IN WHOSE INTEREST?

In Whose Interest is all this anyway?

Cleverly we design our future. Softening the lights to reduce the shadows. The soft haze beckons us and we follow suit dutifully in line.

Sometimes a question arises. but most times the question is drowned out by fear. The question is “In whose interest is any of this, anyway?”

The trumpets have heralded that all things arriving in the form of gratis are from a benevolent master. And the benevolent master with a tearful eye informs that all things meted out are for the “Public Good.” Indeed the writers write, the bobble-heads on television agree with thrills up their legs and all is a calm sea of bright azure blue.

Is it?

Let us take the mundane but hotly contested yet relentless issue of the EMRs for physicians. The digital interface is designed and promoted as the coming of age in medicine for the “public good.” Touted that the EMRs would lead to portability of patient data and therefore less chance of medical errors. But that is not what happened. The error rate in some cases increased. However there was a bonanza for cyber-charlatans in stealing multi-million patient information. The insurers using it to determine who was being reimbursed and how much, created alternate realities of abuse and through it all the face time, eye-to-eye contact between patients and physicians decreased dramatically. The questions from the physician to the patients were directed at the computer screen in an attempt to reduce the time impact in order to fulfill their goal of filling the boxes and crossing the “t”s and dotting the “i”s to the agencies. The alienation between the patient and physician increased. And as a consequence the “Satisfaction Scores” for physicians took a dive. The dominoes of interests however continued to erect themselves. Software and hardware companies like EPIC and CERNER made billions in the process through government subsidies and contracts. Meanwhile the payments to the doctors dwindled substantially. The declining incomes combined with the will to keep their offices open sent many a doctor to the banks for loans, others to leave the field of medicine and still others into depression.

In whose Interest was the EMRs?

Another commonly used belief that is the care of the patient should be based on the population medicine statistics; a new paradigm. let us dissect that one a bit. Imagine if you will that we take a sample of data from a cohort of patients in a urban hospital or two or three and then based on the statistics conjure up a reality that treatment ‘x’ worked in that sample in, lets say 2/3rd of the patients, would that be appropriate for the entire population? If from that tiny experiment of say a 1000 (the world population is 7,100,000,000) we extrapolate that treatment ‘x’ is the best treatment. That is why most studies are not reproducible! Is that wise? and if it does not work then is it “so be it,” because the data says so and we did the best (based on some guidelines) there is. Allowing the physician who is treating the patient with the right to determine the correct therapy that may be ‘y’ or ‘z’ would be the best for the patient, but that is not the case with this new population medicine format. The insurer having agreed on a contractual and budgetary basis that the cost per patient with ‘x’ is cheaper than alternative therapy with ‘y’ or ‘z’ will opt for wherever the costs are lower. In their context the shareholders ultimately benefit with rising stock prices from the higher EPS as well as the CEOs. The critical thinking of the physician is circumvented by the bulldozing baskets of insufficient data. And patient care is mediocre at best.

In whose Interest is the population medicine mode of therapy?  

ABIM Philadelphia Condominium (Doorman included)

It appears that a third party always seems to insert itself and avows itself as the defender of the public good. Case in point is the American Board of Internal Medicine or ABIM, which is a privately held foundation that saw its coffers filled up from net asset value of $13 million to $132 million in short order. It appears that the ABIM in promising that certification of physicians initially was the way to test the knowledge-base of the doctors. But then came the 10-year recertification to prove that the knowledge was still fresh. The physicians complied, as insurers (who pay) and hospitals (who employ) had bought into the zeitgeist. But that was not enough for the ABIM who doubled down and helped them conjure up the Maintenance of Certification (MOC) as a money making annual endeavor.(even though their argument about recertification and MOC had been debunked over and over in the scientific press) This endeavor helped ABIM increase their own salaries and help buy expensive Philadelphia condominium for retreats replete with Mercedes Benzes to drive them around. Ah the vagaries of such banal thought. Interestingly the examinations and the maintenance “modules” designed by the ABIM were merely a mechanism of esoteric questions that had virtually no value in daily patient care by a physician. It was all about money! Or so it seems.

In whose interest is the Maintenance of Certification?

Lets not forget the multitudes of policies, regulations enacted by the Federal and State agencies that control the “public good.” There are many acronyms that the reader is welcome to look into: ACOs, AMP, P4P, AHQR, PCORI, HIPAA, OSHA, IOM, HICPAC, DHQP all these and more in one way or another impact the functionality of the patient’s care. Is it any wonder that 29% of 1st year residents are depressed with thoughts of suicide and 58% of practicing physicians are depressed with 93% of the doctors not advocating their children to go into medicine? Pamela Wible, MD states that the physicians are abused not depressed. I agree. The suicide rate from such regulatory abuse is killing the field of medicine through depression and overall ill health. filling paperwork now consumes around 40% of a physician’s time. A mistake in not crossing a “t” or dotting an “i” is being construed as fraud by the digital sleuths. The relentless drumbeat of “public good” goes on.

