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…”

" HELLO "

The current zeitgeist in medicine encompasses a wide range of “DO NOTs.” The kind that limits a physician’s input in the care of the patient. Without the shade of a thought that medical evaluation is being reduced to a set of guidelines; the “DO’s.” It all stems from the mantra that was proffered some time ago, “Hospital Stupidity Costs 85,000 Lives and $35 Billion Per Year.” After the much ballyhooed report there were fixes attached to the follies that created the problem of these “premature deaths” Everyone in the bureaucratic industry ran amuck with the paper in hand and started pointing fingers and laying blame across the threshold of sanity. The bureaucratic jungle is a flourishing canopy of protective veil that hides its own flaws to the detriment of all. The medical world was stunned, actually stunned by the reporting and not having any numerical values of their own, starting nodding their heads in unison when the media poured out their venom by using simple arithmetic to get higher ratings with the likes of “Medical errors kill enough people to fill four jumbo jets a week.” 

The foothold had been granted and the bureaucratic “dogs of war” had been unleashed. The entire medical care industry was soon tied up in knots with regulatory fiat. Many well-wishing physicians started to move in lock-step with the mandates and guidelines and other entrepreneurial spirited ones devised their own schemes to rip a page off the book of the incipient collective thought and created the terminology of the “public good.” One such entity; The American Board of Internal Medicine ABIM organization added to their once a lifetime certification examination the process of a 10-year recertification process and as the bureaucratic voices within grew their penchant for luxurious items and high salaries grew as well and they added the Maintenance of Certification process; a biannual process that reaped more than $130 million in 7 years.

While these spectacular shenanigans were going on the bureaucrats, policy wonks and legislators wanted to quantify every communication between patient and physician in a “meaningful” way through coding for billing. The CMS or Centers for Medicare and Medicaid Services gave the dog and pony show to the American Medical Association to come up with more lipstick on the pig with the ICD coding system. The ICD-9 codes numbered in the 17,000 for all medical diseases and each coded was fitted with an “appropriate payment.” Seeing a potential for a follow up revenue to the tune of $200+ million the AMA upped the ante by creating the 70,000+ coded-ways to describe medical illnesses with the ICD-10 coding system. This was a bonanza for the AMA, whose survival no longer seemed to depend on membership of physicians but on its alliance with the industry, governmental affairs cash cow and the data mining wonks. This coding system, they surmised would help the medical insurance industry to actually see how and when and where the illnesses occurred, maybe in the hopes that further legislations would help create more checklists and legislations for the common folk with the “DO NOTs” and give the insurance legitimacy in payment denials to the physicians and other care givers. A win-win for all they said.

Meanwhile the patient and physicians started to see barriers erected in the empty space that existed between them. Once the physician would sit and listen to the patient, eyes locked, hands touching to determine the malady, a soothing voice to comfort against the pathos of the cellular machinery now suddenly the space had thick walls of checklists, guidance, warnings, etc. erected between them.
Communication, once a simple process of speaking and listening, soon became a legal verbose jungle that had to be done for the perfect patient understanding of the expressed information. The voice that once said, “Hello Mrs. Smith” now was broken down into the nuance of implied meanings in the word “Hello!” Was there any implied empathy expressed in that word or was their implied coercion or threat? What was the meaning of the word "is" soon took reins. Empathy leaders sprung up all over the medical education landscape to fill that chasm. Linguistic experts were hired to determine the shades of the meaning within the meaning of the word itself. Meanwhile as the sentence was being analyzed by the billion-line codes of the software algorithm, the payment for services rendered by the physician was being held in abeyance till resolution was reached. Ah! no empathy...no claim...denied! Each step of the communication with its many turns and twists had to be carefully scrutinized. Any deviation from the norm coded into the algorithm was rejected and the physician reprimanded for his behavior. At that point payment was not even on the physician’s mind because a much higher fine could be imposed for such a misdeed. This is where we find ourselves today. Ignorance is no bliss.

The universality of error-making, the inevitability of it and the humanness of it are now a forgotten knowledge. What remains is the “DO NOTs” and the “DO’s.” We have ceased to learn from errors. We only need the errors to find fault and point fingers of blame, because it soothes the bureaucratic mind to do so. The bureaucrats and other wonks seem to think that the current knowledge is the last drop from the fountain of wisdom and there are no more springs or pools of knowledge left to behold. That, what is, is IT! What they don’t understand that today’s knowledge will be supplanted by tomorrow’s discoveries and become laughable if not outright disdained. As they print out their mandates and grind to a halt the very machinery of human excellence, a hefty price will have to be paid, someday soon. Economics teaches us the same thing. Forever tinkering with fiscal policy will have its day of reckoning. Sometime the illogic of the rampant bureaucracy blunts even the Occam’s razor with its layers of Matryoshka Russian nesting dolls approach.

The rabbit hole has gotten deeper and deeper as more blinding rain water flows through it. The deluge from the bureaucratic mindset has flooded the lands and only an Arc will save us now.

ME and YOU

If you did not read, would these words have meaning?
I write this in hopes that you might read.
You read and comment in hopes to further thought.
Our very being, presupposes an eye, an ear, a mind, comprehension!
So then dear reader are we linked for our existence?
If we are, then does not our existence imply mutuality?

Heisenberg's duality exists.

Count you out
Is counting me out.
Particle or wave,
we are linked,
through sight.
My presence is through your eyes
My absence in yours.
Our desperate lives, lived in hope
Of connection.

Eve had Adam
To sooth his aching cage.
Shakespeare's idiot, his spectators and stage

My words persuade you to comment;
We are connected.
In your words, I find existential happiness.
In your absence a deeper sorrow.
The art of belonging is the art of love.
The art of neglect, a demented loneliness.

Without you, I am not me
And without me, are you?
Ambiguity lives
And then it is no more
Schrödinger's cat lives!