Whether the canopy of a rain forest or the trading floor of Wall Street, complex systems share certain characteristics. A small input to such a system can produce huge, often unanticipated changes — what scientists call “the amplifier effect.” A vaccine, for example, stimulates the immune system to become resistant to, say, measles or mumps. But administer too large a dose, and the patient dies. Meanwhile, causal relationships are often nonlinear, which means that traditional methods of generalizing through observation (such as trend analysis and sampling) are of little use. Some theorists of complexity would go so far as to say that complex systems are wholly nondeterministic, meaning that it is impossible to make predictions about their future behavior based on existing data.
When things go wrong in a complex system, the scale of disruption is nearly impossible to anticipate. There is no such thing as a typical or average forest fire, for example. To use the jargon of modern physics, a forest before a fire is in a state of “self-organized criticality”: it is teetering on the verge of a breakdown, but the size of the breakdown is unknown. Will there be a small fire or a huge one? It is very hard to say: a forest fire twice as large as last year’s is roughly four or six or eight times less likely to happen this year. This kind of pattern — known as a “power-law distribution” — is remarkably common in the natural world. It can be seen not just in forest fires but also in earthquakes and epidemics. Some researchers claim that conflicts follow a similar pattern, ranging from local skirmishes to full-scale world wars.
What matters most is that in such systems a relatively minor shock can cause a disproportionate — and sometimes fatal — disruption. As Taleb has argued, by 2007, the global economy had grown to resemble an over-optimized electrical grid. Defaults on subprime mortgages produced a relatively small surge in the United States that tipped the entire world economy into a financial blackout, which, for a moment, threatened to bring about a complete collapse of international trade. But blaming such a crash on a policy of deregulation under U.S. President Ronald Reagan is about as plausible as blaming World War I on the buildup of the German navy under Admiral Alfred von Tirpitz.
Public Service Announcement
I know there are a lot of Foursquare fans on Tumblr. I recently saw a story about how some nefarious nincompoops are using Foursquare to target people. What happens is this: the bad guys track when and where people are “checking in.” They then look up their address and rob the unsuspecting Foursquare fan’s house.
I haven’t used Fourquare myself, so perhaps there are some security features that make this practice less probable than it sounds. But it’s worth considering. Be careful out there….
I, Pencil, am a complex combination of miracles: a tree, zinc, copper, graphite, and so on. But to these miracles which manifest themselves in Nature an even more extraordinary miracle has been added: the configuration of creative human energies—millions of tiny know-hows configurating naturally and spontaneously in response to human necessity and desire and in the absence of any human master-minding! Since only God can make a tree, I insist that only God could make me. Man can no more direct these millions of know-hows to bring me into being than he can put molecules together to create a tree.
Leonard Read beautifully illustrates through the example of the pencil, the awe inspiring creative nature of free association and exchange and its ability to meet society’s needs.
Medicare Payment Cuts Coming Soon…lines to follow
Senate doesn’t extend deadline for implementing 21.2 percent Medicare rate cut despite House action.
Although the U.S. House of Representative passed legislation to delay a 21.2 percent reduction in Medicare reimbursement rates, the Senate failed to approve it. The 21.2 percent reduction in Medicare reimbursement is required under the Sustainable Growth Rate (SGR) formula, and will officially go into effect on March 1, 2010. Senator Jim Bunning (R-Ky.) led the effort to block the measure—which would have delayed the cuts for an additional 30 days—over concerns that it would add to the national debt. The U.S. Centers for Medicare & Medicaid Services (CMS) has announced plans to hold claims for 10 days to give Congress time to act. If Congress does not act to either postpone the cut or to repeal and replace the SGR formula by that time, CMS will begin processing claims under the new rates.
I have been doing an informal survey recently in which I ask friends, family and patients what they think a surgeon makes for a particular procedure. I use hemiarthroplasty (half of a hip replacement) as an example as I recently performed one for a patient with a femoral neck fracture. Most people guess that I get reimbursed somewhere in the $5000-10,000 range. Some say $20K +. Ha! Medicare pays me $850. Typical overhead runs about 40-50%. So before taxes I am looking at clearing a cool $425. All that for seeing the patient, documenting my findings, counseling the patient and family, performing the surgery, AND 90 days of post operative care. Knock 20% off of that and you’ve got about $350 BEFORE taxes. Do you want your surgeon to get paid less to hold your life and limb in his hands than the guy that fixes the brakes on your car? It’s happening.