In whose interests are all these agencies?

And then again, there are others that have a stake in this algorithm of human interaction. Read: The Black Cloud of Medical Board Investigations . These politically appointed figures to the Board (physicians, attorneys and public members) by the governors of the state have the power to do "public good." Their power remains subservient to the power of the State governmental oversight and as such they, to a large extent, remain pawns in the chess game. In that "public good" is a lot of pride and prejudice as is decreed in the soul of man. A well publicized case, no matter the cause must be found guilty for political expediency while a well-connected one can be suppressed with a reprimand. Their decisions are final no matter the innocence or guilt while professional lives are buried in the heap. No matter the issue, the attempt is to win a consent of guilt and that proves that the system is working at peak capacity. The poor soul caught in the widening gyre of hurled allegations never sees it coming and proof after proof against the allegations mean nothing. The goose is cooked and the chefs are fattened. To be sure there are a few bad apples (as in any aspect of society) and they should be removed from patient care, but with careful reasoning and judgment and not solely by prosecutorial discretion. From a well-designed and well-meaning system of oversight over physician indiscretion, the system has evolved into a numbers game of how many are thrown to the wolves. If less per 1000 then the oversight is not good. If more, then the state is an exemplar. The evil that men do lives after them; the good is oft interred with their bones. - Shakespeare

In whose interest?

This kind of pain of logic might take you from point A to B but only as Einstein said, “Imagination will take you everywhere.” It appears that the reason has ceased to be the power of wisdom, logic and numbers rule the day. And as Charlotte Bronte expressed, “Better to be without logic than without feelings.” Do the pundits “feel?” in this “for the public good?” Or are they so entrenched in their little silos of punditry that only the artificial hue of fluorescence reaches their retinas?

What makes them tick? Money? Wealth? Greed? Job Security? Power? Influence?

The NORMATIVES

Normatives need some understanding. These declarative (normative) statements over time and through constant rekindling efforts of the followers turn into factual statements. Widely shared statements in this day and age are; blanket the airwaves and digitally swarm the social media and you have a new Norm. It is like the use of the term "social responsibility" that is ubiquitous and bandied anytime when logic is in short supply. The very social structure morphs through the beating drums of the normative clan changes and small "n" numbered polls confirm the selected-biased answer through the tortured network of statistics. Entertainment becomes reality and the human misery index rises to new levels for most are buried in the sea of daily existence. "Oh the web we weave!" The illogic in this "Normative" logic is the fount of the current zeitgeist. Let me clue you in on a conversation that I had with one of these stalwarts.

Really?

“Normative”: You know physicians are destroying medicine!

Me: How so?”

“Normative”: Look at the costs, they are going sky-high. In fact healthcare is costing the US $3Trillion a year. almost 18% of the GDP.

Me: And you think all those costs are related to physicians?

“Normative”: Well yes. Who else controls medicine.

Me: Did you know that medicine has been subverted by the third party-goers?

“Normative”: Like whom?

Me: Lets see, for one, the middleman-businessman/woman managers who have grown 3000+% in the last 30 years compared to around 180% of the physician population. The cost rise is proportionate to the rise in these bean counting busy-bodies. For another the Insurance industry who keep raising the premiums and conflating the stockholder dividends and CEO bonus payouts and three, the pharmaceutical companies with a constant increase of the costs of drugs. 

“Normative”: What about the excess diagnostics and procedures?

Me: That is a two-part problem: One, The patient demands to know what is wrong when afflicted by a symptom and he or she will go to multiple doctors and facilities till they get the answer and two, The legal aristocracy is just waiting to pounce on the doctor for a missed diagnosis.

“Normative”: What about the CT scans causing cancer?

Me: Maybe if you read the study, you would realize that out of 81 million CT scans done a total of 15,000 MIGHT develop cancer. The “MIGHT” was based on a hypothetical risk extrapolated from the Hiroshima and Nagasaki related fallout.

“Normative” Maybe, but you know the doctor’s fiefdom is just about over, don’t you?

Me: How so?

“Normative”: Soon population medicine will clear the hurdle based on guidelines and mandates. And there will be little need for doctors. The Nurse Practitioners and Physician Assistants will be able to handle most of the problems.

