Wednesday, April 22, 2015


Strange how time travels
Away from the moment
Leaving behind memories
Rich and poor.

Like a broken cup
Shattered by a fall
Accidentally moved
Off the table’s edge.
Now shards surround;
Pieces. If all placed
Neatly together would
Make the cup, But no.

Like the writing hand
Having writ moves on
The delicate impertinent ink
Marring the parchment
Filling the shallow valleys
And riding the rough ridges
Forever in the life
Of that pulp, ingrained
With memories on its surface
Dissolve to the first rain drop.

Memories too of childhood
Ghostly beings in ether's dance
Moving further and further
Away from then
Stretching back into oblivion.

Echoes of tortured minds
Leaning this way and that
Filling the space
With colors and black.
You cannot pluck the petal
From the rose, yet still
Smell the sweet smell
And only imagine
What was,
When it was.

The minute hand
Pulls the hour hand
Only one way.

Ah time your arrow
Has, but one direction
Yet you curve under gravity
And might bend to meet the edges
To make travel through moments
Possible. Even if for a fraction
Of a second. Like the crackle
Of lightening expanding
Space and registering time
With the sound of fury
And like that moment
Gone. Lost to oblivion
Within ghostly memories
Haunted by time.

Friday, April 17, 2015


“It’s a 4.5 Liter engine with a 325 pound-foot torque, at 7400 rpm and a 3.81 displacement puts this car ahead of any other…”and attention deficit took over. The backdrop of a car showroom and the voice of a salesman is sweet harmony to imagination.

Yes, I wondered, we can certainly measure the volumetrics of the car engine in precise detail. We can measure most anything on the planet with exquisite precision.

From ancient time when Eratosthenes was able to measure the circumference of the earth to within a few stadia (plural for stadium), man has been on this quest to quantify then qualify through measurement anything that exists on earth, from ether to the rock of Gibraltar. Time has allowed us to gather more and more measuring tools. From ancient times when the distance between the earth and the sun, aptly named Astronomical Unit = approximately 93 million miles, took many failures of measurement from Aristarchus to Kepler, finally it was Christiaan Huygens who determined that it was equal to 24,000 earth radii, man’s quest to measure never wavered. 

We came to find out that the Cesium radiation period determines that "The second is the duration of 9,192,631,770 periods of the radiation corresponding to the transition between the two hyperfine levels of the ground state of the caesium-133 atom." And using this information, humans devised the Atomic clock. Time linearity was harnessed. Progress! 
We can measure the very large galaxies millions of light years away through cosmological red shifts to the miniscule cellular interiors and thence to the absurdly minute small atoms within, with tunneling microscopes. We can smash protons and electrons together to reveal the approximate behavior of the “big bang.” We can approximate the energy of the Higgs boson (the God Particle) at 125 GeV based on mathematical calculations after the smash. And Einstein who could imagine the Spooky entanglements mathematically decades ago was experimentally proven correct!

Image of Saturn surface from the Voyager

Satellites hover and tell us our positions within inches and we send a spacecraft hurtling past into into the interstellar space, named "Voyager." Human ingenuity is Amazing! 

When it comes to humans, measuring humans, we have been even more curious; the developing fetus on a 3-dimensional sonogram lays out features of the baby vividly and from birth starting with the APGAR score to the baby’s height and weight to blood pressure and red cell volume, from intraocular pressure to intra-arterial pressure, from the speed of electrical impulse generation in the brain and its impact on the synapse to the beat generation from the Purkinjee fibers to the myocardial cell contraction, almost everything is measured and quantified. We measure salts, hormones, enzymes and other sediments including circulating tumor cells in the blood. We tie behavior to psycho-neuro-chemicals in the brain. We measure the change in ratios of various elements from health to disease. We check and check and recheck to stay healthy. We graph circadian rhythms and everything from circulation in clogged arteries to emotional volatility, to cancer and throw them all in the stress-me basket. Indeed we have arrived at our purgatory! 
Today, however we have a seismic shift in our thinking as we find a new pleasure in measuring the genes and their mutations that cause loss or gain of genetic function. Some of us have come to realize that genes are motivated by nature primarily and through nurture secondarily in equal measure. We have learnt that miRNAs and methylation processes constantly modulate gene function via external pressures. Oh yes, we can measure the human milieu quite well. Essentially down to what makes us tick. We can outline functional paths within our brain, the moment life begins and even have the audacity for perpetuating a lack of responsibility, to subsume our behavior to the function of a gene code. We can map the brain yet remain searching for the elusive mind, just like we have the body but always are on the look out for the soul? Ah yes, we are the Lewis and Clark muddling through the forests, not figuratively but metaphorically, of digital 1s and 0s and calling it the new dawn!

And the new sheriff in town wants to measure something else. His particular penchant is trying to measure a different metric; the human emotion. He seems to think if we can measure the happiness and quality of that happiness or sadness then we would have measure of performance just like the 10 point numerical scale of pain. Yet what he fails to recognize is the vice within the 10-point pain scale. Is my 5 point pain as a stoic equal to your 5-point volatile emotional pain? If the answer is yes then I guess the metric is valid. If the answer is no then we better go barking up a different tree. What do you think? Where is the threshold? Some qualifiers are definitely needed, “oh but that would make it so difficult!” Whether we use the numerical scale or the Wong-Baker FACES pain scale the answer would be the same. The thinking goes…if we can tie emotions to a scale and the scale to value then we can tie cost to value and voila, problem of costs in healthcare will be solved. The bureaucrats crackle their knuckles as their salivary drools thicken. Does the smile mean happiness and does a frown mean anger, always?

Alas even Kant at his most vulnerable in his hardened shell of the categorical imperatives would have shied away from such acts of calumny. As I understand Kant’s deontological ethical philosophy, he would believe that an action should be judged by its implications, “Act only according to that maxim which you can at the same time will as universal law.” Would such actions become the universal law?  But hey, forget those philosophical fire-hoses of discretion. This is the brave new world, where anything goes just to “feel good,” or be in the act of “thinking of doing good,” or be involved in the “public good” business.  There is no withholding any assistance from the passions but allowing them to promulgate thoughts and those thoughts into actions that hold hostage an entire society. The hypothetical imperatives have now become the categorical imperatives.