FYI- cost of the implant for the same case: $2500.
Contrary to some popular economic theory, artificially fixing prices at low levels does not increase the quantity of goods and services supplied, it does the opposite. Look out for shortages, upset Medicare beneficiaries, more political blame games and parents who encourage their kids to grow up to be mechanics, not doctors.
“ I did not sign away my right to get the best possible health care for myself when I entered politics. ”
Canadian premier Danny Williams on the controversy over his decision to have heart surgery in the US (via randyhaddock)
Green, via his Twitter account, claims to have run a 40-yard-dash in 4.43 seconds, and then claimed to be the fastest baby boomer alive. I’m not going to argue with him.
I am admittedly an unabashed Darrell Green fan. This just makes me even more of a fan of the speedster. A 4.43 s 40 yard dash at 50 years old. Damn! Go Darrell.
In a new paper, researchers have reported recent findings that, in addition to the extraordinary high-energy absorption capability and light weight of their novel composite foams, the “modulus of elasticity” of the foam is very similar to that of bone. Modulus of elasticity measures a material’s ability to deform when pressure is applied and then return to its original shape when pressure is removed. The rough surface of the foam would also foster bone growth into the implant, improving the strength of implant.
“When an orthopedic or dental implant is placed in the body to replace a bone or a part of a bone, it needs to handle the loads in the same way as its surrounding bone,” Rabiei says. “If the modulus of elasticity of the implant is too much bigger than the bone, the implant will take over the load bearing and the surrounding bone will start to die. This will cause the loosening of the implant and eventually ends in failure. This is known as “’stress shielding.’” When this happens, the patient will need a revision surgery to replace the implant. Our composite foam can be a perfect match as an implant to prevent stress shielding,” Rabiei explains.
I started as the main shoulder and elbow orthopedic surgeon at the VA in Dayton back in September. Things are going great. the patients are really cool. many of them have phenomenal stories about the places they’ve been all over the world. If it weren’t for patient privacy, I would have enough to fill my blog everyday for years…maybe I’ll get their permission and write a book. So many dreams so little time.
I like to teach and interact with all of the other staff , therapists, residents etc. So I started a weekly conference with the residents and another separate one with the therapists. The therapists and I meet once per week for 15 minutes or so to go over any interesting or “problem” patients and I think this helps quite a bit. So much of medicine (life?) is communication. Answer a few questions early and you head off large issues down the road. One day per month instead of the usual Q and A we’ll do an educational topic: we switch off, one month I’ll do a shoulder or elbow topic from the surgeon perspective and the next the therapists will do a topic from their perspective. It’s been great. Admittedly residency does not cover physical therapy topics in enormous depth, so it’s a good education for all of us.
One of the therapists gave me a link to a site that produces educational materials for health professionals and patients. The company is called VHI. I really like it, because they have a monthly newsletter with a therapy topic that is supported by a mini review of the evidence. They then showcase some of their many animations of therapy exercises- computer generated 3-D human figures performing exercises that can be viewed by patients as educational tools. The link is above for anyone interested.
We were brainstorming an idea about using tech to enhance the PT experience for patients. It occurred to me that right now PT is being done in 2 main ways: one-on-one monitored therapy with a licensed therapist in an outpatient facility or at home using a self guided program that one was taught by a therapist and then “discharged” and sent to do on one’s own. The advantage of the outpatient visits is the attention and monitoring. The disadvantage is inconvenience due to travel, time and lost work. The advantage of the home program is independence, which of course is it’s main disadvantage - no oversight / encouragement. What if there was an in between?
Take web cam technology ( I think the folks at Nintendo are doing something like this with some of their products) and a series of instructional links on your PT website. Once your patient has graduated to a home program have them log in every so often to check in with the therapists. Have them produce a 2-3 minute video once per month and submit it to the therapist who can then download it, review it and send back some corrections/encouragement via email or video chat.
Maybe it’s already being done, I don’t know. I know it’s not widespread and not currently “reimbursable” by the current system. But I know it’s the future and probably good service.
Maybe we’ll pilot it here. Will keep you posted…
Among more specialized hospitals, there were fewer serious post-surgical complications such as blood clots, infections and heart problems, as well as fewer deaths.
