Today's talk will be the sixth in the year series of 28 Wednesday lectures at this time noon. And today I'm delighted to introduce our speaker who needs a limited introduction in this company, Dr. James Madera. Jim and I have known each other for a long time and have worked together on many projects. An accomplished academic medical center physician, medical scientist and administrator, Jim has served as executive vice president and CEO of the American Medical Association since 2011. Prior to joining the AMA, Dr. Madera served as the Timmy professor and chair of pathology and laboratory medicine at the Emory University School of Medicine. He then assumed the Thompson Distinguished Service Professorship and deanship here at the University of Chicago Pritzker School of Medicine. During his time as dean at Chicago, Dr. Madera served as CEO of the University of Chicago Medical Center and in that role negotiated affiliations with community hospitals, teaching hospital systems, federally qualified health centers on Chicago south side as well as with national research groups. Dr. Madera helped develop and open the Comer Children's Hospital, the Gordon Center for Integrative Science and the NAP Center for Biomedical Discovery. His more than 200 original papers have brought him national and international awards including a prestigious merit award from the National Institutes of Health and the Davenport Award for Lifetime Achievement in Gastrointestinal Disease from the American Physiological Society. In today's talk, Dr. Madera will speak on the American Medical Association, the reform of healthcare for patients, medical students and physicians. Please join me in giving a warm welcome to Jim Madera. Thanks, Mark. It's wonderful to be back on campus for something other than a screening colonoscopy. What I thought I would do today, I'm assuming that most of you know as little as I did about the AMA prior to my coming two and a half years ago and so I thought I'd introduce you a little bit to the organization and then talk about what work we're doing in the three areas that Mark mentioned. We'll organize this as to what is the AMA and the current areas, why did we pick those areas and then I'll close a little bit with a vision of healthcare out to about 2030 or so. We just moved as you see in the lower right, lower left rather, to what used to be the IBM Plaza is now the AMA Plaza right downtown. We are offices for advocacy R and D.C. And our mission statement is to promote the art and science of medicine and the betterment of public health. The origin was from 1847 so we're over 165 years old, I was in Philadelphia. The first meeting was to establish the code of medical ethics. This was the first code of medical ethics in the country and as you can see it's updated, the 2013 version is there and it was to begin to establish some standards also for preliminary medical education as well as for medical school. It was a rough period in the 19th century. If you look at education in the 19th century, you can see that in other countries, Germany for example at the top, from the beginning of the 19th century, cell theory, germ theory, universities embedded this work within them, the UK going back to the 17th century, William Harvey and the like at their great universities. In France, right after the revolution in about 1801, during the establishment of the First Republic, one of the first pieces of legislation was the Medical Education Act that shifted France into a more universally based kind of medical education. Now, the U.S., in contrast to that, had the proprietary schools that you know about. There were very few standards, took a four month class and repeated that twice and you were an MD and you bought tickets for the lectures just like you buy for a movie theater so no certification licensure oversight. It was a mess. So the first 50 years of the AMA was really getting rid of, you know, fighting snake oil and quackery essentially. And then at the turn of the 20th century, there was the creation of the AMA's Council on Medical Education which outlined now the minimum and ideal standards for medical education. In 1905, the ratings of all medical schools in the United States were published in JAMA and this was quite a critical paper criticizing the schools. In 1906, the Council on Medical Education visited every school in the United States and in 1907 published again in JAMA the ratings of those schools and I can't remember the wordings used but they were essentially thirds where there was a maybe okay, worry about this, what are we thinking? And that was published and as a result of that, this work from the CME there was closure of 31 schools. The AMA approached Carnegie to get an arms length third party that was respected in the area of education and Carnegie identified Abraham Flexner as the project director. Now interestingly, the president of the Carnegie at that time was the one that thought of Flexner on the basis of Flexner's recently published book, The American University. And interestingly, one of the major points Flexner made in that book is how the lecture hall outlines of universities for lectures and seminars was so outdated and should be gotten rid of. That was in 1907. So you know the consequences of that then. The CME took Flexner to all of these sites, the Flexner report was confirming and dramatic and there was a winnowing to 77 medical schools. This was a positive thing but there's also a negative side to this frankly and that is all medical education was proprietary. There were African American proprietary schools as well and American universities discriminated against African Americans and did not welcome them onto university campuses at that time. So those two things together really led to there being almost no African American physicians in this country early on and we still suffer from that a bit today. Just to give you an idea of what happened in this country in the 20th century then and Flexner actually also had a role in this. One of his subsequent jobs was as the director of the Rockefeller Foundation for General Education. Then in that job they helped schools establish endowments and since he had done this work on medical schools he did that with medical schools. Now at that time before that activity happened if you took the totality of endowment dollars in divinity schools in the United States it was 10 times the amount of medical schools. So there was also a huge emphasis on moving to an endowment secured base for science and just a couple of benchmarks the clinical one showed at the bottom is in 1900 16 percent of American males died at age one a century later the age at which 16 percent of American males were dead was 61 60 year difference. In the sciences if you look at the first quarter of the century there were zero American noblists in physiology or medicine. In the last quarter of that same century there were 45 American noblists in physiology or medicine. Now to get you have to put this in the perspective to understand the rapidity of this change this change occurred in a you know we've been we've we've been branched off apes about five million years ago and been walking around like we are for about a hundred thousand years. So we take that hundred thousand years and normalize it to one year. This happened in the evening of December 31st and it shows how rapid a restructuring can occur in this area and there could be another one. The AMA is really the sum of multiple parts something I certainly didn't understand. These five parts begin with the House of Delegates. It's the assembly of all hundred