The world has changed stupid, get with the program!
Similarly quality of a human state is a difficult measure. The moment to moment emotional energies that crackle through the brain change the internal and external emotions of the human being. I feel good and the thought of a lost friend kills that feeling. I feel sad and the thought of winning a prize elates me. Measuring such volatility and using that as the parameter of success is tantamount to, perhaps foolhardiness? Must we then ask for everything that is going on in the brain and the mindfulness on a momentary basis? Mustn't we? Or can we compartmentalize, as the experts do writing lengthy treatises?
If value was being judged by a single individual who also happens to have her emotional cake to bake in the measurement, well then all bets should be off. Wouldn't you agree? The multivariate of the "measured" and the "measurer" would be in play and confound answers on a large scale. Yet to a mind indulged with the liquor of metrics none of that matters. Reality is that the "measurer" would have to have their emotive moment to moment state of being, assessed and recorded in parallel too! Maybe the human being is a mathematical model, with limbs tied to the Golden Ratio n’ all and as such can and should be measured for functional efficiency that could be the surrogate to a form of well being? If that's possible?

Speaking of functional efficiency, productivity is one measure that can be allocated to the value of good health, but therein lie the specter of employment, entitlement, vacation time and desire. “I am well,” suddenly takes on a different meaning in different circumstance as does “I am not feeling well.” Speaking from the dais and pontificating the virtues of life before 75 years of age is all well and good, but don’t these high minded priests and priestesses remember what “Said a blade of grass?”  Functional efficiency  is now indeed rooted in a foul jar of expertise!
So what do we do?
How do we measure a human being’s quality? Or for that matter, how do we measure a physician’s work in helping his/her fellow man/woman survive through illness and gain that quality? Oh that one is easy. If the illness is appendicitis, an uncomplicated appendectomy is the answer, unless of course an anomalous artery is nearby or a co-morbid state decides to exert its influence. If it is pneumonia then an antibiotic is mostly curative, unless you develop an allergy to the antibiotic. After all we are all human beings made to order under precise sets of rules and creative force. Aren't we? But what if it is an incurable chronic ailment like diabetes or arthritis or cancer? Is cure the measure? If it is, the best professors in the ivory towers would fail the test. Wouldn't they? They would never admit it though. But let’s just keep that to ourselves.
Scoring value is a difficult thing. A patient recovering from an illness dealt with the news of hospital stay costs would necessarily be disheartened and score low on the “Happy Quality Scale.” Meanwhile a terminally ill patient might have found peace in his or her wretched state and score high. How would that impact the score? A non-compliant patient due to medication cost or lack of access would not be too happy with the world. A compliant patient with dwindling resources would equally not give a smile willingly.
So we arrive at this conundrum of lunacy created by a confederacy of some "very intelligent thinkers” that everything from spit to pee and blood to tears is measurable, hence so should the real quality of emotion. And measuring emotions has value and value is therefore quality and quality can be paid in dollars.

The "turfing" war is about to begin in earnest among well-intentioned physicians!
Therefore if we weight the sampling errors appropriately and place alphas and betas in the equations we would arrive at a formula that will guide the value of therapy as benefit to the patient. Further derivation from that would justify the appropriate reimbursement to the hapless physician. Are there Avogadro's constant or Plank's constants for human beings that can be fitted into our equation to gain that subtle but elusive inference? Not yet! Although the reactive heuristic makes us act as if we do, by latching on to the Confidence Coefficient of 1.96 and with that and the statistical jargon we attempt to prove our hypotheses time and time again, forgetting what the Nobel Laureate Philip Anderson said, "Many good scientist instinctively distrust a measurement which is always on the ragged edge of "statistical significance" and have learned to be very skeptical of marginal statistics."
The new HR-2 MACRA Bill soon to be signed into law, quantifies such actions and emotions- should anyone care to understand, will do the following: Derive risk adjustment calculations, Quality and Outcome metrics, case management, resource use monitoring, interoperability of the EHRs, establish data registries, develop practice assessment checklists, determine the operability of the physician NPIs and their ability to prescribe…and on and on and on, you get the message! Happy navigating the tall grass…
We thus arrive at Kafka's "Nothing alive can be calculated!"

“So the monthly lease on that would be…” I was all ears!

Saturday, April 11, 2015


Now you might have heard about the Dark Pools. No they are not found near the Dead Sea, umm maybe metaphorically one might say they lurk there.

Let me give a very novice kind of a take on these things called “Dark Pools.”

First they are not pools of water. Nothing can swim in them but things can be dunked in them. People can get wet in them and come out “dried out like a prune.” They are dark, because the only light is from the “one who shines it.” Everything is quiet, nary a ripple, just the chaotic, whirlpool like or tsunami-like mixing and churning goings on below the surface. Thus the “oxy” in the “moron” is the light shiner and the others are well, dare I say, “morons.”

To get a real grip on “Dark Pools” it is best to Google the term and you will get the gist. For the more inclined there are several books about the subject and has been captured nicely in “The Flash Boys.”
So there in the dark pools as estimated by some, is almost 20%-40% of the wealth that never sees the light of day, but transacts as if the sun never sets. Stocks trade between well-known large entities like the Morgans, the Stanleys, the BlackRock, the Barclays, the Citadels, the Millennium, the Renaissance, the Two Sigmas and others of the world. In the darkness of daylight they trade large portfolios with no stock price movements for each transaction, while outside in the cold street outside on the ticker tape the stock price shows large gyrations to the uninitiated.

 Most days the dark pools win, unless of course the Algos are at it (aka High Frequency Trading or 70% of Market trading). These wily Quant-satisfied, mathematically aligned codes of IFTTT are always on the lookout for micro-asymmetries in data availability and gain from select information a micro-second makes.

 "So you see, you poor soul, you have no way to win, just plenty of ways to lose!"

There is another “Dark Pool” cluster in DC, where "the dodgy air of opportunism and profiteering" is always in full swing.. This one controls all the other Dark Pools. This one is well-connected and trades favors between competing lobbyists. The colors might be blinding but the intent is there to trade and win for the self. Pinstripes move in and out of these large cavernous halls, slipping favors that only come to light if the powerful on the top are slighted in any small way. You want to fly to the Bahamas, or a Getaway Island where other measly human creatures cannot step foot, there is a flight for you in Champagne-bubbling first class lounge. Oh and yes, lest I forget, if you happen to be in this class of classes, you can participate in a soon-to-be-sky-rocketing-stock that will make you fortunes so you don’t have to read anything you undertake now or in the future. Just take the bicoastal flight in pure luxurious comfort.

