Friday, June 26, 2015

The New BUSINESS of MEDICINE


When I was in medical school, the most important person was the patient. Your entire being was focused on the patient. What can I do to resolve this person’s ailment? In fact at one time, I rattled on about the information I had gleaned from the textbook and was babbling along when the professor interrupted, “That is all good, but what does it have to do with this patient?” That broke my train of thought and all I could do was speechlessly stare at him. Today we use terminologies like “Patient centered” and “Patient Centric,” but we fail to actually embody those words. We talk of “listening” as if listening is a new found treasure. We talk about “outcomes” as if previously we were not concerned with the well-being of our patients. We talk about “performance” as if caring for a patient is a function of a metric related athletic score. Medical care has always been about patient’s well-being. Today however the business oriented statisticians are using population medicine inspired data to treat individual patients. The wrongness of this is obvious, yet they, the experts continue to pontificate with “Hazard ratios and p-values” to the eager ears of the uninformed.

In Business parlance there has been a Merger and Acquisition between the business and the medicine mind. The merger was actuated by the "managers" in the two fields without the consent of the voting block in medicine and now that has morphed into an outright acquisition by the business mind with associated divestiture of the medical mind with layoffs and other cost control measures in progress...

When and where did we as physicians go wrong?

In the midst of this dilemma, I decided, I wanted to learn about what makes the entire healthcare system tick? Who was at the till? And what is the motive? I decided to go to a business school. I wanted to learn how business people think? The dean of the university who interviewed me told me that going through the business school would change the way I think!

It did!

I learned that business minds think differently than medical minds, in ways that are inconceivable to one another.

THE MEDICAL MIND
Let me dissect the medical mind first since I have had it for many years and my heart still beats the rhythm of medicine as surely as it conveys the next moment. The medical mind is quite simple and very complex at the same time. Simple because it has a simple ethos; to conquer the malady that afflicts another human; to salve the wound, to soothe and comfort, to help regain what is lost in human functionality, to help live, to help alleviate pain, to heal and to cure. Simple stuff there! Not a lot to think about. Complex because, what ails the individual and how many different maladies can and do create similar symptoms and signs creates mountains of stress. Further, to differentiate between cancer of the lung and to the lung is a whole textbook somewhere ready for the learning. The dilemma proceeds from medication induced damage to illness related ones, from a benign nodule in the lung to a cancer that kills in less than a year, from a cold causing fever to a more sinister disease such as kidney cancer, which sometime only presents as fever and nothing else. These and others footnotes present the conundrum, a physician faces in daily life. To embark on the correct strategy lives the need for appropriate diagnostic work, experiential intuition, much like Sir Arthur Conan Doyle’s Sherlock. “Elementary my dear Watson,” that only comes after the workup has been completed, the correct decision has been arrived at and executed. The constant vigilance of evaluating the benefits to the patient from that decision is a recurring theme in the medical mind. Medicine is true science borne of empiricism in the strictest sense not through the jargon of ratios.


THE BUSINESS MIND
On the converse side in the recent past what I have learnt from the business world is also simple and complex. Simple, that 2+2 = 4 and 4-2=2, these are, you will agree very simple arithmetic concepts. If the revenue is higher than the expense then there will be income, if the expenses are higher than the revenue there will be borrowing to maintain the business until lenders tire of the lending without evidence of higher forecast revenues. If you thought that was all, you would be wrong. There are many complex shenanigans within these simplified concepts that are employed to obfuscate. Difference between cash based and accrual based is a very interesting scenario to visit and learn from. The “Goodwill” category in income statements also poses a nice source of fodder to hide and not hint. But we will let those issues pass for the likes of HBR to contemplate.

THE HUMAN ELEMENT
My purpose is to look only at the human element in this short treatise. If you look at the “forward looking statements” from CEOs of large corporations you will notice that they always mouth these words, “Our employees are our best assets!” Yet when the net income declines, the first thing these managers do is choke off the employees. Pink slips fly and the “Agency Rule” comes into play so the bonuses at the year end do not suffer. Needless to say the stockholders are happy since the market rewards a rising net income which translates to the Earnings Per Share (EPS), hence the share price rises to meet their expectations. If Net income does not rise with this strategy, then by all means buyback with borrowed money is the order of the day to raise the stock artificially. This short term thinking is evident in most businesses and if you were to look back the past 5 years you might notice the headlines of thousands of workers being fired across the globe and in the U.S. In the latter part of the world there are now 93,000,000+ sitting on their hands without a job. Speaking of stock buybacks, the S and P 500 spent $914 Billion in 2014 in buybacks. Yet thinking of employees as a disposable commodity to beef up the short term quarterly interests for personal benefits has unseen but real consequences in productivity as well. Take for example the difference between Costco and Walmart. The former has loyal well-paid employees that make a decent livelihood at around $43,000 average salary. The latter has a higher turnover rate due to dissatisfaction. The former commands a $21,850 in U.S. operating profit per hour per employee vs. $11,615 at Sam’s Club, a Walmart subsidiary. And if the managers would look at the cause that should light their personal wealth fire; Costco stock price rose 139% and Walmart was up 41%, they would treat their employees as assets and not as expense.  (here: https://hbr.org/2006/12/the-high-cost-of-low-wages.)
Blue: Costco Red: Walmart

