Friday, April 18, 2014

Commoditization of MEDICINE

It dawned upon me, the importance of a name. Unlike Shakespeare who deemed that a “Rose by any other name would smell as sweet,” I beg to differ, not about the smell but about our perception of the rose, if we called it, say a “skunk.”
There is more to a name than meets the eye.

Doctors have long been called “doctors” because they were in Latin considered Church fathers, educators, advisers and scholars. Hmm sounds like a lot of hats to wear, doesn't it? But think about that for a while and you will find truth in it. Doctors do, advise, they are learned in the arts and science of medicine, they educate against unhealthy behaviors. Similarly the word “Physician” in Latin holds court as the natural science and art of healing, something more in line with being a doctor.

But recently the word in the politically correct world does not smell as sweet; it is “Provider!” Now why would anyone shy away from the word, doctor or physician that has been in use since the days of Hippocrates and Osler to this one coined by the elite? There must be something to it. For what’s in a name, you might ask?  Ah! But there is power in it. It (the name “doctor”) has long been immortalized in prose and poetry, in annals and tomes, in sickness and in health, in life and death and in any form of ritual or ceremony. Oh yes the word “doctor” has a significance that none other have. It is not the station or the pulpit but the knowledge and the critical thinking that goes with the art and science of medicine. That art, my dear friends cannot be replicated in the IBM Watson or the Star Trek Holographic guiding image of the future.

So then, why did the elite change the term doctor into provider?

To answer that question, we have to look at the word, “Commodity.” Commodity is a marketable item. It satisfies the “needs” and the “wants,” or “demands” if you will, of the populace. Since the commoditized product is not differentiated enough, the demand is great and the margins (or profits) are low. Hence the commodities that people cannot do without are bandied about in the market in greater supply to meet the demands. These commodities can be “hard” (mined) or “soft” (grown).  Examples of commodities include staples such as milk, wheat, corn, soy beans etc. You get the message.

Why does something become a commodity? Well, if the product differentiation is lost in either its function or functionality and is easily available in the marketplace, that product has been commoditized.  Lo and behold, the word Commodity was first brought into the lexicon by none other than the French, who have a penchant for socialistic ideals.

To commoditize, one has to mass produce the product or has to reduce the value by creating competing products that are less differentiated. Debasement of any product in the market is the first and the unkindest cut of all in a marketplace. Vilify the product, demonize the brand or hurl baseless invective by flooding the airwaves and you change the value proposition of the consumer.

Okay, so those who have followed the trend can easily see where I am going with it. Here are the nine factors in the making of a commodity:

1.       Debase the name. But the long tradition of what the words “doctors” and “physician” represent are difficult to eliminate from the mass memory. So the elite take a swipe and gradually change the title to “Provider.” Ah it is catchy and they use that in various media, oozing slowly into the mindset of the populace. As time goes on the “provider” term starts to take on the nurses and then the home care givers, the technicians, the transporters and the house-keepers. Everyone who might have an iota of influence in being involved in a hospital, private clinic or in a university, is a “provider.” When everyone becomes a provider then everyone in the eyes of the beholder has similar value.  You ask, “who’s my provider?” The answer might surprise you.  And surely as I write this, I find that a certain expert elite named, Ezeke Emanuel, MD of University of Pennsylvania as stated that 80% of all medical care can be provided by Nurses, Physician Assistants, or Nurse Practitioners.  And they are now making noise for equal pay for services they render with less education- so much for cost control here… Huh? Really? Oh but wait, the NPs, PAs and others are rallying behind that cause because they get to be “doctor-providers.” And many wear the white coats and hang their stethoscopes around their necks as they arrive. (And I am not going to make a disclaimer or a politically correct statement here either).

Are they up for the challenge?

2.       Next create guidelines to minimize differentiation in what the “Provider” can do. That reduces the underlying principles of the “Art” in medicine and turns everything into a “soft” science. (And I am being nice here the real word is “pseudoscience”).  So elites and experts now create massive amounts of guidelines in how to treat illnesses. But, and you might have guessed it, they forgot the individual patient. You see no two patients are the same and none ever fit into a category or a cubby-hole. The “Unum” is very much alive in the e-Pluribus Unum. Yet the march to dedifferentiate continues at break-neck speed, maiming all and any defiance.

3.       The third arrow to take flight against the doctor is the new art of “Choosing Wisely.” The concept is so convoluted and does not fit good medical care in the majority of patients that at times it appears that some other element, not being mentioned is the driver behind that program. Everyone falls to their knees and prays to the neon gods and those that don’t are taken to task. And  …

4.       Meanwhile as the commoditization of medicine is in full swing, a constant harping about costs and how the US is far behind other countries in health and survival outcomes is drummed into the spongy brains of non-critical thinking crowds that are busy trying to make ends meet. The graphics are titillating; the charts are colorfully expressing the desires of the experts and the elites, they show; US medicine is subpar and more expensive. But no one, no one looks at the cost drivers.
They seem to hone in on the doctors (here they call them “doctors” and not “providers” to complete the image). Meanwhile the drivers of hospital care and the newly discovered pharmaceutical drugs and the latest innovative devices
and the Administrative Costs remain unmentioned. Only the physician is under the magnified scrutiny!

      On the one hand there is this crush of cost related difficulties and the “fortunes of a great nation is at stake” and the entire fault is laid upon the shoulders of the doctors (er, providers). And as surely as the sun rises, other mandates are drummed up including Electronic Medical Records (EMR). EMRs have created another gulf between the doctor and his or her patient and the value of the doctor through this enforced interaction has further minimized the value of a doctor/physician in the eyes of the patient. However as many have pointed out that EMRs have created larger barriers in medical care and added to the complexity, reduced efficiency and exacerbated the costs (that the experts want to reduce). The drumbeat of progress continues. Oh well!

6.      SIX
      Springing into contention and not wanting to lose out on the revenue stream a hodge-podge of self-appointed experts are making billions of dollars on the plight of the doctors. The costs of the EMRs are astronomical and are never paid in full. But the makers are enriched. Others who benefit are the “data trolls” who glean (mine) and create nuances of “appropriateness of care” and also find means to kill any attempts to expose their deeds by hiding behind software algorithms. For example, Epic Systems had revenues of $1.2 Billion in 2012 from this meaningful enterprise.

