MEDICINE AND RACKETEERING

We are, after all, all humans. We share a common ancestry. If you know a bit of molecular medicine, you would know that there is a “Mitochondrial Eve.” That, all share the same mitochondrial DNA from the “Last Common (Human) Ancestor,” a woman. And yet there are legions of humans who believe otherwise. Perhaps their greed beckons them, or shades their eyes, or perhaps it blinds them to their common end. But there is no doubt that such a progeny of the bureaucrats has arisen and continues to flourish and grow, like weed, to overtake the once plush garden of that Eve.

On looking at the definition of the word, “Racketeering,” one finds this, “dishonest and fraudulent business dealings.” Hmm…simple enough, right?

It is if you have your eyes wide open.

But alas, all the goodness is interred in the sub-level surfaces of human activity, it seems. We define success as the men and women with the best toys. The race to that top of the mountain seems apace at breakneck speed. People climbing on other’s shoulders not to see further in the adventures of innovation and productivity but in the act of stomping on other’s heads to crush and bury them and their meek protests. And if protests do arise, they quickly demonize and or vilify the broadcaster of such protest. Charlatans have indeed gained a copious landscape and a highly visible lectern to pontificate the “Benefits” of their managerial swag.

Kris Held, MD @kksheld and Alieta Eck, MD @AlietaEck deserve the credit to bring this video across my visual horizon. It details the cozy relationship between the government and the private sector all cobbled together by the money bag exchange. It is all about self serving heuristics of those with the power to do so. The politicians want money to keep their enriched power base and other perks of “legal insider trading,” free jet-service to the Cayman Islands and the French Riviera all in the name of “Public Good.” Indeed, any and most actions doled out by these power-hungry trolls in the private sector and the government are marquee events under the euphemistic banner of “Public Good.” So, watch out for those words.

https://youtu.be/aQhsPLcFwN8

This video, encapsulates the racketeering in one sector of Medicine today; Cost of Medicines. And by the way, we are at the pinnacle of this act since the total cost of healthcare in the United States currently stands at $3.4 Trillion and escalating. That number alone is juicy enough to invite the eyeballs of some very wealthy individuals like Buffett, Bezos and Dimon to the stage. After all, why not partake in the health-palooza while the going is good to raise the topline and bottomline of their respective businesses.

Patients meanwhile are being told that their medical care is not “preauthorized” because of such and such reasons…mostly pointing fingers to doctors who it appears never seem to make the correct decisions for their patients. And if should one of those services be rendered then an automatic denial of 12%+ is served up by the insurance company, for the doctor to fight over for the next few months to get “reimbursed." The doctors meanwhile are forced to hire legions of paper pushers in their low revenue offices just to get paid. And that, dear fellow if you do a look back, is the reason why in 2014 thru 2016 the fastest gains in employment, while the whole rest of the world was asunder, was the medical field, was awash with new applicants, (that and bar tenders it seems) lowering the spurious unemployment rate.

Meantime the costs of medicines, if you surely have noticed, was going up. A hoax that seemed to have inadvertently been exposed by the greediest of all the hedge fund and Pharma bro, by the name of Martin Shkrelli.

https://www.cnbc.com/2018/04/18/pharma-bro-martin-shkreli-gets-sent-to-federal-prison-in-new-jersey.html

But he wasn’t alone. He was closely followed by Heather Bresch the CEO of Mylan who did the same with the Epipen; an emergent supply of epinephrine for children and adults in the throes of an Hyperallergic reaction. 

https://www.inc.com/james-kerr/the-mylan-epipen-debacle-how-tremendous-greed-can-lead-to-the-demise-of-a-leader.html

Recently thais was followed by another pretty face called Elizabeth Holmes of Theranos. All these and many more in the business of racketeering, it seems. You guessed it, these people have no virtues, save, extract lives and money, just like a over-taxing, over-regulating, mightier than thou governments.

https://www.vanityfair.com/news/2018/06/elizabeth-holmes-is-trying-to-start-a-new-company

This post would not be complete without mentioning one of my favorite bloggers, a cardiologist Dr. Westby Fisher @Doctorwes who has exposed the many virtue-signaling harms committed by the ABIM and ABMS against the physicians. And these organizations have amassed many millions of dollars in all the fine places for their “Annual and semi-annual Retreats,” all at the altar of “Public Good.” These organizations have never been able to show benefit of their quasi-knowledge tests undertaken under the strict scrutiny of “physical and virtual guards,” in confined spaces. Meanwhile by extracting large sums of money from the physicians they have their lobbyists, lobby the government to mandate their scheme to gain a universal order of such money extraction in perpetuity. So, please extend your kudos to him and Charles Kroll CPA @CharlesPKroll. As the war against these self-appointed middlemen wages on, the outcome is eagerly awaited by most of the physicians whose main concern remains; delivering good patient care.

http://www.changeboardrecert.com/anti-moc.html
https://www.policymed.com/2017/06/anti-moc-laws-picking-up-steam-across-the-united-states.html
https://practicingphysician.org/moc/
https://www.medscape.com/viewarticle/881274

These organizations ABIM, ABMS are fighting back with their “representativeness heuristics” to cobble together estimates of dubious harm and probability outcomes couched in their falsified estimates. It is important to remember that the incidental, anecdotal, irrelevant perceptions and other such haphazard cognitions can and do effect judgment and behavior of those at the higher echelons of power with “No Skin In The Game” (SITG). To the power-hungry crowd only money bags matter. So stay alert at the next signal that repeats the words, ”FOR THE PUBLIC GOOD.”

