So, as some of you may remember, I had a talk with this name in Albania, so it was four years ago. And when I was submitting talk proposals for this conference, I was thinking like, yeah, it's been four years, some changes have, some things have changed, so maybe I could update the talk. That's why it has the year in the name. And then I decided I would be repeating a lot of the stuff, so I'm not going to repeat the stuff, I will just update the Wiki, whatever, and I will just do a lightning talk. You are correctly here for a full talk. That's what happened. And I found out only when I got here to Milan, in the end I decided I will use this log lightning. It has been already assigned, so I have extended some of the stuff. I'm not quite sure how much time I will actually need, so let's just see how this will go. Some of us, though, have not seen your talk four years ago, so if you want to play your time, you can focus a little more maybe on the reminder part. Yes, I can also talk to people who were in there. Still, like, this is technical stuff, there will be some comments still. The idea is more that I will talk about the stuff, but if you are actually going to use it, you will still actually need to look it up, so it doesn't really make much sense to talk about the exact specifics. I meant this more like a review, but kind of the point is, I think there's nobody who will say, yeah, LibreOffice is so quick to build. I think all of us, or I hope all of us have at least some tricks, so if you have some comments during any of the topics or if there will be some things you would like to share, or if you have some specific problems and if there will be time, we can have a look at it. This is just some of the stuff I have collected, I have found, some of the stuff I have brought about, so in case you have noticed that you probably know this stuff, but let's just go over it and see how it goes. So, I still remember times when it was like several hours to rebuild all of LibreOffice. I think the Wiki still somewhere says that the build time is something like 8 divided by the number of CPU cores or something like that, so right now for me I have 8 cores, so the normal build time is 1 hour, which is acceptable, but it used to be worse. So one of the things that we don't quite like to hear about if you want things to be fast, it helps to have fast hardware, which is not always the option, but it's in a way the simplest one, and then it generally helps to get good tools. Surprisingly getting a newer compiler actually generally tends to be faster. On Linux or Generic's platforms, client at least four debug bills seems to be the better option, as far as build time goes, and even that improves like, I'm not sure if you can see this, when I updated to Clang 4, my build time for the library SC, for the Calc library, went from more than 4 minutes to less than 3 minutes. I have no idea what changed, but suddenly more than, there was something like 30% of the build time just disappeared. I have no idea why, it just got better. So if you don't, I suggest, yes? What is the VCH saying about? Sorry? What else there is? Pre-compiler headers. It's other stuff I will get to. So one of the things, if you want stuff to build faster, if you don't, I suggest that you get Clang and preferably a new one. I also got the stuff I have, this one. You can look at the details on my blog. I'll just show the picture. This is, I did some tests. So the topmost one is just the, I think that was the, it was either compiled from the distro or I just built Clang just with the default options, and then I optimised it specifically for my CPU, which is a question if it's worth for you, because it actually takes time. But if you build with LTO, which is link time optimisation, for example, Open Suset builds all the packages this way, you still save some time, and a PGO is profile guided optimisation, which you first run the programme, in this case the compiler, and it analyses where it spends the time, and then if you compile again, it uses the information to make it even faster, so this saves like 30% maybe. By the way, we could probably consider PGO even for building Clipper Office if it's this much how it helps, but that's just a note. And then the pre-compiler headers, the last two are pre-compiler headers, which I will get to, it's a question if it's worth for you to build your compiler, but if you want an improvement, there are other ways. This is just one of the things. So what is the longest time and what is the shortest time? So the longest time is basically just getting the compiler just built in the right way. This is just one source file randomly. It's something big from Calc, and this one, I think the longest one is 14 seconds, and the fastest one is less than 4 seconds. As far as I know, on Windows actually Microsoft compiler is faster than even Clank, or maybe Clank is not as fast there as I remember the last time I tried. A similar thing, you can also use some compiler tools, but we buy default big C-Cache if it's available, which I suggest. I suggest getting at least version 3, because there were some improvements. It has switched internal compression to Z-standard, and it has very little overhead. The compression is enabled by default, so it takes way less disk space. C-Cache is not a magic solution. It needs to be exactly the same rebuild, but for example if you're using often git, rebase, or bisecting, then you will repeatedly have to rebuild the same stuff. It can save a lot of time. In some cases, for example, I have a desktop PC, and I have work laptop. I use iSKIN to distribute it. Back in the time when computers had like one or two CPU cores, I remember in KT times when there was a conference, we set up an iSKIN cluster, and it was so much faster. It's not as impactful today, but it's still an option if you have more hardware playing around. And a little bit. The linker that actually creates the binaries, the final step during building, also may have impact, configure already, at least for the backbells once, if you use the default GNU linker, which is horribly slow. So I suggest getting the LLVM, LLD, or the new linker called mold, which doesn't make a huge difference, but if you have like, if you just edit one file, it still can save a second or two or ten if you use the GNU linker. Another way is actually building glass. For some reason, we try to, by default, try to build all the external libraries ourselves, which means we rebuild it all the time. I myself try to use the system libraries, which is a bit more complicated to set up because the configure run takes a long time. And when it's like halfway done, I tell you, oh, I cannot find the system library. Please install it and run everything from again. So whenever I do a distra upgrade, which... No, not very... If I sometimes don't do distra bit, I just install the system stuff in you and then I need to spend like ten minutes running configure. It tells me something. I installed the missing dependency and need to rebuild it repeatedly, but it tells me don't spend time building the system libraries where we basically don't care normally. If you develop the graphases, you should normally do enable GDB utility, which will set up extra debug checks and so on. And as a side effect, it will also set up some useful stuff, which is generally not a good idea to do for release builds like split debug. It will move some of the debug information into smaller files so that it's faster for the link to process it. This is bad for packaging because then you have extra files, but if you do local builds, it's faster to do it. And if you do enable GDB utility, it will just try to do the smart thing out of the box for you. Yeah, unfortunately, if you use Clang, we have quite a number of them and the way I originally designed them back, I don't know how many years back, they add quite an overhead. It's quite lame coming from me, but I actually no longer use them by default. I normally build without them. And only when I submit it, I just basically just apply again the last commit so the files will be changed and then I explicitly force the plugins so it's once compiled with the plugins. So it actually warns me before I submit to get it. I don't know how to make the plugins faster without completely reworking them. It's what it is. I'm not sure what it's right now. I know at one time it was at least 15%. At some time I reworked the plugins to try to share the structure pass because back then every single plugin worked the entire AST structure of the compile program. I remember to just try to work it once and have a look. I don't remember if it was before or after the 15%. There was a time where the plugins were useful. I think by now I very rarely actually trigger a warning from the plugins. So basically right now I just check before submitting because the warnings are still useful, but I don't consider them useful enough to just trigger them around every single time. Here is another trigger which you may know. Do build system views because we have so many source files and we use GNU make which is slow for this one. If you just run play make, I think if you have ever built everything it still is like 10 seconds, 20 seconds at the very least so you can limit how much gets rebuilt. If you type for example like make SC it will just not only build only calc but it will also only consider calc which then make will have much less to build about. You can specify for basically any target. For example the second bottom line that's how to build just the SC you calc unit test and it's much faster if you tell make to first change the directory to the calc module and then just build the specific target. The target is basically the name of the make file without the dot mk. There's a little complication. Our build system tries to be a bit smart and automatically do silent build and parallel build and I personally don't like it also because it doesn't work for going into sub directory so I personally use it without parallelism and make a small wrapper script which does it explicitly and then I just am used to using my own wrapper. Also the last line sometimes you have dependencies between modules and then normally it feels like you have to use just make and rebuild everything but if I'm for example modifying some library like vcl and then I'm testing only in calc then I need to change only vcl and everything calc needs but there's no point rebuilding for example writer so for that I would write make SC dot all build and it will just rebuild only calc and everything only calc depends on. So let's get to precompiled headers. One of my favorite topics because as you could see on the previous picture and actually in one of the other blog posts I even have a you can watch it, I have a video when I built some calc library without precompiled headers then the middle one is that's kind of a setting which I did some work some which enabled optimizations in calc to compile actually faster if you have precompiled headers so the middle one is without these extra improvements that's about how GCC with precompiled headers would compile and the last one is I don't know if you can... Anyway, so it's like the slowest one is like 12 minutes under does it have time at the end? Anyway, so I think it's like you go from 12 minutes to 8 minutes with the normal PCH to 4 minutes with the faster one you could also see it like here you can spend all the time improving, recompiling or you just turn on precompiled headers and all the previous stuff basically doesn't matter it's just the difference between the last two which is still a couple of persons but it's a couple of persons from way smaller part so... yeah, it's not it's not enabled by default but actually here I'm mentioning we already use enable PCH full which is like the highest level on Windows for Microsoft visual comparison