So this “employees are our assets” is nothing more than  a tired old rhetoric that fits the narrative to exploit the emotions of the employees and the shareholders. A crocodile tear at the right moment when the flash goes off is worth a few front page photos and headlines.

Unfortunately, I feel that same mentality has wormed its way into medicine.

FORCED MERGING OF THE DISCIPLINES
Let us for the moment assume the following; that medicine is a large company and doctors are the main employees. The owners of the “Company,” are the Government and the Insurers, since they dole out the “reimbursements” and the patients are customers. Simple enough! The business mind attracted into the fold of medicine sees the situation in the same context as it does a widget producing manufacturer. The customers (patients) get the widget (care), employees (physicians)are told to work overtime with a lower pay or skimp on the materials (diagnostics and therapeutics) to make the widget, for the sake of the “Company” and if they refuse or if the expenses exceed the desired results are easily discarded from the payroll. Mechanisms of discard include forcing doctors out of hospital staff membership if they don’t comply with onerous requirements of hospital or other private enterprise profitability; MOC (Maintenance of Certification) a continuing annual process of re-certification (for the sake of revenues - more on it below) and Hospitals using sham peer reviews etc. Hospital and Company CEOs are flexing their collective muscles.

UNPROVEN HYPOTHESES INTO PRACTICAL APPLICATIONS
Reimbursements to the physicians are easily controlled; previously through the SGR formula and now through newly minted methodologies (MACRA) via ACOs and APMs which, it turns out, are more punitive than the SGR, bu their full impact will not be known till after 2018. These formulations are the work of managers of the government bureaucrats, insurance company executives, elitists that are bounded by bookends of sly and slippery words and lecture from high lecterns, all the while partaking in large grants and salaries. One only has to look at the American Board of Internal Medicine (ABIM) and the revelations by Kurt Eichenwald in the Newsweek articles of how they have fleeced the U.S. physicians (a humiliation of unparalleled proportions that certainly needs further scrutiny). The carrot and stick model used by CMS of giving a 0.5% raise now to follow the preferential business based guidelines to lower costs vs. 2-5% penalties later for not reaching to those arbitrary standards of cost control (as primary endpoint) is the dujour modus operandi. Patient care is implied as the secondary endpoint (for those of you who like reading medical literature) but is never given much credence. The Kahneman and Tversky Loss-aversion behavioral economics are fully applied with prejudice to medicine. The business side of commoditization (and here on YouTube) with “Less is More,” no doubt a business concept, is allowing unsupervised practice by NPs and PAs in some states that are facing physician shortage, akin to: (Hire the underage workers at Foxconn). There lives a beast that will turn Medusa into stone!

THE AIRLINE PILOT AND THE DOCTOR FALLACY
The idea of constantly retraining pilots and therefore the physicians is simple but here are a few loose ends; training does not equate to wisdom. One can rattle away concepts without a clear understanding that only comes with layer upon layered experience and critical thinking. I am reminded of my professor and what he said at those times. It is easy to train anyone to do a sequential task of minimal complexity, it is altogether another issue to be able to apply wisdom to the need or want for that task that comes from education and experiential reference. One can be trained in triage for routine care but when human pathos complexity hits as it does most times, repetitive training alone will not do!


Let me bring in the Airline pilot training that all the "experts" are advocating, here for comparison. If any of you remember the Sioux City Iowa crash of United flight #232, it was not the training that helped, but Captain Al Haynes' sheer intuitive brilliance that saved 185 passenger lives. In fact 55 test pilots failed to equal his success in the simulator given identical conditions and having been pre-warned of what was to happen. So a word of caution to those beating the drum of pilot training and equating it to doctor training, it is more than training! A corollary to that crash is the more recent Asiana Airline crash in San Francisco where pilots were trained in Instrument flight by the Autopilot and failed to realize that in case of Instrument Landing System failure they had to hand fly the plane and you guessed it, they couldn't! They were trained to manage the autopilot flight!


The intuition gathered from compiling years of education, knowledge and critical thinking is needed in caring for the patient. So if NPs and PAs desire to practice medicine then they should simply go to medical school, follow through with a residency in training and be ready to take on the medical world. I say welcome to that. Doctors learn daily through human - human interaction. Pathology differs in each individual as does to some extent physiology. No two humans are the same.