But as Shakespeare once said, “Mischief, thou art swift.”

Where did we go wrong?
When did we refuse to follow the path of “Above All do No Harm?”
How did we come to this?

We forget the patients, whose misadventured piteous overthrows in finding a sanctuary against illness do with their death, bury the GPOs and PBMs and other hidden bureaucrats between the money-sheets racketeering schemes to keep from visible light. Thus they remain alive and with their viper poisonous tongues and sharp fangs, clot the blood of all civility, confuse the mind’s messages and normal human discourse.

It seems that when the many who rushed to acquire MBA degrees from prestigious universities and got hired at institutions rolling with cheap and free printed paper money, these new hires were expected to come up with their “algorithms” to determine the best mechanism of monetary extraction from the tax payer funded largesse. An endeavor that was quickly replicated across the private industry. There were others as well, especially those educated in the “Streetonomics” of how to get rich schemes, duly exploited the loop-holes in the framework of morality and deceit was writ large. The damage these few have unleashed on the framework of this Great Nation is telling in where we are in our daily dialog. Anger and distrust breeds with equal fervor in our society today.

We have turned into a country of Lobbyists and other large “money baggers.” The bigger the pot, the more “say.” The more the say, the more regulations. The more the Regulations, the more stifling of the “Free Market.” The more stifling of the Free Market, the more the horns of the Socialism dilemma grow. The more of that and we are no different that Venezuela, Cuba and the rest of the totalitarian regimes across the globe. Give that a moment to sink in.

All beings emanating from the Mitochondrial Eve must face the same Common End!! 

So...

For now, ”Live Long and Prosper.” -Spock

Aircraft LANDINGS Made Easy

Let us talk about landing an aircraft, shall we?

Apparently from what I seem to find when flying with another person and even with another pilot, nothing seems so satisfying as greasing the landing. The rest of the flight blurs and is captured into this singularity called landing. You might have dodged a thunderstorm, you might have experienced a wind shear, you might even have encountered a gusty crosswind, but if, and that is the biggest if, if you didn’t chirp the landing, well then, you just displayed your incompetence.

In fact, several weeks ago, I was a passenger in seat 29A in a B737 on a very gusty day, landing at KEWR. The pilot up ahead behind the bolted doors must have been very good, he touched down smoothly without a lurch. Hmm… I thought, I had fallen into the same trap? Actually no. You see most of the flight on this large aluminum tube was on the triple redundant autopilot, but the landing was definitely the pilot’s, so he gets the award.

On the other hand in our tinier aluminum or composite bodied transportation devices, we can and do use “George” at cruise and sometime through descent but once in the 5-mile vicinity of the airport, it is all on the left seat driver. To put it gently, “You’re it!”

Consider approaching the 45-degree entry for the downwind. It is important to scan traffic and look at the departure end of the runway for traffic and potential landing zones if on a later flight the engine decides to pull a fast one. (VSO specified in this example as 60 kts – adjust Vso and tailor the advice to your specific aircraft accordingly). So on 45-degree approach to runway, Speed Vso * 1.6 (in most cases 95-100kts). Stabilized with the appropriate power settings. Left downwind stabilized at 1000 feet (midfield) above the runway threshold keep the speed to VSo *1.5 (In most cases 90-92 kts). Turning Base reduce to Vso * 1.4 (in most cases between 82-85 kts). Turning final reduce power for Vso *1.3 (in most cases 78 kts). The last 500 feet on final are a matter of experience and practice. In short field approaches reduce speed to Vso *1.2 ( in most cases 72 kts).

Ok, ok, I realize the above rhetoric looks kind of pedantic, but now here is the key to the puzzle. Let’s say you are in a Cessna 172 or Archer aircraft where the power settings are by means of the RPM only. The trick is to set the power setting to the most appropriate setting (Maybe 1600-1700 RPM) and then use the flap settings to realize the speed reductions. This is easily done at altitude on level flights. Go out there in the wild blue and practice this to figure out at LEVEL ALTITUDE say around 1000-2000 feet and see what the aircraft delivers. Start with 2000 RPM and reduce your way to 1500 RPM with increasing flap settings to realize the speeds the aircraft delivers, to figure out what works for the aircraft you are commanding. Once the appropriate speed is determined. Write the power settings and configurations down and voila you have a winning strategy. In the Arrow , Mooney, Bonanza and other Manifold (MP) yielding complex aircraft the idea is similar but slightly different. Establish the power setting with a 17 MP and a 2400 RPM (should get you to gear speed) Put the gear down and trim for level flight and then use the flaps for future speed reductions. Further reduction in power starts at 500 feet on final. Hmm…QED.

