Friday, October 2, 2015


Precision Medicine is an strange term. It invokes an image of carefully crafted exactness rather than the reality: medicine is an inexact science - bounded in humility. So those of us looking around the corner for the Golden Age of Medicine need to calm their caffeinated jitters.

Articles abound in scientific literature and increasingly in the lay publications. Authors are doing cartwheels and stepping over each other in the trail of this magically transforming triumphant approach to treatment of human disease. Some claim that human illness will soon be eradicated. The hubris astounds.

Let us look at some of the pitfalls for now, not to be distracted by an anecdote of how this or that person was cured from an incurable malady. Plenty of that anecdotal material can be found in the New York Times and other papers.

The human body has about 25,000 functioning genes, made from the linkage of four nucleic acids Adenine, Thymine, Guanine and Cytosine or A,T,G,C. From these humble beginning a population of 7.1 billion diverse human beings currently occupies the planet. (Malhus must be turning over by now). Each individual, shares the same genetic structure but there are subtle changes in each human being’s DNA that give us our looks, morphology (body structure), intellect, nuanced behavior and other things that are nurtured by the environment. And thus, although monozygotic twins share a 100% of their DNA they too have subtle differences in their gene structures over time based on difference of life experience – the Lamarckian twist!

So in a population of say 1000 people who are not related to each other what is the probability that they will share identical genomic signatures for a given disease. The answer comes from various studies including the one carried out by Mary Claire King looking at the prevalence of BRCA (BReast CAncer gene) mutations. These mutations are at best in 14% of the population and seem to be more prevalent in for example the Ashkenazi Jewish population subset.

Another study in Lung Cancer determined that EGFR (Epidermal Growth Factor Receptor) mutations are found in 15% of the population, or the ALK (Anaplastic Lymphoma Kinase) mutation in the same patients with lung cancer occurred in 5% of the cohort studied.

So then the saying goes, well, if we find the genetic structure we can treat effectively. Effectively, yes. But cure a disease? Not so quick my dear Watson. One might think that if we can study these genomic discrepancies, and then devise therapy selectively for the cohort with the anomalous findings. Ah but here is the $64,000 conundrum: What epigenetic signatures modify the behavior of those genetic signatures still remains unknown. So one might have the SNP (Single Nucleotide Polymorphisms) or CNV (copy number variations) or a substitution of A for C in the DNA but how that is expressed might be in the hands of a lesser known but equally strong power called the micro RNA that might be perched around the gene to mess with its behavior.  Or even the semi fluid control of the Transposons, the genes that jump for the sake of strengthening the survival of the DNA and can inadvertently sit and silence a tumor suppressor gene or over-express a proto-oncogene to accelerate cancer growth. So responses even with known gene abnormalities differ as a consequence of the epigenetic deliverance. Not to forget that the cancer cell within its interior has multiple pathways, which govern the behavior of the nuclear proliferation and hence doubling of the cell. So silencing a gene that provokes the proliferation pathway may be silenced temporarily by an antidote (monoclonal antibody or mAb) that attacks the functional protein product of the gene only to be thwarted by an overactive collateral pathway that gets recruited to continue the wayward cell growth.

Recently reported scientists have discovered a gene called GNAS c.393C;T that seems to cause Ventricular arrhythmogenesis (causing arrhythmia or irregular heart rhythm) and is now thought to be associated with sudden cardiac death. With a HR of 1.2 and a P-value of 0.039, clearly more study needs to be done before we start inserting pacer/defibrillators in people with this genetic anomaly.

A study in the NEJM recently showed that targeting a select molecule (BRAF) in different cancers where its expression is evident yields mixed results at best. and goes to the original Shakespearean premise that "there are more things in this heaven and earth (Horatio) than are dreamt of in (y)our philosophy."

So precision is imprecise at best. Before we start building models of costs, quality and exactness, a tincture of humility might also be in order. Such bravado needs some careful reckoning before we hail the next coming of sliced bread. You know, it would be nice to just call it Medicine for now!

Saturday, September 26, 2015


I came across a man, whose world had played a trick on him. The torture was evident, its imprint on his face evident and his story a living metaphor. He said...