And speaking of Algo codes, unlike the Mid-town Manhattan transfers where milliseconds matter, here the Algos churn at a breathtaking snail’s pace. The Zeno’s paradox is fully in play and the closer you get embalmed in your pinstriped, well-coiffed hairdo, the wealthier you feel.  The trouble with these Algos is that the old code much like the Microsoft’s Windows Program only gets overwritten and the old code is never deleted and likewise needs layers upon layers for corrective actions, which only exacerbate the underlying premise. Eventually in this morass, no one knows what is going on and the Red Queen can at will haul off with, “Off with their heads!” and be heralded as the great monarch.

Medicine, you knew this was a-coming, has large clusters of dark pools and Algos committed to serving it. The clusters reside in Universities and the Halls of Congress. They are called the experts who partake in the walking-in-and-out of the singularly well-known address in the world. They rejoice in lengthy monologues at other universities or places where anyone will listen to them or at the seats of government, where everyone pretends to listen but dreams of the first-class promised vacation. These clever brutes employ their wicked intellect to douse the flames of thought and create complex Algos under the guise of “Public Good,” and “Choosing Wisely” to manifest the meaning in their "lord’s" prayer. Their "lord" is whomever has the throne and control of their actions. To wit, the EMRs so proclaimed to change medicine are nothing more than a form of Algo duping in the reverse. They collect data for insurers and policy makers for control and command and not for the benefit of the patients. This kind of Brownian movement within the small enclave of self-service in these ivory-dripping tower inhabitants is often considered progress. Meanwhile pressed by such nonsense, the obedient, fearful minds lose all color, their eyes turn joyless and bland, and everything about them turns robotic as they hurry their way onto an early date with the Reaper.

"The seeming truth which cunning times put on
To entrap the wisest." - Shakespeare, "The Merchant of Venice"

Like the HR2 Bill passed by Congress, considered as an SGR fix for the “poor docs who have suffered such interminable uncertainty,” they weigh in with a hammer of more provisions to indenture the servitude of the physicians. In legal jargon printed over 263 pages there are interesting roadblocks; HHS Secretary’s control of who can write prescriptions based on the “recognized” NPI number ( If you do not participate in Medicare, your NPI will not be recognized and neither will your prescriptions-so essentially you cannot treat patients), the lobbied MOC need for “Physician Quality Reporting” when MOC has not to this date shown any benefit for the patients or their physicians, but it makes good money for the ABIM/ABMS, A soon to exist, colossal change in reimbursement through the ACO (Accreditable Care Organization), P4P (Pay for Performance) and APM (Alternate Payment Model) and penalties and bonuses to be determined at a later date by a single person-the HHS Secretary is being promulgated. Monarchy has a new name. Sure, the 21% SGR is being removed but it is being replaced by an even more onerous and medicine-destroying, guideline-mandated, population-based non-individual management of a patient’s illness based on cost and resource consumption-the Hippocratic Oath and the ethical standards-be-damned version!

Horrific, you say? Where have you been ol’ chap?

A friendly colleague @RogueRad asked this question, “Do you think this is how the Eloi will have developed?”
My reply:  “If Morlock pathos is to Eloi physiology, then Eloi pathos is to utopian fantasy?”

@RogueRad reply: “Progenitors of Well's utopia didn't believe in utopia. They were lazy. That's the real problem - laziness. Intellectual laziness”

My reply: “Granted Intellect is cake's foundation & laziness is the oozed icing. What if there is no foundation? Then… "Pass it then read it?"

@RogueRad reply:  “You're correct. If the foundation, higher education, is shaky then the icing will topple.”

For those needing info about the H.G.Wells "Morlock and Eloi" species:
The Eloi are pretty and the Morlocks are not
The Eloi are dumb and the Morlocks are not (or, at least, not as dumb)
The Eloi wear clothes, the Morlocks do not
The Eloi eat fruit, the Morlocks seriously seriously do not.
Perhaps most important, the Morlocks work and the Eloi do not.

The foundation crumbles under the weight of pseudo-intellectualism to guide the weary populace as these self-proclaimed intellectuals slurp the icing and fall into a diabetic coma of oblivion.

PS: The term "Algo Duping" borrowed from @MedicalQuack

Saturday, April 4, 2015


Several years ago, my colleague sitting on the far side of the medical lounge piped in “Those were good years!” He was wearing his green surgical smocks with the booties still covering his shoes. He had just finished removing a diseased gall bladder. He looked tired. “In the 80s and 90s we did what we had to do and got paid for the hard work and we were respected. Now it is a different game.” He fell silent on the weight of those words. His shoulders sagged and his head rested against his clasped hands in the back of his neck. “They were great, weren't they?” another colleague piped in.
Indeed those were good times to be in the service of humanity, although the pump had been primed a few decades prior to blow up the “healthcare bubble.”

The Dawn of Public Money:
In 1965 with a signature of the President, The United States offered elderly people on fixed incomes and others with disabilities a safety net of healthcare protection. President Johnson remarked, "Under this plan that the committee is recommending, every American over 65 years of age will guarantee himself comprehensive hospital and medical protection for the rest of his life." It came to be known as Medicare. Medicaid, the other sister agency was specifically for the impoverished and disabled individuals with limited means. Both services were under the umbrella of CMS a division of U.S. HHS Agency. The politicians to the great delight of the voters, created this well-spring of options and the doctors were encouraged to accept assignments for reimbursements against services provided. The patients (the elderly and indigent voters) were saved from filing the claims. The money exchange occurred between massive bureaucracies and both the physician and the patient became oblivious to the costs. As the tax payer funded dollars grew in size and scale, the bounty could be had for anyone who could provide a “recognized” service. The doctors worked 12-14 hours a day as the demand for care grew. There was no “skin in the game,” and no “horse in the race,” neither at the patient level since they only had to pay co-pay, which was a meager amount or the doctor who could ask for diagnostic tests to satisfy any and all potential differentials bothering his or her mind. Meanwhile some entrepreneurial doctors and businessmen and women created businesses that catered to the needs of the patients by providing high cost diagnostic procedures. Some created multi-specialty group practices with scores of physicians the likes of which not seen before. The names on the letter-head looked like a law firm from New York. As Medicare turns 50 years old, the creaks and wrinkles are evident. The system his bloated with administrative costs and is reaching into 1/5th of the GDP.

