Friday, September 26, 2014

From The Healthcare Blog: How To Discourage A Doctor

Dalai's note:  A piece by Dr. Richard Gunderman posted on TheHealthcareBlog.com.  It is unclear whether or not Dr. Gunderman's "discovery" is a real document or not. Still, it would seem to explain a lot of what we are seeing in healthcare today...

How To Discourage a Doctor

Not accustomed to visiting hospital executive suites, I took my seat in the waiting room somewhat warily.

Seated across from me was a handsome man in a well-tailored three-piece suit, whose thoroughly professional appearance made me – in my rumpled white coat, sheaves of dog-eared paper bulging from both pockets – feel out of place.

Within a minute, an administrative secretary came out and escorted him into one of the offices. Exhausted from a long call shift and lulled by the quiet, I started to doze off. Soon roused by the sound of my own snoring, I started and looked about.

That was when I spotted the document on an adjacent chair. Its title immediately caught my eye: “How to Discourage a Doctor.”

No one else was about, so I reached over, picked it up, and began to leaf through its pages. It became apparent immediately that it was one of the most remarkable things I had ever read, clearly not meant for my eyes. It seemed to be the product of a healthcare consulting company, presumably the well-dressed man’s employer. Fearing that he would return any moment to retrieve it, I perused it as quickly as possible. My recollection of its contents is naturally somewhat imperfect, but I can reproduce the gist of what it said.

“The stresses on today’s hospital executive are enormous. They include a rapidly shifting regulatory environment, downward pressures on reimbursement rates, and seismic shifts in payment mechanisms. Many leaders naturally feel as though they are building a hospital in the midst of an earthquake. With prospects for revenue enhancement highly uncertain, the best strategy for ensuring a favorable bottom line is to reduce costs. And for the foreseeable future, the most important driver of costs in virtually every hospital will be its medical staff.

“Though physician compensation accounts for only about 8% of healthcare spending, decisions that physicians strongly influence or make directly – such as what medication to prescribe, whether to perform surgery, and when to admit and discharge a patient from the hospital – have been estimated to account for as much as 80% of the nation’s healthcare budget. To maintain a favorable balance sheet, hospital executives need to gain control of their physicians. Most hospitals have already taken an important step in this direction by employing a growing proportion of their medical staff.

“Transforming previously independent physicians into employees has increased hospital influence over their decision making, an effect that has been successfully augmented in many centers by tying physician compensation directly to the execution of hospital strategic initiatives. But physicians have invested many years in learning their craft, they hold their professional autonomy in high esteem, and they take seriously the considerable respect and trust with which many patients still regard them. As a result, the challenge of managing a hospital medical staff continues to resemble herding cats.

“Merely controlling the purse strings is not enough. To truly seize the reins of medicine, it is necessary to do more, to get into the heads and hearts of physicians. And the way to do this is to show physicians that they are not nearly so important as they think they are. Physicians have long seen the patient-physician relationship as the very center of the healthcare solar system. As we go forward, they must be made to feel that this relationship is not the sun around which everything else orbits, but rather one of the dimmer peripheral planets, a Neptune or perhaps Uranus.

“How can this goal be achieved? A complete list of proven tactics and strategies is available to our clients, but some of the more notable include the following:

“Make healthcare incomprehensible to physicians. It is no easy task to baffle the most intelligent people in the organization, but it can be done. For example, make physicians increasingly dependent on complex systems outside their domain of expertise, such as information technology and coding and billing software. Ensure that such systems are very costly, so that solo practitioners and small groups, who naturally cannot afford them, must turn to the hospital. And augment their sense of incompetence by making such systems user-unfriendly and unreliable. Where possible, change vendors frequently.

“Promote a sense of insecurity among the medical staff. A comfortable physician is a confident physician, and a confident physician usually proves difficult to control. To undermine confidence, let it be known that physicians’ jobs are in jeopardy and their compensation is likely to decline. Fire one or more physicians, ensuring that the entire medical staff knows about it. Hire replacements with a minimum of fanfare. Place a significant percentage of compensation “at risk,” so that physicians begin to feel beholden to hospital administration for what they manage to eke out.

“Transform physicians from decision makers to decision implementers. Convince them that their professional judgment regarding particular patients no longer constitutes a reliable compass. Refer to such decisions as anecdotal, idiosyncratic, or simply insufficiently evidence based. Make them feel that their mission is not to balance benefits and risks against their knowledge of particular patients, but instead to apply broad practice guidelines to the care of all patients. Hiring, firing, promotion, and all rewards should be based on conformity to hospital-mandated policies and procedures.

“Subject physicians to escalating productivity expectations. Borrow terminology and methods from the manufacturing industry to make them think of themselves as production-line workers, then convince them that they are not working sufficiently hard and fast. Show them industry standards and benchmarks in comparison to which their output is subpar. On the off chance that their productivity compares favorably, cite numerous reasons that such benchmarks are biased and move the bar progressively higher, from the 75th “Increase physicians’ responsibility while decreasing their authority. For example, hold physicians responsible for patient satisfaction scores, but ensure that such scores are influenced by a variety of factors over which physicians have little or no control, such as information technology, hospitality of staff members, and parking. The goal of such measures is to induce a state that psychologists refer to as “learned helplessness,” a growing sense among physicians that whatever they do, they cannot meaningfully influence healthcare, which is to say the operations of the hospital.

“Above all, introduce barriers between physicians and their patients. The more directly physicians and patients feel connected to one another, the greater the threat to the hospital’s control. When physicians think about the work they do, the first image that comes to mind should be the hospital, and when patients realize they need care, they should turn first to the hospital, not a particular physician. One effective technique is to ensure that patient-physician relationships are frequently disrupted, so that the hospital remains the one constant. Another is. . . .”

The sound of a door roused me again. The man in the three-piece suit emerged from the office, he and the hospital executive to whom he had been speaking shaking hands and smiling. As he turned, I looked about. Where was “How to Discourage a Doctor?” It was not on the table, nor was it on the chair where I had first found it. “Will he think I took it?” I wondered. But instead of stopping to look for it, he simply walked out of the office. As I watched him go, one thing became clear: having read that document, I suddenly felt a lot less discouraged.

Thursday, September 25, 2014

"Value-based care: Bad for doctors, bad for patients?"