As my strength drew to a nadir and the single path opened before me, the silent suffering yielded its thoughts like bullets from the brain, spewing with unmeasured alacrity, what some might consider a rave, but it was the expression of a broken heart, and shattered dreams that no one understood. Silence does build walls and suffering hides within the midst until the strength weakens and the restraint is lost.And as I look through the frame of my reference into the outer world; my personal universe, I see the opposite: trees are resilient, upright and blossoming. The flowers are colorful and inviting and the birds chirping in their solemn prayer, blissful in ignorance. Even the lashing punishment meted out by the storm last night seemed to have been an evocative play between might and right, all forgotten in the midst of the sun-soaked brightness that illuminates this universe today. Yet, a lingering starch of stoicism and anger is steeled away by the past and bottled in quantities large that threaten to spill and stain in the grandest of scale. "O' that I am angered!" He sobbed.

The Question:

But as time slipped, the turgid seething anger within slackened its hold on his person. The abating sense of freedom awakened once again. What? Should he fight and counter the weakness that has spread through the sinews of his being with this, once-coursing liberating elixir through his veins, again and follow its dictates? Should he relearn the manifestations of the residue of a long and torrid past; to fight the element of resignation and nature’s powers of emotional entropy? Or should he rest quietly amid the weakness that seems so fertile and warm and soft and all-encompassing and with that allow himself to dissolve into its oblivion? Where was the truth? His mind filtered the demands imposed upon it by the slow trickle of that elixir. There is a surge of impatience quickly to be subdued by the coziness of the infinite reflection; to let go or to be?

The raucous riot grows slowly but steadily in the brain, gaining a foothold at each threshold from whence the light of life escapes and plugs the leaks to confine the dark spirit that weakens the flesh. All the suffering from the whips and scorns of time, as Hamlet calls them, common to all sentient beings are laid out on a tapestry. Some succumb to the darkened vagaries of wretched thoughts and allow their minds to devolve into the cycle of self-hatred. Others take arms against their sea of troubles and by facing, end them.  Ah Hamlet knew it well. He knew the human element as no other. He knew the sinews of action and inaction. He might as well be the master-knowledge-keeper of all human psyche? Is the human life defined in those 32,241 words written by Shakespeare? I think it is. Is one just facing the inevitability of life’s progression conjured so beautifully though the Bard’s mind? Is he feeling life’s ordinary tumult? And through the mist, a subsequent bigger question arose; Does he have the strength to stand up and face the sea of troubles, in order "to be?"

The Answer:

Each one of us is gifted with a sense of self. We each have the strength of purpose if we allow it to embellish our lives. It is not in the self-imposed drama of an entropic vision played out in the mind, when faced with a calamity, that one finds the welcoming arms of success. It is what is learned from the weaknesses of moments where frailty and abject abrogation of self-reliance, that one conceives the human heart is strong, the will courageous and the mind resilient. It is in the fall that the rise holds the light. It is in the despair that laughter reveals a path. “Though this be madness, there is method in’t!”

I look out from the tormented pillow of a sleepless night, where dreams might have been made and the window to the outside brings the relief with the first light of dawn. The human suffering continues and I but one am charged to change the course of a life with all its frailties. Each life is a weathered storm. Each moment a memory. It is hazy at first and as I focus my vision, the trees take shape and I can just hear the birds. Life is, once again. The dreadful nightmare has passed as all such unhappy moments do, and the world is whole. In that moment, I realize that I am he!

In each life a little rain must fall and in each life a new green shoot will blossom with that rain. We must learn to get up the eight time after the seventh fall. We must live to see another day, to make a difference, to see a smile, to hear a laughter, to form a friendship, to enrich our soul, to live fully the life apportioned to us.

In the end that is clear. To that contemplated tantrum from a series of frustrations, a modicum of temper must be applied. To that irresistible frustration to lash out in anger, a lather of reason supplied and to the urge to create disharmony a nuance of understanding from where a better person emerges; knowledgeable and wise. 

In that future, there exist endless possibilities!

Saturday, September 19, 2015


"W21.04XA Struck by ball initial encounter."

We go to extremes to measure and quantify and then base assumptions on the likelihood of our premise, whether what we are seeing is reality or a smidgen of it. And if so, how can we predict further into the future about trends and human progress.

Well now, here comes the ICD-10 coding information for billing medical encounters:

Let us look at one specific code for an example: W21.04XA Struck by ball initial encounter.

