Fibroid Embolization is a Better Faster Cheaper Alternative to Hysterectomy

Uterine fibroid embolization is a proven safe and effective treatment for women with uterine fibroids who suffer from heavy menstrual bleeding or pelvic pain. Unfortunately, despite the fact the procedure has been clearly demonstrated to be a viable, appropriate treatment, there remains a gap in information shared by gynecologists, which leaves some patients incompletely informed about all treatment options.

As recently reported in Science Daily:

 "A large nationwide study examining the treatment of uterine fibroids shows that the uterine fibroid embolization (UFE), a minimally invasive, image-guided treatment performed by interventional radiologists, is vastly underutilized, compared to hysterectomies -- especially in rural and smaller hospitals. In fact, there were more than 65 times as many hysterectomies performed than UFEs, despite data showing that UFEs result in substantially lower costs and shorter hospital stays than hysterectomies, according to research presented today at the Society of Interventional Radiology's 2017 Annual Scientific Meeting."

"These findings suggest there is a lack of awareness about this safe, effective and less invasive therapy for uterine fibroids," said Prasoon Mohan, M.D., MRCS, the study's lead author and assistant professor in the department of interventional radiology at the University of Miami Leonard M. Miller School of Medicine. "Interventional radiologists urge health care professionals to present patients with all available treatment options so that the patient can make an informed decision. Patients need to know about the major differences between surgical treatments and UFE, especially that this is a non-surgical treatment that preserves the uterus and has a much faster recovery time compared to hysterectomy."

According to the National Institutes of Health, a majority of women -- almost three out of four -- will develop uterine fibroids by the age of 50. Women are at increased risk for developing fibroids if they are overweight, African-American, over the age of 40, have high blood pressure, have had no children, and have first-degree relatives with fibroids.

Between 25 and 50% of women develop uterine fibroids. Women need to be aware of their treatment options and know that uterine fibroid embolization is an excellent option in appropriate instances. As an example of proper care, Drs John Fischer and Robert Zurawin collaborated on a partnership whereby they describe how gynecologists and interventional radiologists can work together for the benefit of their mutual patients. (Click here for the article)

As discussed in Radiology Today, "The two doctors and their respective partners have found that when gynecologists refer uterine fibroid patients to interventional radiologists and vice versa, everyone benefits—most importantly, the patients....The physicians’ most recent article on the effects of the gynecologist-interventional radiologist relationship on the selection of the treatment for patients with uterine fibroids can be found in the April issue of the Journal of Minimally Invasive Gynecology. The article was based on their study of 226 women seeking UFE for symptomatic fibroids. In it, they concluded that gynecologists’ “fear” of losing uterine fibroid patients to interventional radiologists is groundless and that both specialties get more patients when they each carefully select them."

With uterine fibroid embolization, a small tube (catheter) is guided to the artery supplying the uterus and fibroids. Small particles are then delivered into the arteries, blocking blood flow to the fibroids and causing them to shrink over time. Women undergoing this procedure can anticipate spending the evening overnight in the hospital. Pain and nausea from the procedure can be moderate, but are treated appropriately with several medications. By the morning, nearly all women feel well and are discharged with appropriate followup medications and instructions. Subsequent to the treatment, the fibroids begin to shrink and continue to do so for several months. Typically, an MRI of the pelvis is obtained before the procedure, and six months post-procedure to confirm adequate treatment of the fibroids.

As repeated in Radiology Today, "UFE has an impressive success rate: 85% to 90% of women who undergo UFE experience relief from their symptoms within a few months and are able to return to their normal routines within seven to 10 days vs. four to six weeks with surgery. Also, with UFE, recurrence of treated fibroids is rare."


Radiology Partners Fights For Patient Care

One of the reasons why Columbus Radiology partnered with Radiology Partners is because of patient-focused efforts like Physicians for Fair [Insurance] Coverage. I am proud to be a part of an organization with such a patient-centered, progressive perspective. That focus coupled with the group's size affords us the strength in numbers to make meaningful improvements for the communities we serve.

"Radiology Partners is a board member for a group called the Physicians for Fair Coverage (PFC). The PFC is composed of only hospital based physician groups including those in Emergency Medicine, Anesthesia and Radiology.  In fact, Radiology Partners is the only Radiology Practice on the board for the PFC. The PFC has been advocating to help prevent patients from from receiving surprise gaps in their coverage when they visit an out of network physician at an in network facility, an important problem to solve. Unfortunately, the payers have been trying to solve this problem in a way that is very favorable to the payors."

~Philip Reger

Chief Technology Officer

Radiology Partners

Judge Gorsuch Is A Forgone Conclusion

Although I try to keep this blog tilted towards issues of healthcare, I feel the need to opine on a particular issue currently being discussed. The nomination of Judge Gorsuch to the Supreme Court should be a forgone conclusion.

The logic is simple as follows:

Judge Gorsuch is eminently qualified. And he replaces Justice Antonin Scalia, one of the more conservative justices to have served on the court.

The risk, one will rebut, is that the make up of the Supreme Court is being inexorably tilted towards the conservative.

Let's say, for instance, that the Democrats continue on their current path and block the nomination to the best of their ability. It is a temporary measure, as the Republicans have "the nuclear option" at their disposal. Using that option would irrevocably change the landscape going forward. One might think that it would negatively impact the Republicans but nothing would be further from the truth. 

The "nuclear option" would eliminate the need for future nominees to have to reach the 60 vote threshold as well. Hence, future nominees, also likely to be more conservative than the majority might desire, would be easily confirmed, as the Republicans hold a majority in the Senate.

In addition, as the new "Party of No," Democrats, may find their popularity further diminished, making it harder to foresee them adding to, or even keeping, their current number of Senators.