eighty five medical societies all fifty states all specialty societies societies that you've heard about American College of Cardiology societies that you've never heard about my favorite is the Society of Underwater Medicine. All physicians United States belong to one or more of these societies and it's this house representing those societies that make the policy of the AMA and elect its presidents each year and that's the what that's what gives it the voice I think so powerfully in Washington. And then there's members the physicians that become direct members as well usually for material reasons you know when they want JAMA or business tool about twenty percent of American physicians with the advent of specialty societies that number had decreased over time. Year before last we had the first increase since 89 we increased again last year and this year we know we're increasing the third time. As tools variety of tools that we have we maintain the national physician master file. So for example after Katrina it was that master file we relied on to make the connections of physicians the pharmacy to patients again. We have CPT codes the billing codes. We also had before I came a IT platform for medium sized offices thought we could not scale that seemed to me so in the last 12 months we've developed a partnership with AT&T to scale and a variety of other kinds of practice tools. Research and education JAMA and now the JAMA network with the nine specialty journals our new editor Howard Bachner has done a wonderful job I hope people agree with that when you look at our journals now and also the quality measures half the quality measures in CMS were produced by the AMA and then lastly advocacy both in DC and in the courts. So it's a it's a complex organization that's both a membership organization organization organizations a product a producer research and education and the like. Now our current context is astounding and one can make this point in several ways here here I make it by showing Moore's law which is the red line the increase in transistors on chip over time the green line is the increase in energy of particle accelerators over time the black line is the efficiency of the triple product and nuclear fusion reactions over time these are really fast things can you imagine anything faster than that and I've superimposed two blue lines one is the increase in the genes found to relate to disease in the last 30 years and the lower one with the steepest slope at all that dwarfs Moore's law is the rate of decrease in the cost of genome sequencing in the last 10 years. So we have a complex organization and it's in this really dynamic context so probably not surprising when I came there was a there were a lot of ideas and projects going on and in fact when I surveyed the mission area research and education largely we started there because that's the soul of the organization there were a hundred and ten active projects consuming resources downtown and in DC and so we went through a rigorous process of being more impactful through focusing and part of that of course is deciding what you're not going to do and my view in talking to the board was that you're not doing strategic planning unless you decide what you're not going to do that's the most important part of strategy if you don't do that then you're just shuffling things around all the time thinking you're doing something and calling it strategy so we went through a process where we took these hundred and ten programs and we could package them into about twenty seven financial units financial programs and then we developed criteria to assess these on a desirability versus a feasibility plot and we had pre agreement before naming these programs with the board of the method that we deployed and what we were proposing and so no one had to vote on the beauty of their relative beauty of their children before actually making a decision had a coffee break came back in the room I put the programs up and there were a lot of gasps but for example the large orange circle down on the left was our disaster medicine program we had a disaster medicine journal a large program around this you know if you go out on street and ask five people to name three organizations important in disaster medicine is anyone gonna say the AMA so we reconfigured dramatically and from those hundred and ten we went to three and this required also an import of new skill sets and the like and these three areas serve as an infrastructure for some of the components of health reform I believe and the two things that they all share is they shift the organization from an organized organization that's focused on process to an organization focused on outcomes and they shift the organization from largely a convening organization to an organization that adds to as half of its portfolio doing through partnerships now the organization has always been really focused on the physician patient relationship so if that's been the focus what's derivative from that well what does the patient want patient wants a better outcome what does the physician want a sustainable environment in which she can practice and what does society want a medical education system that produces future physicians that are trained to fit a new type of healthcare that's emerging in this country so those are the three things and we have a narrow focus areas in each of these three which I'll introduce briefly first improving health outcomes for patients we're a natural here in that we as I mentioned produced many of the quality measures but those quality measures as you know are largely process-based and not outcomes we also don't incorporate in our system in fact almost very little in the CMS quality measures patient reported outcomes and I more and more feel that those may be the most important outcomes patient groups like patients like me are not very impressed with what we call quality measures it doesn't really resonate with them it doesn't give them what they're interested in so we're thinking about then outcomes and outcomes in two areas high blood pressure and type 2 diabetes pre-diabetes specifically and I just want to point out the assertion here that the I would assert that the evolution of our healthcare system has resulted in a deleterious separation of care and health so we have this separation of public health for medical care was anyone disagree with that well simultaneously something else has happened and that is as everyone in this room knows we've moved from acute disease as the major disease to chronic so think about that for a minute acute disease occurs in the context of someone gets a community acquired pneumonia sees their doctor is in the hospital for three days with IV drip and goes out to the community in chronic disease most of the pathobiology of the disease is occurring out in the wild in the community not in a doctor's office or the hospital and we currently have this erosion of public health so how do we think about it how we've thought about it to date so for example if you take Kaiser's work on blood pressure beautiful work impressive results but it was all done sort of in the context of the Kaiser health system well if the major path of biology is in the community should we really try to medicalize all of that or should we think about more of the public health approach but if you think about the public health approach when it's eroding you know what would you do well one thing you could do is try to look for places that have big national footprints in the communities and also could have business plans and strategies that