If you are a golfer you will see what I mean. It is so obvious how pathetically limited the measure is in extracting information. For instance why not add a L and a R modifier to the code and make it: W21.04XAL and W21.04XAR for a hook related injury and a slice related injury from a golfer’s club. That way the Insurer and Government can know the predilection of the golfer and his capabilities and send a mandate for all L and R golfers to have their drivers levo or cis rotated for optimization. Another characterization would be to use S modifier for a “skulled” hit. So now we might have W21.04XALS or a W21.04XARS. Given the dimensions of the game an important measure would be the location of the injured individual if he or she is standing less or more than 90 degrees to the golfer with modifier Y for  less than 90 and Z for  more than 90. In that case we might have another modifier: W21.04XA L/RY and W21.04XA L/RZ. But that is not enough either. What about the club and the ball. If it is a Ping or Nike the modfiers could be P or N and if the ball is Titleist or Noodle additional modifiers would help because the balls have different cores the latter is much softer. So a modifier T and N would make it W21.04XA L/RT or W21.04XA  L/RN. We cannot forget the course however as it relates directly to the ability of the injured party and golfer to play in a public course (cheaper) or a private course (expensive). One could use lower case modifiers as pu and pr making our code: W21.04XA L/R/Y/Z/T/N pu and W21.04XA L/R/Y/Z/T/N pr.  One more thing we need to know what time the injury took place for example; morning , noon or evening. The relevance is obvious! The modifiers would be MO, NO and EV at the end: W21.04XA L/R/Y/Z/T/N pu/pr MO, W21.04XA L/R/T/N pu/pr NO, W21.04XA L/R/Y/Z/T/N pu/pr EV. We did forget the fact whether the golfer swinging the club is a left-handed or right-handed and an appropriate modifier would be le and ri: W21.04XA L/R/Y/Z/T/N pu/pr MO/NO/EV le and W21.04XA L/R/Y/Z/T/N pu/pr MO/NO/EV ri.

Here is the code for a patient submitted for payment. W21.04XA R/S/Y/T/pr/EV/ri one would immediately know that it was a right-handed golfer with the injured party standing less than 90 degrees to the golfer on the right side go hit by a slice with a Titleist ball on a private course in the evening.

Armed with this information the Insurer can deny payments for the injured person standing less than 90 degrees to the right handed golfer with a slice, while the lawyer can use it to sue the golfer for allowing the injured party to stand less than 90 degrees to the golfer.

Let loose a couple of bureaucrats and the dogs of war!

A zero sum game - of intellect!

Tuesday, September 15, 2015


When Kaplan met Meier
no one knew about death's spire.
People came and went
through life's dint
swallowing little pills.

There were losses and wins
in the dungeons within
where ignorance roamed
and played to win
but most knew was a shill.

The two choreographed
the dance of death
as little sticks marred
the absence from loss
and time weighed in on the still.

The spurious results
that previously abound
couldn’t hide from the truth
of the elegant reveal.
All was visible in the kill.

Did this pill do
what that could not do
Or did both sire
into equal measure and retire
no one wiser in their gristmill

But Kaplan knew
what Meier intended
and Meier knew
what Kaplan pretended;
death like life cast a visible trill

Each step of the ladder
a loss of life
each vertical stick
a loss in reckoning,
both filled the tumbler of human ills

When pills were matched
on the graph they drew
one steeped low
the other climbed true
both bottom matched in the playbill

In that mathematical file
where the loss is subtracted
and the absence extracted
lives the benefit
or lack of that mill's pill

Breslow held the earlier gains
Tarone picked the middle plains
and Log ranked the last remains
to prove the time
benefits of each goodwill.

It is simple attrition, you see
as each life is a step
away from the majesty,
beginning the painful march
on the step ladder down the hill.

The march goes on
as life moves along
and death lives,
where time is variable,
full of surprises and untimely chill.

So to Kaplan and Meier
A toast to their desire
To highlight death from ills;
the good and the bad, all there
to be seen in their step-wise graphic frills.

(Also Published in Oncology Times, August 10 Issue)

Monday, September 7, 2015


“The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself. Therefore all progress depends on the unreasonable man.”
– George Bernard Shaw

is in the reasonableness as George Bernard Shaw points out and in the Rationality of the mind, which limits options, as John Nash points out that the stodgy sludge of decadence exists. The reasonable person uses rationale and through that reasoning eliminates the one main virtue of creativity and innovation; Cognitive disinhibition.