so it probably makes sense to default it for a new client I already have been using PCH for years basically without problems really only the practical problem is that if you submit it to get it which bills without recompiling headers sometimes this basically works like you make one huge include file which includes everything so... then for people who don't use it sometimes you forget to actually include the values and then the file breaks so... here's the second line from bottom it's useful again to rebuild and use block PCH which will temporarily disable PCH just to check that it bills also without but... yeah, I think I will just bring up on the next ESC call that maybe we could default for it since it can make a huge difference and... as I showed back then rebuilding the huge call library is 3 minutes I still remember times when I was trying to avoid rebuilding call like because it was so many minutes and now I just like changed the main header and like yeah okay, 3 minutes, who cares as I've noticed in case you may have heard C++20 got some new C++ modules I have just done some tests and I haven't looked that much into it but it's a huge step that's not backward compatible and it's long it's a lot of work to change it, so... yeah, if we want faster compass we are probably stuck with the compass for quite a while yes do these things real of course it is a bunch of effort to switch from an include file to an approach to rewriting these things or many of those modules but do you think it's not worth it or not worth it right now or is worth it but it will take a long time to happen well as I understand it and I just have tested it on small projects so I may be missing something but as I understand it you basically need to add the header files into modules format and it's not compatible either way so then we would be stuck requiring compiler which can handle modules and you wouldn't be able to build without it so we would need to spend time rewriting all of it I don't know how the transition would be difficult when you would have just one or you would need to have copies and also additionally building with modules build system support because with PCH you can just run the build and do one pass but these modules as far as I know you need actually a second pass before we just will find out the dependencies so it would also need rewriting gbuild or using a build system if they are already build system which support it so it should eventually happen but right now somebody needs to do it I think it will be quite a lot of work and I'm not sure if right now it's worth the effort someone in the future yes right now if somebody feels like it yes but I expect it's going to be quite some time Yes Can we use the pre-processor to have a single header that is for the module? Possibly there is still the problem with the build system which I don't know how much work it would be to change gbuild to have the second pass Yes Yes it requires C++ module are official official feature of C++ 20 Client also has a different implementation which as I understand it was actually backwards compatible they had some kind of way of important header files into their modules I'm quite disappointed that it wasn't the final thing that C++ decided for whatever reason I don't know the internals I'm personally disappointed with the way it turned out but it's what it is I don't know all the details but this is the way I see it Yeah this is just a mention that didn't really turn out to be good but I tried it LLVM is the project which provides also the Client compiler so they also provide a C++ library it's possible to switch and it's faster again to build but it's kind of problematic if you want to know the actual details we can talk about it later but right now just skip the slide This is build time but building is actually not the only thing we do we also face up to use debuggers so as I said you should use enabled gdb utl because then you get extra useful stuff like gdb index which changes gdb from horribly to just horribly slow which is still a huge improvement or you can use this you can disable auto loading of all libraries and then use the share library command to just selectively load it when it's useful I sometimes use it because I just want to quickly attach gdb and I don't want to spend all the time waiting for it to pass the libraries for those of you who use gdb and don't know that you can switch it to text interface which makes it way way faster I suggest to you google gdb to you text user interface it saves so much time I have also tried to using the LLDB compiler which is again another project for LLVM it's way faster in some ways it seems to be better in some ways it seems to be worse but many of like the workflow is slightly different I still haven't actually switched even though I have already submitted a bunch of features to LLDB kind of like the whole LLVM project personally repeatedly annoys me by being really pedantic in the reviews and I repeatedly get demotivated by just all the reviews but generally the tools are better it just sometimes I force to switch and I think this is the last slide I have another trick you may know about ease of use and disk space as you may have noticed git checkout of LibreOffice is very large even just the .git directory so you can do checkout just once somewhere and then you can use the work3 feature where you can just kind of check out a work3 into separate directories and they all share the one .git directory or cherry pick between the three ones if I for example want to update my master I just go to this main checkout I run git pull there and it doesn't ruin my work3 where I actually built so this is another trick and yeah this is all from me so we still have few minutes so in case somebody has a comment question or you and some of your tricks yeah they're all for developer builds when we're interacting we're building continuously but when I'm doing the RPM builds for Red Hat they're a throwaway build and just building it once and I'm throwing it away so in that case we have that configure option for disabled dependency tracking you can throw away all your dependency tracking you're not collected in the first place it gives you a faster build to rebuild a small portion afterwards it won't rebuild what should be rebuilt but for a one time build for distro packages you have that extra option yeah thank you yeah so there is minus-minus disabled dependency tracking and as I was saying before make one of the part why it's very slow is because so many files creates so many huge number of dependencies which make a lot of time to process so if you disabled dependency tracking it will just skip the whole step the problem of course is that you don't have any dependencies so it's not useful for normal development but I remember I have occasionally used this even for my own things I don't remember why but for one time of builds it's actually useful so one of my key use cases for GDB is I do something that crashes and wouldn't be nice to get a stack trace with real symbols in it and currently it seems like you can attach with no shared library and you can manually load each symbol library as you do it to avoid a five minute wait etc but this seems pretty pathetic is there any way that GDB could just load the symbols for the shared libraries it knows are on the stack frame is there any way that you can do that more easily if GDB could do when you crash you have all of the frame pointers you know where the shared libraries are that you need symbols from in GDB I just wonder if there's any lazy loading that loads symbols when it needs them to show you your stack trace I have looked into this a bit and the short answer is no the symbol loading in GDB is so old code and so complicated that it's very hard to improve it I remember the GDB maintainer like a year ago or so blocked about improving oh yeah that's another case if you get a newer GDB version this has been improved a bit even though I think with GDB index it doesn't matter but basically symbol loading in GDB is so horrible and you always I think you basically what it does is that it loads everything in a shared library one of the reasons why LLDB is so much faster is because it's newer code and it also is better at being actually lazy about it and I think it also has better indexes I think LLDB without indexes is faster at loading stuff than GDB with indexes and other thing to backtraces we have this solve backtrace whatever function if you use enable GDB until it will not trigger during a crash which I think could be added but it it normally uses the glipsy backtrace call which is next to useless but in GDB mode it tries to be smart I implemented it like two or three years ago if you actually now use the call it will try to print a nice backtrace if you are in GDB until mode and you do that with address to line or something outside the process or you use GDB or how do you it uses the other tool line tool preferably again the LLVM one because it's faster basically you get all the stack pointers in the call and then I added some caching grouping whatever and it resolves it so it prints the nice backtrace some more ok so thank you


I'm the love Nice to see you. I'm going to introduce you somebody very special. Okay. Kobe Athletic is your chosen. Yeah, what's the name and he's been studying Islam with Yassin for a while. He's a high schooler 17 years old Hello, right? beautiful Kobe, so I understand that you Shared enough to have a sense to know what means to make shahada to enter Islam And you know the basic principles the foundational things I I know that because of what's been taking place here So if you want to let's do take my hand And you just repeat after me Okay, the shadow a shadow In the eye, you know how you are you know, I love you What I shadow? Muhammad Rasul Allah Okay, one more time. This is very close. It's to repeat as much exactly A shadow In la ilaha And la ilaha La hila hai! Ilv allah Va asshadum Anna Muhammedin Rasulunwonk Art day Asshadun La hila hai! Oh isla! Asshadun Asshadoh Asshadoo Asshadoo, sorry Asshadun La hila hai! Asshaduh La hila hai! Let's只有 Allah There is no god but Allah Ashadu once again, Ashadu la ilaha illAllah wa ashadu anna muhammadin, anna anna muhammadin, anna muhammadin, Rasulullah, Rasulullah, alhamdulillah, alhamdulillah, alhamdulillah. Alhamdulillah, alhamdulillah, alhamdulillah. Alhamdulillah, alhamdulillah, alhamdulillah, alhamdulillah. Ashadu once again, Ashadu la ilaha illAllah wa ashadu anna muhammadin, anna muhammadin, anna muhammadin, aone alhamdulillah. Allah. Sillunee alam abith fa'inil wa sikum. Ilala akun ahla fa'atul lahoo ahlum. La ilaha ila Allah, la ilaha ila Allah, la ilaha ila Allah. Hamal Rasulullah salamun aleykum sharra fa la huqaaakum. Wa damat alaykum nii ma tul wa suru. La ilaha ila Allah, la ilaha ila Allah. Muhammad Rasulullah fa matabatiyah bi dhikr tur. Fa nusum diya ul'ayn nihaqaaan wa nuruhaa bi dhattar. La ilaha ila Allah, la ilaha ila Allah, la ilaha ila Allah. Wa juhaa ahibati fa tilaka salati fi la ilaha ila Allah, la ilaha ila Allah. Muhammad Rasulullah juhul ila ma aas farad al-jamaliha. Adhaat lahal aqwa. La ilaha ila Allah, la ilaha ila Allah, la ilaha ila Allah. Muhammad Rasulullah. What's the question? How did this happen? If you like. Can I talk without the mic? Yeah. You can hear me? But you don't get to drop the mic at the end. My bad Muslim. I grew up under no religion. But we stayed in Oakland for a long time. It was just a mosque next to it. So as I'm growing up, my bad Muslim always walked into my mind and wanted to hear it. Yeah, I just pretty much grew up like that. And that's probably it. Like just growing up and I just wanted to take it serious. Get it together. Yeah. That's pretty much all I grew up around. Like our black, it was just Muslims, really.  