are sustainable themselves so you think about more of a private sector approach to backfill this public sector need so you all know that why we would choose these high blood pressure number one cause of death and disability worldwide the emerging epidemic of diabetes but type 2 diabetes which affects 26 million is probably not our future problem our future problem is the 80 million patients now with pre-diabetes and the approach the pre-diabetes should be largely community-based it has to do with lifestyle choices diet exercise and we pretty much know that that's not really an effective place the doctor's offices are not an effective place for health club you know one can give advice and that advice we all know what happens to that advice and there's a lot of evidence now that some programs can be effective in pre-diabetes the diabetes prevention program is now the DPP which is promoted by the Centers for Disease Control shows that in a community setting and pilot studies that one can decrease the incident of diabetes from pre-diabetes in adults by something like 60% in an adult over 60 by 71% so these are effective programs that do not really rely on drugs and here's where we have to make the connection we have to recognize that we can't medicalize what's on the left we have to take community approaches to what's on the left that's where the patients come from and the time that we see people in the hospital is short we also we also don't sometimes get the right data and I'll talk more about biometric data in a second so we now have a CMI CMMI grant it's we have a formalized partnerships with the YMCA's you may think of the YMCA's as a place to develop your either swimming or your fear of water and exercise Bill Novelli who's the CEO of the Y's has assured me in our meetings that the Y's board has changed their strategy from this community exercise and swimming now to community health and wellness so here you have something with a big public footprint that has a sustainable business plan that you can link to and they've already recognized in a couple pilots they've done that patients will not go on these programs if not told to do so by their physician so we have to get that hardwired which is the nature of the CMI award we now started this within the last month in Wilmington Indianapolis and Minnesota and the award covers then a rollout to those five states and we'd like to find other large footprint community partners as well hypertension the other issue this shows on the right of you know the high blood pressure as you know far and away the number one cause of death and disability and how from 1990 to 1910 it's become the leading risk factor for poor health worldwide and yet we have the same problem there are 30 million Americans not a goal for hypertension and the interesting thing is many of these patients see a doctor and they still don't have controlled hypertension now some of the reasons for this also relates to this getting too far away from the community so imagine someone sees their doctor and is on anti-hypertensive therapy and the doctor sees that the blood pressure is a little higher than it usually is and therefore maybe should change the medication and the patient says well known doc I you know I was a little late so I ran across the parking lot so what's and what's the standard for getting a good blood pressure well the standard is to rest the patient in a quiet relaxing place in a chair upright for 10 minutes you go to a practice it's unworkable almost in a practice most of the data are generated out in the community so we're also working with the wireless community in San Diego toward achieving biometric data real time and then we'll taking the same logic here we're partnering with Johns Hopkins the Armstrong Institute we've identified eight to eleven practice sites in both Chicago and Baltimore and are now rolling that out and we're looking for this community partner to stitch together just as with the pre-diabetes and then also wire in the biometrics so the partners are the CDC the YMCA the Armstrong Institute CMS and this is all part then of our first part of our strategic plan I should say this is the first long-term strategic plan in the history of the AMA like many associations that didn't have a history of doing strategy the way it would be done in say a corporate world so we're making traction in all these areas now because we've simplified and have focused so that's the first one the second is change in melon in medical education now if you read the IOM white paper the WMC white paper the AMA white paper Molly Cook's book everyone agrees that we're doing medical education in an ineffective and wrong way and they agree specifically about what we're doing incorrectly and yet it's not changing now in the context of a curriculum at a university everyone thinks that is changing rapidly so for example I had a dean tell me that you know look we're rapidly moving to an outpatient experience and we're really really proud of that and so I look to see what they were doing it was in two rotations medicine and pediatrics and the highest percentage of time in the outpatient and medicine was 25% and it was non-continuous it was in and out for every hospital admission currently today there are 300 outpatient visits and now we're seeing more a shift toward home kind of measurements as well so lots of things to be addressed here just a couple fundamental things so you know as a dean you always fear you get a senior political figure or a senior business figure in that they're going to ask you questions that you're not used to being asked in a university setting so what would such a person be thinking they would be thinking how do we know the graduates are competent do we know that we do we know the way the airline industry knows measured competency in our graduates and what if I were asked that question it wouldn't it wouldn't be very positive so competency-based measurement and education is needed there are all sorts of outdated you know we have 141 medical schools we have 141 lectures by 141 people on the Krebs cycle you know surely one of those must be the best I know for a fact that there's a bottom desile from my own experience Flexner suggested in 1908 that this was really this was a really terrible way to have medicine in such a large classroom and that is now known to be the case in educational theory and yet we still do a bulk of what we do often in classrooms like this you know the data is just a piece of data it's been known for 40 years for example if you take an auditorium like this a talking head like mine and then afterwards you do testing for retention you get a bell shaped curve not surprisingly and if you tell the person giving the talk what part of retention were weak he or she can come back to the auditorium give the class the same another lecture focusing on those and the bell shaped curve becomes a little tighter and shifts a little bit to the left my my right your left there's only one thing that will collapse the bell shaped curve totally and that's one-on-one and that's why people are beginning to talk about flip classrooms and whatnot that's been known for 40 years and why don't we use more simulation now people think they're using similar simulation because they have a little bit of it we're working with two startups now both on the west coast that are interested in producing adaptive education clinical materials electronically they're competing with each other and we're agnostic as to who wins but you know you take for example the School of Public Health at Johns Hopkins their degrees