Pharma Bonanza:
Seeing the bonanza of tax-payer money, the pharmaceutical companies started advertising heavily on television, radio and rag magazines in a direct-to patient campaign, in order to influence the patients. The cost of drugs rose exponentially, even medicine like penicillin which were to be had for 5-cents-a-pill suddenly and inexplicably cost $1.50-a-pill. The newer biotechnology monoclonal antibody drugs were a different breed. These immunological modifiers cost close to $100,000 per patient per year and the costs were justified by their complexity in creation, “due to the stringent and arduous FDA requirements needed to complete studies to prove the medicine’s worth.” The first of these drugs in cancer care to hit the market was Dendreon’s Provenge used in Prostate Cancer.

This drug was a first in class that was produced using the patient’s own Immune Cells against the cancer, an ingenious idea to say the least. The drug provided a 4-month increment in survival for a $93,000 cost. There was a muted hue and cry from the public and the physicians. The Pharmaceutical companies started advertisement campaigns: “Have yourself tested,” was the banner of the day. Urologists tested every man over 50 with a PSA test and study after study called for early diagnosis and potential for cure against prostate cancer. Breast surgeons clamored for mammograms, Gynecologists urged PAP smears and pelvic examinations as the rigor of the day required. Medicine was in a full swing of ‘capture it early and live another day,’ mode.

Hospital Windfall and Control:
Hospitals too got in on the act. Some used creative coding methods to receive windfall from the tax-payer dollars. Everyone got wealthy through the “healthism” culture. More and more people lined up in doctor offices for “this” or “that.” The doctor complied because (s)he had to address each issue. Seeing the physician income reported in various magazines, the lawyers started feeding on the information and the vicious cycle of more testing to CYA (Cover Your Ass) became the agency of the day. It served two purposes in the minds of the physicians; 1. It generated income and 2. It potentially prevented lawsuits. Pete Stark a Congressman from California wrote a law into effect discouraging any physician from enriching him or herself by creating diagnostic or therapeutic businesses in which he was not a member/owner. The Stark Law had three iterations and the venerable Stark Law III is still in effect. The states also discouraged individual ownership of outpatient facilities as the hospital lobby saw a decline in easy money flow from low-complexity procedures being vented out to those outpatient centers at 1/10th the cost.

The hospitals however were successful in curbing these business ventures of the physician entrepreneurs through the force of their lobby. Henceforth all outpatient facilities had to have 51% ownership by a neighboring hospital to obtain a “Certificate of Need.” Studies started appearing in journals that outpatient facilities were not providing safe procedures. They tried and successfully convinced the political laity that “outpatient infection was a never event!” the public was sold and the American Hospital Association rejoiced in their Gotcha moment! More and more doctors unable to meet the demands of the mandates got hired by hospitals. The Hospital Revenues in 2012 are below:
Total net revenue: $821.3 billion
• Total expenses: $756.9 billion
• Cumulative profit: $64.4 billion
• Average revenue per hospital: $164.3 million
• Average profit per hospital: $12.9 million
• Average profit per inpatient bed: $80,465

Graphic representation of the Revenue/Income streams of Doctors (in Black & Yellow) and the INTERMEDIARIES (in Red).

Administrators and CEOs enjoy the growth bonanza...

Meanwhile the Physician salary continues to implode:

The Curbs:
The privateering was about to stop soon however. The culture of excess could not ripen and like pears or apples, not rot off the tree. The physician services started getting denied and more and more physician offices had to hire extra help to keep up with the “Medical Revenue Cycle” created by the bureaucracy. The resulting hires expanded exponentially and a two person office soon became a 10-person soon. The costs borne of such expansions resulted in lowering of the margins and the doctors had to work harder to maintain their revenues to keep their “offices” open. Eventually the income stream grew smaller and the doctors had to get bank loans to stay operational due to delays in payments by the bureaucracy.

Hospitals were called out by whistle-blowers for their engineering of the code-billing techniques and some hospitals had to pay back the government in millions of unjustified reimbursed claims considered “outliers” by the government. The coding and billing clerks were being taught to spot any "fraudulent-billing" procedures and report to the government in hopes of procuring the 30% reward and a trail of doctors saw themselves march in handcuffs towards incarceration. Billing for services became more than a "cross the t and dot the i." It became a sport for the prosecutors to indict physicians for errors and mistakes and have them accept responsibility through consent so the prosecutors could enjoy the satisfaction of successful prosecution and a climb up on the rungs of their proverbial ladder of success.

The Public Mismanagement Begins:
The private mismanagement had just about come to a close. The doctors started closing practices, unable to make the payroll and hospitals had to cut staff and go lean and try to survive the stringent dogmas of the public sector.

As the new century rolled in, it brought with it the public management to curtail the excesses of the private mismanagement in medicine. EMRs were mandated by the government, pseudo-quality measures through PCORI and PQRS were initiated. Meanwhile, the hospitals took the mantle first and exploited the coding mechanisms to increase their reimbursement rates.

Where could these experts with little or no medical care experience go to stop the bleed of tax payer dollars that had reached 17.9% of GDP and constituted 1/6th the economy? The problems all agreed was the “doctor.” It was he or she who provided all the care, therefore logically controlling his or her actions would limit the expenditure too, the experts figured.

The Middle Manager Bonanza

Suddenly “peer reviewed journals” with “high impact values” started printing the need for austerity in healthcare. The dictum changed from “Do” to prevent disease to “Don’t do” to prevent harm. The paradigm was turned upside down virtually overnight. The acronymically based Societies in Medicine started the “Choosing Wisely” program. But they did not seem to tell that to the lawyers who were still sharpening their pens to bring their grief to the courts. This scenario continues to ripen as we speak.

Now for a little digression, allow me to use the economic debacles that have occurred as metaphors to what has been happening in medicine. There is virtually no difference…

The Great Depression:
The 1929 was a privateer’s boom year with asset bubbles growing at an astronomical rate. Seeing the prices skyrocket,  a change in public policy resulted in the Balance Sheet Problem with the bubble bursting on the nation. The Great Depression started and one year’s U.S. GDP was wiped clean. Unemployment reached 25% nationally and in some sectors it was as high as 50%. Photographs are a great reminder of that calamity.

When the screw of economy stops turning...

If not for WWII the depression would have continued longer. But the WWII caused a massive public spending campaign to build armaments and incur public debt with war bonds to ease the disaster. The heady days of the '50s and '60s were as a result of the belt-tightening in the '30s and '40s and the boom in public spending, private saving and risk taking by new enterprises.

And then starts turning again.