Yeah. Yeah. A little bit. Travis. Does he know? You know I was coming today. But he at work. Yeah. God bless you. God bless you too. If you like, then you're supposed to be me now. Is this supposed to be your friend? No. Hamdullah. There you go. Hamdullah. When you've probably been saying Hamdullah here and there, right? Yeah. Hamdullah. Yeah. Kind of making the final decision. Beautiful. Like I started doing the Christian stuff from my mom. It just didn't work. That's why I feel like I stayed in there.  I don't want to... You probably may or may not have heard the things, like this sister said, when you make Shahada, the things that are said about how blessed you are. You've heard that. The things are true. The thing that makes Islam different from so many other paths. So things are true. They're true. We pray for someone. And the angels pray. If we pray for someone else, the angels pray with us and they say what the person is asking for that person, he could do it. But the other one is the Prophet said to him, he said, when you make Shahada, that moment, the sun came up for you. And everything is purified. We come out pure. We're born pure. And then we all do things we regret. Adele. But all those things are forgiven. But without being too new age, one of the things is you have a unique thing.  But you weren't from a Muslim. But a lot of people here grew up as Muslims. And what I discovered as a convert many years ago is the people who grew up as Muslims, they never had a chance to formally do a tariq dip just now. So I'm going to do something. What we do is that we all join hands. And one of the women can join hands with one of the men. So we're all connected. And we take the baraka. If you don't mind, we take the baraka from you. So can we do that right now? So what I'm saying here is tariq has a blessing from Allah and a gift by this moment. And to be, you know, kind of we're going to take advantage of it. We're going to get all the blessing that we can from you. So by holding hands and connected with him, and by everyone together, by everyone together, doing the same thing of repeating the shahada. For those of you who have not done it formally, we'll do the same thing for all of us. The prophet said to improve and increase your iman, he said, make the shahada. Simple truth. So let's do it again. So, a shahada and la ilaha il'Allah il'Allah wa ashadun anna muhammadun rasulullahu ashadun la ilaha il'Allah wa ashadun anna muhammadun rasulullahu ashadun la ilaha il'Allah wa ashadun Anna Muhammadan Rasulullah sallallahu alaihi wa sallam alhamdulillah Allahu Akbar Allahu Akbar


Today, I am simply delighted that Dr. Gerard Clancy has been able to come up from Tulsa, Oklahoma, to join us for the Disparity Seminar. I don't know where to begin, whether to begin with Dr. Clancy and his interesting background, or to begin with his current role. I think I'm going to begin with his current role, which is President and Dean of the Oklahoma University College of Medicine in Tulsa. It actually has a new name since 2008. It's called Oklahoma University School of Community Medicine, and that school has now enrolled its third class of students, thus far 40 students to a class. It's quite an unusual school, probably the first of its kind in the nation, which has an explicit purpose. Its mission is to improve the health status of underserved Oklahoma communities, both rural and urban. There is no medical school in the country, so far as I know, that has that as its primary mission and focus. To do that, it hopes to build a community that will improve the health of individuals and of their communities through learning and research and collaboration, and to educate a whole generation of new practitioners with these kinds of community-based and individual skills. Listen to some of the things that this new school does. For example, it recruits students nationally, I should say, not just Oklahomans, but it's a national recruitment. It charges no cost for any courses related to public health care, which is interesting in itself. But for those courses that it does charge for, which is to say for medical education, it provides educational grants and forgiveness for service such that students can leave medical school and essentially discharge their indebtedness. I learned only last evening what the cost of medical education is today, that is these days, at the University of Chicago. Four years of medical education in Chicago, this is tuition plus living expenses. Does anybody want to hazard a guess? How much? 300,000. 300,000. And the average indebtedness of our students coming out, I'm told, is between 170 and $180,000. So to think of a class of students coming out who can discharge their debts, it all comes from an extraordinary endowment from George Kaiser and his foundation, who's a local philanthropist in Tulsa that is provided to the students at the University. Mr. Kaiser has, as his commitments, early childhood education, health care, developing a safety net for Oklahomans, and community betterment, and this is part of his health care investment. So it's an extraordinary school, it has, as it's seen, an extraordinary man in Dr. Clancy whose training was largely at the University of Iowa in psychiatry, whose research interests have included the delivery of psychiatric services at the community level to the seriously mentally ill and disease management in behavioral and mental health at the community level. In Iowa City, he was known as, his program was known as psych on a bike. He and his students and residents would ride around on bicycles to find the homeless people of Iowa City, Iowa City has homeless people, and to provide mental health services and medication on site, which is to say in the homeless areas where people lived. He's working these days on changing the medical curriculum, changing clinical teaching experiences, such that both students and residents will develop the additional skills needed to provide health to communities, in addition to providing, as I say, health to individuals. Dr. Clancy has won many awards for his work, including seven distinguished teaching awards. Just yesterday in his new role, quite a new role, as the new chair-elect of the Chamber of Commerce of the City of Tulsa, Dr. Clancy had the opportunity to spend three hours with the recently elected governor of the state of Oklahoma. Her name is Mary Fallon. I expect that most of us here don't know very much about Governor Fallon, except to say that she is among the most conservative people elected in this last election cycle. And Oklahoma was one of the few states that had a state question on the ballot, and the state question was, should Oklahoma opt out of Obamacare and receive 70 percent positives to that question? So the three-hour meeting yesterday with the governor in the light of her own conservative views, as well as this recent state question that was posed, was a challenging meeting to develop resources from the state to support the kind of missions that I've talked to you about, missions of alleviating disparities at the individual and community level. Well, Dr. Clancy has his work cut out for him. Today he will talk to us about health disparities in Oklahoma, it's time for community medicine, and we'll also tell us about his work at the new medical school. Remember, this is not an amplifying microphone, but a recording microphone, so as in the question and answer session, please try to have this in hand as you pose your questions. It's a great pleasure to welcome Dr. Clancy to Chicago. Thanks, Jerry. Thank you for having me. I've had the pleasure of working with the University of Chicago now for the past year. I've gotten to know Eric and Sarah Ann and Dorianne, it's been a great pleasure. We were hosted here about last year at this time, and then we've had two conferences together, one in Tulsa, now one in Miami, and what I'm happy to say is we're all like-minded. It's as if the schools that we're working on, these types of initiatives, we've been working together for many years. Well, the name of this talk is democratization of health advantages in America, taking it to the streets, and this is the Doobie Brothers taking it to the streets album, the first album that I bought in 1977. When I bought that album, I was a dishwasher at Howard Johnson's, the music came on, and listen to this, I rode my bike downtown, cashed my check, and bought an album. None of those things we do anymore. It's just a sign. The students have no idea what we're talking about. So I'm going to give you a somewhat of a tour of Oklahoma as well as a tour of medical education and health care services delivery over the time period, but I need to introduce you a little bit to Oklahoma. So, welcome to Oklahoma, we're ranked 49th in health, and this is at the state fair where they had the donut burger, two Krispy Kreme donuts with a bacon and hamburger and cheese in between, and it was a seller. This is an actual donut burger right there. This person and this person got mad that I took a picture with my iPhone doing that. They knew I was up to something. Well, beyond the donut burger, we also have deep fried butter, which just makes no sense whatsoever. I mean, butter. So we're also ranked 49th in health system performance as well. Clearly diet is an issue for us. So the goals of today's talk, I'm really going to step back a little bit and go through a little bit of the history of health system and medical education design over the past century. The great benefits of that design, but also some of the shortcomings of how we're organized now. An opportunity within health reform legislation for democratization of those health advances. And then we'll do some case based learning with Tulsa, Oklahoma is an example where we've redesigned our medical education system. And we really think there's great opportunities within federal health legislation as well. So over the past 100 years, American medical education has had a great, great century. In the early 1900s, medical education in America was a disaster. It was not well organized at all. And Sir Osler came together and started formalizing how medical education pathways would follow. And the Flexner report came out 100 years ago, and it really married medical education to research and quality improvement. There was a formula for excellence in research and specialization. And over the next 100 years, you saw a tremendous growth of academic health centers. I myself was born in an academic center, health center at the University of Iowa, a wonderful, beautiful place. I was educated there and did most of my early career at the University of Iowa. At the same time, Alpha Omega Alpha, the honorary student society was established really to create a bar for students to shoot for as far as academic and professional excellence as well. So we've really had 100 years of tremendous, tremendous aspirations for excellence in medical education and services. This has contributed, not solely responsible, but contributed to a 30-year advancement in life expectancy in America. That's tremendous. Medical education has become very hospital focused during that time period. And revenues are highest in specialties, manual interventions, and hospitals. That's how you make money in healthcare. You don't make money in primary care. Students are selected that can thrive in this environment and that can afford this environment as Dr. Siegler talked about. And students emulated what they saw. We've seen tremendous growth and fellowship program development really in more and more super subspecialty areas. So here's some trends in federal funding over the past 30 years or so. You see that research dollars have had a nice steady growth in America up to about 16 billion per year now. Graduate medical education funding, the dollars that go to the hospitals that then go to pay for resident education, including our stipends, has had in