Hence, the logical solution to the current dilemma is to allow the nomination of Judge Gorsuch to proceed and for him to be confirmed forthwith. Hopefully, that would set up a slightly more favorable stance on Capitol Hill for future nominees, should they arise during this presidential term.

If nothing else, one might argue that the Democrats' conciliatory gesture would at the very least not result in diminished popularity for the Democratic Party. 

Why I Choose To Be An Unyielding Optimist

I have been accused of being an unyielding optimist. I see positives when many people see only negatives. No, I am not delusional. But I think that I have a relatively unique ability to objectively view the positive and negative aspects of a situation.

No I do not think I am infallible, nor am I bragging. But I do feel that there are two sides to every story and, seeing and understanding those sides is critical to maintain a healthy emotional balance.

I came across a couple of quotes from "Man's Search for Meaning," by Dr Viktor E Frankl, that I think lend insight into my perspective as follows: 

 "To discover that there was any semblance of art in a concentration camp must be surprise enough for an outsider, but he may be even more astonished to hear that one could find a sense of humor there as well; of course, only the faint trace of one, and then only for a few seconds or minutes. Humor was another of the soul's weapons in the fight for self-preservation. "


 "To draw an analogy: a man's suffering is similar to the behavior of gas. If a certain quantity of gas is pumped into an empty chamber, it will fill the chamber completely and evenly, no matter how big the chamber. Thus suffering completely fills the human soul and conscious mind, no matter whether the suffering is great or little. Therefore the 'size' of human suffering is absolutely relative." 

My point is simple:

One can view an adverse situation negatively, wallowing in the pain and suffering and letting it infuse your entire being. 

Or one can choose to stand up against such adversity, find humor in it even where humor seems woefully out of place, and strive to meet its challenges head on in order to turn what seems to be certain failure into a resounding victory. 

I choose the latter. 

Machine Learning is NO Threat to Radiology

Artificial intelligence will replace humans.

We have heard and seen this discussion before.

Apparently, such a scary prediction now rears its ugly head in the field of Radiology. Catchphrases include "artificial intelligence" and "machine learning." People are discussing whether machines will replace radiologists. To me, the concept is laughable. It is as laughable as the concept of computers replacing humans once was. While it is undeniable that some jobs have been replaced, think auto assembly lines, there is no doubt in my mind that human adaptability and ingenuity transcends the ability of machines to send humans entirely into obsolescence.

In a recent article in the Journal of the American College of Radiology, December 2016 volume 13, Ezekiel Emanuel, one of the original proponents of and architects of the Affordable Care Act, suggests the following: 

"The human reading a chest radiograph may be inclined to simply interpret the image, determining if it represents someone healthy or sick and, if sick, whether infection, fluid, tumor, or another issue is present. On the other hand, a machine will treat each tiny pixel on the screen as an individual variable and will seek to organize those pixels into shapes and patterns and, from there, make a diagnosis. "

Ridiculous assertion, if I may be so bold.  How will treating each tiny pixel on the screen enable a machine to view the human whose parts are depicted on the image? How will organizing those pixels better evaluate the illnesses that formulate that person's problem list? And how will the machine then guide and assist the referring physicians who desire radiology input as to the next steps in their care paradigms?

I maintain that the exhortation that we radiologists treat the patient not the image is critical. A radiologist's value is not just in identifying abnormalities on images. Our value has long transcended that menial process. Daily, radiologists meaningfully contribute to patient care by identifying abnormalities, making recommendations, and, in the interventionalists' realm, intervening when necessary. 

I do not fear machines. I recognize the value that machines can and will continue to add to our lives. But I am in no way concerned, nor do I think you should be, that machines will create human obsolescence.  


A New Year's Wish for Israel and all Jews and Arabs

My hope for the New Year:

Only by forging a new path, one of mutual Arab and Jewish inclusiveness, can peace ever be remotely possible.

I pray that Palestinian leadership decides to acknowledge that Jews and Arabs can and do live and love side by side in harmony.

Peace will not come from elsewhere. All outside parties have vested interests and ulterior motives. My only concern is for the well-being of the Arabs, Jews and Christians living in the region who desire peace, safety and prosperity.

May the New Year bring wisdom and light to the leaders who have fought so long to divide and may they realize the benefits of peace are universal.

Immigration Is Progressive

"Immigration restrictions slow economies, but they don't necessarily prove or portend bigotry or racism. Indeed, it's possible for an American government to restrict immigration and foster national comity at the same time. That's what Presidents Warren Harding and Calvin Coolidge demonstrated in the 1920s." ~Amity Shlaes

"Whether one traces his Americanism back three centuries to the Mayflower, or three years to steerage, is not half so important as whether his Americanism of today is real and genuine. No matter by what various crafts we came here, we are all now in the same boat." ~President Calvin Coolidge

"What Harding and Coolidge sought was a breathing space for all the immigrants to assimilate, time for them to learn English and what people in those days called "Americanism." By Americanism they meant of the familiarity with common law, U.S. civics and adequate workplace English." ~Amity Shlaes

Amity Shlaes points out that immigration restrictions instituted in the 1920s did not result in wage increases as much as "restrictionists had hoped they would. Restriction didn't prevent the Great Depression. When, many decades later, Asians were again allowed to immigrate, they prove their social and economic worth through their contributions many times over."

She then goes on to suggest something that is typically controversial. Read the following passage and think about it. "Defunding the official publicly funded bilingualism of the courts and schools would accelerate Hispanics' move into the professional class. Workers are more flexible and integrate better when there is no language barrier. Official bilingualism directs its own wall, a cultural wall." 