Meanwhile guys and gals, ease up on the physicians, if you will. Tone down the demonization! Enough is enough!

USING THE PHILOSOPHICAL BENT
Using syllogisms to prove points are constructs of the pseudo-intellectuals. They use the informal fallacy of "post hoc ergo propter hoc" or this happened because of the preceding that! A classic example is:
The cost of medical care goes up
because of greedy doctors
Healthcare costs are rising
The doctors are greedy

This form of modus ponens methodology obfuscates, confuses and destabilizes the noble profession. In fact the very act of forced balancing a model unbalances it. To prove the point there is a daily barrage of wrongdoings highlighted in the media. Lately caring for patient's in pain with painkillers subjects the physician to criminal charge. But since the modus has been broadcast earlier the corresponding asymmetric il-logic must also be true; doctors are bad people. The result; patients are left to deal with their pain by the physicians for fear of over-prescribing allegations and indictments against the doctor.

HOW BUSINESSES DIE
By now you might have guessed that the business mind differs greatly from the medical mind. It does not discern the effects on the consumer as much as it covets its growth and success, although in the long run, those that survive time, pay attention to the widget creation and customer satisfaction equally. The current business mind however is a short term thinker; the next quarter and the surreptitious mechanisms to inflate the correct numbers to be rewarded for such acts has become an art form. The widget may be of sub-par value but if you say it is great on TV and the Internet through populated bots, it achieves a longer "time value." Enron is a prime example of accounting fraud that destroyed a large number of shareholder savings. LTCM, another entity which exploited small asymmetries in pricing until it took down $4.8 billion in stockholder wealth and needed $3.5 billion in bailout from the Fed.. Also remember the Gremlin and the Chevy Volt in the same context for further illumination of thought. The latter two products (widgets) expose the forced logic of failure with precision. History teaches us but as George Santanaya prophesied, "Those who cannot remember the past are condemned to repeat it."

The business mind is focused on net asset value. They consider the machines, the robots, the buildings, the pencil and paper as assets. Human workers are considered a “Fixed Cost.” Therein lies the greatest misadventures of the business mind meddling in the field of medicine.

The medical mind is focused on human healing, recovery and overall health. The business mind on the next quarterly revenue and net income!

Yes, I did learn to think differently. I see the holes in the dam where the tips of the fingers are visible. How long will it take for these cracks to rupture can only be measured in the “near term!”

Wednesday, June 17, 2015

OUTCOMES

and the FLY in the OINTMENT

Edward Kaplan and Paul Meyer came up with an elegant solution in discussing outcomes. They created the Kaplan-Meyer Estimator; a non-parametric estimator of survival function using timed data. Each entity logged in as present, absent or deceased. No gimmicks! A treatment for cancer would be graphed on an X-Y axis and the survival data would lend itself to an easy view. Each step-wise ladder would denote those that perished to the disease and those still surviving or censored as little tick marks on the steps. Comparisons with superimposed placebo survival curve identify the benefits or risks (as in the graph below) of the new treatment.

But here we are embarking on this lauded “Outcomes” as a metric to determine quality. I don’t know about you, but I have few misgivings about this form of measure. Actually I have two problems to be exact; a) How does one define Outcome and b) how does one define quality?

In a timed data if one were to treat pneumococcal pneumonia with Penicillin and the fever, chills and the chest XRay improved, then one could consider that as a good outcome. Easy peasy! However throw in the mix of fungus, immunological deficiency from age, disease, cancer and what you have putting it mildly is a major conundrum. No easy cure! Now let us bring in a patient with cancer into the equation. Is survival a good measure? If you say yes, then I have a bridge in Brooklyn available for sale. You see survival is not a simple measure in cancer care either. There are many tiny incalculable genes mutating as they play their game of life. The whole biology of the cancer and its rate of growth thing is a complex dance filled with many characters. There is no one character that struts on the stage momentarily to signify nothing. Every moving and non-moving genetic construct signifies something in the life of a human being. The many that are involved have each a bucketful of colorful lives and a plethora of epigenetic sauces to create the soup of life. So will the individual physician’s entire caseload of patients with a certain diagnosis be put through the K-M curve and compared to the national average? If we do that, even then we might be flawed in our thinking, especially if the physician has a disproportionate number of African American, or Hispanic or Asian patients or older or younger or more females than males, or right-handed than left-handed, or more artists than scientists, or movie-goers vs. internet-obsessed in that population (you get the drift).

Survival Curves 20-100 years & % of Survivors 
A: White women in US (1939-1941)
B: Women in India (1921-1938)
C: Theoretical Population with half-life of 18 yrs.

