breezes are cooler still, the flowers are blooming. The air is saturated with voices of little people and their bigger counterparts. Spring has finally arrived and brought out the families. The fathers are out catching ball with their children amid the squeals of near misses and laughter of greater magnitude. And I look at the time gone by.

I remember a day like today when we as a family had decided on a picnic. As we headed out, the infernal beep of the beeper interrupted our plans. We would have to all bundle up in the car and go to the hospital for me to see a patient before heading to the park. There were groans and moans from the children who had heard of this before. But I insisted this time it would be a short interruption. “It is only a minor issue. It won’t take me more than a minute,” I said, as I hustled out the car. An hour later as I emerged the quiet that I had left my wife with was filled with taciturn children, crying and carrying on. I walked back to the car and said, “Okay are we ready!” in as jovial a voice as I could muster. Only grumpy groans emerged. The enthusiasm had long since vanished.

We drove to the park and the infernal beeper beeped again calling me back to the vicissitudes of life; illness. Someone else needed help. I deposited my family at the park and promised, I’d be only a short while to the restrained anger and glare of my wife and the protesting children.

After what seemed a short 20 minutes which turned into another hour gone by, I arrived back at the park and found my children happily playing catch with a stranger. Someone had taken pity on the two lonely little souls and decided they needed some parenting. My wife was quietly reading a book with one eye on the kids and the other within the pages.  After the introduction to the stranger, who it turned out was a remote neighbor of ours, I thanked him and took over the ball. By now my children, it seemed had had enough and they retired to the shelter of their mother’s arms.

The rest of the evening was a blur between beeps and phone calls. The sly disgust on my children’s faces and the resigned look on my wife’s face completed the day at the park.

As a physician, I know about near misses that have great consequences. As a father I know that the near misses that interrupt a physician’s life have a far greater magnitude effect on a family.

And they call us providers?