Dalai's note:  Here is another piece cross published from KevinMD.com. I have a huge level of antipathy toward "Value-Based" reimbursement. From the beginning, I smelled a rat. How could we in radiology in particular prove the "value" of what we do in a manner that would convince those who hold the purse strings that we should actually be paid for our efforts? If, for example, we tell the ER doc that his order for a CT is inappropriate, we save the system money, and risk a lawsuit. If we let it go through, and it is negative as expected, we are dinged for charging the system for something that didn't produce "value". In other words, we are screwed either way.  What follows is a much better analysis of a sorry situation...
Value-based health care is antithetic to patient-centered care. Value-based health care is also diametrically opposed to excellence, transparency and competitive markets. And value-based health care is a shrewdly selected and disingenuously applied misnomer. Value-based pricing is not a health-care innovation. Value-based pricing is why a plastic cup filled with tepid beer costs $8 at the ballpark, why a pack of gum costs $2.50 at the airport and why an Under Armour pair of socks costs $15. Value-based pricing is based on manipulating customer perceptions and emotions, lack of sophistication, imposed shortages and limitations. Finally, value-based prices are always higher than the alternative cost-based prices, and profitability can be improved in spite of lower sales volumes.
Health care pricing is currently a smoldering mixture of ill-conceived cost-based pricing with twisted value-based pricing components. For simplicity purposes, let’s examine the pricing of physician services. As for all health care, the pricing of physician services is driven by Medicare. The methodology is neither cost-based nor value-based and simultaneously it is both. How so? Medicare fees are based on relative value units, which are basically coefficients for calculating the cost of providing various services in various practices, of various types and specialties. The price, which is also the cost since it includes physician take home compensation, is calculated by plugging in a dollar value, called conversion factor. The conversion factor, which is supposed to represent costs, is not in any way related to actual production costs, but instead it is calculated so the total cost of physician services will not exceed the Medicare budget for these services. Buried in this complex pricing exercise is a value-based component. A committee of physicians gets to decide the requisite amount of physician effort, skills and education, for each service. Whereas in other markets the value decision hinges on buyer perceptions, in health care it is masquerading as cost.
The commercial insurance market adds a more familiar layer of complexity to the already convoluted Medicare fee schedule baseline. Unlike Medicare fees, which are nonnegotiable, private payers will engage in value-based negotiations with larger physician groups and health systems that employ them. Monopolistic health systems in a given geographical area can pretty much charge whatever the market can bear, just like the beer vendor at your favorite ballpark does, and brand name institutions get to flex their medical market muscles no differently than Under Armour does for socks. This is value-based pricing at its best. Small practices have of course no negotiation power in the insurer market, but as shortages of physician time and availability begin to emerge, a direct to consumer concierge market is being created, providing a new venue for independent physicians, primary care in particular, to move to a more profitable value-based pricing model.
Unsurprisingly this entire scheme is not working very well for any of the parties involved, except private insurers who thrive on complexity and the associated waste of resources. Upon what must have been a very careful examination of the payment system, Medicare concluded that it does not wish to pay physicians for services that fail to lower Medicare expenditures, and Medicare named this new payment strategy value-based health care, not because it has anything in common with value-based pricing, but because it sounds good. Another frequently used term in health care is value-based purchasing, which is attempting to inject the notion of quality as the limiting factor for cost containment. However, since Medicare is de facto setting the prices for its purchases, there is really no material difference between these two terms.
We need to be very clear here that value-based health care is not the same as quality-based health care. The latter means that physicians provide the best care they know how for their patients, while the former means that physicians provide good health care for the buck. To illustrate this innovative way of thinking, let’s look at the newest carrots and sticks initiative, scheduled to take effect for very large medical groups (over 100 physicians) in 2015. Below is a table that summarizes the incentives and penalties that will be applied through the new Medicare Value-based Payment Modifier.
Value based care: Bad for doctors, bad for patients?
There are several things to note here. First, if your patients receive excellent care and have excellent outcomes, you will receive no perks if that excellence involves expensive specialty and inpatient services, whether those are the accepted standard of care or not. You would actually be better off financially if you took it down a notch and provided mediocre care on the cheap. The second thing to notice is that you will not get penalized for providing horrendously subpar care, if you do that without wasting Medicare’s money.
Another intriguing aspect of this new program is that you have no idea how big the incentives, if any, are going to be. The upside numbers in the table are not percentages. They are multipliers for the x factor. The x factor is calculated by first figuring out the total amount of penalties, and that amount is then divided among those who are due incentives. If there are few penalties, there will be meager incentives. Lastly, those asterisks next to the upside numbers, indicate that additional incentives (one more x factor) are available to those who care for Medicare patients with a risk score in the top 25% of all risk scores.
As with everything Medicare does, this too is a zero sum game. For there to be winners, there must be losers. One is compelled to wonder how pitting physician groups against one another advances collaboration, dissemination of best practices, or sharing of information, and how it benefits patients. Leaving philosophical questions aside, the optimal strategy for obtaining incentives seems to be transition to a Medicare Advantage type of thinking: get and keep the healthiest possible patients, and make sure you regularly code every remotely plausible disease in their chart. Stay away from those dually eligible for Medicare and Medicaid, the very frail, the lonely, the infirm, or the very old, and don’t be tempted to see a random person who is in a pinch, because there is always the chance that he or she will be attributed to your panel following some hospitalization or other misfortune.
The Value-based Payment Modifier is for beginners. It is just the training wheels for the full-fledged risk assumption that Medicare is seeking from physicians and health care delivery systems in general. The grand idea is not much different than providing an aggregated and risk adjusted defined contribution for a group of assigned members, and having the health care delivery system absorb budget overruns, or keep the change if they come in under budget. There is great value in such a system for Medicare and commercial payers certain to follow in its footsteps, and perhaps this is why they decided to call it value-based. Ironically, the equally savvy health care systems are fighting back precisely by building the capacity to create a true value-based pricing model for their services through consolidation, monopolies, corralled customers, artificial shortages, confusing marketing, and diminished physicians.
It is difficult to lay blame at the feet of health systems for these seemingly predatory practices, because transition to a perpetual volume-reducing health care system is by definition unsustainable. The infrastructure and resources needed to satisfy all the strategizing, optimizing, counting and measuring activities required for value-based health care, whether the modest payment modifier or the grown up accountable care organization (ACO), are fixed costs added to health system expenses year after year. However, the incentives or shared-savings are temporary at best, because at some point volumes cannot be reduced further without actually killing people. Either way, in the near future, and for already frugal systems, in the present, all incentives will dry up leaving only massive outlays for avoiding penalties coupled with increased risk for malpractice suits.
And as these titans are clashing high above our little heads, two outcomes are certain: Individual physicians will be paid less and individual patients will be paying more for fewer services. This is how we move from volume to value. Less volume for us, more value for them.
Margalit Gur-Arie is founder, BizMed. She blogs at On Healthcare Technology.

Monday, September 08, 2014

I never understood the loss of empathy during medical training. Until now.

Another incredibly powerful post published on KevinMD.com, this from an anonymous medical student. Read it and weep. I did.

It was 4:30 a.m., and I was on the side of the road, drenched in sweat and tears. I had finally slowed my breathing to normal. I was going to be late for rounds. No time to obsess over possible questions. No time to memorize lab values, or practice regurgitating them.

I thought of home. My family and friend, who I hadn’t seen in months. I cringed when I estimated how long it had been since I called them. And the place itself. The dry, clean heat of the desert. The pump jacks that dotted the landscape. The men with their muddy work boots and weathered skin. The brave, unconventional beauty, the humility of the region. And my heart ached to be there, to go back to a time where I was bright and hopeful. I think that’s where most of my sadness came from. Grieving the loss of her, the girl who wanted to do something that mattered.


I attended my dream school. I remember the day that I received my acceptance letter as one of the happiest in my life. I was going to learn from some of the smartest doctors in the world. I felt blessed. As a young man, my grandfather had crossed the border to pick cotton. His third grade education and shaky English would keep him working manual labor jobs for his entire life. My father was the first to graduate from high school. He, like most men back home, worked in the oilfields. And I was going to medical school. My family couldn’t help me fill out the applications or pay for the MCAT (I worked at a coffee shop to cover that). But they were my biggest fans, my cheerleading squad.

My decision to choose medicine was emotionally motivated. My mother became very sick during my junior year. She spent months in hospitals, on respirators and feeding tubes. I watched my mom suffering, and I hated that I didn’t understand what was going on, that I couldn’t help. Soon after she came home, I announced I was going to medical school. I had never been so sure.

We experienced intense stress and pressure to perform, to produce results. Early on, I stopped attending lectures, and watched from home. I could speed up the recording and learn twice as fast, I reasoned. Alone in the small apartment that my loans afforded me once I paid the hefty tuition bill, I worked diligently to produce what were considered mediocre grades at my institution. It is difficult to explain the isolation, the emptiness of this time. Those are two years I’ll never get back. Two years of youth and good health spent in an apartment.

I would call my friends and family often in the beginning, sobbing and anxious. But how could they understand? To them, to the outside, a doctor’s life seemed very glamorous indeed. After a while, I stopped calling.

The only patient contact I received were not real patients. They were actors. Once or twice a semester, we would conduct earnest interviews with these pretend patients. We would be timed, filmed, and graded. Even our interactions with other human beings were carefully scripted and judged. If my university believed in one thing, it was that there was no human enterprise on Earth that could not be held to a rubric. They had yet to fail in their quest to quantify, to measure all of the qualities of an ideal doctor.

Then the grand finale: step 1, or as I like to call it: “The Most Important Test On The Planet: If You Screw Up You Will Never Get The Residency That You Have Dreamed About Since You Were Three Years Old.” Weeks of cramming material into my head. I drank coffee. I studied. Period. I was motivated by the promise of the clinical years. I was finally going to be able to interact with humans again. I prayed that the motivation, the drive I had lost somewhere along the way would return.

My happiest times in school were early in the morning, before the residents and the attendings were around to expose the holes in my knowledge, or reprimand me for forgetting to test cranial nerve IX, or scold me for my presentation being too long (or too short, depending on the person.) It was listening to my patients as they told me about their children. Their patience as I clumsily stumbled through the interview. The way their face relaxed as I told them that I would bring up their concerns to the doctor. Holding their hands and telling them it was going to be alright. Laughing, connecting, loving. Ironically, the shortest parts of my day. No time for that sort of thing with notes to write, tests to study for, articles to look up.

I attempted to explain the situation to the school psychologists. I tried to convey the sense of loss, the unmet expectations, the dying of a dream. I was told I was experiencing severe depression and anxiety, feelings that were internally generated. No possible flaw in the system, they rationalized. After all, there were rubrics. I was assured it would take months to treat me. Best to get on with it, numb up in time for the next rotation. Instead, I took a leave of absence.