You see where I am getting at? It does grind out the cogs in the wheels of thought. But for simplicity’s sake, let us take a diabetic patient. If the measure Hemoglobin A1C is not below a certain limit then that would constitute a poor measure. Correct? Not so quick my dear Watson! The assumption here is that the world is a perfect place and that certain input leads to a perfect stream of output. But that is not the case, is it? The patient might like their case-load of Twinkies unbeknownst to the physician and never mention that they consume 3, 3-liter bottles of Cola daily and consider that as hydration. Or simply never take their medications on time due to forgetfulness, expense or laziness. How would that measure in the “Outcomes” category? Oh and while I have your attention, Is Outcome like a Warranty? You know like the many page document found with cars and electronic products? The Six Sigma approach might become necessary for root cause analysis in human outcomes as well. Eventually we as humans might need a MTBF (Mean Time Between Failure) for the population, drilled down to subsets of society and then individual level of existence for comparison, don't you think? And if doctors by virtue of intuition considered gods then so be it, let the Kaplan Meyer Curves roll!

Where exactly do Behavioral Modification and Behavioral Economics intersect? At the expense level or at the payer level? Or at the arbitrariness of the expert level, where most things today seem to live and breathe? Your guess is as good as any!

Now imagine given these simple scenarios that the elite experts who reside in those vaunted ivory towers consider outcomes as a measure of a good doctor and make payments predicated on such faulty thinking? Now before you go saying that cannot happen. No one would be so stupid to accept that? Guess what? That is exactly where we are today. “Outcome” is the new big buzzword. And CMS is trying mightily to convince the “Gruber’s Stupid” that, "this is the way it should be."


We are not done yet. Now add to it some “Satisfaction Scores” from the patients and we have a whole new enchilada in front of us. Say a patient perceived your smile as a cynical one. There goes your score. Or imagine you prescribed a medication that cost him or her more money than anticipated, or you did not recognize him at a department store, or your receptionist missed calling him or her on the specified time, or you as a physician had an emergency and the waiting room with five patients turned into one with ten patients sitting and filling out the “satisfaction Score” form? Any doubt that your “Reimbursement” from the Insurance would be returned “denied.” And you will have to jump through hoops to get a fraction of that expense 3 months later. That would constitute a certain Win-Win for the Insurer, wouldn’t it?

Ah the cleverness in it all!

Breathe!

The fly in the ointment continues to flutter its wings, trying mightily to get out, but the ossified mindset seems unlikely to remove it because that mindset believes in that  removing the fly means failure and more arduous hours of toil to rework a new flawed concept from inception. And guess what, according to them, the fly is part of the ointment and therefore makes for a perfect recipe.

Sunday, June 14, 2015

CODON 127


A very interesting study in Nature caught my attention the other day. A misfolded protein causing Kuru or CJD (Creutzfeldt-Jakob disease) and both can be stopped by a single point mutation at Codon 127 (a substitution of glycine for valine). That Codon 127 is the filter that could have prevented the decimation of the 2% population of Papua, New Guinea from “Prion disease.” Imagine that! Eating the brain tissue of the dead relatives is not the ideal scenario as it lends itself to propagation of the prions into animals (mad cow disease) doing the same and the vicious cycle comes back home to haunt humans in the end. Alas this codon mutation is an acquired benefit through the learning agility of the human genome.
Normal Healthy Brain

What about Codon 127?

Assuming you are crafting this thought in your mind, Codon 127 therefore acts like a filter, doesn’t it? Pass through and the brain is inundated with mis-folded proteins that cause signal disruption, chaos and confusion. Filter the pass through and voila no madness!
(Mis-Folded Protein on the right below)


And there it dawned upon me about Big Data and its chaotic perturbations upon our society.

Everything is “Big this or that” even the data and there is a daily bombardment of information boring into our skulls. Some are surreptitious; subtle programmed music to entice you to buy in a department store and others not so subtle advertising in the form of “studies” purporting eating or drinking this or that can lead to good health. We are being, in such gentle and unknowing terms, programmed into thinking thoughts that do not necessarily belong to us, but are the dictates of those that can pull our strings. Even in medicine, actually especially in medicine, this concept is in full force. A hodgepodge of studies with large biased assumptions are being bandied about to convince doctors that, “That is not the way it should be!” But, “This is the way it should be!” Beneath the surface, if one looks deeper, the author is in his birthday suit!

So what is happening is the failure in learning from our experiences to switch our Codon 127. The filter to see through what is real and what is false and by virtue of that insight, eliminate confusion. This filter then defines the nature of reality and removes the extraneous large datasets of useless information and allows us to process reality as it really is. The brain’s fuzzy logic (as in removing the blind spot from our vision) added to the subtle programming nuanced by “others” can scuttle our ends to someone else’s means as surely as the daily barrage of untruths can change the truth (Nazi propaganda) in the minds of the knowledgeable too. Critical thinking is the only means to keep our own wits’ ends.