The findings, which were published online Feb. 11 by the British Medical Journal, were based on data for nearly 1.3 million patients who received hip or knee replacement surgeries between 2001 and 2005 at 3,818 hospitals in the United States.
“The findings suggest that more specialized hospitals have better outcomes even after we account for the type of patients each hospital cares for and the number of hip and knee replacement surgeries that each hospital performs,” said the study’s lead author Tyson Hagen, M.D., fellow in rheumatology at the UI Roy J. and Lucille A. Carver College of Medicine and UI Hospitals and Clinics.
jayparkinsonmd:
New regulations to reduce wait times for medical care in California are due to take effect next year. Under the proposal, primary care doctors employed by HMOs are required to see patients within 10 days of the appointment request, and specialists must see patients within 15 days. Telephone calls must be returned within 30 minutes and patients needing urgent care have to be seen within 48 hours…In San Diego, patients wait an average of more than 3 weeks for a routine physical. In Los Angeles, the average approaches 2 months
How long does it take to get an appointment at the Apple Genius Bar?
When you pay an insurance company $11,000 per year to micro-manage your sickcare usage, you lose the status of “paying customer” in the eyes of physicians and hospitals. Customers are “a person or organization that buys goods or services from a store or business.”
The current customer of the sickness industry (hospitals/doctors) is the health insurance industry.
If you take back the transaction from the insurance companies, you take back “customer” status. And once you become the paying customer, when your body breaks, you’ll start being treated like Apple treats customers with broken computers.
Jay is right on with this post in identifying the deeper reason why doctors are being forced to see patients sooner. When there is a need in an economy that is not being met (timely visits) ask yourself first why the system currently fails to meet those needs without force. Usually there is some entrenched mechanism keeping the need from being met through free exchange. Is medicine so unique that healthcare workers can’t imagine that it might be a good idea to get patients into the office quickly for referrals or return phone calls promptly? Of course not. But it does work under an arcane, labyrinthine payment (read incentive) structure which serves neither patients nor physicians well.
A few examples:
If you see a new DVD or book that you like and you want it NOW from Amazon, what do you do? You can pay $0 for regular 3-5 day shipping or you pay extra to get it overnight shipped.
If your kitchen plumbing gets clogged on a weekend and you want to have a plumber come out and fix it, what do you do? You pay a little extra and a plumber comes to the house immediately and presto- it’s done.
In each case you the customer paid a premium for timeliness. You recognized implicitly that instant service comes at a price. Calling on a business to meet your need immediately meant that they had to summon scarce resources (manpower, transportation, skill) toward your need and hence away from other scheduled needs.
Does this (can this) happen in medicine? In large part - No. When was the last time you got in to see the doctor on your schedule unless you had an emergency or knew somebody? If doctors’ offices worked like the above mentioned businesses, all you would have to do to get in sooner is pay a little higher premium. But because people prefer to pay through an intermediary, this doesn’t happen, in fact it legally can’t happen in some instances. It would be illegal for you to pay a higher copay as a Medicare patient to incentivize the doc to see you sooner. Unfortunately healthcare delivery acts under the same constraints as other businesses: limited time in the day, limited resources, limited energy. But the current payment structure makes no provision for this. For elective care, intermediaries pay healthcare professionals stock payments based on entrenched diagnosis and procedure ”codes”, not timeliness.
This is the tradeoff the patient makes for not being a customer.
After taking a thiazolidinedione (TZD) for one year, women are 50 percent more likely to have a bone fracture than patients not taking TZDs, according to study results. And those at the greatest risk for fractures from TZD use are women older than 65.
I am a big believer that orthopedic surgeons need to take a leadership role in dealing with metabolic bone disease, of which osteoporosis is the primary player. We will see an explosion in osteoporosis and fragilitity fractures in the coming years as the Baby Boomers move into their golden years. Most recognize female gender and advanced age as risk factors for osteoporosis, but a whole new subcategory of patients is arising: those put at increased risk by the treatment of another medical condition. The above article highlights a diabetes medication that confers higher risk of fracture. This is not the only medication that produces this untoward effect. Predinsone (rheumatoid disorders, severe pulmonary disease or chronic inflammatory conditions and dilantin (seizure disorders) are just a few others. I’ll bet we see more of these types of studies as time goes on. How easy is it for a patient to grasp that their diabetes medication may be making their bones weak? I would guess not easy. Most people with diabetes are still coming to grips with the fact that they have to take medication for a disease that they can’t “feel.”