general a nice steady growth as well. But Title VII programs, programs that are really public, medical care infrastructure, have not done very well over the past 30 years or so. They peaked in the 1970s and really has been a relatively steady decline over the past several decades. And we're starting to see the effects of that. As good as the past century has been, we really do have room for improvement. And as I go out and talk to governors and such, I talk about what I call the four C's of health reform. Whenever we start talking about health reform, there are some things that get pushed to the side as far as reasons for health reform that you have to bring back into the spotlight. It is very important. First of all, cost of health care in America is very high compared to other countries. We definitely have coverage issues as far as who is insured and who is not insured. We do not have enough clinicians to carry the load as we go forward and care quality and efficiency is not good enough. And we'll go over each one of these quickly. So let's go over cost first. Health care in America has steadily increased over the past 25 years at a rate much greater than other developed countries. These are the developed countries. This is gross domestic product over the past 25 years. This is spending per capita over the past 25 years. You see the U.S. in turquoise pulling away from the rest of developed world as far as health care spending. So our health care costs are escalating compared to others. Coverage-wise, we certainly have insurance design issues where individuals can reach their lifetime limits. I'm a psychiatrist. People reach their lifetime limits commonly. You can be kicked out for preexisting conditions and you can be cancelled for coverage if your health care costs become too great. We most definitely have coverage issues as well. We have 47 million Americans who are not covered in Oklahoma. That's 650,000 people out of 3 million. In the Tulsa area, we have 150,000 uninsured out of a population of 750,000. So one in five are uninsured. When Eric and I went through medical school, we didn't know about this research. But you worried about it when you were in residency. But now we know it by funding from the Kaiser Family Foundation. Individuals without health care coverage are twice as likely to be diagnosed late with cancer as compared to individuals with health care coverage. And if you look at these cancers, prostate, breast, melanoma, and colorectal, they all have a screening tool. If you look at these cancers, each one when caught early can be treated through surgery or chemotherapy. If you look at each one of them, if caught late, very, very difficult to treat. So it really is a moral crisis that we have ways to identify these cancers, we have ways to treat these cancers, and still people are dying of these cancers. Let's talk a little bit about clinicians. The U.S. is going to be somewhere between 125,000 and 150,000 physicians short in the next 10 years. We have an increasing population. We have an increase in life expectancy. The baby boomers have an increase in demand. In general, over the past several decades, medical school class sizes have gone down until recently. We have a new group of physicians that I call living off the grid who have decided they're going to do cash-only business. In Tulsa, we have several doctors who used to carry 2,000 patients. I've trimmed that down to just 500, and I've told those other 1,500 to go find a doctor somewhere else. And the business that they, the 500 that they care for, pay a subscription fee annually that they're in their special club. Oklahoma is also 49th in the country in primary care physicians. Care quality and efficiency. We have some high-cost populations who are getting very questionable care. I was just telling Eric, I just got back from the Center for Medicare and Medicaid Services, had some great talks with them. The area that they're most concerned with right now is a population that they call duals. These individuals are eligible for Medicare and Medicaid. They are poor and disabled or poor and old. Nine million people cost Medicare and Medicaid $350 billion. They average $40,000 per patient per year in this population, but the average in the United States is about $6,000 per year. This group is not well managed, and it's clear that they're not getting very good care either. This is going to be a target, one of the first things that will roll out as far as health reform, as far as practice on the streets. There's also great evidence that really we have a group of diseases that get readmitted over and over. Congestive heart failure, COPD, diabetes, and in my field, psychiatry, schizophrenia and bipolar disorder. When we talked to our residents, we polled our residents. They're very frustrated that these populations come in and out of the hospital, in and out of the hospital, and they don't have a good outpatient system to go to for them. Here are some examples of heart disease rates. This is heart disease mortality over a four-year period. The more intense red, the higher the heart disease mortality. You can't even see the borders of Oklahoma. We're obliterated, and you can't even see Mississippi. We're 49th in health status. Mississippi is 50th. So with what you've seen so far is just my introduction with the donut burger and the fried cheese. Where do you think Oklahoma ranks when quality of care is plotted against cost of care? Do you think we're a low-cost, high-quality state? Do you think we're a high-cost, low-quality state, or somewhere in between? Northeast, Northwest, Southeast, or Southwest? Where do you think we are? Well, this is Commonwealth Fund and United Health Foundation. Southeast. You are correct. We rank last in health system performance with some measures of quality and health status baked in there. Here's Illinois, by the way, right there. There's Oklahoma. And we're a relatively high-cost state as far as Medicare beneficiaries. The more intense green, the higher cost of Medicare enrolling. And when you plot it, there we end up, we end up down in the southeast corner. That's where we are. And here's Illinois, by the way. I didn't want to do a red because that would confuse you with OU. So I just put the Illinois red, but I'm certainly not a University of Illinois fan here. Okay. So let's move to health reform legislation. We just had the November elections, and there's a lot of things up in the air. What most people don't realize is actually we have three active health reform bills in play right now. The first is the Affordable Care Act that was passed in March. But the stimulus bill itself, passed a year previous to that, is loaded with health reform. Then we have the 1944 Public Health Services Act, which has been modified over and over and over again. So there's a lot of legislation in the air. And even if this is gone after, these are well down the road. So health reform is going to roll out. Those came together, passed into law, and now the agencies at Health and Human Services, including CMS, AHRQ, CDC and HRSA, are working through all the mandates that came from legislation and putting them into policies and procedures. This is a very busy time at those agencies. They have a huge amount of work to do, and they have a huge amount of control on how this will all roll out. The health reform basics that was talked about the most were health care coverage and insurance reform. Health care coverage, the mandate that 32 million will be now covered, 50% through Medicaid. That's where everybody's getting angry, at least in Oklahoma. Don't tell me what to do. The insurance reform limits, not too much arguing about that in the general population. I was doing grand rounds at the University of Iowa right after the health reform bill was passed, and someone handed me the health reform legislation in five-point font about that thick. And they said, here, read this on the way. And I said, yeah, yeah, yeah. But I took it with me. I was stranded in the Minneapolis airport on the way there for seven hours, and stranded in the Minneapolis airport six hours on the way home. I had 13 hours, there was nothing to do. I read the health reform bill. What I was amazed with was how much was not being talked about that was in the bill, and really how well it actually came together. So in the bill is a lot of efforts around workforce, expanding public health, nursing, physician assistance, nursing, primary care, and federally qualified health centers. A huge amount on expanding access to care, primarily through the FQHCs. A lot of efforts on changing reimbursement around quality of care, changing reimbursement around efficiency of care, changing reimbursement to bundle care together, where primary care and specialty care and pharmacy and nursing and occupational therapy and extended care afterwards all comes together. One of the best examples of that is for hip replacement now. There are pilots out there that 30 days of health care is paid for in one chunk. You have the hospitalization, which you have the prehospitalization workup, and the posthospitalization care all bundled together. We're doing one of those pilots in in Tulsa, and everybody's happy with it. There's much greater detection of fraud, waste, and abuse. There are faster transitions from research to care. And the most exciting part is the Center for Medicare and Medicaid Innovation, which allows communities to come together as far as creativity and health care design and payment. That's a really, really wonderful opportunity for communities to control their own destiny. This is a curve that I'm using frequently with our faculty to explain to them how things are going to change dramatically in the next five to six years. Right now, health care revenue is based off of volume, procedures, specialty care, hospital care, and what you negotiate with the insurance companies. What the health reform legislation does is makes payment based off quality, efficiency, performance, bundling, or working together, and actually reducing expenses. We call this transition from here to over here life in the gap, because it's going to be a very confusing time for hospitals, for physician groups, for the students that are going into residency, you're going to be living this. For the residents that are going into practice, you're going to be living in the gap very, very soon. It's already starting, and there will be a lot of ups and downs and a lot of confusion as to exactly how will this roll out. For us life in the gap, what we see is we're going to go from talk about health reform to actually implementing health reform. We're going to go from a lot of uninsured in Oklahoma to many newly insured, 100,000 individuals with health care coverage coming into the system. We're going to go from individual practitioners to team-based care. We're going to go from paper to the electronic medical record to now health information exchange. We're going to go from volume-based care to care based off of performance, quality, and efficiency. We're going to go from fee-for-service to bundle payments. We'll go from distance relationships with the payers to actually the payers being partners with us. Eric, when I was at CMS, surprisingly Medicare said, we want to partner with you. I never thought I would ever hear that. Medicare was something you just didn't deal with. You didn't talk to. They were a big building over in Rockville and you didn't work with them. They want to work with us now. Let's talk a little bit about Tulsa. How will this roll out in Tulsa? Tulsa's history is very important. In 1921, we had the darkest worst day ever possible in Tulsa. We had a terrible race ride where Caucasian Tulsa went across the tracks and burned down what was called Black Wall Street, which is a very affluent, successful part of town, and really wiped out any momentum