To me, it is clear that this great country is made great by its people and those people come from all corners of the globe. We should celebrate immigration while at the same time acknowledging that free and unfettered entry would carry risks analogous to the Trojan horse.

The Key to Healthy Living is to Rebalance Gut Bacteria

People look for a special magic bullet when it comes to weight loss or healthy living.

There is no single simple solution of course. Even my mantra, "Everything in moderation,"  is incomplete.  Education is key. The more we understand about an issue, the better we can devise solutions.

Much of the healthy living and weight loss discussion has to do with the relative balance of intestinal flora, or the bacteria found in our gut.  If the balance is altered, weight gain, or intestinal symptoms such as bloating, diarrhea or worse, may ensue.

Probiotics and fermented foods don't work in isolation. There is much more to rebalancing gut bacteria. For more read this excellent essay published by Johns Hopkins Medicine.

CDC Reported A Drop In Average Life Expectancy?!

Huge question mark here and by no means able to be answered at this time. Remember there are 80 million people who were born between 1945-1964 ("Baby Boomers") and the average life expectancy is 76/81 (M/F). So, unfortunately, the numbers of people dying are expected to increase simply because of the numbers of people in each age group.


ABC News reported that the CDC revealed a decrease in average life expectancy for the first time since 1993.

"The CDC report is based mainly on 2015 death certificates. There were more than 2.7 million deaths, or about 86,000 more than the previous year. The increase in raw numbers partly reflects the nation's growing and aging population.

It was led by an unusual upturn in the death rate from the nation's leading killer, heart disease. Death rates also increased for chronic lower lung disease, accidental injuries, stroke, Alzheimer's disease, diabetes, kidney disease and suicide.

The only clear drop was in cancer, the nation's No. 2 killer."

I'd like to think interventional radiology had something to do with the decrease in cancer-related deaths. 😉👍🏾

Opioids Are Responsible for More Deaths Than Cars and Guns

"The amount of deaths from overdose was greater than that of car crashes and gun violence."

I'm not sure what the solution is, but this kind of statistic amazes me. I don't see the appeal of brain-cell killing drugs but the temporary euphoria must entice the users tremendously. Research and development of, ironically, new drugs to suppress the brain's response to opioids would be a remarkable development. 

As summarized by the AMA:

CDC Says Opioid-Related Deaths At All-Time High

The Washington Post (12/8, Ingraham) reports data released by the Centers for Disease Control and Prevention on Thursday revealed that “opioid deaths continued to surge in 2015, surpassing 30,000 for the first time in recent history.” The data shows “an increase of nearly 5,000 deaths from 2014.” CDC Director Tom Frieden, MD, said in a statement, “The epidemic of deaths involving opioids continues to worsen.” He added, “Prescription opioid misuse and use of heroin and illicitly manufactured fentanyl are intertwined and deeply troubling problems.”

        The AP (12/8, Stobbe) reports that according to the data, overdose deaths rose “11 percent last year, to 52,404.” The AP specifies that “heroin deaths rose 23 percent in one year,” deaths “from synthetic opioids, including illicit fentanyl, rose 73 percent,” and abuse “of drugs like OxyContin and Vicodin” increased 4 percent. Robert Anderson, “who oversees death statistics at the Centers for Disease Control and Prevention,” said, “I don’t think we’ve ever seen anything like this. Certainly not in modern times.” The amount of deaths from overdose was greater than that of car crashes and gun violence.

Was the Supreme Court conservative in 1973?

The question I posed in my title has been asked before. When I went to and typed in the beginning of that question, the end came up, indicating that others had thought to search for the same thing. So I proceeded to click on a link or two and read other thoughts that had been previously written. This link gives a nice summary of each justice sitting on the Court at the time. And fascinating, but the Supreme Court make up was majority conservative in the early 1970s. This tends to turn on its head the supposition that a conservative Supreme Court might rule in a consistently opposite manner than a court made up of more liberal thinkers.

As Justice Ginsburg noted, "In that year, 1971, the Court turned in a new direction. The Justices begin to respond favorably to the arguments of equal rights advocates who urged a more encompassing interpretation of the equality principle, one that would better serve U.S. society as it had evolved since the founding of the nation in the late 18th century."

My supposition has always been that, once placed on the Court, justices tend to make their own decisions using their vast experiences and knowledge to guide them. Obviously, people are concerned that individual biases might come to play. But nine justices seems to me to be a historically reliable number which, on balance, usually results in the right decisions.

21st Century Cures is President Obama's Last Best Move

The final days of President Obama's presidency are passing before our eyes and much of the world can understandably speak of nothing else but his successor. 

Fortunately, the current president has one final opportunity to put into place lasting legislation that can have a substantial impact. 

As reported by the AMA: 

Senate Passes 21st Century Cures Act

The Los Angeles Times (12/7, Levey) reports that the Senate on Wednesday “easily” passed the 21st Century Cures Act. The $6.3 billion measure “to increase federal support for medical research, mental healthcare and controlling the opioid epidemic,” cleared the Senate and “is headed to President Obama’s desk for his signature, delivering a rare bipartisan breakthrough in the waning days of his presidency.”

        The Washington Times (12/7, Howell) says the measure “provides nearly $5 billion for the National Institutes of Health to accelerate research into major diseases, including $1.8 billion for Vice President Joseph R. Biden’s ‘moonshot’ project on cancer, and $500 million for the Food and Drug Administration to make its approval process more efficient.” In addition, it provides “$1 billion in state grants to combat opioids addiction – a key priority for President Obama – and provides money for mental health treatment and suicide prevention, while establishing a new assistant secretary for mental health at the Department of Health and Human Services.”