The Housing Bubble and the Global Financial Crisis:
Leaving aside the tech bubble of 2000, the 2008 housing bubble started when speculators were claiming there was no more land available for building homes and thus existing houses were priced at well above what median income could afford. People went into a buying spree and “flipped” for the sport of making money. The housing bubble started a Global Financial Crisis that brought the world to its knees. Some countries like Greece continue to flounder while Ireland and Iceland have picked up growth once again and righted their respective ships. This housing bubble was not all privateer’s doing, the government had a part to play in it too. The well-meaning politicians encouraged everyone to take a loan with “cheap money” so everyone could afford a “picket-fenced home.” Ah the glory of the progressive thought was the call of the day.

As realization dawned, the bubble burst and privateers could no longer afford to pay for their homes due to collapse of the home prices. Foreclosures and bankruptcies rose. The banks had collateralized the loans CDOs, CLOs and the CDSs were created and existing loans were converted into Mortgage Backed Securities by mixing high and low risk combinations in tranches and no one knew who held the loan in the end. Inside the crusty baked pie was a major uncooked ingredient!

This started Mortgage Holding Companies to vanish into bankruptcy overnight. Fannie May and Freddie Mac, the two government sponsored mortgage entities suffered huge losses that needed bail outs from tax payer dollars.

The Pain of Deleveraging:
The past eight years have been spent in deleveraging by the private companies that gambled in excesses and lost huge capitals for their clients, an example of the Insurance Company with excess weighted CDSs was AIG that also required a government bail out to stabilize its balance sheet and slowly deleverage the excesses. This cost the tax payers $134.35 Billion. The AIG Bailout (in billions)
Fed Reserve Credit Facility (~$60B) $43.458
Fed Reserve Securities Purchase(II)$19.8
Fed Reserve Securities Purchase(III)$29.6
Treasury Preferred Stock Investment$40
Treasury Credit Line (Max $30B)$1.5

Deleveraging is indeed painful. Both the private citizen and Corporations save to get rid of debt. As they do, the wheels of borrowing, investment, and entrepreneurship suffer. Commerce stagnates, unemployment rises, wages stagnate, Treasury Bonds stay low and GDP gets stifled. The “Quantitative Easing” a FED mechanism of printing money to keep liquidity in the marketplace and also to absorb the bad mortgages off the balance sheets of the private firms allowed the ball to keep rolling, seems to have muddled the economy onto firmer grounds recently even though we are not out of the woods yet. Meanwhile the FED Balance Sheet bloats further...

 Talk of austerity at this juncture would create the Hashimoto debacle that crushed the Japanese recovering economy and pushed back several years into 2 decades of deflationary spiral.
The Japanese ended up losing 3 years of their GNP. Yet without consideration to history, the Hashimoto Principle of “Austerity and Taxation” that extended the 1985 Japanese Balance Sheet Problem into two lost decades and because of FDR/Hoover's desire not to allow the debt increase through austerity in spending, pushed the recession further in time, which is now being swiftly applied to the Healthcare industry's Balance Sheet problem, especially to its most important components; the physicians. The Austrian School seems hell bent at just about the wrong time. 

Austerity comes to Medicine:
In medicine the austerity principle of not doing things that may be deemed necessary under the guise of “Choosing Wisely” and some other diktats are being laid down as dogmas. The problem of invoking such policies in medical care is, ultimately the patient suffers when the doctor’s hands are tied. The experts remain double blinded in their thinking, cost in medicine is not going up due to payments to physicians as they envision, as the recent “Medicare Data Dump” clearly showed that out of $1 Trillion expensed by Medicare in 2012 only $77 Billion was paid out to the physicians or 7.7% but by the excesses of the intermediaries; the Hospitals, Pharmaceutical Companies, Medical Device Companies and other armchair administrative types who are given the authority to say yes and no.

The Doctor Data Dump was hypercritical of the physicians but did not take into account all the factors in the healthcare costs.

Austerity principles are good when there is privateer excess and micro-strategies can be employed. It is a public excess of policies and mandates that stifle an enterprise if used unwisely.  Discouraging doctors from practicing the art of medicine on an individual through the lens of population health measures, handcuffing them from their art  is tantamount to control and obfuscation of the reality and hurting the basic principle of…Primum non nocere.

The False Conditionals:
Here is where the story gets even more interesting… The SGR that keeps calling for the 21% cut in physician reimbursements for delivered care, well if one were to add some neurons to this conundrum one would find that cutting 21% off the $77 billion paid as revenue to physician practices will essentially close down the majority if not all the physician practices in the country. Interestingly enough the "SGR fix" is nothing more than a dressed up governmental bureaucracy to help the middling managers to gain a larger share of the healthcare dollars through "Management." The marginalized physicians will gravitate towards the hospitals, who will pick and choose off the litter at bargain basement prices and reel in mega dollars from their expert coding practices. Medicine as we know it will be based on the cheapest and leanest delivery in patient care at the most expense to the tax payer, while keeping the physician in line with threats of pink slips and “there are plenty who will want to fill your shoes,” threats. And everyone will rejoice unless it is them in the hospital bed. It is already happening as 83% of the newly minted physicians climb aboard this "hospitalist" trend and are told what to write on their EMRs in order to maximize returns and minimize expense. The “Private Practice of Medicine” is in a steep decline! The glare will turn towards the real wasteful agencies ultimately, then what?

The Cost of earning a Medical Degree continues to increase, yet the income to payoff the debt continues to decline...

To recognize a structural problem created by private excess requires strategic micro-manipulation. As an example in medicine would be limit the middling managers skimming the top who are providing NO services to the patient care except logistics of where to go and what to do. These intermediaries are not completely unimportant but they do not need the tax payer wealth thrown at their feet in bushels.  The Administrative section in Healthcare has grown nearly 4000% in the past two decades while in 2025 a physician shortage of 125,000 is expected in Primary Care alone as the population continues to grow, aging and disgruntled physicians retire prematurely. If one thinks this far enough one comes to an understanding that there is an imbalance of thought and action and the strategies employed have now created a mega Balance Sheet Problem in Medicine both economically and in physician participation rate. The assets (physicians) are declining and their expertise is being marginalized while the liabilities ( Expensed Costs for all various and sundry items) are increasing.

The private sector in medicine has long been corralled and now the public sector is in full metal gear. The only problem is the over swing to either side that creates larger calamities. In fiscal terms, raising the interest rates to excess stifles demand, while lowered interest rates spur demand for innovation but if low interest rates are left too long that creates hyper- inflation. Maybe some in medicine sitting on the thrones of power might realize this conundrum and can help ease the weighty burdens that are currently squeezing the life-blood out of patient care!