that the African American population had in Tulsa. Estimated that 300 people were killed in this. This community of Tulsa is not over it yet. There is divide in our community. This is just underneath the service, and we have not healed on this as of yet. Understanding that is vital for us to actually start working on some of our terrible health disparities that we have in Tulsa. Our College of Public Health started giving us zip code data on where are the differences in health status in Tulsa, Oklahoma. The first thing that they came up with is that between North Tulsa and South Tulsa, we have a 14-year difference in life expectancy, which is dramatic. I live right here in 74114. This is a five-mile difference to 74106, 14-year difference in life expectancy, dramatic. At the same time, Northeast and West Tulsa have about 40% of the population, but they only have 4% of the clinicians. Our number one reason for patients not showing up to our clinic appointments transportation issues, and the clinics are all down here is where they are, but the patients in need are up here, so we've got a terrible maldistribution. So why do we have a 14-year difference? On the surface, you'd say, cancer, heart disease, stroke are three times higher than the national average. It's a lifestyle choice in its poverty. But as you start understanding the community, you actually learn that we have some terrible policies in the state. We have a very pro-tobacco state. We have a rule called preemption that no community can have a tobacco restriction more conservative, more serious than the state laws. So if a community wants to come together and say, we want to ban smoking in the entire community, you can't do it in Oklahoma. We talked a little bit about the strong desire, 73% of the population voted to opt out of health reform. We can say diet, but it's really access to good food and cost of good food. We can talk about exercise, but it's really a safety issue. We can talk about access, but it's really a transportation issue. And we can talk about infrastructure, but it's really failed infrastructure in Oklahoma, where we haven't taken advantage of the opportunity to build FQHCs, economic development, and do a better job with our schools. Our students run a evening walk-in clinic. They've been running it since 2003. It runs about 10 hours a week. And I was shocked when someone came in with this, and we had our derm clinic going, and I said, Dr. Adelson, what is that? He says, that's squamous cell carcinoma. That started as an actinic keratosis. That started as a little scabby thing that liquid nitrogen would have frozen off that even me as a psychiatrist could have done that procedure effectively. And instead, she waited two and a half years. So this is what when we learned in med school, squamous cell carcinoma is really not that dangerous unless you sit on it. This woman sat on it because she had no health care covers. It's now infected. She now has osteomyelitis, and she'll receive a partial amputation from something very, very simple. We did an analysis of where we short on visits. And in our area, we were 130,000 patient visits short a year, primarily in specialty care. We were 90,000 short on special visits compared to what we should have been doing as far as reaching the undersert. So that was the start of our pushing into renaming the medical school, the school of community medicine. Phase one was really all about access. And we put together more primary care outreach clinics. And then we put together an initiative to put specialty care in those zip codes that had no access to specialty care in the outpatient setting. Then we started working on workforce. We added a physician assistant program. And now we've added a four year track within the bigger College of Medicine with the explicit commitment to improve the health of the entire community. Now we're working on model patient care and teaching environment within health reform legislation. Our belief is that we're going to have to modify how we deliver health care to have a model teaching environment for our medical students. We don't want to have a teaching environment that is archaic to compared to where health care is going to be soon. So we're rapidly trying to change how we deliver health care. This is not totally out of line. Case Western put together in partnership with Cleveland Clinic, the Cleveland Clinic Learner College of Medicine. This is a special themed medical school. Really, we're looking at biomedical research. We thought to ourselves, let's do something similar. Let's do a special themed medical school around service to the underserved. So some of the things we've done is we've developed an outreach network of clinics. We have 19 clinics in elementary schools across the region that serve another total of 32 schools. Those clinics we see a lower ER utilization among those those families going to those clinics, lower absentee rates in school, lower family mobility, and increased test scores for the kids that have the clinics in them because the kids stay in school. We developed our traditional hospital based services in our traditional clinics, but we also have a huge amount of outreach clinics and special programs for special populations. So we have 346 docs doing 98 specialized programs at 52 sites across the region. We call it the Starbucks model of healthcare. We have something on every corner. The most complicated one we're working on right now is our HealthPlex, which is putting an advanced outpatient clinic in the heart of the underserved area where we can do chemotherapy, urgent care, cardiac care, but not hospital care. Off hospital location, we think we can do about 70% of what an ER can do. We'll bring surgery oncology and cardiology to that population that's struggling. It's under construction now. It's called the Wayman-Tisdale, especially health clinic. If any of you are NBA basketball fans, Wayman-Tisdale from North Tulsa died last year from bone cancer. It was a great jazz musician as well, but we named the clinic after him. So things are going along great. We're thinking we're in great condition. We start putting formalization to the medical student experience of a four-year track within the bigger college. We recruit for altruism and surveys show that in the environment we're teaching the students, altruism is holding up. We're comparing ourselves to the other track within the medical school. Altruism is diving. We have scholarships for services for all specialties. We have an MPH program integrated in. Students start medical school with what a six-day course called the Summer Institute where we teach them the anatomy of the community before they learn the anatomy of the body. So they understand who they will be serving. We have two student-run clinics. One is an acute care clinic in the evenings and the other is longitudinal team-based care where the third and fourth year students will have the same panel of patients over those two years and they do it with the nursing, pharmacy, and social work students as a team. Then the day-to-day environment out and about in the community and then they have research capstones on community health as well. We're all feeling good. Things are going great. And then things changed dramatically for us last year, earlier this year. In one week's time we got a very negative newspaper article on OU's Tisdale Clinic from the North Holston newspaper citing failure of OU's leadership. It was the same week we were doing the groundbreaking on the Tisdale Clinic. We were scheduled with the Tisdale family coming in from across the country. The mayor was there, president of the bigger university. It was also the same week that I was scheduled to be the grand marshal of the Martin Luther King Parade. So I'm stressed out big time. And the faculty said, what are we going to do? And I said, folks, this is what community medicine is. Community medicine is being out and about in the community and listening and weathering. Well, here's a little excerpt from that newspaper article. The title was, is Tulsa North being pimped by OU? To Tulsa North Rescue, Oklahoma University has come. Unquestionably, medical care is needed in Tulsa North. Why then pose such a negative question when OU appears to be doing the right thing? Our answer, pimps use the bodies of women to make money. For whatever reason, the women are vulnerable. The residents of Tulsa North are very vulnerable because of their poor health outcomes. Hundreds of millions of dollars will be spent ostensibly for better healthcare for North Tulsa. Who gets the money for such an endeavor, OU will. Who receives $20 million for building the facility, Manhattan Construction. If a healthy community is the goal of OU, does it not recognize that a healthy community involves more than improving traditional healthcare facilities and services? A healthy community must have a good economy, a chance for good jobs for its residents. Tulsa North's personal sense of well-being and its ability to thrive socially and economically are tied together. It's impossible to have a healthy community without a strong educational and economic engine in its midst. Why do we pose the question is Tulsa North being pimped by OU? Do not pimps use bodies to get income. OU will receive income from treating sick bodies. When will OU learn that the elimination of healthcare disparities among population groups is not a zero-sum game? How do you think the faculty and leadership responded? We got mad, mad, you know? We got mad. I couldn't help it. But also mixed in the mad was embarrassed and definitely a boy, we weren't listening to something. Boy, this is a big lesson for us to learn. When we met with the legislators and the leaders of North Tulsa and the writers of the article, the key line was you don't get it. We want you to bring the full resources of University of Oklahoma to help us, not just clinics. Bring business, bring architecture, bring education. Make it so North Tulsa companies build the clinic. And this has really been a turning point for our medical school and for our campus. The leadership of OU, including President Bourne, is really engaged now. It was a call to arm. It was a wake-up call. We've worked a lot with Penn in Philadelphia, broader University, and they had similar experiences where there was a crisis of conscience and culture at one point. And the question was, are you going to work through it, are you going to back off? They worked through it, we worked through it, and we're much better for it. So we really changed our architecture of our campus and our medical school. Of course, we are working on access to care. Of course, we are working on workforce. Of course, we are working on safety, quality, and efficiency. But we started working on linking our efforts to the broader determinants of health. Education, urban design, economic development, safety, literacy, and early childhood. And we're a much better school for it. We now integrate within our medical school initiatives, our early childhood programs, our urban design programs, pharmacy works on health literacy, our social work works on family, stabilization. And it has been much better for us as we've gone forward. So Ground Baking Day did happen in that week, and it was all a happy event. It was really almost a healing day where more leaders in Tulsa were in North Tulsa than had been there in probably 90 years. It was really a great day. This is Regina Tisdell, the wife of Wayman Tisdell. This is Wayman's brother, Weldon Tisdell, the lead pastor in North Tulsa, a wonderful, wonderful man. These are legislators. This is Tedra Williams, our clinical nurse manager for the Tisdell Clinic. Her granddad was a race riot survivor. It's the mayor. Just a great day. This is the Martin Luther King Day parade. Had a great day. And we started actually paying greater attention to