Flaps are a great addition to the wings; they provide drag and 30 degree flaps essentially are like barn doors that decrease air speeds and allow us to fly deeper descents to the field without increasing the air-speed. Pretty smart thinking by Edward F. Zaparka in 1932. They also by virtue of the increased camber of the airfoil (wing) help reduce the stall speed. A double advantaged whammy, so to speak. Lower Airspeeds, Lower Stall speeds and viola you can hover down to a chirper landings...most of the time. Except that one time when the Airbus 321 pilot decided to flair 10 feet above the runway and darn near took my teeth out. I can still some days hear that chatter.

Nuance: In gusty winds add HALF the gust (say 320 10G20) or 5 kts to your speed by adjusting upwards the MP or RPM as the case maybe.

Another nuance: The Dreaded, sweaty and bile eating last 500 feet. How do we address that? Simple. My dear Watson!

The power is in your hand. Get your aircraft visually aligned with the runway. Put the nose of the aircraft right on the approach end of the runway and KEEP it there (as if you are in a shallow dive), now adjust the power (MP or RPM) to maintain the Vso *1.3 till you know you have the runway made (which means in case of complete loss of power at that altitude, you can glide to a safe landing on to the runway). But please make sure if this format is different than your instructor’s advice, practice what your instructor says and if any of the above is helpful to your thought process, incorporate while he or she is stuck in the right seat.

As always… Safety is no accident, so FLY SAFE!

Ahhhh...

A short video of 7 Landings in 7 minutes for your viewing pleasure...

https://youtu.be/ozrowvQYv_M

"PERMITS, LICENSES & CERTIFICATIONS"

Humans have a neural substrate of imagined sounds. In music sometime anticipation is used. At times, the musician will withhold a much-anticipated note to increase the desire to hear it by the listener. In fact, our mind predicts such imminent structural pauses as whetting the desires of the potential future. Ringo Starr of the Beatles did that masterfully in his drumbeats. But what happens when that note fails to materialize? It simply jars the mind. 

Why I bring that up is simply to explain the nuances in our current state of society that have subverted the naturally occurring structural pauses into dead ends. Permits and licenses and certifications are everywhere! The pedigree of these chaotically semi-predictable meanderings has long been passed down as pedogogical constructs. We expect them. We know them to happen as the laws of Nature and civility.

Imagine if you will, a 9-year old sitting on a bare-bone furniture of chair beside a table with the following set of artifacts. A Pitcher filled with Lemonade, some plastic cups and a sign “50c Lemonade.” People come and go in front some with a glance and a smile and others willing to partake in the offering. Soon the child has accumulated $8.00 as her revenue and starts on the second pitcher when a blaze of blue and red lights filter across the horizon and stop in front of her lawn. By then, the child is in tears and the parents are answering legal questions to protect their child and themselves. Far-fetched imagination, you think? Nope. It happens in most of the “ultra-intellectual” states of the United States today.

In fact, the other day there was woman aptly termed “Permit Patti” who upon seeing a 8-year old selling water called the police. Ah yes, she was the whistleblower against the 8-year old child. Permit Patti was looking to put an end to the child’s entrepreneurial spirit and dashing all hopes of an innovative mind of the future. A shame!

Yes, we as a society of the “developed and civilized” world have become the most developed “permit, license, certification needs” hungry society of all times. The legion of Rent-seekers are burgeoning to fill the void where common sense once prevailed. A pity! You want to cut a tree down, get a permit. you want to put up a fence, get a permit. You want to add plumbing to your house, get a permit. In fact, you want to have a garage sale, get a permit. Our lives revolve around the “Permit Alleys” of the Municipal buildings and other such Regulatory bodies daily. Still, I haven’t yet seen a permit for practicing witchcraft yet. But I have seen one for landscapers, pest catchers, pet groomers and all other sort of occupations. It appears, the authorities are at the threshold of every mode of work one can do, collecting fees.

via Charles P Kroll CPA

Case in point, once again; Medicine. You need a license to practice medicine governed by a small cadre of physicians and others called the Board of Medical Examiners (BME) (Hmm... The others include; lawyers, lay people, nurses, insurance liaisons and others sought fit to deem if the physician is fit to practice medicine). Each State in the United States has one. (Then there is a Federation of the Board of Medical Examiners a quasi-non-governmental organization that seeks to rent-seek at the National level and recently tried to acquire a large multi-million dollar building in Washington DC near the seat of power to exact some for itself, but failed). Well okay then, that is the law of the land. And away we go to the proverbial “paddy-fields.”

Next, we get to some off-the shelf, quasi-self-appointed-governing body that has coopted some of the BME power over the physicians by crafting a net over the entire nation and wishes to exact its authority and the physician's financial resources around the globe as the global authority in physician knowledge testing. It is a not for profit organization. Using their “(esoteric-)knowledge-based examination certifying that the physician had achieved a level of knowledge above the rest of his or her peers, they claimed, was a badge of excellence, . No support for this excellence in patient benefit or physician benefit has EVER been found. Yet the drum beat goes on. That examination, initially, was voluntary and would cost around $2000.00. But as time went on and conflicted Authors from that Board wrote self-serving papers trying to prove the validity of the need for that examination as a corollary to a physician’ s competence in caring for the patients, the cost now seems well in advance of $10,000.00-$15,000.00 (if you factor in all associated costs). Soon ABIM/ABMS were awash with money, enough to lobby and win the governmental seal of approval. The Certification Examination being a very expensively generated and with proprietary set of statistical modelling tools, was held in “prison-like environment to prevent physicians from copying the questions. See Dr. Westby Fisher’s podcast. 