Back in the Medical Staff Lounge:
The air in the medical staff lounge, a four-walled, small decrepit space where even the coffee machine worked only when slapped around a bit, two colleagues; a young recent graduate and a seasoned silver-haired sit looking vacantly at nothing, “so this is medicine?” the young one mutters, his thick coke-bottled glasses perched delicately atop the tip of his nose, “all computer work and little patient interaction?”

“It is. It is…” the older colleague’s words trails off. “A Faustian bargain,” he says almost imperceptibly in his hushed silence to himself.
“What did you say?” the young one asks.
“Nothing, nothing…”

Saturday, March 28, 2015


There is a flawed nature of perfection that we seek. Today this goal is governed under the continuous creation within the digital context. The present and future are heralded while the simplicity of the past is ground down into flakes of an imperfect horror of backwardness.

This leviathan has sprawled into the architecture of our humanity. It invades our privacy, dictates our lives and imposes the conforming principles of compliance without hesitation with all the ingredients of the 1 and 0s.

We seemed to have forgotten Robert Browning’s words,

 “Heart, or whate’er else, than goes on to prompt
  This low-pulsed forthright craftsman’s hand of mine.”

Ah the low pulsed forthright craftsman’s hand is forever replaced by the tedium of a glowing screen. Yet there may be light in this. Yet there may be some truth in this. But where that is, I cannot see, for it invades and usurps my own vision and thought.

We clamor for wearables to motivate us while we sit in front of the glow of the screen. Our every move is charted, dictated, governed and recorded for all to see. The digital 1s and 0s in their inhuman repose slip through the slipstream and house in large warehouses to be massaged and manipulated to create an alternate world view to suit the algorithm sponsors.

“Where does machine stop and man begin?” is a question a Dr. Salwitz asked recently. Indeed where does the fine thread of division exist? Our very life is governed and ritualized within the spectrum of the digital universe. Our sleep patterns, our movements, our heart rates, respiratory rates, everything is coded. Indeed how many steps we take symbolizes how healthy we are or will be.

We can share our photographs with a flick of the thumb, place the entire library of Congress on the head of a pin, watch a movie on our smartphones, immerse in the virtual world and never know any difference between what is real and what is implied. We see our doctors not through the eyes of patients as healers but as detached souls clamoring for time, rushed and oblivious to the real underpinnings of disease and illness. We see our patients not through the eyes of watchful vigilance, but through the lens of “one size fits all.” Somewhere there is a loss of trust, of empathy, of living and a gulf that seems to grow large every day.

The digital imperialism is upon us in every walk. We have mountains of data on human behavior that some select to govern the rest. We have burgeoning library of genomics, proteomics and epigenetics and we know less of the interactions between these molecules and human survival. We know more about the cell and less about how it governs itself. The reductionism brings us the mountains of data, unfortunately thus far it remains elusive to tie them all together. Yet there are among us who feel that we have all that we need. We have the tools to march in a certain direction or to take the specific path. But they like the rest of us are pleading to the merciful gods of their desires that they are right in their assumptions.

The digital dynasty is upon us and it has brought many good things to our lives. But there are the swirling storms of desire that every aspect of our existence should be cataloged and governed within the digital domain. As Lao Tsu stated, "He who knows when enough is enough, will always have enough."

Life is mathematics, there is little question about that, but it is also that subtle fine art that cannot be reduced to the simplicity of the 1 and 0. But for that small undetectable grain of truth that garners the spice of life, we would be all robots. Today all we are trying to do is smear, suppress, stomp on or hide that tiny piece of reality that makes us who we are.

The question then remains where should we as humans define the fine line between what is and what is assumption?

Ah, life…

“Life is simple but we insist on making it complicated.” – Confucius 

Saturday, March 21, 2015


Medicine is forever in a flux. There are innovations, new products, new diseases, new therapies that create and disrupt the ebb and flow of this profession. But through it all, medicine continues to prosper with better alignment of resources and improving the overall human health. The life span of humans has progressively increased over the past six decades. Man is enjoying better health then did his grandfather. A woman far exceeds that comparison because of reduced maternal mortality related to birth and enjoys four more years of life then her male counterpart.

Porter’s Five Forces in business seem to apply well to the current model of medicine. 

a. Primary Care Physicians (MD,DO)
b. Specialists (MD,DO)
c. Non MDs

Assuming that the current business model of medicine is the practice of medicine and ingrained within this model are the competing forces of the Primary Care Physician and the Specialists. All are gathered to compete for the individual patient to provide a service. These forces although typically are unified in purpose, also compete as rivals for the patient to provide that care. They compete with the latest and greatest options as a means of product differentiation, that they can apply to achieve the larger patient load. For example, the dentist advertising the clear braces, or the Radiation Facility its Proton Beam Therapy unit or the surgeon advertising his adeptness at Robotic Surgery. Outpatient facilities compete between themselves and against the hospitals for the patients. The non MDs including the Physican Assistants, Nurse Practitioners, RFNAs, are all examples of healthcare givers who are eating up the distance between true medical knowledge and experience and gaining freedoms of providing independent care to the patients through lobbying and political fiat - for cheap. These are the inherent forces of rivalry that exist today. 

The rivalry that exists within the current model exposes inefficiencies and this constant tug from the buyer and supplier should lead to price discounting with more products availability as a cause of the competition. Alas with the intervening governmental and non governmental insurers, the price discounting has been tempered by mandates and regulations that seem to protect intermediaries more than the buyers (patients). Additionally the forces of new entrants makes it interesting by keeping the levers of commerce constantly in motion. These levers however add to the cackle of the intermediaries.


The Buyers are the Patients. In the days gone by, the patient was remarkably innocent to the workings of medicine and at most times in history believed in the potions and magic of the physician and the snake oilmen. Some got better while others did not. That was the way of the past. There was a certain faith in the alchemy of medicine and in it’s practitioner. Times have changed. The patient is now more informed about diseases, less exposed to financial risk if he or she is insured and thus less concerned about the costs.

 Although the information on costs and appropriate therapy is available, it is not easily comprehensible by the patient, both by the complexity of the information and/or by the sheer fear of knowing. The amount of information in the form of data is overwhelming to any one person and more and more is being piled on.