Me: The educational basis of the NPs and PAs is not on par with physicians. Thus decision making skills are different. And besides, the NPs and PAs increase the diagnostic use because of their own insecurity in making judgement calls about diagnoses.

“Normative”: Yes, but if the guidelines tell you what to do based on population medicine then what good is all that knowledge for?

Me: Population medicine is based on sampling errors. Even taking the Bayesian rules and accounting for the statistical probability at 95% Confidence Intervals, we are left with information of about 50-60% of the population at best. The remaining 40-50% are not in the running for the appropriate therapy.

“Normative”: What do you mean?

Me: Say you have hospital conducting a trial and it draws most of its patients from a specific catchment area and the population of that area is mostly “X” type. Would treatment of the “X” population fit the “Y” population? The answer is no since phylogenetic variance are common in communities based on the growth and expansion of the community. Not every community is a “melting pot.” Even adding multiple institutional data fails to conquer this conundrum.

“Normative”: Even so, computers like IBM’s Watson will be able to differentiate between diseases and give a fairly robust diagnosis on an individual basis.

Me: It might but it will be based on percentage probabilities. For example a person with cough might have the following tape readout: 90% Allergy, 85% Bronchitis, 80% Pneumonia, 70% Cancer, 40% Drug effect etc. It will still take a physician to weed out the reality. And that is what physicians do today with their mental calculations, non-verbally.

“Normative”: What about the DIY laboratory tests. That should help empower the patients to make their own decisions. Right?

Me: Actually it will create a larger state of chaos when small abnormalities are noted in the lab tests. Who will interpret these abnormalities?

“Normative”: IBM’s Watson, for one.

Me: We are in a circular argument here, aren't we?

“Normative”: How about most medicine will be conducted via telemedicine based on wearable technology?

Me: Now you are getting somewhere. That is entirely possible one day. The data can be fed into the computers and analyzed for probabilities and then the physician becomes the decision maker on the computer screen. Unfortunately the need for surgical procedures will still be needed until we have Star Trek technology to cure diseases without intervention.

“Normative”: I think you are wrong. The change is coming and soon.

Me: Prove me wrong.

“Normative”: This time next year.

Progress in medicine has been steady. It is geared through trials and tribulations, tests and studies, drug “A” vs. drug “B” and rarely placebo nowadays. Medicine is changing. The Star Trek Hologram “Doctor” is still far away. We should continue on that quest, but not denigrate the current best medical system in the world methinks. Normatives, they will have their day of reckoning, one day…Maybe or maybe not and we will have advanced to a feckless, fact-less, opinion-anchored society. But, then I digress.

MEANINGFUL=MEANINGLESS

It occurred to me, as it might have to scores of others in the legion of medical care that there is something very disturbing going on. Now before we get ourselves in bunches, let me say, this only affects the physicians in very meaningful ways. (There, I’ve lost the majority of the readers). For those still hanging on, lets look at what is exactly going on.

Remember the Electronic Medical Records (heretofore mentioned as EMR or EHR interchangeably)? I’m sure you do. But here is the rub, When the powers that be, all comfortably seated in deep cushioned chairs on marbled floors designed the concept, they failed to understand the basic patient-physician interaction. After all their paradigm was based on the ICD and IPT coding mechanics buried within a sea of paper data within the vaults of the Centers for Medicare and Medicaid Services (heretofore called CMS). The digits when subjected to the rigors of algorithms would displace all worries. So using their best or only information, they (the powers to be) deduced that if all information could be inputted by the physicians directly into the digital format, why, then the CMS could make meaningful decisions, such as appropriate payments for services rendered. Rampant in that thought process like dust scattering from an ailing fantasy was the concept of cost-containment. After all the cost of healthcare was going up and usurping 18% of the Gross Domestic Product. “That could not be!” they cried. So the EMR “Meaningful Use” was invented. Some coddled the green fantasy as well, “Less paper invoice use would save the trees!” Nothing better than that, sliced bread, apple pie and gaia-hood all packaged in one.

The carrot placed upon the dying breed of physicians who really cared for their patients was, “If you implement an EMR in your medical practice, CMS would give you “X” amount of dollars. Doctors felt, “Hey why not. I get to digitize my medical records and have them available 24/7 to me for decision making.” A win-win concept they thought. “Everything on my little smartphone or tablet.” Not so fast, you graphene-loving-silicone-dependent gadget lovers, not so fast.

Along came an enterprising agency with the best ceramic wafers, bestowed as “the EMR provider” by the CMS, whose CEO had paid a significant amount of money in election campaigns, and won nearly half if not more of the software/hardware installations across the global field of healthcare in the United States. But the software was proprietary and therefore not easily, if at all interactive, with other software vendors vying for the same multi-billion-dollar pie (not in the sky). The doctor’s records could not interface with the hospital medical records nor with other physician’s and lo and behold silos developed within the software empires where dollars were raining down by the bushels. from millions into billions overnight, just like the tech-boom of 1999.