they give out a degree as they have in public health for a long time they also give a degree out now that's completely virtual and online they don't distinguish between their graduates who gets what and it's a much more efficacious form of education in the latter that's why you probably saw Erickson and I think was in New York Times last week or this a couple of days ago right with a prediction that probably at least half of American universities and colleges will disappear by mid-century and then a certain upper echelon you know University of Chicago's of the world may have one two five ten million students we don't use simulation at all and it's it's it'll give you one other data point the Department of Defense as you know has a big problem with post traumatic stress disorder there's not enough psychiatrists to treat this problem that they have they now have an adaptive psychiatric avatar the gender of which the patient can select that produces as effective interaction and outcomes as a psychiatrist so if we're thinking this is future too much in the future I think we're a little wrong we also have many types of physician needs and here you know the cartoon is for a fair it's a monkey an elephant a penguin a bird of goldfish and the dean is saying for for a fair selection everyone has to take the same exam please climb that tree and we want physicians of all types and yet we're largely oriented to the group we have both the clinical science and basic science need in our medical education and the reason we've split this is just because basically these faculties are not so missable you can spend a lot of money get some subgroup of physician scientists and then take the rest of the faculty and you put a lot of energy in it's like making a vinaigrette you shake it really hard and it stays in a motion for a while but you know pour it pretty fast because it's going to separate again but once you can remove the constraint of place electronically you no longer have this needed separation so you know for example these are companies you're well aware of and then the two I mentioned are I human and medx that are developing toward medical education and you can mix the faculty types now in an adaptive way you don't need faculty in in one place at a particular time the other thing is you probably need to kickstart this so you get into an adaptive program that has both clinical and basic science to get a common understanding can also be done in a moot kind of way and it probably is not all that complicated if you look at Eric Landers course on the introduction of biology he covers the principles of biochemistry in five 45 minute sessions now there's a lot more biochemistry that you need to know but it can be adapted to the clinical cases as the platform you probably need five 45 minute lessons CEO of a large private payer recently told me that the future impact of site of care is vastly underappreciated we already talked about biometric data that you get from home I was with the CEO of Verizon Verizon a couple weeks ago and he said they've analyzed their company for what verticals they could focus on and the strongest one is healthcare Cisco is thinking of this as their next move in this field as well and it also relates to the fact that you know we do wonderful research at our universities to push ahead the forefront of medicine but if you think about cholesterol everyone out in the street can tell you the cholesterol story yet it's widely unmanaged in its country and there were 12 Nobel prizes given for the work in cholesterol in the last century if we cannot apply the lessons from the last century to our current population what makes us think that new the new science we're doing will affect our populations in the future and we need to prove to ourselves in an effective way that we can do the effect or arm of the science as well so I've listed in the box on the right some examples of correct correctable basic flaws widespread and undergraduate medical education competence individualized old educational methods limited use of technology restrictions imposed by separate groups of content experts the physical plant as our prison playing to pass sites of care you know the the hospital instead of looking to the home with you know recognizing we're moving through outpatient now and soon it will be home and playing to pass poor structural decisions the split between health care and public health you know if you look at there's no question that we spend too much on health and we don't extract enough value in this country I think everyone agrees with that the flip side of that is if you look at data from both the World Bank and the Economic Policy Institute what you find is that if you stack us up against only against the Organization of American European countries and look at our safety network in every measure we are last and if you start taking the safety network public health money and adding it together into one pool what you see is it's actually more comparable now to other other nations and it's also true that in this country if we want to dip into public health in a serious way for our population we're almost forced to medicalize it if you know anything that says safety net program it does best when it's medicalized what's also drives up the cost so we need to think about these things quite differently so what will be the what will be the driver of this in the say the near long term 20 25 20 30 of correcting these flaws it's gonna be largely driven probably by economic imperative education technology 2013 to 2040 going from a fixed place in time to virtual and continuous where we don't have the restrictions of the prison of the four walls etc it's also true by the way that we always think of what you certainly you have to have some amount of individual contact I think you do but we always we have to challenge all of our assumptions in this area Daphne Kohler who's a professor of computer science at Stanford one of the co-founders of co-sera has produced really quite remarkable data of how strong social networks can form virtually and have real dramatic impact rich DeMilo and others working with people also Stanford riches at Georgia Tech has looked at the impact of face to face with your professor and looked at the pieces that are important there it turns out the most important piece is the individually tailored feedback another really important piece is the rapidity and immediacy of that feedback and what seems to be unimportant is the face to face so again I think we need to challenge a lot of our older assumptions here so 2040 medical school what do we need we need a curriculum and faculty much of that can be in the cloud we need patient sites of course and a common one will be in the home we need a classroom and campus and that will be the earth of course one needs students as well but we may not need the physical structures certainly not the way they're contoured today so what are the implications you know well one would you know why include the physical structures in the concept of having a medical school and you could look at this in a couple different ways in 2040 if there are 30,000 medical students in a class you could say well maybe we only have one medical school going to the extreme or since you can individually adapt maybe what you're saying is you have 30,000 medical schools each has their own experiments such as Coursera as I mentioned show valid social interactions need not be physical you know the foot classrooms could affect the science component and the current research intensive AMC's now this is a you know I