“How does one do that?” is the logical question.

 1.  Compiling your own database of right and wrong.
2. Using Common Sense as a filter.
3.  Seeing through the lens of limited bias.
4. Remembering if something is too good to be true, it, of necessity usually is.
5.  Understand the motive behind the action.
6. Follow the money- the trail will usually surprise you.
7. Never assume.
8. Verify and validate the hypothesis.
9.  No one or entity is inclined to pursue benefits for you. They are in it for themselves.
10. True Charity is unconditional as is true love.

You can, I am sure add to this list and please do. It makes us all resilient in the end.

Tuesday, June 9, 2015

THE MISANTHROPIC ITCH

It goes on and on and on! Why, I ask is there such a desire to limit; to limit access to information, to limit access to knowledge, to limit the use of resources, to limit the desire to help some? Why? I think thinking is falling off the cliff! We skirt about the edges of real knowledge and then rush to make streets without plans and build buildings sans codes. All hurried in an attempt to harness the powers of persuasion, for deep in that persuasion lies the lonely seed of power.

"The power of population is indefinitely greater than the power in the earth to produce subsistence for man" -Malthus T.R. 1798. An Essay on the Principle of Population.

Some decades ago an English cleric and scholar had the wild idea that resources on this planet are finite and that the population boom will ultimately outstrip the resources leading to famine and chaos. His heart was in the right place, but his conjecture as it turns out was misplaced. The human capacity to change the future is limitless. What we can imagine we can create. 

Think about the Star Trek tricorder and your iWatch or iPhone already can measure the human body metrics. 


Think about flying and from the Wright Brothers “Wright Flyer” 


we arrive at the latest “Hypersonic Technology Vehicle 2” that flies at 13,000 mph (2011).

 Think about the limited fossil fuel reserves and out comes the “Shale Fuel” horizontal fracking technology, Solar and Wind power. Think about food and associated changes of “crop rotation” and fertilizer use leads to a 35% reduction in land use for more crop yields. Think about the movies in the theaters to now having one on demand on your favorite tablet computer wherever you go. Think about vinyl records and now stream the latest music on demand to a receiver in your pocket. So Malthus was errant and from that error, unfortunately grew a boatload of tyrants that decreed “One child policy” as in China under their Chairman Mao, Eugenics in California and Nazi Germany and the start of the bleeding heart Aid packages to third world nations. Malthusian vogue of crying catastrophe was when the population had barely touched 3 billion on this planet. Now for those keeping score it is at 7.1 billion. The destitution seen in some countries is not for want of food, but for want of desire to cultivate for it. The tyrants remain powerful and the citizenry depends on the tiny subsidy to keep them relatively content. Meanwhile heart-rending photos are flashed across the globe of children drinking from the polluted lakes to entice others to donate to the cause, while the rich get richer and the poor get poorer. However through all the talk about “preventative checks” of population control, Malthus, himself was against “Poor Relief” and was more in line with Adam Smith’s philosophy.

Speaking of what the U.S. Aid package, has done to those poor countries? It has made the citizenry poorer and made their leaders rich! Check it out. De-incentivizing the human mind is a crime of unparalleled proportion. It subjugates, it takes the yearn out of the Yin and sets up a multitudes of frustrations. Eventually in pursuant to such goals, one runs out of other people's money! 
The corpus of the entire thought remains an elegantly designed Utopian mystery. Proponents of the “welfare state” stand erect and demonize those that speak against it. Power and influence is a strong motivator for those standing in between the “giver” and the “taker” and articulating the heartlessness of those who point out to the chinks in the window pane.  Indeed for these few and well-entrenched society members the more citizens that can be forced to fill the roster sheets, the better it is. However as the cartoon suggests, eventually the society crumbles as a whole. Since 1968 the United States has paid out $43 Trillion towards ending the "War on Poverty" and the problem has worsened! From boundless opportunities to Weber's bureaucratic rationales, we have arrived at today.

Unfortunately this Malthusian itch has gotten steeped into the medical elite and the policy wonks that has created new and enriched tortured data-sets to show the similar "virtue" in medicine. “Less is More” is one of those itches and another is “Choosing Wisely.” Both are dream't up in the philosophy of the Malthusian backers. Using “Bleeding heart” technology and “futuristic shocks” as a correlational variables they have devised a path to control the limitless human endeavor of innovation. Even the new innovative movements are designed towards the power to limit. If screening of diseases leads to early diagnosis and successful intervention, they use the power of statistics to claim “harm!” If the appropriate treatment is costly then convoluted algorithms define need. If the physician orders tests to determine the real need in an individual then he is at odds of running afoul with the “Choosing Wisely” program.