Currently families and Advocacy Groups fulfill the needs of the patient by navigating the complex medical jungle. Even within the advocacy groups a certain ignorance lives, because asymmetry of information remains. The "well-informed patient" will have the power of negotiation at price discounting on a one on one basis. Unfortunately the term "well informed" lives within the limits of the acquired information and one-on-one is the least exercised version in this complex. The bargaining power however will also determine the ability of being able to rationally ascertain quality. The focused Decision Making guarantees a successful outcome. It is a forced responsibility at both ends of the spectrum, between the Buyer-Patient and the Supplier-Physician/Nurse. The ultimate benefit will be in the hands of the Buyer-Patient. The media unfortunately berates the idea of fiscal responsibility for the patient, infantilizing their existence and in so doing prevent the "skin in the game" of a social contract.

Other stakeholders with significant influence on the Buyer-Patient are the governmental and non-governmental insurers. Both unfortunately have competing arguments that limit their function. The non-governmental insurers are concerned with their own shareholders’ profitability. Their decision making is based on the profit margins accrued as a result of the balance between Revenues and Expenses, which cause them to continually raise the premiums and or add hurdles to decrease provision of services to their clients, the Buyer-Patients. There subtle agency issues of bonuses that insinuate themselves into the arguments and most times rule at the end of the day. The governmental insurers have a different, albeit under a different lens, purpose; the desire to limit the expense and control 17.9% of the GDP. They use their influence through attacking over utility of services, which is at times a noble cause and at other times a fallacy of thought. However in their zeal to balance the budget (an oxymoron)  demonize all services that are deemed expensive. The push of the costs and the pull of the voters force the governmental agencies into a firestorm of marginalizing one entity in favor of the other an altered perspective through their lens. Thus bureaucracy holds a huge sway in the marketplace and distorts the markets and their freedom to exercise caution, benefit, self-control and innovation. 

a. Insurers
b. Government
c. Pharmaceutical Companies
d. Biotechnology Companies
e. Medical Device Manufacturers
f. EMR makers
g. App makers and other Wearable technologies
h. Attorneys

Physicians are bearing the burdens of this costs as most of the ire is directed at them. But, what of the physicians? Lets look through their lists quickly:

Total allowable billing is $2.9 Trillion in total healthcare as of 2014. However only about $77 Billion were direct payments to the physicians for their care and the cost of keeping their medical practices operated by CMS alone, which expensed a total of $1.04 trillion in 2012. Of the $150 billion billed by physicians and other providers, 49.7% was never collected. It costs the physicians 3.3 statements per patient before being paid at a labor cost of $12 per statement. There is an automatic 11% denial of all reimbursements for service rendered, which creates a $300 billion windfall for the insurers. Physicians are governed by the Medical Revenue Cycle as no other business in the world! There is a 40% of cost in providing the doctors their reimbursement as a part of this Revenue Cycle. The suppliers therefore have a large stake in collecting their fees. These include the government, insurers, pharma and device makers. Of these four large supplier groups, the latter two actually provide service. Modern medicine is in the folds of a large-scale disruption. These disruptive forces are varied and all have influence over the patient-physician interaction. One of these influencers of medical care includes the FDA and the media outlets who determine, marketing and or manufacturing need. The evolving pressure ensues through scientific studies, radio and television advertising and via the print media. These pressures change the behavior of both, physicians and patient, over time and at every turn of the screw. A discord between the "buyer's" desire and his or her need creates forces of demand and denial.

Listed in the supplier category are also the Hardware manufacturers, Pharmaceutical Companies, Software creators, Monitoring Device manufacturers, Curators, EMR and EHR advocates. The Hardware Manufacturers are the innovators that create Defibrillators, Pacemakers, Artificial joints, catheters, hearing devices, viewing devices, Biomedical monitoring Devices like Heart Monitors and EKG machines etc. and personal monitoring devices that are the rage of today. Their pitch is the same; every new device is tantamount to better health, all things being equal. Both the buyer and the supplier are equally influenced in their decision making as a result. Some suppliers are influenced through financial pressures and others through contractual obligations. The free market forces albeit active are subdued under the influence of the larger cult of regulations and thus never are able to set the correct pricing or the need.

The Pharmaceutical companies produce the drugs and bring them to the market at an exorbitant cost (Recent estimates are between $800 million to almost $ 1.8 billion. At times the drug fails and a one-trick-pony company’s dreams ends in a single day. Other times it works and the company can go on to become a behemoth enterprise. Proving benefit of the drug is foremost in a company’s mind and that translates directly into future profitability and solvency for the company. Given the expense and the future earnings potential for a favorable drug, there are large scale statistical-force-manipulation of the data to achieve positive results. Unfortunately John Ionnides, MD has taken the "critical studies" to task and found them wanting in over 50%. In other words, a majority of the "impact" studies cannot be validated and are not reproducible!

The Supply-Demand model of healthcare is climbing the hill of uncertainty due to the limitation of the finite dollars, even during the Quantitative Easing or QE and the printing and supplying of more dollars to provide liquidity to the demand chain. As the value of the dollar recedes, the cost of healthcare in those dollars increases. This increase is levied by the "someone else pays mentality," "availability of transformative innovations," " an aging population," and "increasing burdens of the metabolic-chronic disease from lack of self-control in the land of plenty," terminologies and an over supply of desire.

There is also a constant tug of war between the Brand Labels and the Generics. Patent loss, continually erodes the bottom-line for the brand label drug companies and simultaneously enhance the profitability for the generic drug companies, but sometime that results in a cost of product integrity (Ranbaxy of India and the New England Compounding Center company of Massachusetts debacle). Large biotechnology companies like Amgen, Genzyme(Sanofi-Aventis), Genentech (Roche), Biogen, Celgene and others are the innovators in medical care through molecular research and by creating biologics (inhibitors and enhancers of gene and protein function) as treatment remedies. There is a continuing consolidation through Mergers and Acquisitions occurring between the Pharmaceutical companies and the Biotechnology companies to continue innovation or consolidation of resources at a faster pace. New innovators take the open space and are often gobbled up by the larger predatory ones due to the steep price of new entrants in the marketplace, while the predators are looking for their own survival due to a dried up pipelines and or the loss of R and D accrued at the cost of Stock buybacks to keep their shareholders happy.