love I've been you know Harvard Emory University Chicago I love those places but if I were to ask you do you think our medical students should be trained in in the following way patient-centered quality and value focused team-based does anyone disagree with that have I just described the clinical programs at our leading research intensive medical schools does anyone think I have there's a big disconnect there as well the last piece is physician satisfaction practice of sustainability now when we brought this up there would be individuals say see this this seems really self-serving until I point it out that this is just you know this is natural for any workplace we're worried about patient satisfaction nursing satisfaction we're worried about satisfaction of employees in all workplaces there hasn't been much done some but not much in the way of physician satisfaction and it was interesting you know I had a conversation a conference call conversation with some leaders in this area and I touched on this and two people said in the front said Jim no one cares about physician satisfaction I said well no wait a minute we've just been we've just concluded that patient satisfaction is important they said yes nursing satisfaction is yes in the other workplaces that support yes so so you know where we're at the chain of logic am I am I missing something and I could think of actually no other no other field where people fundamentally didn't care outside maybe the special forces you know where you know we think with you know those guys volunteered to go in ice water for a couple months so it's okay so we've done research and analysis at six sites now our partner is Rand health it is now concluded went up on the web at both web sites two weeks ago three weeks ago we're now doing a dissemination phase and our partner there is booze Allen that has done for us a analysis of 14 other industries that have spread such changes through them and the methods that were deployed and then we'll go through an activation phase it'll include in fact I spoke with Secretary Sebelius about this work maybe six months ago and she said I want to hear about all three focus areas because they maybe should be criteria in CMI for grants so I think there'll be some interest there not gonna go through this in the interest of time the overview is ends up being a high road message and the high road message is the major satisfyer physicians is sufficient time to interact face-to-face with patients and essentially driving home feeling that he or she did the best job for quality care for their patients that day that's the major satisfyer in the studies that come out and the dissatisfiers are essentially anything that interferes with that so the ability to deliver high quality care and by the way also the studies show that physician satisfaction ends up conferring nursing satisfaction and for reasons that are a little less clear a little less obvious physician satisfaction provides a patient population that better adheres to their chronic therapeutic regimens so we would imagine that it's a link to quality as well though it's not yet been shown EHRs have a huge effect on professional satisfaction positive and negative physicians feel that they can see through the HR the potential for better patient care if they've converted to electronics they don't want to go back to paper least in these studies but if I describe their overall pleasure with the HR is currently as as dismal it would be an insult the dismal there are many things that interfere with the patient's interaction so let me just say a couple of things about what we're doing we've identified through this work was boots on the ground 15 tools for physician practices in the administrative clinical area we're taking different approaches depending on whether large integrated systems medium-sized practices are small and we're also working with advocacy in the vendor community for EHRs this work was just completed as I mentioned a couple of weeks ago so we're just beginning to interact with folks like the office of national coordinator and frankly if you look at the EHRs currently they're optimized for two things they're optimized for claims billing and they're optimized for institutional risk mitigation and they aren't optimized for the rapid efficient extraction of clinical data that are needed to help patients so you know the view is that that's where the work needs to be done claims can be retrofitted then and lastly what are we driving towards so those are the three focus areas and what are the implications for the physicians well I think the overall driver is going to be the economic imperative it requires responses now cost you know the delivery value and we're not going to be able to increase that 2.7 trillion anymore in the CPI long term the business model is going to change we'll shift in a period of years to a total cost view rather than these siloed views where right now there are disincentives for hospital the disincentives on both sides or the physicians to keep patients out of the hospital they can actually have a disincentive to do that and yet it saves the system a lot of money so thinking about this as total cost will be important the interoperability we already talked about the EHRs the sites you know we have rapid shift the home care is just beginning there was a week we had just to show you how fragmented medicine is rich umbinstock who's CEO of the American Hospital Association worked with us and we had three weeks ago three and a half day joint meeting of the AHA and AMA in DC that was the first time the organizations had met since 1975 so the fragmentation is all through the system and this is another you know that where the site is is is going to be moving pretty rapidly and the mission health care to health and care so you can see you can imagine three levels of care say if you go out 20 30 20 40 the first is a solution shop what clay Christianson would call a solution shop and that is high technology complex disease where diagnosis is made newest it can be you know multi-specialty inpatient outpatient so it's kind of like an academic medical center that currently exists only with improved curricular structure and importantly a simplification Christianson would criticize academic medical centers currently as mixing two types of business the solution shop and what he would call line manufacturing so that's you know community-acquired pneumonia in a bed for three days getting an IV drip the AMC's cost basis is really high so why would you want to put line manufacturing on that cost base and the reason that's been given historically as well we can't train medical students on heart transplants alone and maybe the conclusion should be well yes that's maybe not where medical students should be doing they're more fundamental primary care training if we're worried about cost as we will be in the system we are converting disease not curing disease we're converting acute disease to chronic looks like we'll continue to do that we'll have medical home care but it has to be patient-centered and when we say medical home and primary care when cancer gets converted to a chronic state that medical home primary care is going to be an oncologist most likely so we'll think about specialties differently and those specialties are going to have to have wrapped around them some specialized nursing skills for common problems that these patients have continuity of care because this chronic is going to be really important and that has something to say something about how we train people around team-based work and handoffs