        The Wall Street Journal (12/7, Burton, Subscription Publication) predicts the legislation, which will accelerate FDA approvals in combination with President-elect Trump, who has said he will “cut red tape” at the agency will bring about an era of industry-friendly regulation of drugs and medical devices.

What Does It Mean to Be Overweight or Obese?

The Washington Post published an article entitled "Nearly Half of America's Overweight People Don't Realize That They Are Overweight," by Christopher Ingraham. The article prompted me to remind myself on what basis do we evaluate our own weight? So I went to the CDC website and found that the definition of obese and overweight are purely based on one's BMI, which is calculated using only height and weight.

The CDC further states:

BMI is a person's weight in kilograms divided by the square of height in meters. BMI does not measure body fat directly, but research has shown that BMI is moderately correlated with more direct measures of body fat obtained from skinfold thickness measurements, bioelectrical impedance, densitometry (underwater weighing), dual energy x-ray absorptiometry (DXA) and other methods 1,2,3. Furthermore, BMI appears to be as strongly correlated with various metabolic and disease outcome as are these more direct measures of body fatness 4,5,6,7,8,9. In general, BMI is an inexpensive and easy-to-perform method of screening for weight category, for example underweight, normal or healthy weight, overweight, and obesity. 

In my estimation, and using a little common sense, BMI is a reasonable indicator of the health status of a person but it is by no means a complete evaluation of health. Yet, unfortunately, as I know from personal experience, conclusions are made about a person's health based solely on BMI. As a personal anecdote, I once applied for life insurance. I am 6' 200 lbs. I exercise daily and am fairly muscular. My BMI calculation yielded the following from the CDC website:

Height: 6 feet, 0 inches
Weight: 200 pounds
Your BMI is 27.1, indicating your weight is in the Overweight category for adults of your height.
For your height, a normal weight range would be from 136 to 184 pounds.
People who are overweight or obese are at higher risk for chronic conditions such as high blood pressure, diabetes, and high cholesterol.

Now I'd like to lose a few pounds just to really get that six pack going, but I'm not exactly sure how to get down to 184, let alone 136!.

The point is that the public perception of their collective weight may not be so "normalized." It may just be that people see the same things I am seeing, have little or no medical training to help guide them, and end up concluding that it is too challenging a topic to figure out. Couple that with the obvious goal of the original WP article, that people need to pay more attention to their health status, and you see why this subject becomes unwieldy.

Public perception could be helped if health officials, and reporters covering these subjects, used more complete definitions of health based on height, weight and body mass characteristics, taking into consideration muscle mass and fat deposits as well as metabolic considerations and preexisting ailments such as hypertension and diabetes, to name just two. Doing so would go a long way towards improving people's understanding of this complex entity we call "obesity." 

Politics and Values are Not Diametric Opposites

Politics is a complicated entity comprised of infinite shades of gray dotted with infrequent black and white decision points. A good friend recently suggested that politics and values go hand in hand. In a sort of epiphany, I now realize that people who disagree on political views also must fundamentally feel that the other party has differing values.

I believe that nothing could be further from the truth for the vast majority of us. In fact, I think the usual political discussion, pick an issue, revolves around differing ways to solve a problem with the same basic underlying values at play. 

Examples abound but here are a few: 

Abortion: For years I have listened to the debate from the pro-choice and the pro life groups. It amazes me that the views are notoriously rigid and unyielding on both sides. Do their values differ? Or is the debate not even about the same topics? Pro-choice viewpoint is one of freedom. Pro-life viewpoint is one of rights. But to suggest that either group values life more or less would be to lack understanding of the basic underlying values that each group holds.  Both groups value life similarly I would argue.

Minimum wage: If a politician votes to raise the minimum wage, are his/her fundamental values about helping people in need diametrically opposed to the politician who voted against raising wages? Or is the opposing viewpoint simply a matter of understanding the ramifications of the economic decision? 

Immigration: If one politician votes not to the deport illegal immigrants who have committed crimes and the other politician votes do do so, does that imply that one politician values the safety of Americans more or less than the other? Do their positions imply that one of them is racist while the other is caring?

With each of these examples, and I could go on, I feel strongly that the values underlying each person's decision are not the main focus of disagreements. But what I have also realized just recently, is that perhaps the perception of differing values is exactly why there is so much difficulty discussing politics between people.

Perhaps if we understood and accepted the probability that we each have similar values but differing opinions about how to solve real-world problems then we might better be able to hear one another and solve the issues at hand. 


Parts of the ACA will stay, suggests Pres-Elect Trump

As John Belushi said in "Animal House," "Nothing is over until we say it is." 

from the AMA: 

Trump Indicates He May Preserve Some Parts Of ACA

The Wall Street Journal (11/11, A1, Baker, Langley, Subscription Publication) reported that during an interview, President-elect Donald Trump signaled an openness to keeping at least two provisions of the Affordable Care Act intact while repealing other parts of President Obama’s signature healthcare law.

        The New York Times (11/11, Hulse, Davis, Rappeport, Haberman, Subscription Publication) reported that during the Wall Street Journal interview, “Trump said he told the president that he would consider keeping two provisions of the law: the prohibition against insurers denying coverage because of a patient’s pre-existing condition; and the one that allows parents to keep their children on their insurance plans until they turn 26.” But, according to the Times, if the ACA mandate were eliminated, this “could send insurance companies into a tailspin, because their costs would rise with sicker customers, and that would not be offset by healthy consumers forced to buy insurance.”

        The Washington Post (11/11, Goldstein) reported that just a few days after the election, Trump began “to revise his health-care agenda in ways that conform more closely to the heart of Republican thinking in recent decades.”