And here is the kicker...Whereas in national meetings the pontificating experts claim, "Don't just stand there, do something!" as in give an antibiotic to a diagnosis of pneumonia in the first 4 hours, in another breath state, "Don't do something, just stand there," implying as in screening for prostate cancer and breast cancer that screening leads to harm. This schizophrenia in the elite is a daunting jungle to traverse and if you are a patient, there is no help on the way!

The buy-in from the physicians is less than stellar so the pith and moment of the movement is to convince the public to read their E-manual to basically give up the pursuit of living for the betterment of the society after a certain age.

Forced limiting childbirth is like snuffing the potential of innovation. Is that progress?  Are we progressive? Enabling entitlements limits desire/incentive and escalates the status quo. Is that progress? Are we being progressive? Limiting use of resources is to guide the principle that the future is bleak and therefore unsustainable. Is that not proven wrong over the past 1000-years? Man was bipedal, walked a few miles, then used beasts to travel further and now travels thousands of miles without breaking a sweat. That is progress!

Data is the new buzz word. We define our very existence based on data. In fact data has reached such an unparalleled position in our society that we simply say, “data suggests…” and all is received and accepted. Population data science is tortured to “best fit” in an individual, even if it has no relevance. Life has become a virtual Amazon jungle with colorful creatures that create strange and enticing sounds to woo and capture the spirit of the yielding.

We now live in an ocean of data that keeps getting deeper and deeper. We use data sciences and torture statistical methods to create an artificial reality that does not exist. We package that as the future and sell it to the hard-working populace that has little time to spend in thought and to the easily fooled. As Emanuel Derman, a professor of financial engineering at Columbia University states, “Statistics…is neither purely a language nor purely a science of the natural world but, rather a collection of techniques to be applied to test hypotheses.” He goes on to say, “Let us not get too enamored of the data science, whose great triumphs so far are mainly in advertising and persuasion.”

Did I say persuasion?
Oh my!

Monday, June 1, 2015

The TRANS-MORTIFIED Data

The syndicates have a surfeit of information but absent any wisdom they flail away at whatever comes to their collective imagination. The asymmetry is causing a burgeoning society of leverage-seeking middling managers that is left to its own limited devices for the managers to come up with shady concepts by touting their "expertise" to continue the facade. They live and breathe and advocate the virtues of Big Data, which they don’t themselves understand and yet here they are in their robust glory, effectuating “outcomes.”

What exactly has gone wrong with our soul-searching algorithm that previously never failed to tell us where the rock in a runaway stream-bed was loose, covered with a hint of moss and therefore a dangerous place to step upon? I haven’t the foggiest! But nevertheless here we are justifying what cannot be justified, rectifying what cannot be rectified and advocating what should never be.

There are philosophical differences for sure between the speakers and the spoken to. One side begins and ends with a monolog and does not take any questions while the other hides behind fears and potential for personal holocaust at the hands of power hungry, self-enrichment motivated power brokers.

The case of a CEO run amuck to destroy the professional life and career of a physician whistleblower, whose complaints had to do with poor hospital working conditions and cause for alarm for his patients’ care is a sign of the times. A recent court however,overturned the verdict and granted the physician his rightful reimbursement for lost wages and reputation, gives credence to the voice of a lone minority going head to head against a Hedge Fund sponsored CEO. Let us try to follow his lead for a bit in our lives. 

Equally we are beset with problems that seem on face value, the greatest thing since slice bread, yet as we delve deeper into the heart of the matter there is no existent electrical pulse of reality:
Affordable Care Act seems to have enjoyed a lot of press coverage and millions of people have signed up for coverage. Yet as we look below the thin iced skating surface the fractures are real. Many signers have limited access to doctors as coverage does not translate to care. To protect the turf a slew of laws in about 20 states nationwide have agreed to allow Nurse Practitioners to carry out the full obligations of a physician without the requisite knowledge or experience. There will be “Doctoring without Doctors” and no one is concerned just yet, especially in the urban blues where the patients still enjoy contact with their physicians. In one state, however, which is encouraging the NPs to function without supervision, is Minnesota and here Physician Burnout is lighting up the press recently! The reckoning will soon be upon us. Is the decision making in the hands of a confederacy of fools?

To explain how the Affordable Care Act is saving money there are many an economic-minded-word-contortionist who will use his or her own version of selective bias to create a study that any reasonable journal will scoff at, and yet the journal, hungry for "impact-value" continues to publish such nonsense as “peer review journalism.”  Now, they are counting on Hospitals saving the money for the ACA! Well let me tell you a little about that deceit. Physician Office based care is 1/6th – 1/10th the cost of similar care in the hospital. Yet given the onerous mandates imposed on medical practices medical students are seeking hospital employment in droves (83% to be sure). What that will do, is create a monopoly for the hospital to “control costs” by providing the least amount of care to the patient. Think, I don’t know what I am talking about? Ask around.  If you are a physician and if you don’t do the CEO’s bidding then your annual contract will not be renewed! So there! 