and then I think the most interesting level that's it's most different is health and wellness here we're thinking about you know you hear these comments about well why don't we get a new set of providers for primary care they're independent well if we conclude that the system's problem is fragmentation why why is it you want to add another fragment instead of making the system coherent and interlinked and here we'll probably need physicians that may be you know working with 80 other professionals 100 other professionals everything from people that are nutritionists to those that predict predict risk based on genetic analysis for well patients and these physicians are going to have to have two additional skills that they don't currently have embedded in medical school and one is high-level management skill and also our training that makes them sort of partway between how we think currently about a physician and how we think about a public health official and of course these will be moving patients will move back and forth depending on their state spending a long time in health and wellness and some a long time in sort of chronic conditions and one of our overarching questions is a practical one is how we retain the physician-patient interface IDO the famous design firm we engaged recently and looked at it was the firm that from which the Stanford design school was started and they always take a very design-based approach to things we expose them to physicians offices and our health care system hospitals and when the physician and the patient are interfaced without a computer in between they define that as what seems to be to them the magic moment in medicine how do we preserve that into the future as well thank you very much thank you to achieve those before yes so I very I think the ACA will have a very positive influence and we'll have a positive influence because of access and coverage we've been criticized a little bit about this again with the rollout of the website but you know you can you can fix a broken website what you can't fix is a patient diagnosed with cancer too late to do anything about it because of the absence of access and coverage it still will cover that the states are making a mistake that they that aren't expanding also you know there have been other governmental rollouts of programs in the past that benefited states and for political reasons a subset of states didn't participate after two to five years in those instances the states are all in I mean absolutely it makes no economic sense for those states not to expand Medicaid thank you very much I just maybe wanted to ask a little bit off question you brought up two really good examples of moving medicine into the street and into the culture where we're trying to treat it and you brought up pre-diabetes and high blood pressure so my question really focuses on the stance and the strategy that the AMA has taken to medicalize obesity you know that seems like it's a great one to take to the street but with the medicalization it comes as you had said a huge increase in cost so kind of like some insight into the AMA strategy for that yeah so that was a policy that was passed by our house that formulates policies and it's been praised and ridiculed as every one of the policies is I think people that work on obesity think that putting a flashlight on it is important and this classification as a disease doesn't medicalize it the sequela being obese medicalizes it so we know what that sequela is I gave a talk in to the health ministry of Japan about eight months ago and as part of that talk I compared the top five causes of death a top ten cause of death the United States with those in Japan and we share five those five make up seventy four percent of all deaths in the top ten in Japan and eighty six percent of all the death I mean huge swaths of death and disease in our both countries the other thing those five share is that in each case we know how to decrease the death rate between sixty five and ninety five percent the simple things we already know about we just don't do it heard yesterday that you know the prevalence of colonoscopy call screening colonoscopy had now did not create increase for the first time in about twenty years and yet we're only capturing about two-thirds to three-quarters the population so we just have to do what we know country hi given given your analysis of the future of future perspective of medicine what do you see the implications for size of the physician pool in twenty twenty five or twenty thirty yeah so as you know there have been estimates of a need for an increased number of physicians about hundred thousand by twenty twenty five hundred twenty thousand you know that's our policy that's the double AMC's view of the world other view of the world that's the view of the president expresses I just would say that we also have to be humble enough to recognize that every one of our workforce analysis predictions in the past has been wrong and if we end up with a disruptive approach by definition it will be wrong so it depends on how this plays out as well how quickly it plays out they the extenders by the way you know if you really have a health and wellness swath that's functioning well we really like those five things that we share with Japan we can prevent a lot of our disease to a lot of our cost fewer people to care for their elders I'd like your thoughts on how we can build in that medical home model a community where you have intergenerational participants helping to care for the aging population which would be a disruptive in a mate innovation in itself and you closed with the opportunity you had to work with the design engineers the ideal brothers and one of them had just gone through a terrain tremendous illness cancer so I was wondering if you were able to glean out if that had any impact in how they looked at helping the medical community organized in the face of fragmentation and creative destruction yeah that great questions I the first one I would say that I don't have the solution but I know where I would look for the solution and that's the private sector we need just for example with the why with some conversations we're having with Walgreens and CVS we need to have private sector business plans that are sustainable that offload some of these some of these elements so the model you describe the intergenerational generational care for the elderly I would think of also private sector and I have to say the we've had great interactions with venture private equity and industry and I thought gee I you know why why does everyone want to come back and talk with us and spend all this time and then I realized the reason is that there's a 2.7 trillion dollar industry that's about to undergo probably undergo rapid reformation and destruction creatively and the opportunity that people are seeing there is really great so you take ideas like this to that community and you can always start engaging in good conversations the other thing I would point out about the investment banking community private equity and venture is how shocking it is what little knowledge they have the current health system really sophisticated business planning but you can say the simplest things to affirm like a in New York and they think they've been delivered manna from heaven and you can't believe they didn't know that right so you're talking about how access to care is obviously really important to essentially getting your goals accomplished and I was wondering if you thought that even if all the states except Medicaid expansion eventually what