via Charles P Kroll CPA

The ABIM/ABMS revenue stream was increasing at a geometric scale but not as fast as the salaries of these “esteemed” board member individuals and their lucrative pension plans. They decided that the initial examination was not enough to sustain their avarice and thus the new dictum came down; “all physicians needed to take the recertification examination every 10 years.” There was another revenue spike to the delight of these few. Soon the Cayman island resorts and associated “free-from the prying jurisdiction of the IRS,” banks were frequented for annual, semi-annual and quarterly “Retreats.” A nice multimillion dollar condo in Philly fully furnished with a Mercedes Limousine and Tax-exempt cash stored offshore for safe-keeping became a “brilliant scheme” away from the prying eyes of physicians and others, didn’t it? Or so they thought, till it was brought to light. They concocted the scheme to have a continuous “Maintenance of Certification” operation inflicted upon the physicians, because, well, physicians, they implied, seem to lose their grasp of medicine pretty quickly and their care could not be trusted, because, well, jumbo jets filled with physician mistakes were crashing and causing a high mortality...see the Susannah Fox piece  virtual patient-loaded-jumbo-jets crashing every week. 

Meanwhile the MOC as it was named generated oodles of money to the tune of $160+ million for the so called Not for Profit organization, yet the handsome salaries, bonuses and pension liabilities of these few, continue to exceed the revenue streams. “What to do?” they must have thought? More pseudo-scientific papers were written to convince the need for the maintenance of certification (MOC). Those with vested interests and no SITG (Skin in the Game) http://www.medtees.com/content/MedicareBilling.pdf sang praises as they lined their pockets,while, in the meantime the physician force was getting despondent, depressed and with the burdens imposed upon it from this organization and other governmental Regulatory initiatives, there was a rash of physician suicides. “No, don’t look there!” they implied, “Look here, where we are doing so much “public good,” by testing the competency of the physicians constantly.” But the gig seems to be up!

A few physicians have seen the charade and the façade behind the whole scheme. More are learning daily. And, the dollar-lined walls of these organizations are starting to show deep cracks. 

“Permits,” it’s all about permits and licenses and certificates Oh My!

A society so constrained from achieving its potential will ultimately die from starved ideas. The bureaucratic hold on innovation and entrepreneurship always destroys the desire of the few lurching towards the “Next Frontier.” Only the few crooked ones make out fortunes for a while until the hammer comes down on them: Theranos and her Holmes face, to name one. Where exactly were the permit-granters, allowing $9 billion investor money and hundreds if not thousands of patient harmed based on inexact diagnostic report generation. Where were these “expert permit granting authorities?” Nowhere close because Elizabeth was smart enough to fill her Board seats with well-known politcos and power-brokers so no one dared, until John Carreyrou, a recalcitrant health-care reporter from The Wall Street Journal did. 

So you see dear reader, this charade of “Permits, Licenses and Certifications” is a game for the thrones. Decrees to pay up and shut up. Who thrives is known. Who gripes, who cares?

By the way, I forgot to mention the Medical Organization… It is the American Board of Internal Medicine (ABIM) and American Board of Medical Specialties (ABMS). Other agencies and organizations usurping physician’s abilities to give good care to their patients also include the now famous American Medical Association with 12% membership and most (Almost $200 million) revenues coming from the CPT coding needed for the Electronic Medical Records and Billing… @CharlesPKroll (twitter) a stalwart researcher CPA, adds these miniature bites to inform us:

AMA Membership Dues vs CPT Royalties 2008 - 2016
☐Total Dues: $362.3 million ☐Total Royalties: $673.9 million
☐2016 Dues Down $5.0 million (-11.3%) from 2008
☐2016 Royalties Up $53.5 million (+97.1%) from 2008
☐2017 Dues Down Another $2.5 million

 The American College of Physicians and other specialties with the word “American” before it, all appear in cahoots with raising their revenues thru these quasi-ponzi authoritarian schemes without concern about the harm to patients.

The "note" of humaneness and harmony is missing and there is grave dissonance in the society these days. Maybe it will pass and maybe it won’t. But it won’t be for the want of telling the truth.

Because Dear Reader, remember, if you harm the physician, you also harm the patient! 

I wonder how they (the rent seekers) can live with that?

https://youtu.be/y0OQEeudpZk 

https://www.huffingtonpost.com/entry/white-woman-sees-black-girl-selling-water-allegedly-calls-police_us_5b2e94a5e4b00295f15cf35f

https://youtu.be/EZJpvZ6ML0c

https://susannahfox.com/2013/02/22/a-jumbo-jet-a-day-who-said-it/

https://www.vanityfair.com/news/2016/09/elizabeth-holmes-theranos-exclusive

WHERE THE SUN STILL SHINES

I found it interesting having just arrived at the meeting from outside, where the grass was velvet green, flowers peeking over each other to get the rays, while the bees buzzed around with their nectar and the trees fully clothed witnessing the chirping birds building nests for a comfortable summer. Indeed, it was Louis Armstrong’s “Wonderful world” day out there.