Like my dad always told me, unfortunately there’s no such thing as a free lunch.
orthoonc:
It is probably not an exaggeration to predict that the medical student of the next decade will not lift a physical textbook. In fact, even ownership of a discrete entity, formerly referred to as a “textbook’, may be a historical footnote. Instead, students may simply rent the chapters they need for a particular course, paying a recurring subscription fee to the publisher for the period of usage.
For many medical students, who have grown numb after repeatedly paying $100 to $200 per book, this more financially sane model probably will not come soon enough. In fact, college students buying multiple texts for a course lasting just two or three months are probably waiting in even greater anticipation.
But, while renting textbooks may seem like a strange and wondrous departure for those of us who still pridefully maintain shelves of outdated medical textbooks, the more necessary revolution will actually be upending the illusion of completion when a textbook finally reaches the printing press.
By this, I am suggesting that the barrier between finished textbooks and the rapidly evolving nature of medical knowledge most certainly needs to be more porous. Going even further, the interactive and non-linear nature of learning are at odds with the centuries-old format of a linear, immutable text.
This is not to say that textbooks are anachronisms. Something very valuable comes out of the care and scrutiny of an author polishing each paragraph and page with great care. But, why should the craftsmanship stop at the moment of publication ?
This is where the iPad and its future kin come in. The proliferation of ebooks and, in particular, e-textbooks will be great for students and practioners alike. At a minimum, ubiquitous availability and more reasonable pricing models will open the doors to more sales and more happy customers.
But, this will just be the beginning. The real golden opportunity will come from continuing the engagement of the authors with the readers and, even more importantly, the readers with each other.
What this would open is a world where learning occurs just as much in the “wild” as it does in the classroom and where the roles of student and teacher starts intertwine. In other words, something like the real world, rather than the sterile enclosure of the lecture hall.
I imagine the authors of a book continuing their engagement with their readers and even acting as occasional consultants, further enlarging and enriching their reputations. I imagine a “book” that changes over time and reengages the readers when new information arrives or when they perform searches on their device.
In short, what I am looking forward to is an electronic book that soars beyond the simple conjugation of a screen and a book.
• Health Care. The plan ensures universal access to affordable health insurance by restructuring the tax code, allowing all Americans to secure an affordable health plan that best suits their needs, and shifting the control and ownership of health coverage away from the government and employers to individuals.
It provides a refundable tax credit—$2,300 for individuals and $5,700 for families—to purchase coverage (from another state if they so choose) and keep it with them if they move or change jobs. It establishes transparency in health-care price and quality data, so this critical information is readily available before someone needs health services.
State-based high risk pools will make affordable care available to those with pre-existing conditions. In addition to the tax credit, Medicaid will provide supplemental payments to low income recipients so they too can obtain the health coverage of their choice and no longer be consigned to the stigmatized, sclerotic care that Medicaid has come to represent….
Paul Ryan’s alternative plans for the future. So here are some proposals that “the other side” has made. This is a truncated version of the full plan. One of the best parts though is how he proposes drastically simplifying the tax code. BUT, he says, you are free to use the old one if you like it better. Funny!
Conclusion: Backpack loads are responsible for a significant amount of back pain in children, which in part, may be due to changes in lumbar disc height or curvature. This is the first upright MRI study to document reduced disc height and greater lumbar asymmetry for common backpack loads in children.
And then there is one very important fact to keep in mind. When, as we did in the preceding observations, one distinguishes between the concerns of the capitalists and those of the people employed in the plants owned by the capitalists, one must not forget that this is a simplification that does not correctly describe the real state of present-day American affairs. For the typical American wage earner is not penniless: he is a saver and investor. He owns saving accounts, United States savings bonds and other bonds, and first of all insurance policies. But he is also a stock holder. At the end of the last year [1961], the accumulated personal savings reached $338 billion. A considerable part of this sum is lent to business by the banks, savings banks, and insurance companies. Thus the average American household owns well over $6,000 that are invested in American business.
The typical family stake in the flourishing of the nation’s business enterprises consists not only in the fact that these firms and corporations are employing the head of the family; there is a second fact that counts for them, to wit, that the principle and interest of their savings are safe only as far as the American free enterprise is in good shape and prospering.
It is a myth that there prevails a conflict between the interests of the corporations and firms and those of the people employed by them. In fact, good profits and high real wages go hand in hand.