does the AMA stance on increasing access to care even further or dealing with the phenomenon of like under insurance so the the AMA policy is that everyone should be covered in fact if you read the policy you would translate it almost into an individual payer although that's never been said this also brings up the the area of access in as it can be done remotely and within a city by telemedicine and there the work is really with the regulators that we're doing trying to make sure that these things fit part of say a Medicare payment package these things would obviously take care of themselves in terms of the payment as you shift to a system that ultimately will probably be total cock the capitation and population health then it's not so these fragments that are efficacious one can do under that global umbrella one of your final slides you referred to the magic moment which I which I understood was the doctor patient interaction will will help perform accelerate those magic moments or the obstacle to this my my view of that mark is that what we were lacking was data so when we talk about the satisfaction for visitors and patients in the interaction there's a different just weren't really high quality rigorous social science boots on the ground data to demonstrate that and so as we producing data I think we get a little more movement both from regulators as well as from payers and hospitals I you know the when I visited the American Hospital Association board soon after I took this job it was clear they wanted me to provide them the combination to the lock where they can unlock the satisfaction for physicians I said well why don't you work toward that end and they said we don't have physician voice I said I've never really I've been in places I've never noticed a lack of physician voice and they said no no no you don't understand what we're saying we're saying not a thousand voices a unified voice with a message with data underlying it what are your thoughts on the cost of medical education another health care education and do you see if health care education is revised as you sort of proposed here that that might decrease the cost and yeah is there any chance the government would take over this cost as many other countries do for their medical education yeah I think medical education is far too costly that if you shift to programs that are more cost-effective like ones I showed costs will diminish I should also say that I you know I don't have a lot of patients for integrated systems that complain about the costs of their medical students for the following reason either and that is that and that's you know this is the logic would let us to so increase our our scholarships here when I was here is that you'll go to a system that's a two billion dollar system and it's an integrated two billion dollar system he said well now why do you have this complex two billion dollar thing connected to a university and the answer is well we have a medical school okay so the only reason you have this is because you have a medical school so what's your biggest problem they'll say cost of education I'll say what is the totality of your education of private school they say 16 million a year if you're in a two billion dollar enterprise and that's your biggest problem 16 million why don't you take care of it what's the rest of the two billion is to clinical care and research well the totality of an integrated system so you know you make those kinds of decisions all the time so I think the cost is unjustified currently it could get a lot less expensive we're beginning to look at a couple of schools that are new to see that you know we form this consortium of 11 schools we provide 11 million dollars to 11 schools and each brings a piece of innovation it could be measured competency for example on one hand adaptive learning and virtual patients on the other and we selected this consortium based on the fact that each innovative piece had already had faculty pre-processing and a champion dean and you put those all together I think within a year we'll be able to start seeing the image of what a medical school the future could be. I think I'll ask you to join me in thanking Dr. Madera.


You see, I saw the flag was up, and so I just thought I'd drop around and say hello to everybody. No. And you call that good? Ah, but this is different. This time... Say, so that's it. Someone was only kidding you. I don't mind saying they had me fooled. Yes, a joke is all right, but not when you make it so serious. I have not yet showed these to Carlos and Alfredo, but I think they're not thinking it's so funny. No, I should say not, especially kidding about putting acid on your wire, or that you must leave the circus or something will happen to you. I wish I know who do this, but I guess maybe something happened so they have another heart, yes? You mean a change of heart? Yes. You're probably right. I suspect there's something behind all this, though, and I have an idea about it, but as long as it's all right now, I guess I'd better keep my suspicions to myself. Always like a detective, yes. You know, Jerry, I think when you grow up, if you get tired of the circus, you can be a great detective, eh? I didn't wonder. Well, here's your note. Say, what did you do, spill water on it? How do you mean, water? Oh, see where the ink is blotted? No, it come like that. Really? See, that's funny. Looks like someone was crying or something. Oh, you see, you cannot help to think always of, how you say, clues. I know, but it's not like that. I know, but it doesn't look that way, doesn't it? All smudged in the street. Maybe, maybe it rains. Well, it hasn't rained for a week.  I wonder what Jason and Bumper are so happy about. Hey, what's the joke, Jason? Jerry, just wait till you hear this. Oh, hello, Carmen. It's really a riot, isn't it, Bumper? Yes, it is funny, but it's tragic, too. Oh, do you mean funny, sir? What kind of a joke is this? Hey, this is terribly funny. Oh, hurry up, what happened? Well, you all know the bearded lady. What, yes. Well, my dear friends, she is no more. What? What did you say? What's this all about? Jason, I'm ashamed you're talking like this. Ah, but what I say is the truth. My dear friend, the bearded lady is no longer the bearded lady. Jason, what on earth are you talking about? It's a long story, my friends, but to be brief and to the point, or shall I say to cut it short, it seems that the bearded lady has been robbed. She is no longer the bearded lady.  Jason, I don't understand you this evening. All right, I'll put it this way. When is a bearded lady not a bearded lady? That's simple. Well, she hasn't got a beard. Good boy. That's it. What? Say, you don't mean that. Yes, jury, that's it. She's lost her beard. No. But how could she? She's not got her beard. Oh, the poor lady. It was really tragic. She was she mad. She practically raised the roof, threatened to get even with whoever did it. You mean to say she didn't cut it off herself? Or do you think a woman who earns her living because she has a fine beard would deliberately cut it off herself? No, that's what makes it seem so funny. Say, may I have some ketchup? But how? How do such a thing happen? Well, that's what nobody knows. She says she was asleep, and then suddenly she heard a noise, a click or something, and then her door slam shut, and she got up in her hurry and happened to catch sight of herself in the mirror. And she screamed. Well, I've been with circuses all my life, and I've never heard of such a thing happening before. Well, has she come into dinner yet? No, and she won't. She said she'd never face any of us again. Oh, what's she doing now, wonder? I don't know. But I got a hold of Randall, and he's talking to her. Say, I'll bet Mr. Randall will be plenty upset. Well, he certainly will be. She's not much good to him without a beard. She's not a very good company when everything's all right. I can imagine she'll be impossible to get along with now. But do you think Mr. Randall will keep her, Jason? Your guess is as good as mine. But who on earth could have cut off her beard? Looks like you've got a new mystery, Jerry. Good night. What's the matter, Jerry? Nothing. I just happened to think of something. Good. Here comes Mr. Randall now. We can all get the dope. Well, good evening, Sam. Hello, folks. No, no, I'm not going to sit down. I've got too much in my mind. Jerry, I'd like to talk to you. Yes, of course, Mr. Randall. I think we better go outside. Excuse us, folks. Well, of course. Sure.  