     The ongoing onslaught continues in the form of a daily banter about “Bad Doctors” (not providers). There is a daily dose of fraud committed by bad actors in the medical field and some are unfortunately doctors also, but they are demonized in large print to make the point that the nobility in this privileged field is no longer. It makes for good news worthy headlines. It keeps the agenda in full Monty.

     The sound and fury is also enjoyed by the legislature, who in their desire to show the public that they are doing an admirable job in their well-entrenched capacities, want more “heads” on the chopping block. The whips and scorns continue to rain on this once noble profession and nary voice is raised in opposition for fear.  Criminalization of doctors remains in full force and escalates daily. Here are three separate insights. 1.  and 2. and this one for sure: 3. “The Criminalization of Medicine: America's War on Doctors (The Praeger Series on Contemporary Health and Living)” First Edition 2007 [Hardcover] by Ronald Libby

To boot Medicare just completed their first MD Data Dump and lo and behold it is the talk of the town, nay, the country. Anyone can see who was paid what. But the details of what was the profit in all that is not deciphered. The obvious reason it seems is to incite the rage of the public that is a willing accomplice in the class warfare. The lynching continues through every means available to reach the end.

When business, politics and medicine converge there are bound to be deleterious consequences. There are! You might be in the ivory tower making the claims, you might be a nobody who has found a fog horn to exclaim, you might be a self-serving individual bleeding the life out of the noble profession for pecuniary gains, you might be a believer in the commoditization of the doctors and medicine as a whole or you might be an intellectual in pursuit of another paper to serve your own needs, whoever you are, know this, there are unintended and deleterious consequences to these actions.

One cannot take the “Art” away from medicine and one cannot make decisions on the shifting sands of contrived “evidence” and base all decisions on such contrivances. The Art works hand in hand with the Science. Both flourish together and neither survives without the other. For instance Washing hands with soap and water is better than Purell! But someone is making a boatload on selling Purells. These little bottles are ubiquitous, mandated to keep our hands sanitary. No one wants to appear dirty, right? But through it all the most ancient of life (viruses) continues to spread as it will, because it is ancient and it has learned to survive. One day the virus will have mutated to understand the Purell mechanism, and a new "Improved Purell" will be concoted by someone and the inexorable march of one besting will go on...Meanwhile Simmelweis...But I digress...

Does Healthcare need a reform? You bet! We definitely need it!
But what kind? And how to implement it?
Should it be cost driven?
Should it be care driven?
Should it be based on arbitrary "Evidence?"
Should it require input from Physicians, Economists, Politicians, Public at large?
Should it be based on the Economics of Political Science?
Should it be based on the Politics of Economic Science?
Should it be based on Pseudoscience of Correlation?
Should it be based on the Business Model or modeled after a Business? 
Should it be based on Patient care or Care of a Patient?
Should the patient have a stake other than healthcare being free in the care of his or her own health?
Should 3rd Party reimbursements be removed thus removing incentive for physicians?
Should a direct patient-physician relationship remain private and not doled out into the digital realm?
Should Medical care subscribe to the data-mining pseudo-evidence as a surrogate for reality?

I mean I could go on... You decide the right question and the answer to it yourself. You are so armed with information!

Currently Karl Marx is here in spirit and pounding his chest with pride!

Saturday, April 12, 2014

LISTENING: Encoding and Decoding

The other day, I received a call from an old friend whom I had not heard from in ages, 10 years to be exact.

“Hi there,” he said. How are you?” I might have detected a snicker in his voice over the telephone. The conversation was the usual, hello and then to the point; he and his wife wanted to meet with me and my wife for dinner. I promised I would text him back about the time and date for dinner. The “snicker” what about the snicker, you ask? I don’t know but I felt it. Okay well maybe because a few years ago after a similar invitation we were asked to loan him a reasonably large sum of money (my perspective)  for an enterprise he had embarked upon. Since then, I had not heard from him and never received a call back after my three futile attempts.

"The most basic and powerful way to connect to another person is to listen.  Just listen.  Perhaps the most important thing we ever give each other is our attention.".- Rachel Naomi Remen

What was he up to? (my inner voice) Should I even broach the subject with my wife? I can just see her reaction now. “What? No!”

How did he put it, “Hi there!” How is that for a reintroduction with a lot of money owed? Maybe, he thought, I would have forgotten that by now and maybe he was trying to reestablish the friendship? Maybe, but not likely!

When I introduced the subject of dinner with my wife, her response was predictable. But then that tiny little wrinkle above her nose made me realize her gears in her brain were shifting and a new thought was a runaway process. Like interpersonal communication is a complex process, so is thought and bias and assumptions. 

What was the code in that telephone call? I really did not know. But my decoding mechanism was in full swing. What was his real intention and what was I thinking was his intention? I could not really tell. My assumptions were based on a past experience from a few years ago, even though a bad one at that. Could I put a positive spin in my own mind and reframe the conversation so that I did not see him as Darth Vader?

My wife answered my thoughts almost immediately, “You know Jim might have been through hell in the past ten years. He was after all one of your better friends. So he deserves a friendly night out. We won’t bring up the subject about the money, unless he does, right?” She was clearly more empathetic than I was in my own mind. She opined further, “I can see you are still upset, based on the wringing and un-wringing of your hands.” She put her hand on my shoulder, smiled and said, “Maybe he just wants to say hello and rekindle the friendship. Other than the money issue, there was never a bad word spoken between either of you, Right?” She was right again. And then she said, “Besides how can we know his intent by what he said over the telephone? Meeting him in person is the right thing to do.”
She was right of course… (empathy is not sympathy).