Take for example the current vogue in medicine; organizations and associations are placing enormous burdens of their collective rationale on patients and physicians in how to manage healthcare. There are programs, to name a few, being given wide berths: “Choosing Wisely” and “Less is More” and not to forget “Maintenance of Certification” (MOC). None of these programs bear any semblance to the reality that exists between the patient and the doctor. The grand bargain is mostly about costs. But since reasonableness and rationale persist in such syrupy doses, no one actually questions the thickened false narratives, which underlie the premise. All three programs are about money. The first two supposedly to save costs related to healthcare and the latter about enriching the coffers of an organization (ABIM). In the former two concepts that are widely disseminated, through eager and of unequal and limited intelligence digital and print media, the focus is on the over-utilization of services and in the latter it is about physician competence. Yet no one actually realizes the 800lb gorilla in the cost-room that constantly sucks away, admittedly by any standards, around 30-40% of the actual costs of management in Healthcare in the United States.

Additionally another 20-30% of costs are related to redundancy and waste in care:

“More than one-sixth of the U.S. economy is devoted to health care spending and that  percentage continues to rise every year. Regrettably, our system is not delivering value commensurate with the estimated $2.7 trillion spent annually on health care. Experts agree that about 20 percent to 30 percent of that spending – up to $800 billion a year – goes to care that is wasteful, redundant, or inefficient.” ( )

Don’t you just love the words: “Experts Agree…”

Extricate the Insurance industry (the middling middle-man) and the cost of medical care on an individual basis goes down dramatically as well as for the nation. There are physicians already making inroads into the concept of direct pay and transparency of cost without the intermediation from insurers and administrators. The difference the public needs to understand is, what is and what is going to be offered for “free.” That “free” is neither free nor good for the individual…behold high deductibles and denials of care. So as the burgeoning models and concepts (first two premises) look only at the waste and come up with monikers to embed into the minds of physicians and patients, the elites ignore the real cause of such waste: the abolished “Skin in the game” for both the patient and the physician. A simpler model will emerge, should an “Expert” engage in a thought process. - I guarantee it!

“There are many causes of higher health care costs and spending. These causes include higher prices for medical servicespaying for volume over valuedefensive medicine, use of new technologies and treatments without considering effectiveness, and a lack of transparency of information on prices and quality. There is also evidence that provider consolidation is having a significant upward pressure on health care costs. The causes of higher health care costs and spending are not simply or easy to solve, but they must be addressed or the impact will be severe.”

The MOC concept seems to have evolved from utilizing the moniker “do this for the public good.” According to the ABIM organization physicians taking tests, made of unrelated materials and not cogent to their practices, supposedly improves patient care. It doesn’t! It wastes physician’s time and places patients in jeopardy for not having access to the physician, even when excluding the monetary costs to the physician. Without a shred of evidence that any of the “Maintenance of Certification” examinations employed for the doctors has yielded an iota of public benefit or helped enhance public healthcare, the rolling boulder continues to track down the mountain, as the ABIM organization parses its statements and pushes to move the needle by virtue of alliances with industry, hospitals and the government. And in so doing has enriched itself with over $100 million while waging the war on physicians. (here)

So where does that lead us?

It is about the minority opinion, which evolves from cognitive disinhibition that questions the majority’s runaway train carrying bushels of dollars. It is time to review the actual and not the feared, the reality and not the proposed, the individual and not the population, the reason and not the uninformed collective word. It is time to question the sanity of the arguments based on real facts. All too often we fall prey to the predatory influence of the mob mentality and are unable to think for ourselves, because it is easy to follow and more difficult to lead, because it is easy to take orders then to analyze their virtue and change the paradigm, because “life is difficult as it is” so why make waves, because “that’s the way it is.” Yet because of all the preceding “because” it is in the interest of humanity and that of the individual to grasp the truth and consider the “Why.”

The fallacy of building an aircraft carrier with a faulty rudder is obvious, but using strawman arguments to continue building it is a cause for genuine alarm. Using proof of contradiction as a means to validate a process with “proof” being established from unreasoned collective words is equally damaging. Logic and reasoning must prevail when entertaining hypotheses before embarking on the experiment. The current experiment in U.S. healthcare rests on a layer of quick sand waiting for movement.