But in the cramped darkened quarters of this large auditorium where almost all seats were occupied, the speaker was animated and challenging with questions to keep his audience from dozing. He seemed to paint a picture of a bleak world, no, not the one I had exited to enter his. It was a bleak world, devoid of color. Metaphorically he had dressed down the trees to their bare branches and painted the grass a drab patchy-brown color. And flowers? Forget them. Not a one in his dystopian viewpoint. Clearly this was a significant (not in a statistical sense) departure from my perceived neural substrate. The space-tie continuum was disrupted. The space where I was, the time just passed and what it is this talking head expert was proposing for the future, were at odds. Minsky would call this the collapse of his “Temporal Segmentation Boundary.”  The expected norm was violated and in its stead was a rude exposition of a single mind’s dilapidated shack in the air.

And yet, here I am trying to reconcile the beauty outside with this throw the darkest color on the brightest of canvas and call it a masterpiece sort of view. What was this speaker’s angle, besides the doleful drab and murky future? Another mechanism directly gathered from the Heath brothers book “Made to Stick.” Call up an anecdote and generalize it to all then make the claim of your personal ideal or ideology and push it in through the exercise of marketing and promotion. Soon the legions of the pseudo-journalists pick it up and claim their favorite Newspaper front-page column and all is well in this corner of the cubicles, except what is really out there, the… truth!

Ah yes, he claimed that physicians were responsible for 95,000 to 135,000 unforced errors that led to premature deaths. Of course, he brought up the “Jumbo Jet” analogy of “1 jumbo jet crashing every week of the year,” correlating mightily between imagined stuff and estimated stuff, thus making all sorts of “stuff.” He cautioned however, those were very conservative estimates. Implying there were more in the morgue than met his eye. From there he polished off some more “talking points” of the experts. “Too many tests,” he said, “was causing too many unneeded procedures.” Okay, I thought, where was he going next?

I didn’t have to wait too long, “Imagine,” he said, “the healthcare costs of $3.4 Trillion,” and he laid emphasis on the “Trill” of the trillion with a shrill that had everyone on the edge of their seat as if watching “Exorcist” for the first time. His sermon continued for what seemed an eternity, filled with graphs and statistical jargon only an illiterate would love. Struggling to keep my attention, my mind was back to the living world outside.

There is mercy in time. The whole darkness lasted a full 90 minutes and then everyone was allowed to mill around, stretch their legs and grab a coffee to awaken their senses or what was left of their temporo-parietal-frontal cortex.

I find this disjointed, poorly thought trough ode to disaster being played out at most medical meetings and in all the opera houses of the medical Academies and Associations. All of these “experts” seem bent on pointing the fingers at every one of their former colleagues as the cause of the plague that has beset the medical industry. And there is no question about the fact, that Medicine is now an Industry. It employs more MBAs and administrators than it does doctors. Perhaps you know that in the waning months of the 2015-2016 the fastest growing segment in employment to keep up with the regulatory burdens of yesterdays, was the medical office complex. So, clamoring about the rising costs and blaming the physicians has now become a “art du jour” an art-form perfected to a point where non-physicians are considered better in rendering patient care than physicians. To that effect the non-physician industry is booming at a 30%-90% growth rate per year as the overall physician numbers decline steadily from attrition, depression, suicide and other assortment of non-fun reasons. This is helping the bottom-line of the Insurer industry whose Topline and bottom-line continues to grow YOY. Payout less for mediocre services and call it topline care. Yet as history has taught us in the last 2 years the diagnostic workup has escalated dramatically due to indecision and lack of understanding of medicine. Cheaper labor, cheaper product and marginal healthcare is what the Medical Industry is glowing in the dark about these days.

Treating patients is a complex chore of understanding the malady and rendering an opinion for alleviating the rub. It comes naturally to those who have happily gone into the profession for the sake of healing, spending countless months and years in the process. Yet, if one were to listen to that “esteemed speaker,” the sky was falling with deaths and destruction everywhere and all around due mostly at the hands of the physicians’ follies.

Why such a disconnect? It appears there is more to the story than meets the eye. Experts and the wealthy lobbyists who have “NSITG” (No Skin In The Game) have determined that their future is safe and that they can pay their way to a healthy future by the world leading authorities in subspecialty medical care should they need it, but the rest should be limited in the use the resources. For the plebian, the non-physicians would serve as the gateway to average health, just shy of full recovery. After all Malcolm Gladwell’s 10,000 hours are now trimmed to an average of perhaps 2,000 hours. And I for one still think that 10,000 was the bare minimum in just comprehending the nuance of Anatomy and Physiology.

But here is the interesting part in that 90-minute lecture that I failed to mention earlier, simply to keep you on the edge. At the end of the lecture, a wide eyed newly minted free thinker asked if the current state of medicine was more as a result of the administrative complex with its associated managerial brigades acting as middlemen and women collecting large sums as intermediaries, rather than the costs of the physician’s rendered care? The hush that followed was spell-binding. After a few ‘ums” and “ohs” the speaker countered with a question, “So your premise is contrary with the facts, I just mentioned?” Huh? What facts? He was merely pontificating without any facts in his more than 60 slide-deck of see this then do that. Slowly the rumble started and other hands shot up and an abrupt end came when the organizer had to usher everyone out to the beckoning fruit plates, croissants and coffee outside the auditorium. Another disastrous reality averted.