I call him religious who understands the suffering of others. - Mahatma Ghandi
I had been arguing mentally, creating a mountain the size of K2 in my head, all from the shimmering of a mental bias that would not quit chattering inside my head! There might have been nothing further implied, except a renewal of a friendship. As far as the money was concerned, my wife and I had both written it off in our minds. So the only argument that kept nagging at us, was what if he asked for more? Would I be able to say no? My wife answered the question easily, “We can simply tell them the truth that we do not have the financial capacity to honor any further requests.” Truthful and quite simple!

It was a darker than usual evening without the moon as we walked into the restaurant. Jim and his wife were already at the table. He reached out with a smile and gave us both a hug. His wife followed his queue, both faces in full bloom.  “God it is great to see you both. I was half afraid you might decline.”

“Why would we? We are friends after all.” I replied trying my false airs of magnanimity. He was comfortable, loose and kept his focus on both of us, shifting his gaze from one to the other. My internals were warring inside, “here it comes.” Or “here comes something!” But nothing came. We had a pleasant dinner.

Soon the incipient breezes of comfort and the past carefree lives we had spent together as friends washed the last ten years of dispute  away and all four of us were smiling laughing and crying over jokes, and he is a great joke-ster. Soon the veil of bias and intent gave way to empathy and understanding. The focus from negativity to assimilated positivism, the mental arguments dissipated and the bias oozed out of the circle of friendship, judgment gave way to the meaning of friendship. It was a wonderful reunion!

It was time to head back to our homes. Just before we were ready to leave, Jim pulled out an envelope and asked me to open it. In it was a check for an amount far greater than I had given to him. “That is for the loan and the interest on it.”

There was a snicker in whose mind?

Who was listening and not managing his filters?

Was I listening? Or was I bending to the whims of my bias?

Was I talking in my own head and not giving “listening” a chance?

I was all that and more. My wife deserves the credit for that reunion, as she does in most cases related to social analytic concepts, which come easy to women, I realize. I try not to anymore, but I know I still do and the battle continues to subvert the voice inside.

...but for a chance to LISTEN... as listening is not the same as HEARING...

The friendship has moved along at a pace that it would have been without the ten year interruption. Jim was prosperous, is an understatement. He often asks if he can help me in any way. So much for intent! The difficult times seemed to have made him tougher, better, stronger and more productive. He gives us credit all the time, but we all know better.
Time Spent Communicating
A 'pie in pie' chart to show the significance of listening. (c)2012
"70% of our time is spent communicating and of that 45% is spent listening and 30% is spent talking." Adler, R. Rosenfeld, L and Proctor, R. (2001) Interplay: the process of interpersonal communication (8th. edition). Fort Worth, TX: Harcourt.

"Learning is a result of listening, which in turn leads to even better listening and attentiveness to the other person. In other words, to learn from the child, we must have empathy, and empathy grows as we learn." - Alice Miller.

I would venture that 70% of clinical diagnoses would be established without a drop of blood being drawn through effective listening by the physicians! And an equal number of disputes could be resolved through the simple act of using both the ears rather than exercising the might of one tongue!

Sunday, April 6, 2014

The function of x ~ f(x)


It is a beautiful morning.  The sun is bright and warm and the sky is azure blue. The breeze lifts the veil of life’s opacity and shows her assets. Ah it is good to be alive. What should one do today? Maybe work in the yard, maybe go for a bike ride, maybe roller-blade on the side-walks and worry new moms cuddle their minors closer to them, or maybe just sit on the grass and read a book. So the “x” in the equation is the beautiful morning and the “f” is the function that I am willing to perform as a result of the “x.”
Now that we have it, let us explore how the science world has mutated the norms of their and our thinking. The function of “x” has become over time “x” itself!

Let me explain:

1.       Take for example the hammer. It is always looking for a nail, otherwise it is mostly useless, wouldn't you say? So if we have this new hammer that we bought for $10 we want to pound some nail somewhere to find utility in it. A similar corollary would be discovering a drug and finding a disease to apply it against to find relief. The problem with both is that we have not really seen a problem but through acquisition of an “x” we want the “f “-related to it. So now we have to throw this drug in meaningful ways at different diseases and through the art of statistical manipulation come up with a tightly bound Gaussian metric and negate the null hypothesis, or simply find proof (you know like the one that proves that the absence of your friend is due to alien abduction and the Alternate true Hypothesis is the absence of your friend is due to the fact that he is on vacation)!  Ah, Ha! We exclaim, lo and behold we have found the cure for disease “y!” But did we? Or is it just the manipulation of the hammer to pound down further something that looks like a nail buried in the wood? The example here would be the “Statins:” Once the charmer that was to cure/prevent all of coronary artery (atherosclerotic) heart disease, Pravachol seems to have morphed into its various iterations and now seems poised to find some inkling in curing or at least besting cancer by improving survival rates. Well, and this is only a minor well, the Patent on the powerful statins in cardiovascular care seem to be coming to a close, so it might be time to find another "f". The “x” looking for an “f” then looking for another "x"?  Other beautifully rendered scientific articles with appropriate graphs and tables seem to pop up every now and then on the unbelievable benefits of Vitamin D. It can cure almost everything or can it? But here is the lasting memory of a fond desire to everyone or anyone who loves chocolate. Chocolate is great for your heart! Okay, I’ll buy that, even if it tastes good! So the current science or pseudo-ness of it is to prove whatever you set out to prove and with probability manipulation of a few numbers and voila, there’s the proof!

  The same experts that prattle on about the symbolic “f” of a certain “x” now bring the two together in another well-advertised episode of “f(x)” by using the self-enriching models of creating such endless hardships of NO utility as the Maintenance Of Certification (MOC) for doctors. The “x” here is the biannual expense of $5000 cash outflow for the doctors to the inflows for the American Board of Medical Specialties and the “f” in this examination is deemed as means for the doctors to be tested for their knowledge and abilities. Huh? Knowledge and abilities tested every 2 years? The makers of this MOC test (x) propound that the public deserves to know that their doctors are knowledgeable. Indeed the doctors have to fulfill the Continuing Medical Education credits of 50 hours per year to maintain their license in the states they practice and that is the “f” of the test of practicing medicine “x.” But these self-serving agencies have now put themselves right in the middle to promote themselves as the arbiters of physician knowledge. What is most interesting is that there is not a single shred of real “EVIDENCE” that the tests that they profess to be the greatest thing since sliced bread for detecting “unknowledgeable” doctors have any proof. But they carefully craft the queries to the willing about how they “felt” the examination helped their knowledge base. So the “x” here is in place in the form of MOC and the revenue stream to the agency and the “f” is grinding out the template of acceptance and acquiescence through enabled doctors (selection bias) who will affirm the “x.” What is not mentioned that the ABIM a branch of ABMS brings in more than $49 million/year and the President of ABIM makes about $750,000/year. The “f” of this “x” is plain to see, isn’t it?