Physicians, oh yes lets not forget those “middlemen” as some called them, were stuck with thousands of out of pocket dollars in purchasing, implementing, training employees and themselves, losing hundreds if not thousands of hours that should have rightly been spent in caring for their patients. The reward after expensing a large supposedly reimbursable “X” amount from CMS they were shocked to realize that of they paid $30,000.00 for a system and $10,000 for implementation, the reimbursement was around $16,000.00 - $18,000.00. But, hey the Return on Investment would be the speedy reimbursement from CMS that would take a bite out of the Medical Revenue Cycle, and that, the physicians thought was worth the loss they were incurring. The only caveat was if you were tied to medicare for reimbursement for services rendered and you did not dive into the EMR business you would face a cut in payments also.

Not so fast Watson, CMS decided to implement the ICD-10 coding system and told physicians to take a loan for keeping themselves afloat during the governmental transition and delayed payments. Oh okay, but everything would be alright afterwards. No worries!

The stick followed the carrot in lock-step. And as we all know accepting money from a governmental agency is filled with a stack of papers that have to be signed, boxes to be checked, “Ts” crossed and “Is” dotted. The next hammer was a Medicare (CMS) Audit of all the physicians who had claimed the EMR bonuses. If the use was not “Meaningful” in the auditor’s opinion then doctor would have to return the bonus back to CMS. Oh and by the way, the auditors were outside agencies empowered to go and find out those that had not complied and these auditors for their efforts were to receive 20-30% of the returned bonus bounty. This might sound sarcastic, but the incentive for the auditors makes them slightly porous to the wild idea of “dinging” the doctors (agency theory) to improve their own bottom line (hey that’s human nature -  don’t blame me, I’s just pointing it out to you).

Meanwhile studies started tumbling down the express corridor that “EMR Meaningful Use” had not improved medical care for the patient at all. In fact patients began complaining (as if anyone was listening to them in the bureaucratic stronghold of CMS) that the doctor spent more time looking at the computer screen then at them. The doctors ambushed with costs, audits, denials of service, patient dissatisfaction, became disillusioned and depressed (over 54% if not more). They were told that their expertise was subpar to the algorithm based on some wide eyed, bushy-tailed 18-year old software engineer and may not based on decades of experiential reference. Oh no, the codes told the story and treatment had to be based on the codes or the rain of sparking embers from CMS would engulf the physicians into a spectacular conflagration. Care would be based on Costs from now on and more and more Societies and expert physician bodies mirrored the meme of this rapidly unfolding paradigm. 

The story goes on…

The fingers keep pointing at the patient - physician interaction and at the physicians. In one breath Healthcare costs ($3 TRILLION) are tied to care delivered by the physician to his or her patient. No where is mentioned the 800lb businessman/woman gorilla that loves to ransack the honey-ladened spread under the tent.     

Don’t get me wrong, there are a few bad (apples) physicians and other providers in the healthcare field that give a bad name to us all. But they are few and can be weeded out easily without destroying the best medical care in the world.

The answer… cometh soon.

TARGETING LUNG CANCER

Lung cancer is the second most common cancer in both women and men, eclipsed only by breast cancer in women and prostate cancer in men. ACS estimates 221,200 cases in 2015 with 158,040 related cancer deaths. It accounts for 13% of all cancer occurrences and 27% of all deaths related to cancer. Early diagnosis and treatment meets with cures although only 15% of the NSCLC are diagnosed early.

NSCLC treatment has mostly revolved around, surgery, radiation therapy and chemotherapy for the longest time. The marginal successes have had little impact on overall survival. Today the era of Molecular medicine hopes to change that paradigm.

Non Small Cell Lung Cancers are grouped into Adenocarcinoma (50%), Squamous Cell (30%) and Others (20%). Each subset carries its own characteristics of genetic mutations, although overlap is commonly seen amongst the groups.

Common known Mutations in Adenocarcinoma: 

1. Epidermal Growth Factor Receptor (EGFR) is the most common one and is present in 50% of the Asian patients and 10% in the non-Asians.
2. KRAS mutations in 25% of cases are less common among smokers and absent in Asians.
3. ALK and EML4 fusion is present in 2-7% of the NSCLC (mostly adenocarcinoma) non-smoker patients.