It appears, and you might have noticed it also, that when a question is asked against a set of conjured facts, the answerer can only be responded to with another question or with hyperbole of a prepared rhetoric. To confuse and obfuscate under the duress of falsified data is the name of the game. Get used to it, or fight it, I say. Kudos to the free thinkers amongst us.

Calls into question the malarkey that exists in medicine and the larger society as a whole.

Well back to the beauty outside where the sun still shines and the birds still sing and the children still at play. Enough with these Medusas and their serpentine “values” that turn one into a petrified urn of fear.

THE STENCH OF TRUTH

The stench of truth
Shaven off its husk
Fitted to a frame
Anchored in reality
Breathed into the air
Relieving the burden
Of bold and white lies.

The toll of that bell
for what it rings,
Its pitched dissonance
Rocking and rolling,
End over end,
Unceasing chaos calls
Of warring Liberty and
Her Sister; Imprisonment.

Factions in opposing camps
Vested to ideology
Buried in debts
Of human thought
Forever in deadly embrace.
To kill or be killed.

Winning is death
For both and neither.
While truth lives
And fiction dies
To be reborn
To die a thousand deaths.

Like hope from a fractured cry
Forever its piercing words
Drowned in the battle hymn
Reshaped anew;
Like time, recurring.

What is in man
That bends the truth
lies like a serpent
Cold hearted and
Weakened from the kill
Yet hungry for more.

What is it?

Life goes on
As lies proliferate
The Sun bakes
The breeze soothes
The leaves whisper
The petals fall
With regret.

Once again stench rises
To relieve the land
Of these untruths
As truth fills the air
To ease the burden.
The cycle renews,
The earth breathes.

Defining VALUE

I went looking for a widget, only to find there were many kinds of the same widgets in the store. So, I asked which widget would work the best? The savvy salesperson answered with a question of his own, “What is it that you need it to do?” I listed some required needs and he ushered me to a stall with 3 different kinds of almost similar widgets. “Which one has more value for you?” he asked inquiringly. Hmm…after much finger, thumb Rodin-like expression, I picked up the shiny digital one over the battle-tested raw metallic one. Needless to say that 24 hours later, I was back asking for a replacement widget.

Based on Need

The term “Value” is a nebulous cloud of molecules that only collide to create an image based on the individual’s perception. You might consider the following thought experiment; Do you value Ford over than GM? The answer might surprise you. And there are many imputed variables there to bring about a rational and satisficing decision. Or better yet a decision between a Coupe and a SUV is based on need but between the many different kinds of SUV lies a choice and that is also fulfilled by desire and need. Or an even more extreme version of “Value” lies in a bottled water. At an airport you will find scores of cylindrical, squarish, small, medium and large, colored or plain bottles touting the freshest, most delicious water for your flight. Which one has value to you is based on your hierarchical metric of this amorphous thing called “value.”

Based on Armchair determination

By now you might have conjured up the concept that “value” probably lies in the eyes and mind of the beholder. While somethings might have “Value” to one person it might not for another. Since we all come with our own suitcases full of predestined baggage, acquiring loads and loads more as we move through time. Thus “Value” differs with different phases of life and time. In some cases, finances are involved, in others aesthetics, in still others pure function and lastly for some pure unadulterated desire and want.

But that is not what the “Experts” from the Elite School of “We are the Experts” like Slavitt, Gruber and Emanuel, have come to the conclusion. They have been screaming from the rooftops that in medicine, value is based on the outcome related to therapeutics offered. Hmm, okay, now let’s take a chill pill before we go answering to this loco-motivational self-righteous morality-signaling bunch’s point of view in medical care.

Based on Marketing and Promotion

The bluntness is partly a function of the historical mess these “experts” have created and partly because they have made a mockery of the philosophical integrity of the Value Theory. This theory states that Value is divisible into “Moral Value” as in those belonging to the character of an individual and “Natural Value” as those belonging to an object. A “good person” versus a “Good thing.”  Ok, I admit it is just a theory, nonetheless it has some gravitas. These “experts” have cunningly crafted a meme that seals both those disparate values into a combined whole where attempts to void inseparability, destroys both. Let me give you an example… The term “Public Good” is designed to make you think that some virtue is at stake, if whatever is recommended is not done, but look deeper and you realize that it is manifestly only good for the “Public employee” their promotion and pay check and potentially a disaster for the private person or his/her ruin. Merging the two “Values” has come to claim at least one life recently, i.e. Alfie Evans in the UK under the aegis of the National Health Services (NHS). These memes crafted as they are, are designed to assuage the softer minds in all of us; words to comfort but deeds to actually destroy is their credo. (Read Here)

These minions serving bigger minions have combined the Business lexicon into their empathic virtuosity vocabulary. They have merged Value with Metrics. Please do not snark at this. Look up the two words individually or collectively and you will understand the goal of the oft repeated and revered term “Value Metrics.” Look deeper and you will find it embedded in all forms of Healthcare discussions. Why? Because, starting a conversation from that baseline leads to the merger of the “Moral Values” and “Natural Values.” If you start there, then the merged premise becomes the anchor and the frame of reference. (Definition:A value metric (also called a pricing dimension or a pricing axis) is basically the foundation of your pricing model).