We live in a dichotomous society; those that have the force to enforce a will and those that live in fear of that enforcement. What was Yin is now Yang and neither comfortable in their present place.

Another example of this debauchery is in Medical journalism. Medical and Scientific articles continue to outpace the paper journals available, so new journals are created. Most of the studies appear bogus or notverifiable, but no matter!  Life is still “publish or perish” even if it is nothing more than utter nonsense. The scientific medical publishing world is in the hands of a few that determine who pats their back and how much does that translate to in real dollars! but if it makes the news story under the watchful eye of their benefactor on the 11-o’clock News then so, be it. Scientists too have turned to looking for the fast fame,,, The 15 minute fame is all some seek nowadays anyway. Crush the concept later! Doesn’t matter! "I got me in the papers dude!"

Oh and if the “trans-mortified” data appears too difficult to be realistic, hey what the heck, print it anyway, there will be sycophants to carry the written words through and make it a legend.
We have become a society of Grubernauts and Krugmanites. Nothing fits, so make it fit, because the majority of the hard-working people are “Stupid,” the former says, while the latter having proven wrong doubles down in his economic models that has laid bare the fine threads of the tattered economic fabric of some countries with his Keynesian meme.

Where will this end?


I don’t know. But we will find out sooner than later.

It is time to open our eyes and see that reality is not a fictionalized event via a heart-rending anecdote, but what you encounter in your daily life.

‘Nuff said!

Tuesday, May 26, 2015

REHAB 2.0

Life flows from warmth to a chill but sometime the chill can get sandwiched between the warmth, like a low pressure between two highs and stay stationary, as in this case; a patient caught between the extremes of human-created double jeopardy- between a hospital and a rehabilitation center.

A fellow I know lived an active life. He happened to find the unfortunate uneven step on the roadside that felled him onto a concrete slab. The slab was not hurt but the man’s skin needed the eye of the needle as it thread through some layers of epidermis and a staple gun to keep the thicker gashes closed. With repaired bones, stitched and stapled skin he went on to receive inpatient rehabilitative services in a facility that boasted the best services in town. “Living healthier lives” the banner claimed.
Unrelated image from Internet 

The facility was clean, almost immaculate; starch white floors with rubberized marked walking paths in its hallways, food served on glassy clean trays, and all care givers dressed in pure white. The only thing that marred the white was an occasional black stethoscope draped around the neck. The plenary focus seemed to impress and exude cleanliness a virtue of godliness as a means to faster, quicker and better recovery from the ill-gotten misfortunes of living impetuously. 

Yet in almost a whisper the hallways had a story to tell, a strange one at that. None of the infirmed denizens of this famed and storied facility seemed to be bipedal. They were all rolling along in their wheelchairs. Some with their legs firmly planted on the foot rests and others with one or both sticking out in front like the bow of the boat parting the air at any obstruction in front for careful clean passage.

The personnel seemed happy and cheerful. The infirmed seemed content too. This did seem like a Shangri-La of rehab facilities after all, just as advertised. Or was it?

I asked…

“How come, none of the patients were ambulatory?”

That caught the woman in the white starched uniform by surprise. “Ah, well, when they are ambulatory, we discharge them.” She replied with an imprint of discomfort in her voice .
Wow, I thought…what a concept of rehab. Bring the patient to the edge of their ambulatory ability and boom, ‘off you go!’

I learnt the secret later from a slightly verbose worker, “Well you see,” he opined as his head turned to look quickly at both sides like Regan in The Exorcist, “we do not want anyone to fall accidentally and hurt themselves. So we have a strict policy to allow full ambulation in the rehab rooms when they are with the therapists, that way, no fall, no lawsuits!” He finished.

“How long do most of the patients stay in the facility?” I asked.

“Oh, anywhere from two to four weeks,” he replied.

“And how many hours of therapy does each patient get?”

“Usually the therapy lasts 45 minutes, because most tire quickly and that is twice a day on alternate days otherwise once a day.”

“The rest of the time…”

“They are in their rooms in bed, being monitored by closed circuit TVs. If they need to go to the bathroom or shower they are given full assistance.” He smiled, “after all, safety is no accident, is our motto!” He added, “Keeps the lawyers away!”