all the different initiatives beyond the medical school that we were working with in improving economic vitality within our community. We changed how we build the building. Instead of just putting things out for a bid like the normal university policy is, we gave points for local participation. The highest amount of local participation for construction of clinics or any buildings in North Tulsa in the past had been six percent. We got it to 24 percent, which was very good. The city council called it a game chaser. New pharmacy next door to where the clinic will be. We started a new initiative called Taste of North Tulsa that highlighted all the restaurants as far as healthy food options. That was a great event. And our urban design studio is now working with community members on redesign of the community for a much healthier community. It's been a great experience as well. On health reform, there are some big opportunities as far as payment modifications that will line things up and hopefully get the incentives in the right place as well. We talked a little bit about this at the beginning. The Center for Medicare and Medicaid Innovation is going to be looking at special populations that are at risk. So when I was cycling a bike, the name of our program was called Impact. And we provided daily outreach care to a group of patients with very, very severe mental illness that were just on the edge of not being able to live independently in the community. We had an interdisciplinary team of doctors, nurses, social workers, substance abuse specialists, and actually client peers. We go out and do that care daily. And the nice thing was we pretty quickly reduced symptoms, improved independent living abilities, improved patient satisfaction, and we saved the system $15,000 per patient per year by delivering care differently than before. The Feds are now going to be looking for the same thing with this dual eligible program, dual eligible population. Opportunities for the University of Oklahoma, opportunities for the University of Chicago right now are significant within health reform legislation. And they really fall into three buckets. The first is the Federal Agency called HRSA is putting $11 billion into health workforce expansion, physician loan payback, and clinic expansion. The Center for Medicare and Medicaid Innovation is putting $10 billion into initiatives that decrease costs, increase efficiency, increase quality. And then CMS with local or with state Medicaid programs will ensure roughly 32 million Americans across the country. What we use that as our starting point to put together our strengths of our community to then hopefully build a much more rational healthcare delivery system in Tulsa. But the bottom line is our goal is to create a model healthcare delivery system for teaching the next generation of clinicians. So getting back to where we were with democratization. This is age adjusted death rate over the past 25 years. Death rate in the United States has dropped very nicely, a 30% improvement in death rate in the past 25 years. The age adjusted death rate in Oklahoma has only improved 11%. Something happened in 1992 or before that, that we started diverging from the rest of the country. I can't answer what that is, but it's probably multiple, multiple factors. But it's clear whatever is happening across the nation as far as improvement of health, we're not enjoying it in Oklahoma. So one of our missions is to catch up. Last week of the double AMC, Dr. Fitzhugh Mullin. Dr. Mullin really got national attention earlier this year because he put out an article in Anals of Internal Medicine that ranked medical schools by their ability to meet social mission. Well he was really a popular speaker this year at the double AMC, which shows that people have great interest in what he sang. But his closing comment was in the 20th century, science and medicine combined to create great benefit for humankind, leading to a 30 year expanded life expectancy. The imperative of the 21st century is the democratization of those benefits, so making sure everybody gets the benefit of those improvements. So my famous quote after that is, health reform legislation provides an opportunity to begin that democratization. With underserved communities like Tulsa, New Orleans, South Central LA, South Side Chicago, Detroit, Camden, probably standing to benefit the most if we can get organized. And I think that's a great topic for this series which starts with ethics. And this is ethics of populations. Well, I hope that was entertaining. If you don't mind, I would just like to hear more narrative about the article that you referenced. I mean, were you completely blindsided by it or had people reached out? I mean, it seemed like it was very strong on opinion. So was it reported or was it an op-ed? It was a front page story. I was tipped off to it the night before. And I think the intent, it was very intentional in when it was planned to really draw attention. And it was very successful in doing so. I mean, we really responded to it. Rather than trying to minimize it, trying to ignore it, we had no choice but to recognize it with those two big events coming. Martin Luther King Parade and the groundbreaking, it needed to be addressed. And I thought it was actually brilliant as far as how they timed it. Since Mark mentioned you had a three-hour conversation with your conservative governor, I'd love to hear more about what that involved, if you'd be willing, and how you expect the future to go forward given this scenario. That's a great question. It kind of starts with, I think of many of the, of all the medical specialties, one of the most misunderstood is psychiatry in the first place. So I'm used to being misunderstood in the first place.  I think that's where we are with explaining to the general population, the health status of America, how out of step we are with other countries, and what opportunities are there to improve things. So my conversations with our very conservative Oklahoma legislators, all of them are very conservative except for Dan Bourne, has really been educating them first and foremost. There's a lot of benefit in here. Rather than being so philosophically for or against, take some time and look at all the benefit that's in here. 80% of what the Republicans wanted in the health reform legislation ended up in the legislation. I mean, there was a huge amount of overlap. I mean, there really was. So my greatest frustration is, this is not about logic. This is not about what's best. This is still political maneuvering. And unfortunately, healthcare is being played as one of those pawns in political movements. And we need to make it a moral issue. We really do. If you think about this country, every 50 or 60 years, this country gets itself ready to take on a major civil rights initiative, from independence to women's rights to civil rights. Every generation or so, we take on something that is significant as far as civil rights movement and maybe the unfairness of health. Maybe we're ready for that as a country. I'm certain that you and Eric and Sarah Ann and Dorianne have spoken about ways in which your program and Tulsa and our program here on the south side might intersect. I wonder if you could say just a few words about that. This really was started by Eric. Eric invited me in September of 2009 to be part of the University of Chicago's set of symposiums on education and healthcare in Washington, D.C. last year. He invited me. He invited Joe Greer from Florida International, a physician who had won the Presidential Medal of Freedom. And when we three got together, it was as if we'd known each other for 20 years as far as what was important to us. You have Joe Greer coming? That's number one. Get ready. He's a lot more entertaining than I am. But from that we said we need to get together and what Florida International is trying to do, what you're trying to do, what we're trying to do is very similar. Eric knew people at New Orleans at Tulane. I knew people at New Orleans and Tulane, so we invited Tulane as well. Rand Corporation knew Eric and Eric knew Rand. Rand suggested Wayne State University in Detroit as well and Charles Drew University, UCLA, in South Central LA. So we have six communities that really have urban underserved populations with medical schools embedded in them that those medical schools really have an opportunity to play a leadership role in raising the health of that population through their clinical services, but also creating a new generation of physicians that are ready to take care of that population. And it's a really lofty goal. We've come together twice now as far as summits. They've gone very well. And as they've gone well, people are hearing about it and wanting to join in. Now Denver, University of Colorado wants to join, and Camden, the new medical school at Camden wants to join. So we think we're on to something as far as at least one arm of what medical school leadership should be taking on. Kind of like Case Western Cleveland Clinic, not every medical school needs to do everything incredibly well. You can have themes, you can take on submissions within the broader mission and do it very well. I just wanted to find out what lessons you've learned from being a part of the University Oklahoma system and taking this particular focus. And is there things that you could teach us? And secondly, you've been, I would say, blessed by having a benefactor who wrote a very large check and dialed faculty that allowed you to recruit people from all over the country. And to what extent do we have to look for those kind of angels as opposed to getting your state school and you likely wouldn't have gotten funding through state channels? You know, how do we replicate this? So that's a great question, Eric. How do you go forward with this? Starting point for us was data driven, understanding the data, the health status of the community by data. But that alone was not enough. We also needed to understand the emotion, the culture, and the history of the community as well. So the traditional knee-jerk response of most academic institutions is data driven, we're right, we're really smart people, we'll take care of things. But if you slow down and listen to the community and learn the history, learn the culture and get real feedback, now you've got good balance. You've got good data and you've got understanding. So I think that was lesson number one is those two have to have to integrate with each other. The second lesson, I think, is you've got to tell the story over and over and over again. So this is a brand new talk. I can give them this talk tomorrow for the Oklahoma Hospital Association. Now they're going to get glazed over on this real quick. So you have to be very repetitive in the talk. I think the third getting to funding is the ability to talk with multiple leaders at multiple levels. So we've talked to CMS, we've talked to the AMC, I'm in the Chamber of Commerce, I'm talking to the governor, and you've got to talk it to multiple, multiple power brokers. I think it's an important lesson. I think the next lesson is you've got to go where the money is. And right now the money is not at the states. The states have no money. Private philanthropy is coming up a little bit right now. They've had a pretty good year. So there's some money back with private philanthropy and clearly there's money at the federal level as far as opportunity for at least seeding funding to go forward. So I think those are some of our lessons. Good question. Yes, sir. It seems to me that part of the problem is in the funding stream that if you have the majority of funding through private for-profit organizations, you will always have disparities. Have you looked at, first, there are some states that are experimenting or at least there are some proposals for single payer systems? And what have you looked at other payment mechanisms other than bundling and efficiency that might decrease specifically disparities?  