I have been silent for too long. I have asked, “What’s wrong with me?” when I should have been asking, “What’s wrong with this?” I am compassionate and hardworking, yet I have been daily made to feel inadequate. I have been isolated from the people and the pursuits I love. I have given up everything, paid thousands of dollars, thousands of hours. I have repeated to myself over and over, “there is only medical school.” I almost believed it.

I never understood the trend of loss of empathy during medical training. Until now. See, when you’re in so much pain that if you thought of your life past this moment, this singular point in time, you would implode, pain seems as natural as breathing. Pain is part of life. Pain is nothing. You can’t stop to nurse your own wounds, you can’t talk about how much you hurt. So how could you possibly have enough room in your broken heart to take on someone else’s pain? So you don’t. You cover your bases and survive. You become that machine that you swore you’d never become. Because it hurts too much to feel, and it’s so much easier to float than swim.

I fantasize daily about leaving medicine for the endless sky back home. I miss the person that I was so very much. But I’m still here. And I hold onto my faded dreams in my little hands.

Why?

I remember that hospital room that smelled of isopropyl alcohol and sickness. I remember changing the sheets my mom soiled because the nursing staff was short in our small hospital. I remember the cold, detached doctors that came for ten minutes once a day. I remember how they spoke in riddles, how they seemed so far away. I remember.

I promise I won’t forget. I’ll never forget.

Tuesday, August 19, 2014

Out Of Site Visits

Because one of our sites has decided to replace some generations-old equipment, I had the joy of going on two site visits over the past couple of weeks. Both were sponsored by BIG NAMES, and both fell rather short. Which prompts me to examine the entire concept of the site visit.

In brief, the site needs two quite different pieces of equipment, both sold by the BIG VENDORS in question. Both teams got only half of it right, one showing us the first, and one showing us the second. Both seemed to be a little oblivious to the fact that we needed one of each. My recommendation at this point is to buy one machine from one vendor and the other from the other. I doubt that will happen.

So what went wrong? I'm not totally sure, but I think it probably comes down to someone not listening. I think we made our needs pretty clear, but...

Site visits can be fun, at least they were in the old days. I've been on what might have been one of the more expensive equipment junkets in the history of imaging. We had two Elscint CT's at the time, and the company wanted us to consider their MRI's. Our trip started at Elscint HQ in Haifa, Israel, and then took us to Kiel, Germany to see the only prototypes in existence of the machines we sought. The machines were actually quite impressive. Elscint had created one of the first high-field scanners, a 2T device, as well as a dual-gradient machine. There was just one little catch. The week before we left for the trip, Elscint was SOLD! GE purchased the nuclear medicine and MRI divisions, and Picker (later Philips) snagged the CT business. So GE ate the bill for me and my partner to look at scanners that were never manufactured! We did have a good time, though.

What is the point of a site visit? To see the machine? Here's a little secret: Most every scanner is a big box with a hole in it. Some have prettier cowling than others, some have a water-chiller in the corner, which looks rather like a fridge. Some have really nice LCD displays over the gantry. Whoopie. More importantly, one gets the chance to talk to the users, technologists, physicians, whomever. Usually, the salesmen have the tact to disappear for a moment so the bad stuff can be discussed as well as the good. (Bad stuff does come out..on our Fuji PACS site visit years ago, the PACS admin said, "Fuji support isn't so good and we have to maintain the system ourselves." Which was the end of Fuji.)

Of course, the most important part is the obligatory meal at vendor expense. But the days of picking the most expensive wine on the list are gone, and frankly I never felt terribly comfortable spending the vendors' money on frivolity anyway. Not that a fancy meal or trip can or should influence my choice, but the optics are what they are.

Ultimately, I think the days of the site-visit are numbered.

My friend Mike Cannavo, once again the One and Only PACSMan, ghost-wrote this paragraph for my RSNA Christmas Carol fantasy:
“Isn’t it obvious?” (the PACSMan) asked. “Here’s the deal. No one knows where healthcare is going, so we’re all going to start enjoying Thanksgiving again for the first time in 75 years. Instead of freezing our asses off, we’ll do an interactive virtual conference with scheduled demos and everything. No muss, no fuss, and no ‘free’ meals. As a bonus, system prices will drop 30% because vendors won’t have to pay for RSNA. It’s sheer brilliance, I tell ya!"
Mike was referring to the vendor extravaganza at RSNA, but I think this applies to site-visits as well. There is simply no need to haul people across the countryside (or country, for that matter) to see the scanner. They all look pretty much the same, and decisions are not made on the basis of their appearance. (Bore size and other specs are important, but that's all in the specs.)

Conversations with the important people can be choreographed by phone with little difficulty. And images, the most important piece of my puzzle, can be sent, hopefully in a form that will easily load on the customers' PACS. (Yes, that can be a problem.)

Hey, I like a paid day off as much as anyone else, but I'm getting too old to drag my carcass around the neighborhood and indeed the country to spend 5 minutes in the presence of the Holey Box and its keepers . Let's save a few thousands (or tens of thousands) of dollars and try it my way.

I've probably just made myself a target for those who like getting wined and dined and taken to various exotic places like we just were, but time change, boys. Go spend the time with your family instead. That goes for the vendors, too.

"Speaking Truth To Crap"

Dalai's note: This piece is reprinted from today's American Thinker. It is one of the most eloquent, heartfelt, and most importantly, ACCURATE renditions of the Mideast situation today. It is a long essay, but well worth your time. Know the history. Know the TRUTH.

Speaking Truth to Crap


By Dan Gordon

I've been home from participating in Operation Protective Edge for about a week. I am in uniform no more, though I still wear my dog tags in solidarity with my brothers in arms, who, like all citizens of Israel, await the outcome of cease-fire talks in Cairo. Because we never wanted this war. It was forced upon us by Hamas. The current cease-fire is set to expire Monday at Midnight Israel time. Hamas has repeatedly rejected and/or violated each past cease-fire, so no one knows what will happen with this one.

I admit to being a bit cranky.

I don't think it's PTSD, though I've been to too many funerals, had a few too many close calls with rockets and mortars, had people with whom I'd celebrated the night before be killed the next day, seen chunks of the skull of a sixteen year old blown off by shrapnel from a mortar round I successfully dodged, only through luck and the grace of a loving G-d, who, I choose to believe, still has some use for me on the planet.

The song "Fire and Rain" is playing on the local oldies station and I think to myself, " Oh James, you Sweet Hippie Child, you haven't seen anything..."

You haven't been in a shelter during a rocket attack trying to comfort a little girl with nothing but the BS of an adult trying to comfort a child in a rocket attack, who knows better. You haven't seen people race for cover knowing they have only seven seconds before risking being blown apart. You haven't met people who've had to lock themselves in a so called safe room, while only a few hundred meters away a dozen terrorists, armed with anti tank missiles that could incinerate their home, machine guns, grenades, thousands of rounds of ammunition and hand cuffs, with which to take them prisoner and drag them through terrorist tunnels, into underground cells, are on the prowl, and they, this sweet family in a locked room, know that they are their targets. They will live or die in the next hour, depending upon the skill and bravery of eighteen and nineteen year old boys and girls, who are willing to lay down their lives, not to promulgate any occupation, nor subjugate another people, but to protect their homes and families, and on this particular day, some of those kids will do just that. They will lay down their lives to protect this family and others like them. The terrorists' secret "Divine Victory Plan" to kill, maim and take hostage, Israeli men women and children will be foiled and there will be new funerals of nineteen year olds who've given their lives to save the lives of that family huddled together behind a locked door in their home. And you think you've seen Fire and Rain, James?

Since I'm back I've become appalled by the lack of journalistic integrity I've seen in some coverage, and the sheer ignorance in the coverage of others.

I like listening to NPR on weekends. They have a comedy game show called "Wait, Wait Don't Tell Me." I'm driving from a friend's house and searching for it on the radio and an NPR news cast comes on. It's about Gaza, so reflexively, like all Israelis, I turn the sound up. Are we at war? Are rockets falling again? The reporter comes on. She has well modulated, upper crust British Public School pronunciation, as she describes the plight of Palestinian Fisherman in Gaza who now have a five hundred meter limit placed on their fishing activities by the Israeli Navy in the wake of the recent war. She describes it as if it is some cold hearted, at the very least, collective punishment of innocent Gazan Fisherman.