Conjectures are the green shoot; the gist of human genius is in the knowledge of the seed. Any darkness of ambiguity or false assumption can rock the beauty of the garden.

“Therefore all progress depends on the unreasonable man.”

Friday, September 4, 2015


Music has this immediate and powerful grab on the soul. It wraps you and then transports you into another dimension. That dimension might be a memorable past or some future unrealized.

Listen to this piece by Milana Zilnik where she interprets Beethoven’s Fur Elise and then mixes in some of her own melody.

by Milana Zilnik

Listen and you can imagine yourself floating In a sailboat on the still waters of a lake as the breeze slowly lifts you and you feel the sensation of the lift as the beautiful white sails fill and surge to the demands of the wind and the bow cuts through the water parting it to move yonder, daring to feel the future. The gentle lull as it seizes upon the moment slowly withdraws you from that sensation and the luff of the sails momentarily brings you back to the present. It is a push and pull of the notes, the surge of the desire and the melody that transports you into the peaceful vistas where human’s rarely visit. The colors splash from blue to orange to gold against the darkening sky. A glimpse of what is and what will be all bottled in the now. The layers of time merged onto one plane visible through the chime of each carefully struck note.

Anon, why there is the magical floating island and the roots of the trees just hang below while the plush green trees overwhelm the surface with a canopy of cover from the bright sun lurking in the cloudless sky. And there you are as the gentle breeze tugs away at the lapel of your shirt and then all is lost in the dream as the misty clouds blanket you in their cool comfort.

The colors splash here and there and the Spartan landscape soon is enriched with each drop and each stroke until the majesty of the canvas is a phantasmagoric rendering of the Masters.

And yet the desire is still incomplete as Milana weaves away the knots and folds of this beautiful tapestry into a version of Beethoven’s masterpiece that transcends the master’s own version. Each note a surrogate of tireless thought, each sound a mix of desire and each melodious offering a captured intensity. The continuity is all.

There is something about music that moves the soul. Something about the way it creates a resonance and the involuntary physical movement that accompanies the flow of the movement without a conscious thought evoked. This magical movement of the notes wrap themselves around the neuronal matrix in the brain and stimulates the electrical impulses quite adeptly with a bright unconscious illumination. It stops babies in midstream even in hunger, children pause to play their next move, adults unload their weighty burdens of life, allows the elderly to float away on an island where their brushes with harsh reality is forgotten and in that brief of time many lifetimes are explored.

Music transports, illuminates, educates, expands time and makes us contemplate meaning of that momentary arrows flight. Slowly and perceptibly the deeper strata unveil their mysteries and a clock's hour is stretched many fold. Superficial strata no longer pleases. As the melody ends, you wish it would continue…And you play this...Erik Satie's Gymnopedie No.1 and feel satiated!

Friday, August 28, 2015


What if I am wrong and everyone else is right? How will I reconcile my thoughts to the reality? Indeed what if I am right and everyone else is wrong? What do I do?

These scenarios play out in our lives daily. Risk mitigation strategies are nothing more than links of multiple “What ifs!”  The actuarial data creates the template and probability thrashes out through the Bayesian lens, numbers that speak to the risks. All is contained. All is accounted for. All is measured.

Is it?

Yet, yet the blood curdling thought turns black the phantasmagoria of the colorful dream when the “What if” chimes in. And it does, if one does not swim in the lake of delusions.

Let me take you on a short aviation encounter of the real kind…

Flying as we all know has known risks. The fatality rate of commercial operators as in Airlines and General Aviation is a miniscule 0.42 per 1,000,000 passenger miles travelled while Auto accident related fatality rates are 3.4 per 1,000,000 passenger miles travelled or 10 fold more. So neither modes of travel are exempt from risk. And if you carry this thought forward, it seems that the drive to the airport is almost 10 times more hazardous than the flight itself.

Since we are inclined to toast the virtues of aviation and link them to the nearby disciplines of medicine and in some cases of business, let us carry this heavy ball and chain further. I commented while delivering a lecture on Aviation Safety, “What if things don’t go the way you anticipate?” There was silence. “What if you run out of fuel in the air?” A hand arose from the rear of the room. “You wouldn’t let that happen!” the voice claimed.