Targeted Inhibitors designed to target these molecular structures include:

1.              Erlotinib and Geftinb are most effective in cases with exon 19 deletion, exon 21 L858R, and exon 18 G719X. The Pan-Asia study showed a 9.6 months survival in gefitinib-treated patients, versus a 41% ORR with a median duration of response of 5.5 months for the carboplatin/paclitaxel chemotherapy group. (Maemondo M, Inoue A, Kobayashi K, Sugawara S, Oizumi S, Isobe H, et al. Gefitinib or chemotherapy for non-small-cell lung cancer with mutated EGFR. N Engl J Med. 2010 Jun 24. 362 (25):2380-8). However resistance is noted after one year of therapy with these Kinase Inhibitors. A specific mutation noted at the exon 20 T790M is found in the resistant cell lines. these mutations have been targeted effectively with another Inhibitor Afatinib with modest success. In the LUX-Lung Trial, results showed the Afatinib group’s progression-free survival (PFS) was 11.1 months compared with 6.9 months for those treated with pemetrexed/cisplatin chemotherapy regimen. (Sequist LV, Yang JC, Yamamoto N, O'Byrne K, Hirsh V, Mok T, et al. Phase III Study of Afatinib or Cisplatin Plus Pemetrexed in Patients With Metastatic Lung Adenocarcinoma With EGFR Mutations. J Clin Oncol. 2013 Jul 1)
2.          However Cetuximab a monoclonal antibody to EGFR noted to have activity in NSCLC (adenocarcinoma) without the EGFR mutation, later a post hoc analysis revealed that the EGFR mutation status conferred a better response rate.
3.          For patients with ALK mutations Crizotinib and Ceritinib have modest efficacy. Trilas showed response rates of approximately 50% to 60% with crizotinib. Response duration was 42-48 weeks. (Kwak EL, Bang YJ, Camidge DR, et al. Anaplastic lymphoma kinase inhibition in non-small-cell lung cancer. N Engl J Med. 2010 Oct 28. 363(18):1693-703). (Shaw AT, Kim DW, Mehra R, Tan DS, Felip E, Chow LQ, et al. Ceritinib in ALK-rearranged non-small-cell lung cancer. N Engl J Med. 2014 Mar 27. 370(13):1189-97).

In (Squamous Cell Cancer or SCC) NSCLC The demonstrated impact of molecular targeting is less clear since the targets have as yet to be clearly defined. in about 5% of SCC cases the EGFR, KRAS and ALK mutations are noted presumably from the mixture of cell types (adenocarcinoma + Squamous Cell) these patients after a Cisplatin based chemotherapy regimen show a 18% response rate to the small molecule targeted inhibitors such as Erlotinib, Afatinib. SCC is a well known entity that occurs secondary to dysplastic changes in smokers and other environmental toxins. These dysplastic cells have variable damage to the genetic structure early on. Further oxidative stresses to these dysplastic cell lines increases the genetic mutation burden and leads to cancer.

The following targets have shown success in SCC:

1.        Monoclonal Antibody PD-1 (Nivolumab) and (Pembrolizumab or MK-3475 an Anti PD-1) an immune checkpoint blockade in unselected SCC cases lead to a 16-23% response rate and disease control rates of up to 50%, especially with the PD-L1 over-expressers. Smokers seem to benefit from the anti PD-1 and PD-L1 checkpoint blockades. Anti PD-L1 agents currently in Phase i/II trials with encouraging early results include MPDL3280A (atezolizumab) showing a 25% improvement over Docetaxol in a head to head comparison.
2.        Anti CTLA-4 (Iplimumab) that restores downstream immune activation against the cancer has had limited success in SCC with Phase I/II trials in progress against advanced NSCLC SCC patients.

We have come a long way in securing newer targets to attack against Lung Cancer. The success will ultimately depend on the durability of the response in improving overall survival hopefully with improvement in the Quality of life as well. Combinations of molecular targeted therapy with Immune checkpoint blockade as well as Restoring Immune surveillance in limited disease lung cancer can be personalized to the patient in the future.

There are many other paths that have yet to be travelled...

Only the curious have, if they live, a tale worth telling at all - Alistair Reid

PHILOSOPHY OF PATIENT CARE

"There are more things in heaven and earth, (Horatio), than are dreamt of in your philosophy"

-Shakespeare



Cold or warm, tired or well rested, despised or honored, hated or loved, happy or sad, we all face life in its many varied forms. The trauma of existence is placated only by the moments of free thought, of fulfilled desire, of understanding. So what is in these many moments where life exists that makes us want more.

Turns out, if you have time to pay attention to little matters of time where true grit as true happiness lives, you might come away with that it is in seeing the joy in another’s face.