There is a new breed availing itself of this dynamic marketplace and they are the curators of the data. Their main purpose is to store data in various formats. Like the libraries of the past, the digital age has spawned large databases housed in various servers.  There is a price for obtaining the data. The data mining folk are busy extracting information from the data, albeit at times the results are colored with the premise of selection bias. This bias has a tremendous impact on patient care. The seemingly perfect potion or pill based on selected bias or population medicine causes more harm than any good. These purveyors play a pivotal role in masking, enhancing premises that color thinking of the supplier, sometime to the detriment of the buyers.

The legal system  influences every aspect of the medical care system. Lawyers are involved in Medical malpractice, they team up as Lobbyists for self enrichment and sustenance, as Regulators and creators of new Regulations to bolster their own needs. The field enriches itself through the pervasiveness of the litigious mind-set of the populace with the continuing precept that more regulation is better and "zero-tolerance" for error or any unfortunate "event." The forget that to err is human and to err is universal. It is through error that we learn and progress.

The EMR (Electronic Medial Records) and EHR Electronic Health Records) advocates are the ones who have helped foster the software and hardware services to a new hype in medicine. The implied view is to help improve patient care but at $40,000.00 a clip and no evidence that patient care or cost reduction has been achieved,  the uncertainty remains. The costs have risen due to the ICD coding embedded in the EMR software for each complaint the patient might have. Notwithstanding the lack of formal evidence, the influence to force this digital climate upon the physician is here and now when implemented stands as a huge barrier between the physician and the patient. The cost of the EMR program envisioned by the government has cost the tax-payer $300 Billion and it will cost an additional $9 Billion for maintenance. meanwhile the physician incurs the annual costs of service contracts, software enhancements and computer outage risks. The EMRs will work only when they become an invisible background and actually increase efficiency of the care rendered! Until then they are nothing more than a shiny piece of gadget that collects information for the insurers and the government entities and stands in between the buyer and supplier as a deterrent.

a. Homeopathy
b. Acupuncture
c. Reiki Therapy
d. Alternate Medicine
e. Over the Counter Medicines

Addressing the needs of the skeptical mind, there are forces that carve a niche for themselves in the medical care field. The driving force here is the alternative form of healthcare remedies. The homeopathic medicines, Herbals and the vitamin industrial complex (here the pharmaceutical industry is also a force supplying ingestible medical products not needing FDA approval) is in full dress rehearsal touting the wild and wily benefits of various extracts from plants, fruits and vegetables-some might be helpful, but most are hype.

 Other Substitutions include the various fields of Acupuncture, Reiki therapy etc. These do provide service to the Buyer-Patient at a different level and feature the “Alternative Medicine” route. Their function seems to be attributed mostly through the placebo effect of an energized mind. Meanwhile under the shadows of marketing, the constant tug of war continues between the Allopathic and the Alternate Medical proponents. The influence created by the dynamics of advertising between the two industries brings to bear on both the Buyer and Supplier forces.

a. Medical Students
c. Obamacare

The entry barriers in the field of professional medical care, is extremely high. The cost is prohibitive for the Suppliers, where licensing, regulatory demands and constant evolution is more a need then a want. The physician for instance has to bear a cost of medical education that can run between $250,000 to $500,000. Even after they graduate, they have to apply and maintain a license.

The various medical Organizations that have taken seats of power in the governance of the physician activities create more and more guidelines, eventually turning them into mandates. Initially for instance, the physicians were encouraged to certify themselves from their specialty Boards, Now realizing the financial bonanza, the American Boards of Medical Specialties, have crafted a 10-year recertification requirements and within that a Maintenance of Certification that requires a biannual cost to the individual physician. These costs are not trivial. Every two years the physicians are forced to spend $2000.00 and a two to four week of rote learning, with no patient benefit as proof, to pass the tests. Not only does that take away time from patient care, but it has not shown to have any benefit in caring for the patient. The Boards themselves have a financial incentive to stay in the game as their hired staff gets large salaries to the tune of $1,000,000 annually, lofty condominiums in ritzy neighborhoods supplied by Mercedes Benz limousines, to drive them around and bonuses to fly first class just to advance their own financial agenda. ABIM now has net assets worth over $50+ million an increase of over 300% in under a decade. Meanwhile the Insurers continue to reduce reimbursements to the physicians, especially the ones who have taken assignments to accept insurance payments directly and the doctor works harder and harder to keep his or her doors open, squeezed at both ends. Seems that the puppeteers are having a field day at the Fair.

There are consequences...

Mergers and Acquisitions in Biotechnology and Pharmaceutical Industry curbs innovation. Some products are shelved arbitrarily, some promoted for more research. The end result is a smaller pie. 
Since the exit barriers are extremely low but unfortunately the cost borne by the Entrants is enormous. A failure is a shuttered door with losses in hundreds if not thousands of employees seeking unemployment. Short term benefits succumb clear thinking of Innovation. Innovation brings together new approaches and ideas and creates a milieu for new efficiencies. It also announces itself as a substitution at times. Innovation in product, a creative new methodology or even at gaining a new understanding of an old product or service is the hallmark of future success and sustainability.

The PPACA (Patient Protection and Affordable Care Act)  signed into law is a new entrant in the market place. The cost of bringing this mandate into fruition is expected to climb over $2.9 Trillion.

There are hidden taxes, penalties and a large numbers of new regulations embedded within the Act. The Entry barrier was low since the government was the entrant, although challenged at the state level and at the Supreme Court level where the measure was approved with a 5 to 4 vote. The state level issue has yet to be resolved, with challenges remaining related to economic downturn, fiscal restraints and the burgeoning rolls of the indigent population under Medicaid. The full and direct influence of this mandate is yet to be felt by the nation as the healthcare costs continue to outstrip the GDP. Litigation at The Supreme Court of the United States via the King v. Burwell still has the potential to throw the whole scheme into disarray at a further cost to the tax payers.

Porter’s Five Forces in Medical Care are vibrant and meaningful in their influence over the care rendered to the patient.

In essence as all transactions ultimately relate to the desire and need of the buyer. The patient is the buyer in Medical Care and he or she should decide what is the best form. Times have changed from a one-on-one interaction of the past where only two forces existed; the patient/buyer and the physician/supplier. There were no intermediaries in the profession. The business net has been cast and the forces of business are at the gate. These forces exist to mature the system into the very essence of it being a business and to that effect, the once patient-physician relationship is also filtered through many lenses before the eye catches a glint of the other eye. The patient once viewed as an afflicted soul from nature’s wrath is now viewed through the lens of currency. There is a certain shame in that, but then I digress.