Election Fever

“The election becomes the greatest and, as it were, the only matter which occupies people’s minds. Then political factions redouble their enthusiasm; every possible phony passion that the imagination can conceive in a contented and peaceful country comes out into the light of day… As the election draws near, intrigues multiply and turmoil spreads. Citizens divide up between several camps each of which adopts the name of its candidate. The whole nation descends into a feverish state; the election becomes the daily theme of newspapers, the subject of private conversations, the object of every maneuver and every thought, the only concern of the present moment. It is true that as soon as the result has been announced, this passion is dispelled, all returns to calm, and the river which momentarily overflowed its banks returns peacefully to its bed.”

Alexis de Tocqueville

I Refuse to Look Backward

I refuse to look backwards to what might have been. I choose to seek the way forward regardless of how dim the view ahead. The world is bright. The earth revolves around the sun. And we are but specks in the universe. How lofty the view that ours is the most awesome plight when in reality it is merely the blink of an eye.

Menschkeit - A Way of Life

The following description of Menschkeit was borrowed with permission from Peter Swank, MBA.

The Definition of a Mensch:

  1. A person having admirable, noble, or dignified characteristics, such as fortitude, responsibility, and firmness of purpose: "He radiates the kind of fundamental decency that has a name in Yiddish; he's a Mensch." (James Atlas).

  2. A person who is admired, respected, and trusted because of a sense of ethics, fairness, and nobility.

Alternate Spellings: Menschlichkeit

The Philosophy of Menschkeit:

Menschkeit is a philosophy... a way of living... a selfless, innate drive for doing the right and decent thing, in every possible situation, according to the foundational ethics and values shared by most people in a society. Below is the philosophy of Menschkeit (including, but not limited to the following principles). No Mensch possesses all these qualities, but he does spend his life trying to attain them. No one knows how many or which of these qualities one must possess to be a Mensch, yet one Mensch knows another when he sees one.

  1. Strength - physical, as well as of conviction

  2. Honor - Every Mensch has a Code of Honor.

  3. Integrity - A Mensch is honest with firm moral principles; his word carries the weight and trustworthiness of an iron vault.

  4. Loyalty - fierce, to his fellow Menschs, loved ones, wife, children, mother, and family

  5. Sacrifice - A Mensch's personal desires are subordinate to Menschkeit.

  6. Uncompromising Ethics - A Mensch always strives to do what is right.

  7. Intelligence - not necessarily academic, but raw intelligence

  8. Control - A Mensch has the ability to forge/manhandle/bend a situation towards his will; if not in control, a Mensch will find a way to be in control. Alternatively, a Mensch will relinquish control in order to be in control.

  9. Stoicism and Toughness - high pain tolerance; absence of complaining

  10. Fairness - A Mensch always considers all sides.

  11. Knowledge - may be specific to a particular area, as long as it is at the level of mastery

  12. Killer Instinct - A Mensch goes after what he wants like a bulldozer, makes things happen, gets things done.

  13. Independence - A Mensch draws upon the inner strength of Menschkeit.

  14. Instinct to Protect - a Mensch's loved ones, wife, children, mother, family, and those close

  15. Perseverance - A Mensch never quits until he succeeds, or until his intelligence tells him there is a better path.

  16. Instinct to Survive - "never say die" attitude; A Mensch is reigned by wisdom (knowledge, intelligence, and ethics), but will fight like a cornered animal when necessary.

  17. Open-Mindedness - A Mensch is not so foolish as to be complacent with his ideas.

  18. A Certain Degree of Crudity - A Mensch realizes what is important and what is not; as such he is at ease with himself and not inhibited by meaningless proprieties.

  19. Directness - A Mensch does not mince words; he says what he means and means what he says; "When I use a word, Humpty Dumpty said in rather a scornful tone, it means just what I choose it to mean - neither more nor less." - Lewis Carroll

  20. Discipline - Every Mensch is Master over himself.

  21. Work Ethic - A Mensch spends his life breaking his back; a Mensch enjoys hard labor, and the equivalent in any pursuit.

  22. Self-Sustainability - A Mensch needs very little to survive, and, indeed, be happy; in certain cases, only Menschkeit alone is needed to sustain life.

  23. Perceptiveness - A Mensch has the ability to see in a flash, like an X-ray, the core of a person, situation, and/or place, with 100% accuracy.

  24. Judgment - Because of his perceptiveness, a Mensch possesses the uncanny ability to consistently make the best decisions possible; a Mensch always knows what to do.

  25. Mechanical Inclination- Some of a Mensch's closest friends are his tools.

  26. Camaraderie - Every Mensch possesses an unspoken bond with his loved ones, wife, children, mother, family, and those close.

  27. Vision - A Mensch always has a clear goal in mind, and affects that goal with supreme efficiency through use of his Menschkeit qualities: If a Mensch sees it, it is done.

  28. Absence of Fear - A Mensch knows that his Menschkeit qualities will carry him through to triumph over any situation.

  29. Composure - A Mensch never appears perturbed or shaken, but maintains a mental evenness that allows him to navigate any situation.

  30. Ingenuity - A Mensch has the uncanny ability to find novel and creative solutions, 10 out of 10 times.

  31. Craftsmanship - Nothing satisfies a Mensch more than to have created something from scratch with his bare hands.

  32. Dependability - A Mensch can be counted on as the sun rises.

  33. Fertility of Mind - A Mensch always has some sort of project running on the side to satisfy his creative impulses.

  34. Appreciation of Women- A Mensch appreciates a good woman and the beauty of the female.

  35. Physical Endurance - A Mensch takes a beating and keeps on ticking; in fact, a Mensch welcomes a beating.

  36. Awareness - A Mensch is simultaneously aware of all that is around him, his mind ever present, ever vigilant, his surroundings accounted for, every scenario considered, weighed, and chosen at will.