Nowhere is life more evident, more clear, more raw as in caring for another human in need. Physicians qualify in this realm more than in any other discipline.

Physicians live in a unique world of elation and despair. The wildly gyrating confines of this existence gives motive and cover to the mind of a physician. That one patient who finds cure from an interminable illness promises the healing for the many in despair. Each person is a life, each person a story, each person a face of society, brings with him or her a quality unique to humanity. No two individuals are alike. Therefore no two can be treated alike.

The former President Jimmy Carter just made news with a report from his recent cancer follow up MRI that showed complete radiological remission of the brain metastasis from the malignant melanoma.  His treatment included radiation therapy and Keytruda, an anti PD-1 immune therapy. There are several interesting and promising signs from this reveal. First, healing an individual and especially a former president at the age of 91 is worth noting. So age should not be a limit to proper treatment at any age. Notwithstanding experts like Zeke Emmanuel, MD who implied that after 75 years of age, people should not be treated and that they should be retired to the pastures. The obvious flaw stands out in stark relief now, doesn't it? Second, aging individuals have a lot of wisdom to offer and the young ones should take note of any pearls they drop in their communications. it is obvious that President Carter has a lot to say about his life and the world he has inhabited. Whatever that wisdom is. Wisdom is a philosophy on to itself. And you ask what is Philosophy? nothing more than the “love of wisdom” as Pythagoras called it, or the knowing the underlying fundamental nature of reality. One can tease at the fibers of this philosophy fabric and even in its threadbare form it reeks of some ancient understanding steeped deep into the veins of knowledge-keepers where blood flows.



Philosophy must be wise and therefore rational? Right? “ça dépend!” It depends on many things, but most of all on the questioning of all that is there. An individual’s philosophy would differ, based epistemologically on his or her beliefs, ideas, attitudes of the community and nurturing.

Our philosophy is nothing more than an improvement in our understanding of nature and ourselves. So should we then change the current thought paradigm that places age and cost ahead of fixing illness?

Consider this question; Should we advocate death as the primary focus in healthcare? Some will proffer the cost as a major hurdle for treating the elderly. They will claim that healthcare costs are currently 17% of the GDP in the United States. But they fail to recognize that costs are not due to the care administered, but as New York Times recently pointed out; a direct result of the business people involved in administrating the business of medicine.  So if that vital middling managers can be eliminated, the cost of care would come down drastically and become at once really affordable. More people would get treated and their insurance carriers would not be averse to paying for the care while still making oodles of money for their CEOs (Median total compensation in 2014 for the 117 CEOs for whom Modern Healthcare collected compensation data was $5.4 million, with a median increase of 9.6% over the prior year) and their shareholders.

Consider another question; Should we use a standardized lesson plan of “Choosing Wisely” as advocated by the American Board of Internal Medicine and co-opted by other entities like American College of Physicians as the correct model of patient care?  Experts say these programs are based on “Evidence based Medicine.” What is “Evidence?” I ask. Evidence changes as new information is received. So what is standard today becomes an “old thought: tomorrow. And further if the evidence is conjured by a set of tortured statistics, that furthers the illness within the science of medicine, how exactly does that further the agenda of good patient care? It is akin to building a perfect emptiness contained within straight lines in a chaotic world. Most of us would love to live within those bounds of comfort, happily suckling on sweet nectar without a care, but is that reality? Defining evidence is at best difficult! Yet if we claim “Evidence” as evidence enough to change belief of the majority, then all is pardoned and acceptable. And therein emerges the concept of “Evidentialism,” writ large "Evidentialism is a theory of justification according to which the justification of a conclusion depends solely on the evidence for it." The new subconscious is derived from consciousness at individual level and new belief becomes the new zeitgeist for that individual. And justification upon justification becomes the unwieldy latticework difficult to untangle for most except for those independent thinkers.

As the Big Data scientists gather their tools and computers, a cry from one of its own Hannes Leitgeib said, “ Overall and ultimately, mathematical methods are necessary for philosophical progress.” Ah yes, this progress, where we find the sinews of medicine wasting away today under the hard, weighty chains of pseudo-scientific tortured statistics. The general and special belief system slowly mutates to the turn of their statistical screw.

So, what is your philosophy as a physician in caring for your patient?

Maybe it is time for some Critical Thinking?
Maybe it is time for some thoughtful analysis?
Maybe it is time!

KARL AND HIS CHI SQUARE

Poetic Solution to the Two Variable Problem...

(O = OBSERVATION, E = EXPECTATION)




O Karl of the Pearsons
What have you done?
Created a mythic creature
Of sum.
The misfolded law
Of manifold
Exposes the ignorance

Of the many who hold
The reins of power
Who count the gold.