The business is here. Everybody's here is sick. Yeah. I think that's a great question as well. We're just starting to dip our toe into, it's kind of our, so I showed those different paths that we're working on, access, workforce, quality, safety, efficiency, linking to the broader determinants of health. That's our next chapter that we're just getting into is how do we work with payment to make it work right? Fortunately, we're a relatively small state. Oklahoma's got 3.1 million people. Oklahoma Medicaid really likes what we're doing, so we think we can really do some creative things with Oklahoma Medicaid. Oklahoma Blue Cross Shield really likes us as well. So we've got two major payers, but what exactly we'll do, I don't know yet. I mean, it's a great question of how do you align incentives to get the right behaviors out of the clinicians and the right behaviors out of the patient? I don't think anybody's cracked that note yet. I think that Obama mantra of keep hope alive is when you think about educators who've been trying to keep students and residents in working in underserved community, it's keeping altruism alive. And so how do you keep that going in medical school? What are the things you do to keep that going? Great question. Yeah, question is how do you keep that altruism alive? Several layers. The student that really has the calling in the first place, that's helpful. Student that altruism is not new to them, so that's helpful. The environment that the students learn in is key. You can't talk one way and walk another way. You have to walk and talk the same way on this. I think the very first days of medical school are very important. It's as if you go back in childhood and they are very formative years. I remember the first day of medical school like it was yesterday. I mean, I was so nervous and so amped up and I mean, I remember it very, very well. So the setting the tone in the very first days is very important. Dr. Siegler and I talked about this. There needs to be greater attention to the career paths that altruistic physicians want to follow. And it was the start of our loan payback program. Why penalize someone who wants to be altruistic and do good work? They're not asking for a whole bunch of money, but they're asking to be at least taking care of someone as far as debt. I also think we have to pay great attention to the patient care teaching environment that those faculty are in so that they can do it for the long run. I think it's one of the areas that the federally qualified health centers across the country and the National Health Service Corps have struggled with is that they have not paid attention to the environment you're going to be in. One of my good friends in medical school was sent to Northern North Dakota right on the Canadian North Dakota border and he's bitter still about it. It was a terrible, terrible experience for him. And whereas I did my Air Force time in Rapid City, South Dakota and had a great experience because the team that I was with, I was not isolated. I had a great, great experience with that. I do think pairing academics and service together is a nice combination. I'm in academics because I love the students. My wife knows when I've had a good day because I've been with the students. She goes, you've been with the students today, haven't you? Because I'm in a better mood. And that happens to almost every academician. The more time you have with the students, they are just uplifting. They're the next generation. They are wonderful. They are eager. They keep you on your toes. And I think pairing service with medical education is a wonderful combination that gets ignored. Within the health reform legislation is a new set of programs for the FQHCs to become teaching health centers. Waco has done it well. Boise has done it well. And Billings have done it well as far as family medicine residency programs. But it looks like they want to do more of those. And I think that's a real important piece to take care of. Good question though. I work a lot with our medical students on campus and some of their extracurricular activities. And I know that your campus is shaped a little different. I know a lot of the stuff that you guys probably do are very service-driven. I was wondering if there was any unique or just interesting extracurricular activity that your students are doing that isn't necessarily part of your direct medical education, but it's one of your strongest programs? No. Our students have a choice of going into the traditional program on our track. I think those that choose our track in the first place are a little bit more risk takers, maybe a little bit more mature. They're very committed in the first place to doing it. They really own our student-run clinics. And we staff those clinics with physician volunteers. The faculty come in as volunteers. And we put it on the students to do the recruitment of the faculty. And boy, do they get ticked off if they get mad at the faculty. So I think those are some of the pieces that are unique. But as far as extracurricular activities, we really let the students kind of take care of it. I don't meddle too much. Good question. This is a bit unrelated to what you want us to take home from this conversation. But earlier in the presentation, we talked about the cash-only practices and how doctors were some of them moving towards that. I'm wondering what happens to those patients when they need surgeries or something more that's not with their primary care doctor, or something like, how does that, how do they account for that in the system? Because surgeries and emerging care are very expensive. And I just, how do they, how do they figure that out? I guess it's my short question. Well, the patients don't come off the grid, as I call it. So they're still in shirt. So the patient plays a $1,500 a year subscription fee that he is in that physician's club, but they still have their commercial insurance. So those physicians are clearing between $500,000 and a million dollars before they see a patient just by having the patient in the club. Then insurance is billed on top of that. What we've seen is six or seven docs have done it in our local area that previously had about 2,000 patients in their panel. They went down to 500. Those 1,500 they got left out are desperate to find a doctor. It's really tough, really tough right now. Jerry. Hi, Grant. Can you talk a little bit about the viewpoint from either the Tulsa Department of Public Health or even the state of Oklahoma and your approaches to community medicine and their thoughts about health disparities and health outcomes? Great question, Dorianne. Our Department of Health locally, our county Department of Health has actually gone from really being a provider of primary care and actually downsize that dramatically. They really are in surveillance, vaccination roles right now. They've not really decided to get back into health care. So they've almost become a non-factor as far as delivery of health care. They are with us in the schools on the prevention side of things, but we struggle to really work well with them so far. We've not been able to accomplish that one yet. We're not there yet. The state health department, what we did was hire one of their associate directors as a part-time faculty member with us to create those relationships so things would start going. We'd be planning together. We just started in that. I had a question about the different tracks. How is there cross pollination between the sort of community tracks and the traditional med students because you worry that there's this dynamic group of people who are really on fire and really motivated and mature, who never interact with their peers to get them there or to expose them to it? Well, they're back and forth to Tulsa and Oklahoma City a fair amount. They do know each other well that way. They do a lot of coursework together in the first place, not as if they're entirely separated. What has happened is that as the community medicine track has done new things, the other track has said, well, we want to do it as well. So it's actually stimulated them to do things alongside that so there's not much of a difference. LCME right now, we're still accredited as a track within the medical school, so the LCME does not let us get too far away from what they're doing anyhow. Can I ask some questions? Yes. So Eric, you've just been to DC. What are your lessons from DC? So the double AMC meeting just in, is this still going on or is I left? So I don't know if it's still going on. So on Sunday I did a talk on a panel at the double AMC, the Association of American Medical Colleges. The panel was focused on health care reform and how research can inform patient experience, the health of populations. We talked about the work we're doing on the South Side and also some of the things we're doing jointly. To a room of maybe about 300 plus people, it was a really nice crowd. And I ended up getting approached by the University of Michigan and other major academic centers trying to understand more about what we're doing. And then the next day I went to meet with the folks at HRSA that oversee the Fairleigh Qualified Health Centers. And the way you're presenting, the way we're thinking about our South Side Health Care Collaborative where there are 33 community health centers working collaboratively with us and other hospitals on the South Side is where they're trying to move. So it was clear to me after spending, and I was supposed to be there an hour, I spent two and a half hours with them, that they think there's some fertile ground and they were asking about were we affiliated with our effort because I don't know if you all had just been there the day before or whatever. I also spent some time with the folks from the Congressional Black Caucus. They have a health brain trust and a group of Congress persons who bring together innovative folks in health care twice a year. And so I know we've gotten invited and hope to have Dorian Miller and some of her work just recently with the community on mental health and a play that Dorian wrote and community participants participated in and brought the best of the cutting-edge mental health services or I should say evidence-based mental health as well as the resources that are available in our community. So they were really jazzed about that and want us to have Dorian and some others come make a presentation in April of next year. So I didn't get a chance to go to the meeting with you to the Centers for Medicaid and Medicare Innovation but it's clear we're in the right spot for where health care reform is going. The other person I met when I was in D.C. was Don Weaver who's the head of the National Service Corps. Our REACH program which pays about $40,000 a year for each of four years for our graduates who practice in this network of clinics was something he was excited about because it dealt not only with primary care but also with subspecialty care. Holly Humphrey presented a paper at the W.A.M.C. meeting that also was well received about REACH. So I think that between Tulsa, our work, New Orleans, L.A., we're in the sweet spot of where health care reform is going. I think so too. That was one of the things that I really noticed is that at the W.A.M.C. this year there was a real energy about medical schools playing leadership roles in improving the health disparities. It was stronger than ever, stronger than ever that I've ever been in. I've been going to W.A.M.C. now for 14 years and clearly there's a swing as far as national intention of medical schools to play role. I think this has been a wonderful discussion, great questions, great presentation. Thank you again so much for coming up.