  37. Quality - The job a Mensch does is the best. No question. Hands down. Finished.

  38. Economy of Speech - A Mensch does not talk much; to those without Menschkeit he may seem reticent, but in reality a Mensch is a master of his spoken language, using as few words as necessary to precisely convey his message. In fact, most Menschs have transcended language. This explains why two Menschs hardly ever talk, yet never miss a step. Whereas the non-Mensch must blather on, a simple nod from a Mensch suffices.

  39. Logic - In any stressful situation, a Mensch always chooses his path by logic; his logic is never swayed by emotion.

  40. Work and live to serve others, to leave the world a little better than you found it, and to garner for yourself as much peace of mind as you can. This is happiness.

While America Debates, Civility Is At Risk

George Friedman, with an introduction by John Mauldin, points out that debate is good provided we remain civil when doing so. Now, each of us has approached, and likely crossed, the line at one time or another and felt that the person with whom we were debating must somehow be mentally incapacitated. But that defies reality because the usual debate encompasses current events for which a complete set of facts is not readily available. 

As Mr Friedman says below: "Mexican immigration, climate change, mutual assured destruction and the national debt are all topics worth serious discussion among serious people, each holding open the possibility that the other is right. But when it is declared that the debate is over, that means that there can be no debate and no changing of minds. If it is a matter of the apocalypse, that is a reasonable thing to say. But if everything is apocalyptic, then no conversation on anything is possible."

In civil discourse, let us remember to keep things, well, civil. 

John Mauldin's Outside The Box follows:

The Origins of American Incivility and Fear

by John Mauldin | November 02, 2016

My friends and associates know that it is very rare that I am sitting at my desk at 4 AM, as I was this morning. I am not an early morning person. But every now and then I wake up and the mind turns on, and rather than fight it, I go sit at my desk. And almost immediately this morning, I was greeted with this paragraph from my friend Michael Lewitt in his latest letter:

The 2016 presidential election is carving deep scars on the American soul. The country is on the cusp of a constitutional crisis after the FBI reopened the investigation into Hillary Clinton’s use of a private email server. The reputation of virtually every individual and institution touched by this election is ruined – the media, Justice Department, FBI, the candidates, their surrogates and supporters, both political parties and those holding high office. Our so-called elites disgrace themselves on a daily basis. The nation is left to pick up the pieces after November 8th. Financial markets are starting to react to the coming turbulence but remain dangerously complacent.

Which made me realize the importance of the essay my good friend and business partner George Friedman of Geopolitical Futures published yesterday on “The Origins of American Incivility and Fear.” There have frequently been periods in our history, George reminds us, when we Americans dreaded that our nation was in severe decline. The ’60s and ’70s was one such period – we endured a great cultural rift that centered on the Vietnam War. The economy was in rough shape in the ’70s, too – inflation climbed from 4% to 14% during the decade, and unemployment more than tripled from 3% in the late ’60s to nearly 10% in the early ’80s. The DJIA plunged from 7318 in 1965 to 2227 in 1982.

But, says George, American dread of social turmoil

… has deeper roots, particularly in the 20th century. Two events, about 12 years apart, have left a permanent scar on the American psyche. One was the collapse of the stock markets in October 1929 and the following depression. The other was the attack on Pearl Harbor on Dec. 7, 1941 and the following war.

There was a common link between the two. Neither was expected by the public. Both were a shock that transformed everyday life for the worse. An argument can be made that both should have been expected. But they weren’t. These two events engraved a single principle on the American soul: that lurking beneath the surface of peace and prosperity are forces that break through and destroy both.

Now, just a week before Election Day, we once again feel ourselves poised on the brink – and not just over the presidential outcome but also because of the parlous state of the economy.

Yesterday in USA Today, election rules expert Michael McDonald made the case that if the election is a tossup, it could very well “go into overtime,” and that “in this environment” an uncertain, protracted outcome could “rip this country apart.”

Well, maybe. I’m not saying it can’t happen. But as George points out in the piece you’re about to read, we emerged from the Depression and WWII as the world’s strongest nation; and we weathered the ’60s and ’70s, righted the ship in the’80s, stood by (and maybe nudged a bit) as the Soviet Union collapsed and Japan was struck by an economic tsunami of its own making … and then enjoyed an intense period of technological innovation and economic growth.

Will the outcome be fundamentally different this time around? Will the powerful disruptive forces that are gathering be enough to take us down? I doubt it. The republic has weathered some serious storms in the last 240 years, but it survives. And I see no reason that we will not weather the coming storms, though I admit they’re going to be difficult.

However, glibly saying the Republic will survive doesn’t mean we don’t have to respond and grow our society in ways we haven’t before. It doesn’t mean we don’t have to change, and perhaps change in ways that make many of us uncomfortable. There have been many periods in our history where the changes we were going through made significant numbers of us uncomfortable.

Each of us has the ability to control our own personal destiny by our choices, especially if we can recognize the need to change rather than blindly assuming tomorrow will be like today and that the next years will be like the last years. I take comfort in the fact that I have had to change many times over the years, often in ways that I would have preferred not to; but so far, like the republic, I survive and so do you.

That being said, is this not the most surreal political scene since, possibly, 1824? No novelist, even in my favorite genre of science fiction and fantasy, could have scripted the twists and turns of this election process, let alone the inexplicable last-minute scenario of hundreds of thousands of emails surfacing on seriously discredited Anthony Weiner’s computer, some of them allegedly messages from Hillary Clinton via Huma Abedin. It would render ridiculous any plot line to include something so bizarre. (Seriously, who has that many emails saved on one loan computer?)