From observations squared
We extract expectations
Squared above and below
To arrive at conclusions;
Significant or not
Based on a number
between the freedom
In degrees and artificial bounds;
Where confidence grows
Capturing more ground.

Alas Chi is riddled with
Axioms, which rankle the soul
Expectations, what are they?
Where do they grow?
When did we arrive?
And what do they show?
Do we know?
Is it the premise of Bayes?

Or the wanton expectation
Of expectation
From where we derive that
Significance when looking at
observations?

So Karl
How do we measure the real
Truth, that hides beneath?
Do we add another decimal to soothe
Conscience’s sheath?
Or do we live on
in ignorance
Tied to the strings of your
laudatory treatise?

Ah but Karl is not here
The drama we face
Must go on
Incalculable in calculus
yet calculable
From eugenics to philosophy
Rewards so Faustian.
So square the difference and
Divide by the axiom
And live the dream
Of a dream,
in statistical fiction!

The many proofs we seek
Are weak
Diluted in jest
Under the wild eyed guess
Of a once nobleman
Who sought to nurture
The world
With Marxist Justice
And a function of
Probability when nothing else
Lurked to soothe the
Possibilities in a distant future.

The distributed frequencies
Of exclusive events
Sparkle in defense
Blossom and glow
To fill the particularity
That connives within
The Theory,
Resident in it

Stately distribution.
Proof it is, the falconer claims
As the falcon spirals in its gyre
Yet lift precedes the game.

Now probability has risen
To proof
And Null, where is null?
But the ever sinking hull
Of the ship
Beneath a sea of categories
Numbered to negate
The existential
Commonness of reality
Bound between intervals
That remain arbitrary.

How man in his infinite jest
Has clamored to
Bring the best of the best
And numb their minds
Of reality.
From an irrational number
A fraction of a fraction
which goads
And boasts that
Brass is gold.

Oh wicked, wicked
hymns of sharks
preying on the branches
of age old trees
that tilt to the breeze
in defiance
but remain rooted in place.
No sound, no fight
Just woosh,
They are free!

Maybe like the trees
Understand the force
Bend to its will
Yet forge a path
To raise your mind
Above the rest
Feel the breeze
And know the difference

What is

And
What is real.


THE DILEMMA OF THE TWO VARIABLES:

                 Yes                No              Total

Yes             x                    y                 x+y

No              z                    d                  z+d

Total          x+z                 y+d               n


FORMULAS BELOW:

                  Yes                No                Total

Yes       (x+y)(x+z)/n   (x+y)(z+d)/n      x+y



No        (z+d)(x+z)/n   (z+d)(y+d)/n      z+d

Total          x+z               y+d                     n

SHAKESPEARE AND THE DOCTOR

A SICKNESS IN THE WITLESS KINGDOM

“In my heart there was a fighting that would not let me sleep…Our indiscretion sometime serves us well, when our deep plots do pall; and that should learn us there’s divinity that shapes our ends…”

Such are the pains that grow and grow and keep us from living a comforting life. The tumult that shudders and causes pain relives in our dreams. We march to the cry of the pained and the harmed to sooth and comfort as our comfort is discomforted, yet we march on in search of love for humanity. The wakeful moments when sleep surrounds and the flesh is laid bare, the white sinews glisten as the red blood congeals under the surgeon’s scalpel. Time is spent to heal.

“Tis dangerous when the baser nature comes between the pass and fell incensed points of mighty opposites.”

The argument ensues between the physician adamant and rigid in his demand to serve his fellowman comes face to face with the mandates of the powerful and finds himself at odds to do right or acquiesce to the tyranny. And yet when all the power is drained from the powerful the end is the same between the two: “A man may fish with the worm that hath eat of a king, and eat of the fish that hath fed of that worm.” What lies at the end is the monument, a testament to the grave-maker; “the houses he makes last till doomsday.” The power like time is fleeting. The madness is also passing. The arrow of time flies and having flown it brings a strange opacity to the past and color to the future. Some are bewildered by the strangeness of that hue, easily moved and rendered unmoving to all other voices save their own. Reason is imprisoned by their desires. All is material. All is passion.

“Give me that man that is not passion’s slave and I will wear him in my heart’s core, ay, in my heart of heart…”

Through reason and deductive efforts the doctor must understand the nuance of a wince, a groan, a loss of desire, of melting flesh, of fragile bones and via that knowledge plead with the consolation of his virtuous thoughts to end what nature or nurture has begun. In doing so, end the “thousand natural shocks that flesh is heir to…” and render health or find the blanket of comfort and soothe to console the imperiled life. A doctor is indeed the very firmament of reason. His virtue is in to mend, to heal, to seek and to reason.