Medicine is both an art and a science. Do you agree? If you don’t, perhaps you might consider reading something else, since your mind is already made up. But if, if you do agree that there is Art in medicine, then stay with me, friend and we shall explore this a bit further.

Assume two patients, both diagnosed with the same bacterial pneumonia are admitted to the hospital for their care. Both of equal age, one with more vigor than the other. Both treated with similar and appropriate antibiotics. The less vigorous one responds while the other requires additional resources to circumvent this rapidly multiplying micro-monster in her blood stream that has established a beachhead and breached the immune surveillance defense. In the eyes of the “Experts”, especially those that sit in cubicles and do some patchwork of “billing denials” (to the order of 12% of all medical bills) in order to thwart the requesting physician from receiving a timely payment for services rendered.  The complex world of the medical industrial complex, has now become the norm. That denial keeps the “Time Value of Money” squarely for the agency (Insurer) and creates 6-12 weeks of Medical Revenue Cycle (wait period) for the Physicians who struggle to meet the payroll. Permanent denials are also handed out because “Value” in the eyes of the “experts” has not been met by the requesting billing physician and if you fail to challenge, you don’t get anything period. Failing to challenge is easy when you are a hamster in the wheel, working 12 hour days and managing this complex medical arcade.  In actuality, given the above scenario, both patients survive the onslaught of their malady, one’s stay was less expensive than the other. The authorities deem the longer stay as the physician’s lack of good care and absence of average skills to manage the condition appropriately. After all, how can the frail person recover quickly while the robust one had 3-4 extra hospital day stay? It must be the physician’s fault.

You might think the same, if you were not well versed in the nuance of each patient’s biology. But reflect on the fact that a minor mutation of one’s gene might have trifled with the protective white cells functional ability to defend against the onslaught. And therefore, the response of one exceeded that of the other. The “Value” as determined by the person in the cubicle was expense based on “Value-Metric” and not the breach in the immune surveillance. Not being educated, how would he or she ever know such a nuance? This faceless person is doing the bidding of the customized checklist manifesto. A manifesto granted him/her by the hierarchy, designed algorithm from a set of other algorithms, strictly based on the IFTTT (IF This Then That) and cost the department, division and the Insurer (Government/Private) oodles of money had to be accurate. Ah, and here these agencies tout, “no emotional Homo Sapien element was involved in the denial process.” What utter malarkey! 

Based on Mandates & Regulations

“Value” as breathed by the “experts” is a relative term and the relativity is based on the hard and finite resource of money, read “Value Metrics.” It has very little to do with the rendered care or the nuance of individuality dealt expertly by the physicians rendering the care.  But alas legion of Twitterati, Facebook and Instagram followers are already sending reams and reams of digital information touting the benefits of such “Value Metrics.” After all they ask themselves, resplendent in their googled knowledge and fully vested with the simple concept of “Less is More” therefore “More is necessarily Less” and therefore should not be “gifted”/reimbursed in any way. They forget that “Less is More” applies to a knowledgeably determined need of an individual and not a capriciously based algorithm combined with a useful idiot punching keys. Less diagnostics have a place in medical care, but less needed therapy has no place in society. Life cannot and should not be equated to money. Equating the two is a slippery slope and leads to life-long trauma on the well-being of an entire society. There is definite need to circumvent frivolous care. But there is no need to reject appropriate care on the bases of cost.

Based on Mandated Outcomes

Another case in point is the Hospital Readmission Rate used to redefine “Quality,” a primary metric (or as previously mentioned of “Moral Value” implying, lesser the rate of readmission means better care apportioned) and then as “Natural Value” (less cost to the insurer and the government) as a secondary metric. It turns out, after this mandate was enforced on Hospitals, the heart failure death rate rocketed up. More people were left to die without care because readmission was frowned upon and the patients if they did attempt to go to the hospitals in distress, were discharged before 24 hours (not considered an admission) or simply turned away from the Emergency Department of the Hospitals. After careful analysis, not a whole lot of “Natural Value” was saved from this “expert’ meme, because legions of more administrative staff were needed to oversee the mandate, but a lot of “Moral Value” was lost. (Read Here)

Based on Minions

And as I have often hollered through my words. The “Cost of Medical Care” in these the United States is not based on the care rendered. It is mostly from the administrative minion costs, be that at the insurer level, government level or at the medical practitioner level. All contribute to the $3.4 Trillion annually. Here again the “Natural Value” of blaming the physicians for the high cost of care is hidden behind the “Moral Value” of virtue signaling by the Insurers and the public policy managers who do not want the attention focused on their paychecks and their “paper pushing techniques.” And by the way, seriously, if one wanted to get all these fat cats and their administrators out of healthcare, the cost of healthcare in the US would drop by at least 1/3^rdif not ½. (Read Here)

For now, like the salesman that I met, “Value” lies in the eyes and the pockets of the moneybag “Holder.” 