So here was care driven through the eyes of the policy-makers with one eye on litigation risk, and the other on padding the bottom-line rather than true benefit of patient’s care. The staff was happy and well paid and the patients were content, watching TV and being served with no effort required. The only thing missing was real advancement in the patient’s abilities. One might wonder how many of these “discharged patients" would find their way back to the hospitals from falls related to atrophied skills. But those statistics are difficult to come by. Those statistics are only meaningful in readmission rates. So why not rehab the stitched patients for 4 weeks and then discharge. Ah the cynic in me is loath to deliver the benefit of doubt easily.

Rehabilitation 2.0 is the nuanced version of dotting the “I”s and crossing the “T”s for reimbursement checks, for longer duration of stays and for confining the patients from progressing rapidly towards optimal health. Place the metric in the wrong cubicle and what you will get is more quantified nonsense. But it makes people happy! It makes the deliverers of such care wealthy and it makes the pundits gloat with certainty how they have “streamlined” the system for outcomes.


What a system the system has spawned!

Sunday, May 17, 2015

The DIALECTIC: MOC is dead. MOVE ON!

A curious idea came into my head the other day. A concept, really, as it  furnished itself into a full blown thesis. You might ask what the thesis was about. That…

Man is meant to fly!

Looking at those creatures that take flight under their own power, the answer would be no. Man therefore was not meant to fly. That then is the original antithesis.

Yet when I look at the airplanes, man has learnt to utilize material to allow himself to fly through the air. True that! And recently the Jetmen who flew over Dubai, suggests that man is coming closer to the original hypothesis of man is meant to fly. This then is the new synthesis.

The dialectic proceeds and furthers our notion that we as humans go boldly “there” wherever “there” is because it is there. The original thesis continues to be reframed by the antithesis. The mind forces the world and brings it to its knees. Space and time are forced through the dialectic of a mind into substance and causality. And eventually the antithesis reforms the original thesis; “Man is meant to fly but with an assist!” This might change in the future, since there are antithetical arguments already in place to re-synthesize the newly reformed thesis.

The universal paradigm of giving birth to a thesis also leaves a constant trail of evocative pebbles in its wake. Not every concept takes flight after all. Each pebble a “run in with the antithetical monster,” is a constant reminder of how the world is shaped. Each pebble an outcast, lost in the whirlwind of the antithetical argument, never to realize its goal. In golf there is a truism about putting, “Not up, not in.” That is true for the discarded pebbles in the trail of a shaped reality. One such fresh pebble lies behind our last footstep, forced by the antithetical force of truth and finds itself heaped in the basket of ruined thought.

This thesis that lies bleeding, by a thousand cuts, is the Maintenance of Certification (MOC) requirement for physicians. Here the thesis propounds some fallible arguments pitched only by the conflicted souls of the organization. The originators of the MOC, ABIM/ABMS, claim there is a need for MOC and the importance of MOC is for the benefits of the patient care; public good is implied. Hidden, but recently revealed, is that there is no benefit to either the patient or the physician from MOC compliance, except only to the agency (the ABIM/ABMS), that collects millions of dollars in fees pays the officers handsomely in 7-figures and then plows the remainder into the ABIM Foundation.

The thesis suffers another deadly and paralyzing blow when it is revealed that the chief and pilot reason for this thesis to take shape in its current manifest form is to rake in money to avoid the organization from falling into the abyss of bankruptcy. Meanwhile, the money flows from the guileless physicians and the system lavishes itself with the royalties from the same distracted, confused and easily persuaded group under the guise of “do no harm.” Ah the muddied waters get muddier by the hour. The blows are many and the MOC’s outstretched limb for regulatory help might be a bit late to resurrect its image of a once beloved and dedicated organization. Indeed money has re-framed the shiny robe into a moth-eaten fabric of greed. The environment has decayed, ripe and teeming with the entozoon.

The only correlate that I can find to the MOC phenomenon is a malignant leukemic cell that thrives in its micro-environment where it is fed by supporting cast of other like-minded cells to prosper and proliferate at the detriment of the host. Sad but true. That is the Yin and Yang of life. To kill the beast or perish under its weight.

The antithetical argument to MOC seems to have found its stride. MOC was never meant to be helpful to the patients and their physicians - this much is well established. The original tenet was faulty! The antithesis is robust. Hence no synthesis is possible. A human response antidote is needed. The dialectic is fractured. The vein of fiction is ruptured and the vessel exsanguinated. There is no life to support here. The EKG is flat lined! No breath, no pulse, nothing! The thesis is dead! 

Move on!

But, “No,” say the enriched tarnished brass pining for the polish to shine, “The MOC is dead. Long live the MOC.” Apparently the new/old thesis has not been fully realized by the players yet. The old verified and validated thesis being, “CME is still king.” NBPAS (National Board of Physicians and Surgeons) seems to understand that very well and so do most 97% of the physicians (based on a SERMO survey).


“Move On!”