I mean how cruel can these Zionist oppressors of the downtrodden Gazan fishermen be?

We're talking fishermen here!

Peter was a Fisherman. Jesus preached on the shores of the Sea of Galilee...to Fishermen! Just like these poor Palestinian Fishermen whom the Israelis cruelly limit to fishing only five hundred meters from shore!

Nazis!

I can almost see a new site to match "Jesus at the Checkpoint," which tries to say if Jesus of Nazereth were alive today he would be a poor Palestinian, harassed by Roman-like, Jewish, Nazi soldiers at checkpoints in the West Bank. Jesus would be, were he alive today, separated from his neighbors by "The Apartheid Wall"!

Never mind that the checkpoints were a response to, and preventative measure against, the suicide bombers who claimed a thousand Israeli lives, who blew up women and children in pizza parlors and Passover Seders.

As for the so-called " Apartheid Wall," it is a security fence, only three percent of which is a thirty foot high wall. And why is there even three percent which is a thirty foot high wall? Because for years Palestinian terrorists from Kalkiliya and Tul Karem would shoot at cars on the Trans-Israel highway and kill Israelis. And by the way, since the barrier has been there, it's stopped almost a hundred percent of the suicide attacks. Period.

It's not Apartheid you bozo! It's self-preservation!

Twenty percent of Israel's population are Arabs, many of whom define themselves as Palestinian. They sit on our Supreme Court, which recently sent a former Israeli president and a former Israeli Prime Minister to Jail. They study and teach in our universities, serve in our military, are doctors and nurses in our hospitals, and enjoy the protection of the least corrupt, most liberal judiciary in the entire Middle East. Indeed no Arab country affords them the rights they have as citizens of Israel. Does that sound like Apartheid to you? I'll tell you what sounds like Apartheid. It is the fact that virtually every Palestinian leader has said that not one Jew will remain in a Palestinian state once it is created. In other words Judenrein. Jew-Free. Hitler's wet dream

But I digress.

Pardon the rant. I said I was cranky. Back to the poor Gazan fishermen who can't fish beyond a five hundred meter limit imposed by the Israeli Navy during the current war. What this Brit twit of an Oxbridge reporter fails to mention is that Hamas terrorists attempted to stage a water-borne terrorist attack on Zikkim beach near the Israeli city of Ashkelon. Happily, they were engaged and killed by some more 19-year-old Israeli kids willing to lay down their lives to protect the Israeli civilian farmers at Kibbutz Zikkim, where the terrorists were headed. That's why there's a five hundred meter restriction! Because Hamas terrorists, posing as poor Gazan fisherman, indeed, tried to carry out a terrorist attack against our civilians. Gazan fisherman are paying the price for Hamas terrorist attacks on Israeli civilians. But the Oxbridge modulated tones never mention that. They just sadly intone her name, and solemnly bear witness to yet another Israeli act of tyranny.

Gimme a break!

Do your homework you twit. Keep your prejudice, if you like, in the melodrama you wrote in your head before you ever even got there, but provide at least a little bit of context. Whattaya say?

All of which brings me to Jon Voight.

Mr. Voight recently penned an open letter to Javier Bardem and his equally talented wife, Penelope Cruz, for signing an open letter condemning Israel as a war criminal without once mentioning the name, let alone the deeds of Hamas. Mr. Voight took them to task and recounted Israel's history in a workman-like fashion, hoping to educate them, and his readers, regarding the facts leading up to the current conflict.

Mr. Voight has thus, recently been taken to task himself, by a member of Academia who has chosen to identify with the downtrodden, put-upon, maligned and much misunderstood freedom fighters of Hamas.

He has done so by taking his stand against the capitalist, pig, oppressors of the Palestinian masses, namely the dreaded Zionists.

He flaunts his academic credentials to poor Mr. Voight, a mere actor, and present the true facts and myths surrounding Israel, even going so far as to cite like-minded Jewish and Israeli academics, in order to enlighten the aforementioned, and hopelessly naive Mr. Voight. He, after all, has written and edited books specializing on (his grammar, not mine) the history and contemporary realities of Israel, Zionism and Palestine. The conclusion which the professor has drawn is that the United States and Israel are to blame "for the suffering Israel has inflicted on the Palestinian people." And to ice that academic cake, and bolster his argument to irrefutable heights, which, no mere actor could ever hope to scale, he quotes that leading expert on all things Middle Eastern, none other than John Leibowitz!

Oh...what's the matter ? You never heard of John Leibowitz?

That's because this particular proud Jewish comic, unlike guys named Seinfeld, Sandler, and Stiller, felt he couldn't make it merely on his talent. I mean, who ever heard of a Jewish Comedian? So he Anglicized himself into becoming a homey of the Oxbridge Patron Saint of Palestinian Fisherman, and thus, was born again as, Jon Stewart.

I like Jon Stewart.

I think Jon Stewart's a funny guy.

I think he's so funny, in fact, he could even have made it even if his name was Leibowitz.

But I'd no more depend on his analysis of the current conflict in the Middle East, than I would consult with Dr. Pepper about a medical condition. Dr. Pepper's a heck of a soft drink. But by Doctors, he's no doctor.

So this is not an open letter to this bozo of new left chic Academia. But it is a refutation of the same talking points raised by his fellow travelers seeking to delegitimize Israel's very right to exist as the sovereign nation state of the Jewish people. First of all, what you have to understand is, the very notion of a sovereign Jewish state, within any borders, is anathema to this crowd. They live in an enlightened, post-nationalistic mindset, where the only people in the Middle East entitled to be nationalists, in fact, are those who wish to establish, not a nation, but a Caliphate.

Regarding the birth of Israel in 1948, Mr. Voight rightly cites it having come about as a result of Israel's acceptance of the 1947 UN plan to partition Palestine into two states, one Jewish and one Arab. The Arab League and the Palestinians, represented by their revered leader Haj Amin Al Husseini, rejected the partition plan and the establishment of any Jewish State within any borders, and as Mr. Voight pointed out, Israel was subsequently "attacked by five surrounding Arab countries committed to driving them into the sea,"

The professor counters that poor Mr. Voight has been taken in by a Zionist myth. "This is a distortion of the actual history, which saw Zionism arrive on the soil of a Palestine that was already in the midst of its own modernization." The Zionists, he states, deployed "the conquest of labor" and then "the conquest of the land" to increasingly powerful effect once the British conquered Palestine in 1917"

I have heard this particular talking point from various radical left professors who have almost inexplicably cast their lot with misogynistic, gay hating, democracy hating, female genital mutilating, child bride abusing, murderous thug terrorists! I am a child of the left. I attended my first civil rights march at the age of ten. My first presidential campaign was for Jack Kennedy and my second was for Bobby. You can still find my blog supporting Barack Obama's first election on the Huffington Post. To have people who proclaim that they are for the universal rights of man, for equality of the sexes, for peace and justice, side with Hamas terrorists and claim their superiority over a Western democracy like Israel, makes me want to puke at the very perversity of the notion.

As the saying goes, everyone is entitled to his own opinion, but not his own facts.

So what exactly was this "soil of a Palestine…already in the midst of its own modernization" when Zionisim arrived? Well let's quote someone who was there, on that very soil a mere fifteen years before Zionism arrived. Mark Twain toured the Holy Land in 1867. Zionism arrived in 1882. What was the soil that Twain, no slouch of a social observer he, saw and described in his book, Innocents Abroad?

In describing the Valley of Jezreel, he states, "There is not a solitary village throughout it's whole extent -- not thirty miles in either direction. There are two or three clusters of Bedouin tents, but not a single permanent habitation. One may ride ten miles, hereabouts, and not see ten human beings."

I mention the Valley of Jezreel in particular, because that's where I was partially raised, went to high school, from whence I went into the army, where I was married, where I taught high school and farmed and wrote and where my first born son, of blessed memory, was born. I know the Valley of Jezreel as well as I know any place on earth. It is the breadbasket of Israel, home to some of the most successful and stunning agriculture on earth. It is alive and bustling with farming villages, schools, colleges, high tech industry, and agriculture R&D that is the envy of the world. It abounds in forests, each tree of which was bought and paid for by Jews around the world, as was the land itself, which was stolen from not one Palestinian, because it was worthless and desolate and sold at inflated prices to the Jews who were so insane they paid handsomely for barren soil, which they turned into paradise through..."the conquest of Labor"!