“What if the High Pressure turned into a Low Pressure area and you were faced with head winds instead of tail winds as calculated in your trip planning?” Again the hand raised, “Set the plane down at a nearby field, anticipate the potential based on the speed, fuel and distance calculations.”
What if you are over a mountainous terrain?” I countered. This time there was silence. Inspiration hit the back of the mind that had been responding, “Set the plane down before the mountainous region, fuel up again and then continue the journey.”

“What if there were no airports within a 50 mile radius?” Stumped? Not really, the Phoenician hand rose again, “You have to anticipate that when you begin your journey!” She was right again!
Having found one listener who was engaged, I switched tack, “What if you lose engine power on take-off at 400 feet?” A hand rose across the sea of heads, this time from the back again but the other side of the room, “Go back to the airport!” The baiting was over and the opening I had been waiting for had arrived.

“If you make a turn back to the airport below 700 feet universally that is a no, no! As you turn you lose the vertical component of lift and the potential for stall and spin is extremely high. So the only option is to land straight ahead or 30 degrees left or right of the departure end of the runway wherever there is an open field.” I paused and a few heads nodded. “This brings me to another question, what do you think the main reasons are for doing a traffic pattern at a non-towered airport?” More hands raised, a cacophony of, “See other aircraft in the pattern, arriving and departing and any potential hazards on the airfield itself, such a waste of time, waste of fuel, totally unnecessary” were the main thrusts. “What about using the traffic pattern as a means to observe both the departure end and the arrival end of the runway for the potential of what if?” Blank stares greeted me on that. “What if you lose an engine on departure from the same airport and having surveyed the field on arrival, knowing the terrain surrounding the airport, one can safely figure out a location to set down the aircraft and walk away from potential of harm.” The bulbs of inspiration and understanding lit up. Hey that makes sense was the general brightness that illuminated the attendees.

What if, is a game of chance and played by those that seek not to rely on luck but on mitigating the potential of risk. In business, the smart money always plays the game. Ever see Shark Tank on TV, it is all about the potential of success vs the potential of Risk. The ratio above 1 gains an investment from the Wealthy Sharks while those with an irrational number (fraction) go home. The Sharks look for fiscal trends of the business, the emotional needs and the desires of the public at large, the investment costs and their Return on Investment (ROI) through acquisition of part of the business. Sharp, shrewd and uncannily business wise!

In medicine too doctors continually play the game in their minds and when discussing cases with colleagues. What if I give this medicine, how would the heart react to it and what would that do to the kidney function and how would that affect the lungs. Or this chemotherapy or biologic therapy harms the heart x% of times and the benefits are y%, if the y% exceeds the x% substantially then it’s a go otherwise search for another option. Oh by the way, if you didn’t know this, here is a clue, the practice of medicine is every bit art as it is science. Don’t let the pundits and experts fool you otherwise, they for the most part sit and push papers.

Life is a game of chance and not as the current cookbooks concocted in the ivory tower realms of population medicine purport. Each human is unique and each human has a unique genetic signature that determines a different response than what might have worked within the 2 standard deviations of the normal distribution curve for the majority. My genetic signature is as unique as yours, like East and West and never the twain shall meet in health nor in disease manifestation nor in the response to similar treatment. We are a unique species conceived of a 25,000 gene product built on the foundation of a four nucleic acid code. Now that is impressive in terms of uncanny diversity within a 7 billion population spread across the globe!

Technology can crunch numbers faster than the human mind! Yes, but what if a 50% benefit based on a 95% Confidence Interval is the metric utilized to treat an individual that has a completely different set of genomic signature and does not comport to the “landmark study” being used as the template for treatment? What if the numbers in the medical study were derived from a subset of population that does not equate to the region from whence this patient came? What if the “large” data set of a 1000 patient in that study is a very small subset of a larger population that does not represent the whole even within the 95% Confidence interval and even after the Bayesian rules have been brought into play, but skews it downwards to an alpha of 10 or more in reality? What if we are wrong in using population statistics to govern the health of individuals? What if?

"What if" scenarios are thought experiments without real consequences. These are designed solely to appoint a guardian of luck as you travel across your chosen path. Humans have the uncanny ability of using this argument and making appropriate decisions as they wade through the murky waters of chance.

What if you are right and they are wrong? What if…