In this weekend’s letter I will probably allude to the even more ridiculous plot line that is playing out in Europe. The interposition of massive debt and the Italian referendum loom large. Has anybody noticed that Italian interest rates are beginning to rise? That there is a huge amount of money hightailing it from the rest of the continent for Switzerland, even as there is a 75-basis-point penalty for holding cash? It boggles the mind. I agree with my fellow writer Jared Dillian: it is not clear what is going to happen, but the likely outcome is more volatility. The long vol trade that he is talking about makes a lot of sense to me.

Your ready for this election to be over analyst,

John Mauldin, Editor
Outside the Box

The Origins of American Incivility and Fear

By George Friedman
November 1, 2016

U.S. history has left Americans unsettled even in prosperous times.

One of the more striking things about the United States is the sense that it is in decline. Donald Trump’s main theme is that he would make America great again and that it has been in severe decline over the last decades. It was an effective campaign theme because it touched on a deep American dread. In Europe you will find a different sensibility, which is that while Europe has problems, they are nothing compared to the problems in the past – the Soviet threat, Nazi Germany, the mass slaughter of World War I. Europeans look at their past and are grateful to be living when they are. Many Americans feel a sense of a lost greatness and a looming catastrophe.

This sensibility is not new. During the 1970s, there was a deep and oft stated sense that America was in decline. At the end of the Vietnam War the enemy’s flag flew over a capital we had been defending. During the same time, there was a massive social and cultural divide. The culture of the lower-middle class and that of the graduates of the best universities were in sharp contrast. On the whole, it was the lower middle class that fought the war and supported it. The universities were the center of antiwar sentiment and contempt for those who supported the war. The contempt was mutual. The economic situation was catastrophic for many. Unemployment and inflation were both around 10 percent for a good deal of the decade. Interest rates were in the high teens, and buying a house was out of reach for many. At the end of the decade came the Iranian Revolution, with Iranians taking American diplomats hostage and the United States helpless to protect them. The disaster at Desert One followed – a task force sent to rescue the hostages collapsed, with planes destroyed and men dying before the rescue attempt began.

The sense of decline was rampant. It could be seen in crime and decay in the cities, the surge in Japanese exports to the United States, and the sense that the Baby Boomer generation, unable to settle into family or career, was destroying the fabric of society. The feeling was that the Japanese were surging ahead of the United States economically, the Soviets were surging ahead militarily and we were held in contempt by the world.

That was some 40 years ago and clearly the sensibility was wrong. What followed was the Japanese economic crisis, the collapse of the Soviet Union, recovery of the hostages from Iran and the United States emerging as the only global power. Interest rates plunged, as did inflation, and we came into a period of intense innovation and economic growth.

Having passed through the 1970s, as we did, it would seem reasonable that it would serve as a benchmark. A lost war, an extended economic crisis and social stress had not led to catastrophe. Yet, there are few lessons taken from the 1970s to provide some perspective. Similar circumstances are expected to yield the same dreaded disaster.

The sense of dread is more than a response to a particular time. It is also not that Americans lack the ability to use history to frame our concerns – although that may be the case. It has deeper roots, particularly in the 20th century. Two events, about 12 years apart, have left a permanent scar on the American psyche. One was the collapse of the stock markets in October 1929 and the following depression. The other was the attack on Pearl Harbor on Dec. 7, 1941 and the following war.


There was a common link between the two. Neither was expected by the public. Both were a shock that transformed everyday life for the worse. An argument can be made that both should have been expected. But they weren’t. These two events engraved a single principle on the American soul: that lurking beneath the surface of peace and prosperity are forces that break through and destroy both. In the more extreme formulation, both 1929 and 1941 were known to the elite, who not only protected themselves from the consequences, but also profited from them.

The 1920s were a time of prosperity in the United States (outside of the regions that experienced the Dust Bowl). As with all times of prosperity, the seeds of its own destruction were there from the beginning; people began to believe that it was the new, permanent normal. 1929 stunned people because it was unexpected, but it was the brutal grinding of the Great Depression that scarred the American soul. It created a national memory of hardship emerging without warning. At least some of us approach the best of times with a bitter certainty that hidden behind the false screen of prosperity, disaster is lurking, whether rooted in impersonal economic forces or the hidden hand of the powerful.

Pearl Harbor drove home to Americans that an enemy might strike the United States at any time, without being detected, and decimate the country. Most Americans suspected that the United States would enter World War II at some point, but they believed that it would be at the time and place of our choosing. The idea that the Japanese, whom many Americans held in contempt, could strike without warning and destroy the Pacific Fleet changed the world. The change was not simply that the U.S. was at war, it was deeper. It was the sense that war would come without warning and perhaps destroy us.

These two events changed the American sense of the world. It is overstated to say that before these events, the United States was innocent and carefree. The 600,000 dead in the Civil War would prove otherwise. But the Civil War did not strike out of nowhere, nor did the previous economic crises last for a decade. Combining the surprise at the events with how long and deeply they cut into the United States, a new sensibility was born. It was a sensibility of deep suspicion, not so much of people (although a fear of conspiracy was implanted), but simply of the fragility of American life and power.

The fear of the hidden disaster lurking to destroy us is not necessarily delusional. I happen to think that the 1970s provide a framework to think about our current decade and discount the worst fears we have. But there are reasonable fears and fears that will turn out to be reasonable regardless of my view. These fears serve as an engine for intensifying emotions and going to extremes.

Take two examples from opposite sides of the political spectrum. The concern that massive immigration from Mexico will transform American society and cause crime and disorder is not an unreasonable fear. Most immigrant movements to the United States resulted in some criminal activities and social instability. That is in the nature of immigration. However, when you attach the underlying engine of dread to an argument that may be wrong in this case, but isn’t absurd, you reshape the argument to a level of fear that means anyone who disagrees is a fool or a monster.