There was a time when leftists actually praised labor! But this was Jewish labor. Jews working with their hands in backbreaking labor and I am old enough to have actually known that founding generation, and their love of that land which was as bare and desolate as when Twain first visited. They made it bloom through "the conquest of labor." Unlike these pious Academic poseurs, they engaged in backbreaking work to plant forests and create thriving agricultural villages. They were idealistic young students who displaced no one in their "conquest of the land," which any enlightened progressive today should realize was carried out by the oldest and most effective ecological society in the world, The Jewish National Fund, which saw to it that Israel was the only nation on earth to enter the twenty-first century with more trees than it had in the century before. And you creeps dare to distort that into some kind of crime!

Here's is Twain's description of the Galilee before the arrival of Zionism: "These un peopled deserts, these rusty mounds of bareness, that never, never, never do shake the glare from their harsh outlines...; that melancholy ruin of Capernaum, this stupid village of Tiberias, slumbering under six funereal palms...A desolation here that not even imagination can grace with the pomp of life and action." That was the Galilee then. Visit it today and be amazed at "the pomp of life and action" all of which was brought in through the conquest of labor of the Zionist Jews literally reclaiming the land from the desert it had become.

Regarding Israel's acceptance of the 1947 UN partition plan and the Arab/ Palestinian rejection of same, the professor states, "The Zionist leadership ‘accepted’ the terms of the 1947 Partition Plan. In reality, they had little intention of actually fulfilling them, and over the next year, through inter communal conflict and then all out war, three quarters of a million Palestinians were permanently forced from their homes,"

Again the intellectual dishonesty by a supposed academic is simply staggering.

Here are the facts:

There never was a state of Palestine. Never. Not once in history. Prior to WW I, what is called Palestine, which comprised Israel of today, Gaza, Judea and Samaria and all of Jordan, comprised a sleepy backwater province of the Ottoman Empire. The Ottomans sided with the Germans, In WW I, and for those who don't remember, they lost the war. The League of Nations, forerunner of the UN, broke up the old Ottoman empire and at the San Remo Conference of 1921, passed a resolution "In favor of the establishment of a national home for the Jewish people…." The resolution went on to state. "Whereas recognition has thereby been given to the historical connection of the Jewish people with Palestine, and to the grounds for reconstituting their national home in that country..." the resolution went on to appoint Britain to have a mandate over Palestine, which "shall be responsible for placing the country under such political, administrative and economic conditions as will secure the establishment of the Jewish national home.... The Mandatory shall be responsible for seeing that no Palestine territory shall be ceded or leased to, or in any way placed under the control and Government of any foreign power."

That last point is particularly important because Britain, in contravention of its duties as a mandatory power, lopped off the bulk of the territory and created out of whole cloth, with 70% of what was to have been the Jewish National home, a Palestinian Arab country, and called it Transjordan, which today is known simply as Jordan. But under international law it was to have been part of "The Jewish National Home"!

In 1936, following Arab massacres of ancient Jewish communities in Hebron and Safed, the British appointed the Peel Commission, which offered to partition the 30% of remaining land into two states; one Jewish and one Arab. Two thirds of the state would have gone to the Palestinian Arabs and one third to the Jews. The Palestinian Jews accepted the plan and the Arabs, who called themselves Arabs, and not Palestinians, again led by Haj Amin Al Husseini, rejected it. The Jews accepted this tiny enclave for one reason. It was 1937 and they knew what was about to happen to the Jews of Germany and Europe. When Hitler wanted to rid Europe of its Jews, not one country in the world would take them in and they literally went up in the smoke and ash of the crematoria of Hitler's death camps. Had Israel been born, even in it's Lilliputian form in 1937, six million Jews and all their descendants would have been alive today.

But, say the esteemed academic supporters and enablers of Hamas and their ilk, that just proves their point. The Palestinians had no part in the Holocaust, and yet they were made to pay the price by accepting into their midst the European survivors of European mass murder, that had nothing to do with them.

Really? Really?

Here are the facts, yet again, troublesome as I know they are.

When Britain went to war against Nazi Germany, the Jews of Palestine rushed to enlist in the British Army and eventually formed the Jewish Brigade which, together with its predecessor Jewish Palestinian units, fought valiantly in North Africa and in Europe, and played their part in the defeat of Nazi Germany.

And where was Haj Amin Al Husseini, the revered leader, indeed founder, (and uncle of Yasser Arafat) of the Palestinian Arab National Movement?

He was Hitler's poodle in Berlin.

So don't peddle this revisionist crap that the Palestinians had no part in the extermination of European Jewry and Nazi war crimes, because their leader Haj Amin Al Husseini sure as hell did!

He met with Mussolini and Himmler and Eichman and Hitler himself.

He joined the Nazi war effort by helping recruit Muslim units under German SS command that were responsible for mass murders in Croatia and Hungary.

Indeed Yugoslavia sought to have Haj Amin Al Husseini indicted for war crimes for his role in recruiting 20,000 Muslims, who participated in mass murders of Jews and others in Central Europe. In 1944, on Radio Berlin, Haj Amin Al Husseini, the father of the Palestinian National movement said, "Arabs, rise as one man and fight for your sacred rights. Kill the Jews wherever you find them! This pleases God, history and religion!"

He issued a statement saying, “Those lands suffering under the British and Bolshevik yoke impatiently await the moment when the Axis powers will emerge victorious. We must dedicate ourselves to unceasing struggle against Britain, that dungeon of peoples."

That's what the leader of the Palestinian Arabs was doing when my foster father and the other members of His Majesty's Jewish Brigade were fighting and defeating the Nazis in Europe.

As to the 1948 War of Liberation, far from being invaded by five surrounding Arab countries determined to make the Mediterranean red with the blood of the Jews, the professor claims that the Arab forces were minimal and badly trained and equipped, and were sent to prevent themselves from looking like collaborators, and to prevent their rival, Haj Amin Al Husseini, "from establishing a state".

Wait a second! Did this Bozo just say the Arab armies invaded the nascent state of Israel to prevent the establishment of a Palestinian state?

You bet. That's what he said. The Arabs, not the Israelis, prevented the establishment of a Palestinian state.

Egypt conquered Gaza and annexed it, without giving its inhabitants benefit of Egyptian citizenship.

Jordan annexed the West Bank and all the Palestinians there became Jordanian citizens. And by the way, no one at the time suggested ever turning those lands into a Palestinian state. At those times when they referred to occupied territory, they were talking about, and Hamas still talks about, Tel Aviv!

As to how badly trained and equipped the poor five invading Arab armies were...no less an expert than General George Marshall, Chairman of the Joint Chiefs during WWII and President Truman's most trusted advisor, said that if the Jews declared independence they would be wiped out within two weeks. And he was right to think so. The "poorly equipped" Egyptians had a 10,000 man armored column less than an hour and a half drive from Tel Aviv. There was not one Israeli soldier between them and Israel's largest city. On the next morning they would drive into Tel Aviv and the two thousand year old dream of a Jewish state would be over. And what did those colonialist, imperialist, pig, Zionists have, with which to fight that 10,000 man armored column?

They had four Czech-built ME 109 fighter planes which had been smuggled into Israel in pieces, re assembled in hangars, had never been test flown, had never had their weapons test fired, possessed neither avionics nor radios so the pilots had to communicate with each other with hand signals, and for aeronautical charts had Palestine Auto Club road maps and boy scout compasses glued to the dashboards.

I know because I am privileged to know the man who led the attack of those four ME109s. He refers to me as his younger brother and it is one of the greatest honors of my life to be counted as his friend. His name is Lou Lenart. He and his three other pilots were told that the fate of the Jewish state rested on their shoulders. They were to take off and stop that armored column. If they failed, Israel was dead. Lou pulled out onto the tarmac, looked behind him at the three other planes and saw the entire Israeli Air Force.

But they did it.

They stopped the Egyptian column dead in its tracks and bought Israel the time it needed to survive.

Of the four pilots, they suffered fifty percent casualties on their first mission.

In Israel's war of Liberation in 1948 it lost one percent of its population killed. That would be the equivalent of America losing three million killed in one year. America has lost a little over one percent of that number in ten years of combat and they say America is “war weary.” What do you think Israel was?

Finally, these mouthpieces for terrorist thugs, wrapping themselves in the robes of Academia, claim that it was Israel that started this current war, and not Hamas.

But that's quite simply a lie.

And we know it's a lie because Hamas did not start digging those thirty two terrorist attack tunnels when Israel started it's aerial campaign against them. Those tunnels were an offensive weapon which was to have handed Hamas their "shock and awe," their 911 moment that would have brought Israel to its knees. They began digging those tunnels five years ago with the cement and steel they stole from their own people, with the cement and steel that was meant to rebuild Gaza, to build schools and hospitals and prenatal clinics. And instead they used it to build terrorist attack tunnels under Israel's internationally recognized 1967 border, aimed exclusively against Israeli civilians, whom they would have murdered, maimed and taken hostage by the dozens. This was their offense, planned and executed at the time of their choosing. But following their doctrine of carrying out terrorist attacks and then claiming the mantle of victimhood, with so called academics as their mouth pieces and enablers, they had to make it look like it was a response to Israeli aggression. So they publicly ordered the kidnap murder of three Israeli schoolboys on their way home from school.

And Israel didn't fire a shot into Gaza. They just engaged in a campaign to round up Hamas terrorists in Judea and Samaria, where the boys had been kidnapped and killed.

Then Hamas started firing rockets at Israel and Israel said repeatedly, “Calm will be answered with Calm."

They must have thought to themselves, " What's a guy got to do to start a war with these Jews?"

Then they upped their rocket attacks to a hundred a day and Israel still said "calm will be answered with calm" while they began their aerial campaign.

Finally a ceasefire was to have taken affect.

Israel accepted it.

Hamas rejected it by launching a major rocket barrage, and then the first of six terrorist tunnel attacks, and that's when Israel had no choice but to respond with a ground invasion to take out what was indeed an existential threat.

Of the 1800 Palestinians killed in this conflict, 1600 of them would be alive today if Hamas had only accepted the cease-fire Israel accepted immediately and unconditionally.

But as I said, they weren't interested in a cease-fire.

This was their war and they thought they could win it.

And don't you buy the crap so-called academics are peddling, that Hamas was the duly democratically elected government of Gaza. Hamas took power, not in an election, but in a bloody coup, machine gunning their fellow Palestinians, blindfolding, binding and throwing them off of multi story buildings. They have terrorized their own people, not only Israel. Their people, indeed, live under the yoke of occupation, but not by Israel, by Hamas.

And as for the apologists and enablers of Hamas, who contribute to the misery of Palestinians and Israelis alike, while sitting in their club chairs in the faculty lounge, may I suggest that from now on they speak only through the orifice which Mr. Voight has so eloquently enlarged for them, since what they are peddling is pure, unadulterated crap.

Monday, August 18, 2014

Sensitivity Or Specificity? Which Would YOU Prefer?



A typical day at work...from I Love Lucy, first aired September 15, 1952

There are days when the grind feels a lot like Lucy's candy factory as seen in the clip above. But the beat goes on, the images keep coming, and they have to be read. As one of my professors used to say, "Miss 'em slow, or miss 'em fast, boys!" Of course, that was a joke. Of course it was. Definitely.

You probably know the difference between sensitivity and specificity. In essence, sensitivity is the percentage of the time you find something that is actually present. Specificity is the percentage of the time you don't find something when nothing is there. In other words, were I 100% sensitive, I would find every cancer that comes through on the PACS worklist. Were I 100% specific, everyone I declare negative will truly be without disease. Put in tabular form (courtesy of Penn State's online Stat course):

I want all my positives and negatives to be true, with no false positives (saying there is disease when there isn't) or false negatives (saying there is no disease when there is.)

There is a whole science surrounding this stuff. Everyone, and particularly every radiologist, has a different set of sensitivities and specificities, and this is all wrapped up in a concept called Receiver-Operating Characteristics, or ROC. From MediCalc:


In a Receiver Operating Characteristic (ROC) curve the true positive rate (Sensitivity) is plotted in function of the false positive rate (100-Specificity) for different cut-off points. Each point on the ROC curve represents a sensitivity/specificity pair corresponding to a particular decision threshold. A test with perfect discrimination (no overlap in the two distributions) has a ROC curve that passes through the upper left corner (100% sensitivity, 100% specificity). Therefore the closer the ROC curve is to the upper left corner, the higher the overall accuracy of the test (Zweig & Campbell, 1993).
Got it? Just remember that everybody's ROC is going to be different, with different blends of sensitivity and specificity.

Fellow radiologist and wannabe writer Saurabh Jha, M.D., takes the concept one step further with his "fictional" colleagues, Drs. Singh and Jha. I'm guessing the second isn't fictional at all, and I'm sure he based the first on someone he knows.  Anyway, Dr. Jha wrote this piece published in the Healthcare Blog, and republished by KevinMD, and also cited by several radiologist friends of mine.

Who Is the Better Radiologist?
By SAURABH JHA, MD

There’s a lot of talk about quality metrics, pay for performance, value-based care and penalties for poor outcomes.

In this regard, it’s useful to ask a basic question. What is quality? Or an even simpler question, who is the better physician?

Let’s consider two fictional radiologists: Dr. Singh and Dr. Jha.

Dr. Singh is a fast reader. Her turn-around time for reports averages 15 minutes. Her reports are brief with a paucity of differential diagnoses. The language in her reports is decisive and her reports contain very few disclaimers. She has a high specificity meaning that when she flags pathology it is very likely to be present.

The problem is her sensitivity. She is known to miss subtle features of pathology.

There’s another problem. Sometimes when reading her reports one isn’t reassured that she has looked at every organ. For example, her report of a CAT scan of the abdomen once stated that “there is no appendicitis. Normal CT.” The referring physician called her wondering if she had looked at the pancreas, since he was really worried about pancreatitis not appendicitis. Dr. Singh had, but had not bothered to enlist all normal organs in the report.

Dr. Jha is not as fast a reader as Dr. Singh. His turn-around time for reports averages 45 minutes. His reports are long and verbose. He meticulously lists all organs. For example, when reporting a CAT of the abdomen of a male, he routinely mentions that “there is no gross abnormalities in the seminal vesicles and prostate,” regardless of whether pathology is suspected or absence of pathology in those organs is of clinical relevance.

He presents long list of possibilities, explaining why he thinks a diagnosis is or is not. He rarely comes down on a specific diagnosis.

Dr. Jha almost never misses pathology. He picks up tiny lung cancers, subtle thyroid cancers and tiny bleeds in the brain. He has a very high sensitivity. This means that when he calls a study normal, and he very rarely does, you can be certain that the study is normal.

The problem with Dr. Jha is specificity. He often raises false alarms such as “questionable pneumonia,” “possible early appendicitis” and “subtle high density in the brain, small punctate hemorrhage not entirely excluded.”

In fact, his colleagues have jokingly named a scan that he recommends as “The Jha Scan Redemption.” These almost always turn out to be normal.

Which radiologist is of higher quality, Dr. Singh or Dr. Jha?

If you were a patient who would you prefer read your scan, the under calling, decisive Dr. Singh or the over calling, painfully cautious Dr. Jha?

If you were a referring physician which report would you value more, the brief report with decisive language and a paucity of differential diagnoses or the lengthy verbose report with long lists on the differential?

If you were the payer which radiologist would you wish the hospital employed, the one who recommended fewer studies or the one who recommended more studies?

If you were a hospital administrator which radiologist would you award a higher bonus, the fast reading Singh or the slow reading Jha? This is not a slam dunk answer because the slow-reading over caller generates more billable studies.

If you were hospital’s Quality and Safety officer or from Risk Management, who would you lose more sleep over, Dr. Singh’s occasional false negatives or Dr. Jha’s frequent false positives? Note, it takes far fewer false negatives to trigger a lawsuit than false positives.

I suppose you would like hard numbers to make an “informed” decision. Let me throw this one to you.

For every 10, 000 chest x-rays Dr. Singh reads, she misses one lung cancer. Dr. Jha does not miss a single lung cancer, but he recommends 200 CAT scans of the chest for “questionable nodule” per 10, 000 chest x-rays. That is 200 more than Dr. Singh. And 199/ 200 of these scans are normal.

I can hear the siren song of an objection. Why can’t a physician have the sensitivity of Dr. Jha and the specificity of Dr. Singh? The caution of Jha and the speed of Singh? The decisiveness of Singh and the comprehensiveness of Jha?

You think I’m committing a bifurcation fallacy by enforcing a false dichotomy. Can’t we have our specificity and eat it?

Sadly, I’m not. It is a known fact of signal theory that no matter how good one is, there is a trade-off between sensitivity and specificity. Meaning if you want fewer false negatives, e.g. fewer missed cancers on chest X-ray, there will be more false positives, i.e. negative CAT scans for questioned findings on chest X-ray.

Trade-off is a fact of life. Yes, I know it’s very un-American to acknowledge trade-offs. And I respect the sentiment. The country did, after all, send many men to the moon.

Nevertheless, whether we like it or not trade-offs exist. And no more so than in the components that make up the amorphous terms “quality” and “value.”

Missing cancer on a chest x-ray is poor quality (missed diagnosis). Over calling a cancer on a chest x-ray which turns out to be nothing is poor quality (waste). But now you must decide which is poorer. Missed diagnosis or waste? And by how much is one poorer than the other.

That’s a trade-off. Because if you want to approach zero misses there will be more waste. And if we don’t put our cards on the table, “quality” and “value” will just be meaningless magic talk. There, I just gave Hollywood an idea for the next Shrek, in which he breaks the iron triangle of quality, access and costs and rescues US healthcare.

If I had a missed cancer on a chest x-ray I would have wanted Dr. Jha to have read my chest x-ray. If I had no cancer then I would have wanted Dr. Singh to have read my chest x-ray. Notice the conditional tense. Conditional on knowing the outcome.

In hindsight, we all know what we want. Hindsight is just useless mental posturing. The tough proposition is putting your money where your mouth is before the event. Before you know what will happen.

This is the ex-ante ex-post dilemma. In case you want a clever term for what is patently common sense.

Dr. Singh is admired until she misses a subtle cancer on a chest x-ray. Then Risk Management is all over her case wondering why? How? What systems must we change? What guidelines must we incorporate?

Really? Must you ask?

Dr. Jha, on the other hand, is insidiously despised and ridiculed by everyone. All who remain unaware that he is merely a product of the zero risk culture in the bosom of which all secretly wish to hide.

The trouble with quality is not just that it is nebulous in definition and protean in scope. It can mean whatever you want it to mean on a Friday. It is that it comprises elements that are inherently contradictory.

Society, whatever that means these days, must decide what it values, what it values more and how much of what it values less is it willing to forfeit to attain what it values more.

Before you start paying physicians for performance and docking them for quality can we be precise about what these terms mean, please?

Thank you.
So what is quality? I guess getting it right every time would be a good start. But that really isn't in the realm of human performance. No one has a vertical ROC curve. If you read enough X-rays and scans, you will miss something. The old saying goes that the only way not to miss anything is not to read anything. That's not very practical.

Our fictional Dr. Singh misses one lung lesion for every 10,000 studies read. Let's say that she reads 200 studies per day; she will miss something every 50 days, every two months or so. Is this acceptable? Frankly, it is fantastic. A rate within acceptable human parameters would be more like missing something on one of every one hundred exams, something like once or twice a day. Is this acceptable? Not, I suppose, if the lesion is in your chest, or your relative's. But it is a completely reasonable number for a flawed human being. Average radiologist miss rates have been quoted at anything from .1% to 30%. An ACR presentation based in part on Dr. David Yousem's materials reveal the following uncomfortable facts:
  • Radiologists error rate reported at 30%
  • >70% perceptual
    • abnormality is not perceived, i.e. “missed”
  • <30% cognitive
    • Abnormality is perceived but misinterpreted
  • Error does not equal negligence
    • Negligence occurs when the degree of error exceeds an accepted standard
  • Missed diagnoses are the major reason radiologists are sued 
    • Most commonly missed: 
      • Cancers (breast and lung are the largest percentacge) 
      • Spine fractures 
  • Retrospective error/miss rate averages 30% (i.e. hindsight is 20-20) 
  • “Real-time” error rate in daily practice averages 3-5%
So back to sensitivity and specificity. Is it possible to be 100% sensitive and find every single lesion, never having a false negative? Yes, if you read VERY slowly and call everything positive, then yes, you will pick up every cancer, but in the process, you will prompt a lot of unnecessary negative scans (and a lot of anxiety) for all the little dots that weren't really cancers after all. This is the fictional Dr. Jha, and no one appreciates him, it seems. Can you be 100% specific, never having a false positive, and never send anyone on to an unneeded followup scan or biopsy? Sure, and then you get sued when you do miss something. And you will. I've heard it said that sometimes the lesion and the radiologist simply never meet. True enough.

The bottom line is that human beings (and their ROC curves) are anything but perfect. We can try to seek perfection by applying quality metrics and such, but in the end, what do we achieve? Possibly an outlier will come to light, someone whose miss rate is well beyond his or her colleagues, or perhaps well below the rest for that matter. So in the end, this implied rating process accomplishes nothing more than the perpetuation of the fiction of our perfection. Which raises impossible expectations in our patients, and sets the trial lawyers to licking their collective chops. After all, how can we possibly tolerate anything less than perfection? Because perfection doesn't exist.

I've told you the story of Mar-Mar, my Mother-In-Law, and her untimely passing, which was assisted by a radiological miss. My musings at the time are apropos for this discussion:
I've got enough friends who happen to be litigators to know that two things drive a malpractice suit: anger and greed/envy, and they go hand-in-hand. (And as an aside, the majority of cases appear to reach the attention of a lawyer because ANOTHER DOCTOR told the patient that something wasn't done as well as HE would have done it.) As with the young lady driving the beat-up car, an accident or even an incident that approaches such is enough to promote rage in some of us, perhaps even most of us. It doesn't matter that the act was unintentional. I did not set out yesterday to trash some kid's little red jalopy. I think it's also reasonable to say that no physician decides some morning to cause harm to his patient. A missed finding, like a parking-lot collision, is an accident. It is not meant to happen, and everyone would prefer that it doesn't. This is where greed and envy can augment the madness of rage. The young lady above, at some level, realized that my truck was likely worth 8-10 times what her beater might bring, and no doubt this got her all the more riled. Why should that doofus have a nice car? Who gave him the right to almost plow into me? He must think he owns the road, having an expensive car like that. I'll show him!

In the case of a miss or other adventure in medical errors, I think the same thing applies, although certainly with a little more justification. There is clearly a relationship between doctor and patient. If something goes wrong, the patient feels betrayed And the patient gets angry. Given the perception of docs as wealthy, the next step in the mental equation may become: he hurt me (or could have hurt me) and he's going to pay! He can afford it!

While a financial award could put a car back together again, it may not be able to fix what was broken by the medical error. Somewhere along the way, our society has decided that money can compensate for the damage, and maybe that is true. However, juries of our "peers" are wont to award huge sums as punitive measure to "punish" the "bad" doctor. And let us not forget the fact that the litigator might receive 30-50% of the proceeds.

This is wrong. The whole scenario is horrible, and accomplishes nothing but padding the pockets of the litigating AND the defending lawyers. It leads to millions and billions of dollars spent for "cover your ass" procedures and tests. And it's all predicated on the anger over an accident and the thought that there might be a gold-mine to be had having won the malpractice lottery. This must stop.

I want this to be Mar-Mar's legacy: we must forgive those who make honest mistakes. We need to remove anger, greed and envy (and lawyers) from the equation, and somehow set up some entity, some body or board, that would determine actual damages and arrange for those to be made as whole as possible, but without multi-million dollar punitive, redistributive, awards. I know this is next to impossible, as there is way too much money to be made by trying "rich" doctors in front of a jury of their "peers" who would love nothing more than to sock it to them. But it is the right thing, and all but those who profit from the malpractice industry, not just the lawyers, but the plaintiff whores who sell their testimony, know that I'm spot on. Mar-Mar would approve.
Hopefully the above discussion of sensitivity and specificity brings this all full-circle. You can see the pressures under which we operate. We are to produce the work with decisive reports one after the other after the other, functioning as Dr. Singh, but we are never to miss anything, wearing the Dr. Jha hat. Why not just do both? Because we are human and humans can't do that.

No doubt Elliot Siegel will eventually teach Watson the Computer to read imaging studies, and then we will achieve perfection. Well, maybe not. But I'd like to see the litigators sue IBM instead of us.

Sunday, August 17, 2014

Dalai The Glasshole




We've all heard the hype about Google Glass, but bleeding-edger though I am, I have not yet succumbed to the pressure to invest $1,500 in the future of the future. Fortunately, a friend in the healthcare software business has allowed me to borrow his for a prolonged trial. My conclusion? Nice first effort, Google, but it needs some work.

I'm not going to attempt a full review of Glass, nor will I dabble in the discussions about privacy and so forth. That's all been done many, many times out there on the web, by folks much more eloquent than I. On the privacy issue, my only real concern would be someone wearing Glass in a public restroom. Otherwise, have at it, Glass-wearers. I try very hard not to do something in public that would embarrass me, video'ed or not. Remember, most every cell-phone has a camera, too.