“The spirit that I have seen, may be a devil and the devil hath power t’assume a pleasing shape…”

When with suddenness and without warning there follow uncalled for unexpected riches in the name of ‘good for the many,’ the spark of question must also follow. Is the individual not the portion of the whole community or society and does not making him or her, the sole purpose of all endeavors? Healing him may yet heal the whole! Yet in these heady times the good of the many betrays the good of the one. He or she is lead to the gallows forsaken under the premise of ex-multis. The powerful then “abuses me to damn me.” Ruthless desires overtake to circumvent the need of the one under the egalitarian umbrella. After all such actions are the consequence of thought that churns and bleeds the fiscal brain with the comfort of; “What is a man if his chief good and market of this time be but to feed and sleep.” And think, “That capability and godlike reason to fust in us unus’d,” is but bestial oblivion.

“What a piece of work is a man, how noble in reason, how infinite in faculties, in form and moving how express and admirable, in action how like an angel, in apprehension how like a god! the beauty of the world, the paragon of animals—and yet, to me, what is this quintessence of dust?”

The physician devotes his life in the learning, finding new ways to limit agony, new methods to purge disquiet and new techniques to ward off discomfort. He marches to the beat of the infirmed and the vulnerable. Power and riches do not entice him or her; the need drives him. To quell, to soothe and “to take arms against a sea of troubles and by opposing end them,” is the quintessence of his being. The wretchedness of the body’s decay, do not fend him or her off. She whispers softly and labors with, “grunts and sweats under the weary life” each day and night to bring solace to her fellow being. The doctor in her cries as she looks upon her patient, “What is he whose grief bears such an emphasis, whose phrase of sorrow conjures the wand’ring stars and make them stand like wonder-wounded hearers?” This then is also her salvation. The quiet and hum of life, healed! For  most physicians feel as Hamlet feels; "O God, I could be bounded in a nutshell and count myself a king of infinite space, were it not that I have bad dreams." And those dreams are the voices of sorrow, of pain, of anguish and anxiety.

“We defy augury.  There’s a special providence in the fall of a sparrow. If it be now, ’tis not to come. If it be not to come, it will be now. If it be not now, yet it will come—the readiness is all. ”

We act as if our actions have little or no negative consequences. The unintended ones lurk underneath and yet we defy the omens, the dull grey beads of disaster that come in slow but hypnotizing fashion clouding the brain. “I shall win at the odds,” is the only thought and doggedly marches to that drumbeat. Neitzsche observed, “ Not reflection, no – true knowledge, an insight into the horrible truth, outweighs any motive for action…” We do arrive at incremental truths about the state of the state in medicine and yet with a flourish of this and that we do away with the warning signs and blink them into obscurity. Their minds are made up. It is what they must do and there the illogic fails for the powerful. For in the end, “And thus the native hue of resolution  is sicklied o'er with the pale cast of thought, and enterprises of great pith and moment with this regard their currents turn awry and lose the name of action.”

Polonius advice to his son, Laertes: “This above all: to thine own self be true, And it must follow, as the night the day, Thou canst not then be false to any man,” is remarkable in its hypocrisy. Whereas he is the meddling intellectual that proffers from the inferences he draws to influence the mighty king, he simultaneously offers that Hamlet, without proper reasoning, is mad, “Though this be madness, there is method in’t.”

There are many who embody the flesh of Polonius. They contrive and conjure to manipulate circumstance. These clever and studied orphans of untruth live in the dichotomy of their stardom and villainy; one desired the other earned! They spin from the wombs of their mentality a web so intricate that it confounds the minds of many. The complexity so intricately weaved that only simplicity alone can undo. Yet the wandering, believing minds that cannot chart the course to reason find ways and means to consolidate their thinking and in so doing any words to the contrary that attempt to alienate such unholy wisdom are demonized. The vile mechanism meanwhile feeds the; “Eyes without feeling, feeling without sight, ears without hands or eyes, smelling sans all…” There are also many a Rosencrantz and Guildenstern in society willing to take on the task of distraction, of execution of opinions and reviling sense with nonsense to gain favor and trust of the kings. These are fools that “cleave the general ear with horrid speech, make mad the guilty and appal the free, confound the ignorant and amaze indeed the very faculties of eyes and ears.” These are charlatans, whose folly is only known to those that reason and think and who understand and wait with patience and true knowledge. For villainy “though it have no tongue, will speak with most miraculous organ.” Eventually!

“Make you ravel all this matter out

That I essentially am not in madness,

But mad in craft…

O shame, where is thy blush?

Rebellious hell…”