Healthcare cost has been the topic of conversation for several years now. Yes, it is spiraling and you know why? Because it is an incentivized system of care. The misplaced responsibility onto the middle man (the Insurers, Medicare, Medicaid) to pay for any and all ailments of the elderly and the indigent. This incentive creates a sense of entitlement. The doctor’s offices and the Emergency Rooms across the country are bursting at the seams with patients who have arrived there with every minor ailment that time can heal. But what is lost in the jungle of honking noses, dried out coughs, red cheeks and low grade fevers are the real medical horrors that have difficulty being seen by the physician. So cost containment is a need. If responsibility is shifted to the patient for a larger portion of payment and the rush to the emergency room will most likely be reduced. But no, the experts have taken a different tack.
They are refusing to reimburse the entity that cares for the sick by denying reimbursements for re-admissions, for infections that become evident during hospitalization claiming them as a result of hospital error and the like. The votes seem to propel the politicians into this circuitous thinking of find the wrong “f” for the “x” all the time. Find the fault with the physicians or providers as the doctors have been demoted to nowadays. These same experts burying their heads in the sand find arcane and clever ways to arrive at reasoning  that we should not be trying to diagnose an illness too soon as it causes unnecessary tests and potential harm. They go against mammography (breast cancer screening and PSA test for prostate cancer suggesting “lead time bias” as the root cause of too many diagnostic errors. They also have determined colonoscopy is an over utilized screening tool. But then studies recently have shown an overall dramatic reduction in colon cancer as a consequence of the screening colonoscopy. They flood the digital and printed ink universe with their version of the “f” (harm) for the “x” (costs). Who is the general populace to believe? The current vogue answer to that question is; the adoring media and its “Made to Stick” format and their "Buy-in." A travesty upon travesty!

EMRs. Now here is an “x” that was contemplated at the political level through the arbitrage of the experts willing to create the hardware and software for self-aggrandizement at a large scale. So they duped the consciousness of the physicians and the general populace into thinking that the Electronic Medical Records would reduce errors and give a better handle over the disease to the doctors. Did it? Simple answer: No! Did it create a gulf between the physician and the patient? Answer: Yes! But for the “f” in this “x” which was done for monetary gains of the companies that got the contracts, it seems that the physician practices are in disarray due to complexities of the EMR and its meaningless use after spending thousands of dollars that they have been refused reimbursements for by the agency. It has created a mound of useless verbiage through “cut and paste” in the medical records that are done to satisfy some arcane rule of the insurer for documentation and the most devastating of all, it has taken the eyes off the “Ball” -the patient. The eye to eye communication no longer exists and the patient drones on about his or her ailment while the doctor is busy trying to fit round pegs in square holes in the arcane digital universe. This paradigm shift in patient-care is uniformly destructive to the field of medicine. The holistic view however of human care is in the understanding of another’s dilemma and then to solve it through knowledge, experiential reference and a pulse on the frailty of the other. It is not as some experts will have you believe that medicine is but a ceramic/silicon away from being dehumanized and perfected.

Kahneman and Tversky famously discovered the utility of the “f” of “x” and not “x” itself. In other words, the relative rise in the utility of one’s wealth as measured by the benefits had a far more meaningful nuance than sitting atop a mound of coins as Uncle Scrooge. You see, the small incremental “f” of “x” have a larger core of happiness in it then a large “x” sitting in a vault that these experts are accumulating on everyone’s dime.
The “f” today is manufactured, sometimes created out of thin air similar to printing money by the FED. The artificiality of this “Goldilocks soft-landing” will have a price to pay in the end. The “x” here unbeknownst to most is the lost asset of many trillions by the middle-class, and the ΓΏ" here is the white-wash, but that is another story…

Know your “f” of “x” that is...

Live only to accumulate the “x” off of others by a false “f’ prophet and one day not too distant in the future the Lorentz Strange Attractor will have your head for the false "f."


Tuesday, April 1, 2014


     The wish for healing has always been half of health - Seneca
You finally get into the exam room and your physician enters and greets you. For a brief moment he looks at you and then his head is turned towards the computer screen. He asks questions and you answer in a sort of mechanical way. There is very little reaching across the divide. When he is done he briefly examines you and then writes an order for a test. He smiles and wishes you well, you see him turning back to the computer screen and frowning at the blinking message, as a nurse escorts you into another room, where you sit while the office staff member call various agencies to gain authorization for the tests the doctor has ordered, so you are told. A half an hour later the nurse comes in and apologizes that the insurance carrier has refused to pay for the tests today and that you might have to go to another facility or return again should the insurance company prove to be accommodating.

Welcome to the Mousetrap! Nay welcome to the perfect mousetrap!

The perfect mousetrap is one with four corners, a door and no exits. The mice are supposed to be baited with peanut butter and then disposed.

Now let’s look at the this healthcare trap. The four corners represent the four sentinels guarding the boundaries and the trap is laid for the physician-patient duo. The lure of this intriguing mechanism is its gilded bling as expressed by the designers. This, “they” say, is the perfect lodging for the practitioners of this noble of professions called medicine. Who are “they?” You might ask. And the answer will reveal itself shortly…
Healthcare costs are high in the US. But is it all about the doctors providing the care? Seriously comparing Sweden or Switzerland with the US one is really comparing apples and oranges. The personal responsibility is taken seriously in those countries. They exercise and have a limited diet, hence their life spans are better. Not because of the wonders of the healthcare dollar but by their own volition. Ah but the experts won’t tell you that. Besides there is very minimal if at all any discoveries, experimentation, innovation that is being generated from those countries, yet the drumbeat goes on to serve a purpose.