There is the concern that human activity is changing the climate and that that change poses a threat to humanity. The argument is not irrational, as we have seen increased temperatures that might well cause serious harm. When the argument on global warming is linked to the culture of dread, then the argument becomes a certainty and the only outcome is catastrophe. And those who take issue with it are fools or monsters. If things are as bad as those who want to stop Mexican immigration or those alarmed by climate change claim, then anyone who rejects the argument is like someone who refuses to see that the house is on fire.

Pearl Harbor defined the Cold War. If an attack can come at any time, then the United States must be ready for war 24/7. We drilled out a mountain in Colorado Springs to house the North American Air Defense Command. We had B-52s constantly airborne, submarines on constant patrol and crews in missile silos standing by ready to fire. I am not sure there was another course, but I do know that having raised the possibility of another course would have encountered rage.

When people write to me talking about the trillions of dollars of debt that will crush the American economy, they do so out of fear of the lurking force that will destroy everything. If you say, “It’s a problem, but we can probably manage it,” you might be called a fool or perhaps part of a conspiracy to destroy the economy.

Mexican immigration, climate change, mutual assured destruction and the national debt are all topics worth serious discussion among serious people, each holding open the possibility that the other is right. But when it is declared that the debate is over, that means that there can be no debate and no changing of minds. If it is a matter of the apocalypse, that is a reasonable thing to say. But if everything is apocalyptic, then no conversation on anything is possible.

In retrospect, we were all fools not to expect the Great Depression or Pearl Harbor. If we missed those, then what else are we missing? Someone will be happy to show you what else you are missing and with utter sincerity, he will try to convince you that you are not two reasonable people disagreeing, but that he is trying to save the country, and you are trying to destroy it.

We wonder at the growing incivility of American culture. Going back to the 1960s and 1970s, I remember the chant “hey, hey, LBJ, how many kids did you kill today?” Even in this election, I have heard nothing that uncivil. Nor have I heard that someone has a list of 100 communists in the State Department. Nor have I seen the dead of Antietam. So no, I don’t believe this is the most uncivil time in America. Not even close. But given the deep anxiety bequeathed us by 1929 and Pearl Harbor, we can see the fear of unexpected disaster can fuel spectacular incivility.

A belief has emerged in America that we are surrounded by hidden dangers that will strike when we least expect it and with a terrible fury. We are enraged when others don’t see it, for the same reason someone being ignored when he says there is a fire will be justly enraged. But everything is not on fire. Our time is no worse than the 1970s and that time was not nearly as bad as the 1930s. But then we think of the Depression and Pearl Harbor and we wonder if we are being lulled into a false sense of security. We are not uncivil. We are afraid. Our fears have serious origins. But reality does not always lead to the apocalypse.

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MACRA Update

CMS published its Final Rule update to MIPS and APM in MACRA on 10/14/2016. This information is critical for physicians who are trying to navigate the shift in reimbursement from "volume" to "value." The bottom line is, pay now or pay later.

The following discussion is courtesy of MBX:


On Friday, October 14th, the Centers for Medicare & Medicaid Services (CMS) released the long awaited Final Rule for the Merit-based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive payment provisions in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

Along with this policy came the announcement of
a new Quality Payment Program (the collective term for MIPS and APMs) website which is a valuable resource for eligible clinicians. Quality Payment Program (QPP) website contains detailed information on MIPS, APMs, how to participate, reporting options, MIPS measures and activities, access to the Final Rule, MACRA legislation, and many more helpful links.

Final Rule differed from the proposed rule in a few ways, including having 2017 be a “transition” year in which 4 MIPS participation options are available for eligible clinicians:

  1. Report to MIPS for a full 90-day period (or ideally the full year); exceptional performers are eligible for an additional positive adjustment for each of the first 6 years of the program.

  2.  Report to MIPS at least for a full 90-day period but less than the full year, and report more than one quality measure and improvement activity, or more than the required measures in the advancing care information performance category to avoid a negative MIPS payment adjustment and possibly receive a positive MIPS payment adjustment.

    3. Report one measure in the quality performance category, one activity in the improvement activities performance category, OR report the required measures of the advancing care information performance category and avoid a negative MIPS payment adjustment. Eligible clinicians opting to NOT report even one measure or activity will receive the full negative 4% payment adjustment.

    4. MIPS eligible clinicians can participate in Advanced APMs, and if they receive a sufficient portion of their Medicare payments or see a sufficient portion of their Medicare patients through the Advanced APM, they will quality for a 5% bonus incentive payment in 2019.

    5. Under the Final Rule, small practices are given protection under the QPP. Low-volume thresholds have been set for exclusion from MIPS: less than or equal to $30,000 in Medicare Part B allowed charges, or less than or equal to 100 Medicare patients.

    6. Another important change from the Proposed Rule to the Final Rule surrounds the “non patient facing” exemption. The proposal was to allocate this exemption by specialty, however, the Final Rule changes it to threshold based. The exemption will now apply to eligible clinicians who have 100 or less patient-facing encounters during the 12-month determination period September 2015 to August 2016. In addition, the Rule states that if 75% of a group’s physicians meet the non-patient facing criteria, then the entire group does as well.  This is good news for interventional radiologists – Danny Hughes, PhD, of the Harvey L. Neiman Health Policy Institute says, “This will allow radiologists that primarily perform interventional procedures to continue to add value to their groups without adversely affecting the group’s opportunities to succeed in performance review under MIPS”.


    The QPP website can be accessed here: