What is an Algorithm?

Expanding the horizons of computer intelligence – mimicking human understanding in more realms – is one of the grand challenges in science. I.B.M.’s Watson and Google’s algorithm makeover highlights not only the accelerating pace of human progress, but also how much remains to be accomplished.

Steve Lohr, “Google Schools Its Algorithm: Programmers Try to Retool Software To Understand Human Language, and Then to Outwit It and Outsmart it.” New York Times, January 6, 2011

What is an algorithm?

Some sort of logical rhythm?

A kind of cerebral biorhythm?

Beats me- But I’ll go out on a limb.

Even If I appear technologically dim.

It is Google and IBM’s Watson,

Trying to human brains outrun.

Health Reform: Talk Is Cheap

Everybody has a theory of what’s wrong with American health care and why costs are high.

I have my own theory – talk is cheap. By this, I mean Americans and third party payers are unwilling to pay more for what mere talk is worth.

They do not want to pay more for a visit to the family doctor, other primary care physicians, or a psychiatrist. They pay primary care doctors only 55% of what average specialist makes, and only 30% of what an orthopedic surgeon takes home. A psychiatrist is the lowest paid specialist.

A front page headline in the March 6 New York Times nails the problem. “Talk Doesn’t Pay, So Psychiatry Turns to Drug Therapy.”

A psychiatrist can make $150 out of three 15 minute sessions with a patient followed by prescription, but only $90 for a 45 minute talk consultation. A prescription pad has replaced the couch.

A visit to the shrink has become a brief chat, a prescription, and you’re out of there. Many of the nation’s 48,000 psychiatrists no longer provide talk therapy. Instead, it’s a 15 minute session with a prescription adjustment.

The situation is similar for primary care physicians. Only the visit may be even shorter, 10 minutes or less. As Steven Sharfstein, a psychiatrist who serves as president and CEO of the Sheppard Pratt Health System, Maryland’s largest behavioral health system, says of a psychiatrist's practice, “It’s a practice very reminiscent of primary care. They check up on people, pull out the prescription pad; they order tests.”

Practice becomes all about volume. Treatment becomes a production line.

So, fewer doctors enter primary care and psychiatry. Doctors in these fields switch to other specialties, retire early, or become health care executives. More health policy types bewail the primary care shortage. Increasing numbers of onlookers say we have to re-jigger the payment system by paying “cognitive doctors” more like “proceduralists." Critics seek to restructure the RUC (Reimbursement Update Committee), in which a specialist-dominated committee appointed by the AMA and slavishly submitted to by Medicare, sets doctors’ fees.

But there’s a huge cultural problem nobody talks about. We’re an action-oriented people. We like strong silent men of action. Talk is cheap, and we're unwilling to pay more for it.

Americans want action – a prescription, a laboratory test, a CT or MRI, a procedure.

Anything.

Something concrete. Something we can touch, feel, take, ingest, inject, point to, biopsy, grasp, identify, undergo.

Something we can share with friends and family, even if it’s a surgical scar, a pacemaker, a vascular port, a hip or knee prosthesis.

Americans get all the talk we want – from talking heads on radio and TV, from channel news shows, from the Internet, and from bloggers like me.

Other than rewarding talk and recognizing and rewarding cognitive physicians for time spent with them , we should, of course, pursue the big things. '

Joe Flowers, a health system change guru, suggested five of these things (”Five Things Hospitals and Health Systems Have To Get Good at Fast’) in a recent piece in The Health Care Blog.

1) New business models – retail care, urgicare centers, free (but profitable) fee-for-service clinics, specialty clinics, bundled care organizations, onsite clinics

2) Integrated systems

3) Organizations featuring shared financial risks

4) Building a stronger primary care base

5) Applying management tools – leaner care models, benchmarking , continuous quality improvement, and checklists.

I am all for these things. If Joe will forgive me, let these Flowers bloom. But in the meantime, let us pay our thinkers and talkers, our cognitive doctors, more.

A New Dartmouth Health Reform Twist- Geographic Practice Variation "Unethical"

Insensibly one begins to twist facts to suit theories, instead of theories to suit facts.

Arthur Conan Doyle, Sr. quotes (Scottish writer, creator of the detective Sherlock Holmes, 1859-1930

We have to make sure patients are really fully informed about their options, and that they get to choose the elective procedure that's the right one for them. At its very heart, it's an ethical issue.

Shannon Brownlee. MD, lead author, “Improving Patient Decision-Making in Health Care,” 2011, Dartmouth Atlas Report

I see the Dartmouth Atlas crowd, who use Medicare data to blame the “quality chasm” on regional variations among doctor practices, are at it again. They have just issued a 43 page report “Improving Patient-Decision Making in Health Care.”

In essence, the report says if doctors do not "fully inform" patients on the outcomes of invasive procedures vs. conservative approaches and do not give patients the “choice” between the two, the doctors are somehow unethical.

The Dartmouth sages, have chosen 8 clinical situations to make their case.

1. Early stage breast cancer

2. Stable angina

3. Low back pain

4. Osteoarthritis of knee and hips

5. Carotid artery disease

6. Gallstones

7. Prostatic hyperplasia

8. Early stage prostate cancer

Surely, the Dartmouth authors say, if patients were fully informed about the risks and outcomes or surgical intervention vs. conservative therapy, surgical interventions would plunge, care variations would be reduced, 20% of patients would choose conservative approaches, with the savings of millions of dollars and lives.

One of the authors, Michael Barry, MD, explains the “ethical issue” this way.

"The patient safety movement in the last decade has worked very hard to make sure that the wrong patient doesn't get surgery, that Mr. Jones doesn't get taken down to operating room for surgery that was scheduled for Mr. Smith, and that's really important.”

"But if Mr. Smith were fully informed, and would then decide he would neither need nor want this surgery, then taking him to the operating room is like operating on the wrong patient as well."

Doctors, Barry claims, are not "correctly" informing patients of their alternatives.

Richard Wexler, MD, a director at the Foundation for Informed Medical Decision Making, collaborated with the Dartmouth Atlas on this report, says doctors are making decisions without considering the patient's point of view. Medical practice is “doctor-centered” rather than “patient-centered.”

The implication is that most patients never really fully informed of reasonable and effective options that don’t involve surgery. Doctors, it seems, are deliberately withholding information for their own convenience and profit without consulting with patients about alternatives.

This speculative argument is the latest twist in the Dartmouth argument that if somehow, someway, we could standardize and make uniform care in every section of the country based on Medicare data, we could simultaneously save money and improve quality. If every patient were “fully informed,” and “fully understood” risks and outcomes they would make different choices.

This assumes policy-makers in their ivory towers know best what should transpire on the ground, and doctors are acting unethically by putting their interests ahead of interests, outcomes, and safety of patients.

This is an unverified opinion and assumes the Dartmouth gurus know what goes on the in the minds of doctors and patients. Therefore, it makes little sense to call the theoretical and hypothetical unethical.

"I TOLD YOU I WAS SICK!"

In 1925 W.C. Fields (1880-1946), writing in Vanity Fair, proposed this epitaph for himself, “ Here lies W.C Fields, I told you I was sick!”

As it turned out, his final epitaph in Hollywood read, “Better here than in Philadelphia.”

But I digress. I thought of W.C. Fields when reading But Doctor, You’re Wrong! (Real Story Press, 1999). Its author, Eileen Radziunas, lives in Old Saybrook, Connecticut, with her husband, Ed, an IT Specialist for United Healthcare. She is 61 years old and is incapacitated by a rare multisystem disease, Behcet’s syndrome.

Behcet’s syndrome is a disease that causes inflammation of blood vessels. It causes problems in many parts of the body. The most common symptoms are:

• Ulcers in the mouth

• Ulcers of the sex organs

• Other skin lesions

• Visual difficulties

• Pain, swelling, and stiffness of the joints

More serious problems include meningitis, blood clots, inflammation of the digestive system, and blindness. In Eileen’s case, she has experienced all of these problems, including two strokes, which make it impossible for her to use the computer.

The gist of her book is this complaint: She knew something was wrong with her. She visited over 100 doctors nationwide over the course of 22 years – primary care doctors and specialists - locally and in university centers.

She ran the full gauntlet of tests - CT scans, MRIs, and batteries of lab tests. She kept insisting something was wrong, but the doctors kept telling her they could find nothing wrong , that she was dermatologically, opthalmalogically, neurologically, and rheumatologically normal.

Besides, they said, she looked and spoke too well to be sick.

But she knew differently, and finally, Yusuf Yazici, MD, of the NYU Medical Center, known nationally for identifying and treating Behcet’s Disease (one of nearly 1200 rare diseases recognized by the National Organization of Rare Diseases (NORD), located in Danbury, Connecticut), established the diagnosis based on the following.

• positive genetic marker (HLA-B51)

• frequent, recurring oral, nasal and genital ulcers (resembling canker sores)

• eye inflammation (associated with visual loss, swelling, optic nerve hemorrhaging and intense pain)

• arthritis

• scarring skin lesions

• meningoencephalitis

• digestive tract inflammation

She is currently being treated with immunosupressive drugs, steroids, and a TNF (Tumor Necrosis Factor) drug.

She told me, “ I hope something positive can come out of this diagnostic nightmare.” By writing her book, by informing her list of over 100 doctors of what was wrong and where they were wrong, and by conducting a seminar on rare diseases at a local senior center, she is doing her part in making the public aware of rare diseases, which collectively, are not all that rare.

Perhaps, by writing this blog, I can do my part too. If you are a patient and suspect you are sick with some rare disease, you can call the headquarters of the National Organization of Rare Diseases (NORD) in Danbury, Connecticut (1-203-74-0100, 1- 800-999-6073, or to one of three emails, RN@rarediseases.org, orphan@rarrediseases.org, counselor@rarediseases.org.)

Or you may wish to visit the government website for rare diseases, NIH Office of Rare Diseases Research (ORDR) at Rarediseases.info.nih.gov.

Or, finally, you might want to look at a website called Isabelhealthcare.com, developed in 1999 by the father of his daughter, Isabel, who suffered from a rare disease The website contains diagnostic checklists of symptoms, signs, and tests for rare diseases, and is said to be a “differential diagnosis generator.”

As a physician, I look at this problem of delayed or missed diagnoses of rare disease as a product of three converging forces –

One, an over-reliance of technologies rather than listening to the patient’s story

Two, over-specialization with one-track mindsets, rather than thinking outside your specialized box

Three, a tendency to overlook the power of a simple use of Google to elicit a list of diagnosis possibilities.

As an example of the latter, do this. Type into Google these symptoms - visual loss, oral ulcers, genital ulcers, and arthritis, or combinations thereof – Behcet’s disease immediately pops to the top of the screen.

When I was in medical school, we had a saying,”When you hear the sound of hoof beats, don’t look for Zebras.” In other words, common things are common, and rare things are rare. But, when nothing fits, and you can’t think of a diagnosis, use horse sense. Consider a disease of a different stripe. Google the patient’s signs and symptoms.

Obama Health Reform Rope-a-Dope

In legal circles , they call it “waivering,” i.e. giving up a claim or right. In partisan legislative circles, they call it “flexibility” or “compromise.” In health policy circles, they call it a “swing to the center.”

In boxing, they call it “rope-a-dope,” a defensive stance against the ropes, absorbing punches, to tire your opponent while conserving your energy for a counterattack when you return to the center of the ring. In the conservative media, they call it a “mirage of flexibility.”

In health reform , I call it “Anything but Markets,” or ABM for short.

It may also be good political poker, not showing your hand until absolutely necessary.

In health reform, President Obama is a master of all these tactics.
His strategy? Avoid a knockout blow. Go the distance until 2012.

Here is how the Obama strategy works. Don't knock it. Polls indicate he remains the favorite for 2012, even though his health care law remains unpopular, even by margins of 67% to 32% among seniors, the most reliable voting bloc.

• Appear to give ground at the margins, but stick to your command-and-control entitlement agenda.

• Ask for cuts in your annual budget, but do not give an inch on Medicare or Medicaid or Social Security.

• Tell the state governors they can design their own Medicaid packages, but only if they offer the same expensive benefits as the government, and only if they supinely ask for permission.

• Give your political allies $2 billion dollars. i.e. unions, worth of waivers to escape health reform costs, but turn down similar requests from Big Business or other perceived political enemies.

• Never, never, never, let the market have any role in health reform.

. Give lip service to “innovation,” by setting up “Innovation “Centers for Medicare and Medicaid , but only on government terms while stifling innovation in the private section with thousands of new regulations and $500 billion of new taxes on health care corporations.

• Outlaw physician investors who seek to create doctor-owned hospitals that offer quicker, faster, better services with greater amenities and, Gasp!, a profit.

• Do not stoop to market-based tactics such as offering health plans across state lines, tort reform to bring down malpractice rates, letting doctors repackage or reprice services outside of Medicare or Medicare guidelines, permitting doctors to set their fees outside the Medicare coding system dominated by RUC (Reimbursement Update Committee).

• Or, Heaven Forbid!, allowing all citizens , corporate or self-employed tax deductions across the board for health care costs, or encouraging ordinary citizens and individuals to become members of health plans with high deductible or Health Savings Accounts (HSAs).

“The reality is, “ as a Wall Street Journal editorial today, puts it, ” that the liberals who wrote this bill really do think they have a monopoly on good ideas, and they do not include markets. Democrats are more than happy to give the states more freedom, as long as the states use it to impose comparable government control.”

Or, as the poet in me, explains,

Government may think it knoweth,
What is the best for most of us,
But the market tends to bestoweth,
What is best for the rest of us.

Health Reform: Four Reasons Why Geographic Variation Persists.

John Wennberg, MD, founder of the Dartmouth Atlas of Health Care, which uses Medicare data to lament geographic variations of health care delivery, has been preaching the gospel of “unwarranted” variations since 1973, without noticeable impact on medical practices.

Since 1997, MedPac ( Medicare Payment Advisory Commission) has joined in the hunt to track down variation as a means of reducing spending, again without much impact on the ground.

The “unwarranted variation” argument goes like this. If 90% of hospitals and doctors at the high end of Medicare payment spectrum would act like those in the lower-paying bottom 10%, we would save 30% on Medicare costs.

Ergo, 30% of health care expenditures are “unwarranted,” “unnecessary,” and “wasteful.”

The Dartmouth Atlas people say the number of procedures done depends on where you live, for example, “Men over 65 with early stage prostate cancer who live in San Lois Obispo, California, are 12 times more likely to have surgery to remove their prostate than those in Albany, Georgia.”

So? So it logically follows that “ unwarranted waste” stems from lack of standardization, provider greed, and ignorance of the harm of rampant variation.

If only the United States would homogenize care, i.e, make it more uniform, in the 400 Medicare regions based on evidence–based medicine and outcomes data, we would not only save money but improve “quality.” I have placed “quality” in quotes because “quality” is in the mind of the beholder.

So why have these compelling , logical arguments, so prevalent in managerial and government mindsets, failed to reduce geographic practice variation?

This failure comes down to human and societal variations and to the inalienable reality that equal results for all are well-nigh impossible in a democracy.

Here are four reasons why subduing practice variation is so difficult.

1) Doctors Do What They Are Trained to Do - Two thirds of America’s doctors are specialists. They do what they are trained to do. Surgeons cut. Ophthalmologists do cataracts. Cardiologists do stents. Orthopedists do hips and knees. Colonoscopists do biopsies through scopes. Specialists do what generalists who refer them the patients expect them to do, and what patients expect to be done.

2) Hospitals Do What They Need to Do to Stay in Business – Hospitals do what brings them the margins to have to capital and to remain viable. The highest margins have to do with heart, brain, orthopedic, oncologic, radiologic , and robotic procedures - high tech, high ticket items. These items are what hospitals market. These procedures are why many patients come to hospitals - to have the latest and best things done.

3) Patients Go Where They Are Entitled to Go - They go to the doctors and those hospitals where government and their employers and their health plans pay the freight and where their own purses remain relatively untouched. Patients care not whether they meet some standard, whether they receive more or less care than their fellows, or whether the state or federal governments are going bankrupt in the process of providing them with care at government rates.

4) Poor People Go Where They Have to Go When They are Sick - They go to doctors or the ER. Richard “Buz” Cooper, MD, a professor of medicine at the University of Pennsylvania, maintains most geographic variation stems from poverty rather than from greed or lack of knowledge about outcomes. Cooper says poverty in places like the American south and inner cities causes higher Medicare expenditures because patients there are poorer, sicker, and need more care, not because of lack of standardization, ignorance , or avarice. Doctors simply treat what comes to them.