The first corner and wall is inhabited by the Federal Government with the likes of HHS, CMS (Medicare and Medicaid) and now the IRS. The initial buy-in in 1965 by the populace was that Medicare would provide care for the elderly at a reasonable affordable cost – a kind of a safety net. Those that could not pay would receive the Medicaid benefits free of costs. Well realizing that most doctors were not enchanted with the formula since the patient would spend the reimbursement checks and the doctors would be left holding the empty collection bag. The HHS/CMS came up with a solution for the doctor buy-in with “accepting assignment.”  The logic was that the physician would get paid directly for services rendered, albeit at a lower rate. This seems good on its face since collection issues would be rendered moot. And so it went until SGR formulas were created to limit reimbursements to the physicians and over a10-year period while the cost of living continued to rise as all federal employees and private sector employees garnered the appropriate increase in revenues, the doctors were mired in the perceptible risk of being raked over the coals with a 21%, then a 24% and now a 30% cut in reimbursement fear tactic. Each cut faced a deadline and the doctors held their collective breath each time. But each time the dark clouds passed since Congress realized the drama that would unfold for the Medicare beneficiaries as doctors would stop accepting Medicare. But now, get this, now the government through its agencies has decided to determine the right cookbook methodology of treatment for all high reimbursable ailments. It is now determined by experts like Ezke Emmanuel that 80% of the care can be rendered by Nurse Practitioners and Physician Assistants, so why educate more doctors. Plus, and this is a big plus, reimbursement for the NPs and Pas would be lower, hence the healthcare costs would be lower. But no one has ever looked at the real costs of healthcare and where the money is flowing. For every $1, 12% goes to physicians for services rendered and expenses. 36% to the hospitals, 35% to the pharmaceuticals and device managers, 17% goes to administrative purposes. Oh and if you missed this, you might want to know that CMS (Medicare and Medicaid) spends $385 billion annually on administrative expenses to its own employees.

The second corner belongs to the Private insurers and the Hospitals. I lump them in one as the lobbyists groups from both are strong and tend to change the Congressmen and women’s minds about how much they should be paid. While paying millions of dollars as benefits to its upper managers, the insurers and hospitals cry poverty in front of the lawmakers. ‘We cannot survive this without charging a higher premium or lower corporate taxation or both.” And there are many more excuses. The insurers delay, and deny payments to the physicians and at times to the hospitals making them jump through hoops that take time and effort away from actually helping patients. The hospitals in their theatrics, cry poverty and throw the risk of closing their doors and hurting the large community of hundreds of thousands if they don’t get the proper reimbursements through their active lobbyist the American Hospital Association.

 And every congressman or women knows that (s)he will never be reelected should this come to pass that the hospital will close its doors. No, not ever, Nyet! Meanwhile the cost of a single aspirin charged by the hospital to the private insurers goes to $50, which they collect from other write-offs in their ballooned 10Ks. 

And equally befuddling is the United Healthcare’s recent payout to a New York Podiatrist for $178,080.00 for surgical repair of two hammer toes that took less than an hour. Truly the left hand does not know what the right hand does! And to rub this wound into a mound of salt, the reimbursement for a open surgical cholecystectomy (gall bladder removal the doctor makes between $485-745 for the surgical procedure and the 90 day of care thereafter). Go figure that out!

The third corner and realm belongs to a new rising star in the private arena and it is the American Board of Medical Specialties and the American Board of Internal Medicine. These two entities have crafted a calculated strategy of requiring physicians to pass the Certification examinations in the specialty that the physician practices medicine. The physician buy-in initially was that they wanted to distinguish themselves as having achieved the “Board certification status.” If you were certified, you could keep that certification for ever. Recognize that phraseology? The revenues to ABMS and ABIM were modest and so they determined the revenue cycle had to be modulated to yield higher values. Enter the need for re-certification.  After 2000 everyone would receive a time-limited certificate of 10 years. Doctors entering the medical arena did not know any better so accepted the formula, while those grandfathered kept quiet. Now however, even time unlimited, (grandfathered) certificates will also need re-certification.  Ah, but that is not all, the revenues recovered from just the re-certification consequently doubled from this minor fiat, but the ABMS and ABIM were not done, they, then created the Maintenance of Certification or MOC as it is called, rule. Every two years a doctor would need to fulfill the criteria of MOC and only then they would be allowed to take the re-certification examination. Well then the 2010 revenues of ABMS rose to $49 million and the salaries of their President went to $750,000.00. Turns out that the president Christine Cassel MD (who had not practiced medicine or never was recertified) also happened to be on patient safety commissions and other boards influencing the needs of the certifications and the MOC processes (No one saw the conflict of interest, until maybe now and that scenario has yet to be played out). The conflict of interest was recently discovered and investigation is ongoing. But here is the kicker, MOC, no less the Board certification has NEVER been proven to show that a certificated physician is a better physician than non-certificated ones. (Disclaimer: I was certified in Internal Medicine and twice certified in Medical Oncology) I have never found that my expertise or knowledge was ANY BETTER than those who had not sat through this examination.” And what does ABMS have to say about the benefits, "MOC is recognized as an important quality marker by insurers, hospitals, quality and credentialing organizations as well as the federal government."  (Nothing about patient care or patient outcomes or patient well-being or differentiating quality of healthcare rendered by certificated and non-certificated physicians, however they imply the potential but are unable to provide a factual impartial relevant study.) So, what gives? Money, as in $$$ that one would quickly guess. And to formalize and ossify the need there is a continuous push by the ABMS and the ABIM to make MOC the necessary criterion for Maintenance of Licensure in each of the 50 States so the revenue cycle continues unabated and increases with each passing day. Oh and if I haven’t said this before, did you know that the pass rate of the certification examination just started to fall in the last two years. Why? You ask....Elementary my dear Watson they fail the physicians so that they have to come up with the $5000 again for the next year examination…Another productive solution to increase the ROI (Return on their Interests), Top line and Bottom line for these unaccountable entities. Wikipedia states: "Maintenance of Certification (MOC) is the process of allegedly keeping physician certification up-to-date through one of the 24 approved medical specialty boards of the American Board of Medical Specialties (ABMS) as well as some of the medical specialty boards of the American Osteopathic Association (AOA).[1] Some studies, funded and performed by highly conflicted employees of the member boards, have shown that board certified physicians deliver may higher quality care than their non-certified colleagues and that board certification is correlated with." :

The last corner of this mouse trap is the Litigation. 