But back to Glass. Technologically, this little strip of electronics attached to an eyeglass frame is pretty amazing. Specs (pun intended) as outlined in the WiKi include:

Technical specifications[edit]


The Explorer's LCoS display optics use a PBS, a partially reflecting mirror beam splitter, and an astigmatism correcting, collimating reflector formed on the nose end of the optical assembly.[26][27]
(For the developer Explorer units:)
  • Android 4.4 [110]
  • 640×360 Himax HX7309 LCoS display[6][25]
  • 5-megapixel camera, capable of 720p video recording[7]
  • Wi-Fi 802.11b/g[7]
  • Bluetooth[7]
  • 16GB storage (12 GB available)[7]
  • Texas Instruments OMAP 4430 SoC 1.2Ghz Dual(ARMv7)[6]
  • 2GB RAM [111]
  • 3 axis gyroscope [112]
  • 3 axis accelerometer [112]
  • 3 axis magnetometer (compass)[112]
  • Ambient light sensing and proximity sensor [112]
  • Bone conduction audio transducer[7]

In the end, it is a super-duper Bluetooth headset, with the addition of video viewing and a still and video camera. (I had invented the Bluetooth headset camera idea myself in 2008! Too bad I never patented it.) And position sensors, etc., out the wazoo. But an appendage it is, and it needs a smartphone in your pocket to perform all of its tricks, although a WiFi connection will go a long way. This is almost a full-fledged computer system you wear on your face, but it's not quite capable of independent operation. Still, the technology is truly incredible, and quite an achievement for a first-pass.

In actual use, I was not as impressed as I wanted to be. Battery life was horrible, giving me just over an hour of heavy use. Of course, you could bring along a battery pack and cable and keep Glass plugged in. But even if you go to that length, Glass will shut down periodically due to overheating, and it does get quite warm to the touch.

I wear bifocals, and my dominant right eye is more nearsighted than my left. I've reached the age of presbyopia (this actually happened when I was 40 which was quite a while back) so I need close-up correction as well. The Glass display lives somewhere in your right upper outer visual quadrant, and as you can see in the bathroom mirror pic above, one has to look up to see it. To me, the display went in and out of sharpness, and my perceived resolution was fair. Text had to be pretty much full-screen to be readable. The size of the "virtual" screen is about the same as my 70" TV as seen from 20 feet away. But my TV is much sharper. We need some better optical correction.

Control of Glass might be its worst aspect. There are two ways in. First, there is a limited touch pad at the temple piece. You can tap in the manner of a mouse-click, or slide back and forth, evoking a linear menu of sorts, depending where you are in the OS. Stroking down dismisses whatever screen you have up. I'm not terribly impressed with this, but the second input, speech recognition is a deal-breaker for me here as well as in transcription. To be fair, the limited voice commands actually do work, as long as you wait for the proper prompt and begin with "OK, Glass". As in, "OK, Glass, Google why are people looking at me funny?" But therein lies the rub. Out here in the real world, you simply cannot go around talking to yourself and not get funny looks at the very least. It looks odd, it sounds odd, in the work environment it will bother other people, and at a bar it will inspire large gentlemen to assist you in divesting yourself of and ultimately destroying the $1,500 toy. Making a spectacle (ha ha) of myself is something I try to avoid. And think about the joy of having a bunch of Glasses operating in a single room. Which "OK, Glass" will the headset actually believe? There is also a third, limited input, that uses a strong eye-blink to activate the camera. So if a Glasshole winks at you, don't wink back unless you want to see it on Facebook.

Ultimately, Glass attempts to be the interface between the real-world of the user and the virtual world of Google. A laudable goal. However, neither the software nor the hardware itself are quite there, though the potential is obvious. Glass offers connectivity of sight and sound and position. It has a camera which sees what you see, and a display to feed you information visually. The microphone hears what you hear, and the bone-conduction speaker talks only to you. Glass knows where you are (via the phone's GPS) and where your head is. Assembling one or more of these capabilities can yield tremendous power, limited only by the imagination. Google outlines many of the tasks already available, such as Googling (duh) things, asking for directions, taking and sending photos and videos, and making phone calls. While it isn't particularly limiting, Glass lives in the Google universe, and your communications are predicated on using Gmail, Google +, Google Habitats, and Google Porn (gotcha). They all work, but not necessarily my favorite way to do things.

The onboard software and additional Glassware apps (loaded via MyGlass app for iOS or Android) take advantage of one or more of the headset's properties. My favorite is Star Chart, which reveals the secrets of the night sky as you gaze directly at the Heavens (or at your ceiling.) It will focus on the star or celestial body at center screen and verbally describe it to you via the ear-piece. Here, we are using the proprioception and GPS to figure out where you are looking, and the display to show the proper star-map.


I was shooting for Polaris, but by the time I captured the image on the iPhone's MyGlass app, I had moved my head. But you get the idea. See the Big Dipper in the center?

There have been a number or attempts to use Glass in the healthcare field. For the most part, these simply use the camera as a live-feed for sharing operations and such, or the display for piping imaging studies or other data in real-time to the surgeon or whomever needs them. If I may be so bold, these are really mundane applications piped through novel equipment.

My patron, the kind fellow who loaned me his Glass, wanted my impressions of how Glass could be used in Radiology. I'm not sure where he wanted me to go, but I'm going to do my best to think outside the box. And I'll probably disappoint him and you, dear readers.

Being an imager, my first thought was to use Glass to analyze images, perhaps to recognize pathology or to send a scan or slice thereof to a colleague for consultation. But the more I thought about it, the less sense that made. Why add extra links to the imaging chain? Look at the specs of the specs. Yes, the camera is 5MP, but the lens is really, really tiny. I pulled up a CT image from the 'net to simulate this process, and with an "OK, Glass," took a photo of it. (Which prompted Mrs. Dalai to suggest that I TAKE THE DAMN THING OFF AND STOP TALKING TO IT.  See what I meant above?) Anyway, here's what I got with my face about 4 inches from the screen:


OK, Glass, this is workable, although I don't like to stick my face that close to the monitor. The nose-prints get nasty after a while. But does it make sense to do it this way? Not really. We have the full resolution image right there ON THE SCREEN. It doesn't make sense to get the image into the system in a round about way when the image is already in some system. Perhaps the best approach would be to add software to the workstation (or laptop?) itself that talks with Glass. Perhaps the heads up display (HUD) could show a cross-hair to show the software where you are concentrating. But, no, that's foolish too. Point at it with the mouse and be done with it. Maybe we could use voice commands to decide which images to capture? Ummm...why bother? Proper PACS software should make that a lot easier. Scratch that idea.

Similarly, looking at images on the HUD doesn't make a lot of sense. The display has 640 x 360 pixels, or 0.23 MP. And with my eye, it doesn't even look that good. I can miss stuff at 3MP. I don't want to even contemplate what will get by me at less than 10% of that.

You see the pattern. Glass is meant for roaming away from your computer. It has some great possibilities for situations where you don't have access to a "real" computer and particularly a monitor. Glass pales miserably as compared to a proper workstation, and really shouldn't be compared at all. Radiology, being a workstation-based field, at least from my end of it, just does not as yet lend itself to this iteration of wearable technology.

At this point in time, Glass isn't a lot more than an expensive toy for bleeding edgers. It has too many problems and limitations. But it is certainly the first step in a major revolution. We will need to see some major improvements for Glass to be more practical even for its current limited applications. Battery life has to improve, and the interface needs to be trashed and redesigned. I'm not really sure what would work better than the unholy combination of voice and a very limited trackpad, but there has to be something. Maybe using the camera to watch hand motion? Of course, this would bring a new meaning to the term "hand-waving"...

Most important for imaging is the image. The itty-bitty HUD is a technological tour-de-force, but it isn't adequate for my purposes. The optics are not good for me, and several other Glass users have had the same problem. Google will have to improve upon the lensing of this tiny display. I would assume the actual display piece would have to be larger to allow for more pixels, which would add weight and bulk. A stereo display with bilateral HUD's would be wonderful, though incredibly odd-looking. The possibility of a 3D HUD brings to mind some Sci-Fi level approaches, such as superimposing volume-rendered scans over a surgical field. "Cut Here" becomes a reality at last.

OK, Glass. We've had some good times, but I'm afraid it just isn't going to work. Can we still be friends? OK, Glass, I know I was a Glasshole, but it's time to move on. Google it.