TRUST BUT VERIFY

At the heart of medicine is the expansion of knowledge and its governance. Let us explore that a bit as we go along on this journey together…

First imagine forcing a cotton thread through the eye of the needle; the fibers catch the sides of the eye and the thread twists and turns making the progress difficult. Science too works through fits and starts, from moments of eureka to utter despair. One cannot force a braided thread through an eye of the needle that does not cater to those dimensions. It is akin to forcing a square peg through a round hole. Dimensionally, that is a challenge. So, first some elation; these are some of the tales of human ingenuity forged through diligence and perseverance …

The first part of knowledge is an old streaming phantasmagoria of the past; an acquired information that is understood and then verified. Take Marie Skłodowska (Marie Curie) for example; only one of two people in history to have received the Nobel Prize in disparate fields of physics and chemistry. One has to look at two other greats in science who paved the way for her discoveries; Wilhelm Roentgen discovery of X-Rays in 1895 and Henri Becquerel discovery of the penetrating powerful rays from Uranium salts. From those humble beginnings and pitchblende arose Radium and Polonium via differential crystallization. All in all, a magnificent feat of human endeavor!

Marie Sklodowska

Another simpler time brings back a past shared by a certain Edward Jenner, who through keen observation had determined that milkmaids were somehow immune to Smallpox. His assumption was that the pus from the blisters on the milkmaids’ hands were rendering them immune. Harkening to his mentor Sir William Osler’s advice, “Don’t think, try!” he inoculated an 8-year old James Phippes, the son of his gardener with cowpox and rendered him immune to Smallpox. During the 18^th century Smallpox had decimated 20% of the population. In 2015 through vaccination, we have extinguished the disease.

Edward Jenner

Now a couple of tales that don’t get out of the bathtub and make you run naked through the streets…

Top among such human foibles is the Tuskagee Syphilis experiment. Between 1932 and 1972, 399 impoverished individuals with known diagnosis of Syphilis were observed without available treatment to determine the disease progression and timeline. ( Here)  Or another in the name of science was the Japanese experiments during WWII on native Chinese inducing vivisection without anesthesia, induced gangrene, live weapons testing, germ warfare infections, and other such macabre testing in the name of science.  While the story of Thalidomide and children born with phocomilia is well known, ( Here ) there is little heard about a 2007, drug trial with THN1412, a leukemia treatment that caused significant harm and death to the participants.( Here ) Josef Mengele’s experiment on eugenics and twins is another lasting memory of despair.

Tuskagee victims

What would make humans conduct such experiments? It boggles the mind. Yet as the Stanford psychology Professor Philip Zimbardo’s prisoner experiment clearly shows humans when given the power use it without discretion. And to further the damage the ones treated as prisoners develop varied forms of the Stockholm syndrome; acceptance! ( Here )

Today most of the “science guys” are happily running with the banner of “Optogenetics” (modifying the cerebral genes into being switched on and off, on demand. ( Here ) We think of the Large Hadron Collider as a means to discover the “Big Bang” and in doing we as yet have not mathematically or through physics determined whether we might create an abyss that has its own virtual event horizon.

In medicine (you knew I was going to go there, weren't you?) there is the newest version of experimentation that seems to have ignited the mind of the scientific world. This experimentation arrives at us through the aegis of the Economists. To boot they seem to have a predilection to the Keynesian world of thought…It starts and ends with costs!

The driver of today’s experiments is money, period! There is little in the name of patient care and benefit and more in the purpose of costs. Our focus has shifted from one of curing the maladies of yesteryear and today, to the potential only of saving dollars. The louder the cry, the more the economists and their agents seem to be benefiting from such diatribes. They seem to point fingers as they gather large reals estates and flashy, fancy cars, all in the name of public good. The scientific journals are filed with jargon and meaningless pseudo-intellectualism.

Pyramid

to

The Statin era that created a 20-year enrichment cycle for companies is now falling by the wayside as patents expire and eggs and cheese are no longer considered the bad foods. The “Food Pyramid” once touted by the USDA, the American Heart Association and by the experts in various scientific literature is now flattened into the “Food Plate.” The “Food Pyramid” probably has to share some responsibility in the Obesity epidemic of the 20^th and 21^st century- if you were inclined to think about it further. ( Here )

                                                                      ....Plate

As we mightily profess the wonders of End of Life discussions in a myriad of ways that exposes all the virtues of Tantalis, we seem to forget in those many ways how it is to Live our Lives; to take care of ourselves rather than be dependent on the most mundane of newest "studies" that this potion extends survival and that pill rips your rectus abdominus. That, there is fear boiled into every moment of our living by the many informants, is the curse of  this information age! The asymmetry of information is forced upon us as reality. The Orwellian doublespeak is over-polished and rules our days and nights.

1. Learning from history is good if you are not blinded to repeat the past. The answers lie in front of us.

1.     2.  If you experiment use basic science, not the fiat of correlational junk science. Use the correlational data to go further through verification from basic science.

2.     3.  Use the p-values more for the next step in validation rather than as an incontrovertible truth.

3.    4. Expose the economists at their own game…follow the money trails. Fiat (not the car) by any other name is fiat!

4.      5. Always have the goodness for the human, in human experiments, in your thoughts.

5.      6.  Refrain from using experiments as a means of self-enrichment. They eventually get found out and fame is replaced by infamy. Good science will bring its own rewards.

6.       7. Think how to advance the knowledge without harm when you conduct experiments.

And as one very smart person once said, “Trust, but verify” both in human affairs and in science!