The legal eagles spend $1500 per capita in PAC money to lobby the Congress so as not to allow any bills on Tort reform, cap damages for pain and suffering and definitely not consider those filing frivolous law suits should have to pay the court fees. No that would hurt the poor indigent people who have been wronged they preach. No, never, that will never pass, because the trial lawyers (And Shakespeare had them right on) do not wish to let this golden goose lay its eggs in another’s basket. Thus the tort reform sits and sits while Law firms hire and hire and get bloated with hundreds if not thousands of lawyers in each firm, while the solo practicing doctor finds it difficult to keep his or her practice open. By the way a Trial by Jury is unheard of in non-criminal cases in most if not all other countries except, you guessed it, the United States.

And that now brings us to the two little people in the middle, “The patient and the physician.” The one that ultimately suffers from all these concocted mechanisms of care delivery is the patient. He or she will ultimately pay for limited, substandard care while the doctor is made to become a secretary to check boxes for the governmental mandates and get the insurer’s pre-authorization checklists toiling away to build a large database for the enormous Big Data warehouse so that analytics will define what is and what is not medicine. The patient will pay more out of pocket because that is the next step to limit access to the doctor or the emergency room or the hospital and he or she will pay more in premiums to pay for those that do not or cannot pay for insurance coverage. Not only is the patient in danger of sub-optimal care as a consequence of this recipe-style medicine but he or she is also at risk of being marginalized for proper care if the costs outweigh the productive benefit as it is related to age and ability.

Lastly the doctor, he or she will have to live by the cookbook style of guidelines in medical care, thus going against the Hippocratic oath at times, especially if (s)he is a hospitalist and the job depends on a productivity contract. Admissions in the hospitals are being scrutinized and hospital stay days are the metrics for reimbursement by the CMS in most areas thus discharging patients in an untimely fashion to garner a larger margin from the admission might jeopardize the patient’s health to say the least. The constancy of cost as it relates to care might become the overriding concern of most hospital employed physicians who want to go-along to get-along and maintain their job security. Medicine will fail and that is exemplified in the National Health System (NHS) in the United Kingdom where there is nary a day when some hospital, a part of the NHS, isn't shown to be understaffed, dilapidated structurally, where employees show lack of concern with the conditions, patients and at least in one hospital where aborted fetuses were burnt to heat the hospital interior- their new HVAC system!

So there you have it, the perfect healthcare mousetrap that will catch a lot of sub-optimal, substandard, sub-par healthcare for the patients that fall into the trap.

Please think beyond today and beyond your paycheck. This format hurts everyone. It rips the nobility in medicine, destroys the faith between the healer and the patient. It renders moot humanity and glorifies the silicone chip and the almighty $dollar$.


Monday, March 24, 2014

The MAMMOGRAM Conundrum

To know is to know that you know nothing.That is the meaning of true knowledge - Socrates.

The recent Canadian study posed two questions for breast screening:

1.       Does mammography create over diagnoses?
2.       Does mammography as a screening tool help survival?

The answers gleaned from the study were “Yes” and “No.”

Now my two cents...

Let us look at some facts: The predicate of over diagnosis is based upon the argument that early diagnosis is an over diagnosis. In other words finding and treating a DCIS (Ductal carcinoma in situ) is an over diagnosis. Or so some will have you believe. They cite the SEER data and presume that some DCIS can regress back to normal states. Has anyone seen or documented a DCIS regression back to normal? The answer surprises us with a definitive No. Has anyone determined a DCIS by radiological means and then just followed the regression? The reverse answer however can be answered unequivocally that DCIS lesions have been noted to break through the basement membrane and run amok elsewhere in the body when left untreated over time. Studies in the past have estimated reduced mortality (0.3-3.2/1000 women). So if a woman’s life is saved that is a 100% save rate for that woman. Population data does not reflect the need of an individual. It only shows probabilities.

Another way to look at it is, knowing that 10% of all “abnormal” mammograms represent (true positive) cancer diagnosis and only 8-19% of the screened individuals have cancers detected as DCIS. That means over 80% of the cancers are invasive. Invasion indicates propensity to metastasize thus at least 8% of women will be diagnosed early and potentially saved.

Another remarkable non-statement in the study quotes a 5 year survival rate of 100% but fails to mention the 10 year survival rate for DCIS to be 98%. The 2 percent, loss due to breast cancer related mortality, seem not to fit the paradigm of limited disease in the paper.

So the question that we have to answer then is; does screening save lives? The NSABP-17 trial: Of the 818 women enrolled in the trial, 80% were diagnosed by mammography, and 70% of the patients' lesions were 1 cm or less. At the 12-year actuarial follow-up interval, the overall rate of in-breast tumor recurrence was reduced from 31.7% to 15.7% when radiation therapy was delivered (P< .005). Radiation therapy reduced the occurrence of invasive cancer from 16.8% to 7.7% (P = .001) and recurrent DCIS from 14.6% to 8.0% (P = .001). And the EORTC 10853 study: Similarly, of the 1,010 patients enrolled in the trial, mammography detected lesions in 71% of the women. At a median follow-up of 10.5 years, the overall rate of in-breast tumor recurrence was reduced from 26% to 15% (P < .001) with a similarly effective reduction of invasive (13% to 8%, P = .065) and noninvasive (14% to 7%, P = .001) recurrence rates

  The answer, if we are to follow the population based thinking comes from both cohort studies and randomized studies that show a decline in breast cancer related deaths since 1980s when mammography screening was mass utilized. After the initial significant decline post mass screening, the mortality rate from breast cancer has been steady. These trials were initiated between 1963 and 1982 the Health Insurance Plan study, the Malmo study, the Swedish Two county trial, the Edinburgh trial, the Stockholm trial, the Canadian National Breast Screening studies 1 & 2 and the Gothenburg Breast Screening Trial. All but the National Breast Cancer Screening found mammography to result in significant reductions in breast cancer mortality. . 