Looks like it. It's an extreme night, too. All right, Jerry. I'm pretty busy. Yes, Mr. Randall. I'm coming. I wouldn't do this if it weren't pretty serious, Jerry. Yes, sir. But I don't know what this is all about. You will, as soon as we're outside. Now we can talk. This is between us, and there's no need for the rest of the circus folks to know all about it. Jerry, do you know anything about what happened to the bearded lady? Why, yes, sir. Jason was just telling us. Yes, of course. I suppose everyone will know about it in another hour. But do you know the rest of the story? Why, no. What do you mean? Jerry, did you have anything to do with this? Well, Mr. Randall, what are you talking about? You're sure you didn't do this thing as a joke or a prank? Well, of course not. I'm certainly relieved to hear you say that, Jerry. And I want to believe you. But there's something about this thing that seems to involve you. Well, how do you mean? Well, needless to say, the bearded lady is pretty hysterical at the moment. However, while I was talking to her, I noticed a pair of scissors on the floor. Oh. You know about them? Whoa. What is this, Jerry? You do know something about this. No, honest I don't, Mr. Randall. Well, you might as well tell me right now. After all, I recognize those scissors as the type that Clara uses. And I've just come from talking to her.  Yeah. So, you see, I know all about that. But, Mr. Randall, I didn't... All right, Jerry, it's possible that it just happened as those scissors are similar. Well, you give me the pair you borrowed and you'll be clear of all suspicion. What? Well, I can't ride away. I'll get them for you, though. All right, Jerry. I'll be waiting for you in my office wagon. But remember, I've got the pair of scissors that I found. And you'd better have another pair or... Or what, Mr. Randall? Well, we'll worry about that when the time comes. But get over to my wagon as soon as you can, Jerry. Yes, sir. I will. No one will be happier than I to have you care to this thing. Well, I'll be over as soon as I can, Mr. Randall. Bye. So long, Jerry. I wonder... Jerry! Oh, hello there, Major. What are you doing hiding around the corner of the wagon? Collie, I'm sure glad you're here, though. Well, to be frank, Jerry, when I saw you leave the dining room with Mr. Randall, I was pretty worried. You? Jesus, you didn't do it. I cannot tell a lie, Jerry. Yes, I cut off her beard. But how could you? Do you get into a lot of trouble? Mr. Randall's awful man. Yes, yes, I know. But he must never know I did it. Nobody must. But they're bound to find out. But they mustn't. Well, I have the bearded lady thought that I did it.  You know how excited she gets? She just doesn't know what she's doing. But, Major, the scissors... Imagine dropping them and it woke her up. If it hadn't been for that... But, Major, Mr. Randall has those scissors and he knows Clara gave me some like it this afternoon and he'll blame me. No, he won't, Jerry. But he will. He just told me to bring in the scissors or he'd hold me responsible. But you didn't do it. I know, but you'll think I did if I don't give him the scissors. Well, Jerry, I don't know what to say. I don't want to get you into trouble. Of course, you know I haven't the scissors. What'll I do? I don't know what you can do. I suppose you'll have to tell him everything. I can't have a boy blame for something he hasn't done. And yet if that woman finds out that I'm to blame, well, I might just as well be dead. Anywhere you're going. Over to the office wagon. But what are you going to say to Mr. Randall? I don't know yet. I'll walk over with you. That's me. I wish I'd never been born, Jerry, to get my good friends into trouble. Oh, don't worry, Major. I won't tell him you did it. Yeah, but he'll know. Well, how? Well, when you tell him you got the scissors for me. Well, I won't tell him. You won't? Well, no, of course not. Not if you're going to get into so much trouble. Well, Jerry, you know why I did this, don't you? No, not exactly. Well, Jerry, I'll tell you, it was the bearded lady that sent those notes to Carmen. So I had to protect the Spanish senorita. So I had the bearded lady write a note. Yeah, I saw it. And you did? Well, now Carmen won't worry anymore. And now I fixed the bearded lady, so she won't be around here anymore endangering people's lives. But she's no use to a circus without a beard. I meant to sacrifice her for the good of the circus. I didn't mean to get you into trouble. It's all right, Major. Well, here we are.  Well, good luck, Jerry. And be sure to let me know what happens. Yeah, I will. Goodbye. Goodbye. Mr. Handel. Yeah, come in, Jerry. Mr. Handel. Yes? I haven't got the scissors after all. Jerry. I'm awful sorry. Jerry, how could you do a thing like that? Well, I... Jerry, cutting off that beard was bad enough. It's much worse than a prank because it brings a lot of trouble to the innocent victim. Well, how do you mean? Well, of course I can't use the bearded idea like that. I'm afraid I'll have to let her go. Oh, no. That's bad enough. But have you lied to me? Well, honest, I didn't. Mr. Handel, I didn't... Well, have you lied to me is... is worse than to have had you do such a thoughtless and unkind thing.  You must believe me. Then someone else is involved in this? Oh, so that's it. Yeah, I thought as much. I'm sorry, Jerry. I don't like to ask you to tell on another. But in this case, I'm afraid I'll have to ask you to tell me who did this thing. I can't, Mr. Handel. I'm sorry, Jerry, but this time I'm afraid you'll have to tell me. I insist on knowing who used those scissors. You... you won't tell me? You've been awful good to me, Mr. Handel, and I appreciate it, but... Well, this is just something I can't talk about. Well, Jerry, I'm sorry, but I'm afraid you're going to have to take some pretty stiff medicine. Yes, sir. I'll have to tell Clara not to make up that costume for you. Why? Because I'm going to have to let someone else go into the ring with that elephant act. Oh, Mr. Handel, oh, no, please, please. I just can't tell you, but... but I just got to do that act with El Mundo. I've been practicing and thinking about it so much, and I... I'm sorry, Jerry. And I'm good. Honest I am. Carmen says so-and-so dissolves in it. Oh, gee, Mr. Handel, do something else to me, please, but let me work with El Mundo in the ring. It's too bad, Jerry. I feel as bad about this as you do. But I can't have performers who don't consider the show above everything else. I don't like tattling any more than you do. But this case is a little different. And, well, I... I guess we'll just have to forget about you working that elephant in the ring.