The NCI report and the SEER data show an incidence of DCIS has increased over time: 5.8/100,000 in 1975 vs. 32.5/100,000 in 2004 which is partly due to mammography yet remains meager to the 124.3/100,000 for invasive breast cancer. Most trials have shown reduced mortality from mammography. Does that mean we are over diagnosing? Or catching it early with a potential for cure? But even relenting a bit, the overall incidence of invasive breast cancer has declined since 1987 and especially since 2000 partly from the HRT knowledge and from catching the disease early. So, thinking this through further we find, a review commissioned by the AHRQ assessed the effectiveness of needle biopsy. The authors synthesized the evidence from 104 studies and concluded that 24% of tumors with DCIS identified from stereotactic guided automatic gun core needle biopsy were found to have found to have invasive breast cancer upon surgical excision (95% CI 0.18;0.32). Early diagnosis and removal therefore does have a decent payback.

What will happen another decade from now if the current professorial intuit plays out and makes women fearful of screening? Only time will tell.  The tragedy of more than 200,000 women being diagnosed with breast cancer and 40,000 dying from it annually in the United States is a reminder to all the well intentioned souls. 

The answers then might be answered as “No” and “Yes.”

Diagnosis and Management of Ductal Carcinoma in Situ (DCIS)Evidence Reports/Technology Assessments, No. 185.Virnig BA, Shamliyan T, Tuttle TM, et al. Rockville (MD): Agency for Healthcare Research and Quality (US); 2009 Sep.

Fisher ER, Dignam J, Tan-Chiu E, et al. Pathologic findings from the National Surgical Adjuvant Breast Project (NSABP) eight-year update of Protocol B-17: intraductal carcinoma. Cancer. 1999 Aug 1;86(3):429–38. 
Smith BD, Haffty BG, Buchholz TA, et al. Effectiveness of radiation therapy in older women with ductal carcinoma in situ. J Natl Cancer Inst. 2006 Sep 20;98(18):1302–10. 
Solin LJ, Fourquet A, Vicini FA, et al. Long-term outcome after breast-conservation treatment with radiation for mammographically detected ductal carcinoma in situ of the breast. Cancer. 2005 Mar 15;103(6):1137–46.

Nystrom L, Andersson I, Bjurstam N, et al. Long-term effects of mammography screening: updated overview of the Swedish randomised trials. Lancet. 2002 Mar 16;359(9310):909–19

Roberts MM, Alexander FE, Anderson TJ, et al. The Edinburgh randomised trial of screening for breast cancer: description of method. Br J Cancer. 1984 Jul;50(1):1–6.

Frisell J, Lidbrink E, Hellstrom L, et al. Followup after 11 years--update of mortality results in the Stockholm mammographic screening trial. Breast Cancer Res Treat. 1997 Sep;45(3):263–70.

Miller AB, To T, Baines CJ, et al. Canadian National Breast Screening Study-2: 13-year results of a randomized trial in women aged 50–59 years. J Natl Cancer Inst. 2000 Sep 20;92(18):1490–9.

Miller AB, To T, Baines CJ, et al. The Canadian National Breast Screening Study-1: breast cancer mortality after 11 to 16 years of follow-up. A randomized screening trial of mammography in women age 40 to 49 years. Ann Intern Med. 2002 Sep 3;137(5 Part 1):305–12.

Bjurstam N, Bjorneld L, Warwick J, et al. The Gothenburg Breast Screening Trial. Cancer. 2003 May 15;97(10):2387–96.

Shapiro S. Periodic screening for breast cancer: the HIP Randomized Controlled Trial. Health Insurance Plan J Natl Cancer Inst Monogr. 1997:27–30.

Friday, March 21, 2014


I admit that I love skiing! But then so do the hundreds of thousands others. And they are probably more avid then I and probably better at it too.

Mountain sports have an inherent fact that most of us ignore as we expectantly run to the ticket windows. Ah for that cold icy fresh air first stoking the warm fire of desire. The chairlift awaits and the gondola beckons but there is something amiss, just ever so slightly that you cannot put your finger to it.

So let me count the ways that, that amiss has some physiological ramifications to it.

I first became aware when my daughter would wake up at a resort in the Colorado Rockies and start heaving up her last night’s dinner. No fun there. I was annoyed (imagine) that she was really not interested in skiing but wanted to veg out in the room. Then it became certain even to the most resistant one (me) that every vacation a similar episode developed. What was happening? Just about then, the resort started offering a canister full of oxygen for purchase. I bought several of them and gave them to everyone in our family. Guess what happened? No more heaving! No more complaints! She was the first one out with her skis and poles.

Okay so what happened? It appears that when a sea-level dude or "dudette" comes over to a 8000 foot elevation without acclimatization the hypoxemia (low oxygen levels) in some generates a gastric regurgitation (upchuck). Additionally I was noting myself a tiny residue of headache and always filtered that through the lens of a difficult work period prior to a vacation (taking care of all the sick ones that required attention immediately for the time period I would be away). But those two to three whiffs from the canister cured that too. No more headaches. Voila, amazing two problems solved with one swing of the bat.

Then I started thinking about other possibilities that might also be at play:

A friend of mine with a labile hypertension controlled with low dose anti-hypertensive medicine ended up in the emergency room after being airlifted due to a hypertensive crisis. His blood pressure was sky high and fear of strokes was a significant consideration. Thankfully it was resolved with additional medication. The next year, he told me that he carried extra blood pressure medicine when he went to more than the mile high resort and lo and behold a similar occurrence was at hand but one he was prepared for (he is a physician). The logic from this suggests that hypoxemia (low oxygen levels) seem to drive the vaso-constrictive mechanisms of the arteriolar system, with an associated rise in the heart rate and respiratory rate as a compensatory mechanism. (You will notice shortness of breath when you walk the mile in your ski boots carrying your skis and poles at that high altitude).

Another visual at the airport one time while returning from our vacation, I observed a young woman in the wheel chair being pushed to the gate for departure. I found out that she had been hospitalized with a blood clot and was returning home from a miserable “vacation.” That was sad in itself, but what of this blood clot? I wondered.

It turns out that similar to the risks of developing a blood clot in the long flight a similar mechanism migh be at play in a mountainous resort for sea level dwellers. The high altitude with its marginalized oxygen levels associated with dry air that saps the moisture from within the body at rest (and more with exercise) and the vaso-constrictive phenomenon, I mentioned earlier can be a doozy for a blood clot in the leg. Add to that potential a mutation of the Factor V Leiden mutation present in 5% of the population and or the less common Prothrombin mutation that are promoters of blood clots the results can be terrifying and hurtful. (I am not going to mention all other risk factors such as age>65, existence of cancer, birth control pills, obesity etc. Suffice it is to say there are many other issues that can predispose a person to developing blood clots)

When all the factors are present, what makes the clot itself? Imagine a blood flow through a smooth blood vessel. The flow is linear. The “stuff” red and white cells and platelets all stay in the middle of the stream while the “liquid” as in plasma surrounds the core. A disruption due to a crossed leg, a injury can impair the linear flow and the platelets “fall-off” to the sides and with the other ingredients mentioned as in dehydration (thickens the blood and slows the flow) hypoxemia (causing compensatory vaso-constriction) and the last hammer (Factor V Leiden mutation) makes factors in the blood including platelets “stickier,” you now have the set up for the disrupted blood flow and piling on of the clotting factors around the nidus of the platelets and ouch, the leg hurts. The higher risk is that one of those clots can run the venous blood stream and end up in the lung with compromised breathing and endanger life. To prevent is simple, Drink plenty of water, invest in a canister of oxygen and use it and take a baby aspirin (81 mg) provided your doctor (not some “provider” but the real critical analytic decision maker) agrees to the use of this medication based on your history.

Oh and I might not have mentioned that skiing is a dangerous sport because there are inherent risks of falls and crashes that can cause broken bones, separated shoulders, ACL (Anterior Cruciate Ligament in the knee joint) tears and other sundry eventualities that twitter friends like @hjulks in the Orthopedic field know all too well and how to manage and fix.

Mitigating risks is easy once you know the hazards.

Skiing/snowboarding without a helmet does not prevent accidents but may save you from a brain injury. Now that you have chosen your "bling" on what to wear and show off, don't forget the "thing" that protects your noggin. Skiing and snowboarding under control can also save you from visiting the orthopedic department, the hematology department and the neurosurgery department.

Enjoy your vacation!
Know the risks!
Prepare in advance!
Have a ball!

Sunday, March 16, 2014


The gathering storm seems to instill a foreboding in all things living. The dark skies, the billowing clouds, and the quiet of the birds and the first raindrop spell danger. Something this way comes, something, which strikes dissonance into the harmony of human existence.

The storm comes, lashes its collective wrath and moves on and those that survive gather their collective wit and start to live again. It is the existential human drama. Life recouples, survives and redoubles her efforts to keep living.

But there is a new kind of storm that pricks the edges of our understanding. This one carries a darker more sinister purpose. This one is blacker than black. It is not a storm of nature’s doing. It is man-made, conjured up in that 3-pound universe that drives humanity. This storm is called ASSUMPTION.

Assumptions exist in most all things scientific. Theoreticians who conjure up new probabilities and create models that describe the human condition and its existence; live on the ragged cliffs of thought. Let us take the existence of Black Holes, which was the mathematic model created by Stephen Hawking. It was the creation of a fecund mind subsequently visualized in reality.

We see assumptions drive every aspect of society nowadays. Once what was considered the purview of theoreticians is now the domain of the “journalists” and self-proclaimed “experts.”

A short course in today’s expertise is evident in the controversies that surround the scientific world. A review of the scientific literature reveals that 50% of the studies cannot be duplicated. Leave alone the concept of verification and validation of any experiment as the hallmark of rigor, here the initial premise is so false that duplication is well-nigh impossible. The falsity is based on the notion of the many biases that form the prejudice behind the “study.” Biases run the underworld of the false prophets of profit. Biases induce assumptions to satisfy the end result that one is predisposed to at the outset.

Let me explain: If you want to prove that Product X leads to Effect Y then all one has to do is manipulate the question of how to evaluate Effect Y. Or select individuals that are more likely to answer in the affirmative. Or build on the expectation of the Product X using the “Placebo-effect” as the surrogate to arrive at the conclusion. Then use the “intent” to remove those individuals that do not conform to the paradigm of the cause and effect to distill down the argument to obtain the relevant p-value. And voila you have a study that becomes “EVIDENCE” for the rest of. There they go harping the benefits of “Evidence Based…!”

Two recent cases come to mind: The mammogram Canadian study and its fall out in medicine. The “experts” continue to “wing” their way into one or the other camp. Both sides are passionate in their thought but both are prejudiced under the weight of their bias. The other subject of recent hifalutin assumptions is the disappearance of Malaysian Flight #370. The missing aircraft, crew and passengers continue to fuel assumptions. Everyone stokes the flame a bit. “Experts” abound but not one has any idea of what happened. Might it not be prudent to just keep one’s opinion to oneself until facts reveal the truth? But, that does not keep the 24-hour BS cycle of non-news News and the wealthy journalists employed with their million dollar salaries happy. The News must be created. The minds must be cajoled to a certain viewpoint. The paradigm must be polished every day. When one considers that 1 out 4 Americans surveyed do not know that the earth revolves around the sun, what hope is there for that 25% to realize the difference between truth and fiction and for that matter have any scintilla of self-emboldening critical thinking?

I shudder to think.

“I must be cruel only to be kind; Thus bad begins, and worse remains behind.” - Shakespeare