Hi everyone! Today we'll talk about the technical side of creating an online travel agency. Don't click away, we're going to explain some interesting behind-the-scenes details about the works of travel market. My name is Andrey Chebotarov and I'm travel technology competence leader at LTECsoft, and I'll explain you the basic functions of a booking engine and the challenges that arise when building this tool. It's called an engine for a reason. You see, searching in booking online should be automatic, otherwise people would still be going to travel agents' offices. So, an engine exists to carry the load and do the hard work automatically in the background. A booking engine requires lots of engineering efforts and something else to build. Basically, building a booking engine is maneuvering a few complex layers of an OTA and combining them into one mechanism. What are those layers? First, integration with suppliers. Second, search rules. Third, pricing changes. And finally, booking and ticketing flows. Let's start from the foundation, connecting to suppliers. Inventory providers are each OTA's main treasure. They may be global distribution systems, individual airlines, hotel wholesalers and so on. As I explained in the previous video, it's important to have individual agreements with at least some suppliers to get best deals and survive the competition. It takes months of negotiations to establish exclusive conditions and obtain advantages commissions to keep the end prices competitive. But there's a technical side of things. To make, say, flight search available, you must be integrated with the global distribution systems via an API. A booking engine has all those integrations and controls plugged in and it manages how searching booking happens on your website. These integrations allow you to do a number of things. Request for inventory, flights, hotels, cars and others. Check availability for this inventory. Get prices. Book those products. Receive tickets for them. And then an ancillaries. So the integration layer takes care of how and where you get this raw information. Usually you are integrated with one or two GGS's, several hotel suppliers if you sell hotels and several other travel product providers. But integration themselves don't define what exactly travelers will see when they search for flights or accommodation. It's a booking engine and its settings define which results to display. So how exactly does search work on OTA's? Let's say a customer wants to find flight tickets. You can just suggest generic results with standard prices which are fairly the same as different suppliers, but it's not very efficient if you want to stay competitive. So a booking engine is as smart as you make it. To know where and how to search, it should use a handbook of business rules that allow you to narrow down the search using specific parameters. And obviously an OTA staff must be able to manually tweak those rules for different cases. For instance, you may define that travelers that booking flights across the US would see the results that you source from the Saber GDS. And those who travel to Europe would see the results that Amadeo suggests, because you have better deals for these destinations for these suppliers. It's usually more complicated than that. Most OTA's may use multiple travel agent IDs to access different suppliers' inventories, as each ID may have different negotiated deals tied to them. Working with multiple suppliers is also a challenge. You must aggregate data from many sources, and if it intersects, for example, you can get the same hotels from different suppliers. You have to map them to each other on your end. And on top of that, you can augment search results' page with personalized offers for some users. If you know that this particular traveler usually looks for quality flights, results' page can automatically prioritize these over-budget deals. To wind up with a search engine, it's a complex mechanism that does two critical things. It decides where to look for the products that a traveler requests and what results to display. What the search engine doesn't do is defining pricing rules. Okay, this may get a bit confusing. If the search engine is looking for deals considering the prices, why do you need separate pricing rules? You see, you get products from suppliers for their prices, but you still have to get some margins selling them, right? That's where pricing rules are used, to adjust OTA margins that come on top of the supplier's price. In travel, prices are fairly flexible. They can dynamically change, and an OTA can tweak the pricing rules. On owned platforms, you can consider a ton of different factors to set them up. For instance, you can adjust your margin based on current demand, your inventory suppliers, competition, season, the sources from where your customers came from, you name it. Rule-based, or with machine learning, these techniques allow you to keep balance between competitive pricing and profitability. The most common example is adjusting pricing for meta-search engines. Smaller OTAs allocate the biggest share of their marketing budget to get listed on meta-search engines like Skyscanner or Kayak. Most of your visitors will actually come from them, so managing how your listings appear there is an important task. You, of course, want to display the cheapest price for some destination to reach the top of the search results, because there is a whole list of other OTAs like yours on the same page. So you need a dynamic pricing strategy to pass competitors and keep the business profitable. Marketing and revenue managers analyze all those factors to come up with flexible pricing rules. Another level of complexity with dynamically changing prices is how to keep them up-to-date. Your suppliers change prices and availability, you change margins, and it means that displaying real price all the time would lead to a slow processing. If you process the search results for a couple of minutes, most likely your visitors will leave for good. So OTAs usually batch prices and cash them to increase processing speed. And yes, most of the prices that people see on the OTAs results page are cashed and don't necessarily display the real current pricing. But if you update the cash regularly, this trade-off between the speed and up-to-date info is worth it. So you have to constantly balance between these two factors. At the end of the day, pricing rules is one of the most intricate mechanisms of a booking engine. Since it defines how to balance between the competition and profitability, you and your revenue managers can't mess this part up. Okay, those challenges concern the search alone, but the main task of a booking engine is to manage, well, booking flow. What's the challenge here? A booking flow is a set of consecutive steps from the availability search to the transaction. From the UI point of view, it might be the same regardless of the supplier, but on the back end things aren't that simple. Usually you would have multiple booking flows depending on an inventory supplier and other factors. For instance, we at Altecsoft have experience with OTAs who work with two different GDSs and each GDS has its own booking logic and specifics. That means that under the hood, the process varies depending on each individual GDS, bad bank or any other supplier. How do you request booking? How do you generate passenger name record? How do you chain messages via an API to keep them compliant with the rules of each individual supplier? How do you process payments? Setting up and plugging in new booking flow leads to architectural changes. Learning how to integrate two or three booking flows is manageable. But as your list of implementation growth, your engineering team ends up in a difficult position, trying to maintain old architecture, develop new business logic and keep it all working smoothly. Besides, you have your own business workflows that have to be aligned with external ones. But booking isn't ticketing yet. You can probably guess what ticketing does. Ticketing is issuing a confirmation that the seat was paid for and belongs to a particular traveler. In the era of electronic tickets, all passenger and flight data is kept in the airline's passenger service system, while a document that a traveler receives early are a seat. It seals the whole deal. Usually, ticketing happens some time after the booking. This time gap is needed to check if the passenger information is valid, the credit card is fine, and there weren't any other problems in the booking flow. OTAs can issue a ticket if they have an IOT accreditation, which is expensive. To bypass this accreditation headache, some OTAs partner with consolidators or other IOT agencies to do ticketing for them. Let's quickly sum up. A booking engine is a massive machine to interview. It needs mechanisms for smart search and flexible pricing. It's responsible for connections and booking flows with different providers. It's also responsible for payment and ticketing, whether you do it on your end or delegate to third parties. And this machine always keeps changing and scaling up. Building a booking engine is difficult, but possible with smart management, a talented team and domain experts. I hope this video helped you understand the processes in the heart of an online travel agency. I hope you enjoyed it and see you in the next video.


Wonderful. Well, thank you all for incredible reflections on what potential solutions look like. I was charged by the team with trying to summarize everything that went on today in five minutes. And it caused me to realize that virtually every one of our panels, maybe every one of our panelists, their main points, each of which could be an entire day-long session to really dig into. So I'm not going to do that. But let me, you know, a couple of things that really came through to me in the conversation. One is really the criticality and the clarity of the voices that are coming forward now in terms of patients and practitioners, whether it's the physicians who are taking care of the patients, the pharmacists who are there to serve them on the front lines. Those are really the stories that are going to drive the dialogue as we go forward.  And so that's really quite critical and I think we heard that today. You know, from the explaining the problem panel was fascinating. I think we got a great understanding of how complicated it really is. And yet, and I think we heard this throughout the day, everything circles back, as Lauren said, to everything hanging off the price and the launch price. And that's at the root of the problem.  I think we heard the critical, I would say the public opinion. This is a politically attractive issue and therefore there is the opportunity to try to push policy in the space as we go forward. I was really touched by Steve Pearson's comments around looking at the entire drug ecosystem and the need to look at it as a whole, pricing still being at the center. But also, as he just said, many of the players inside of that drug ecosystem are increasingly uncomfortable with the established economic relationships that have been there for a long time. I mean, we're all here. Many of us have imperfect economically rational incentives and yet we see there's a huge problem that needs to be addressed beyond the cold-hearted economics of it. Lauren, your comment on there's no one solution, I think, is something that I've always said that shouldn't stop us from dealing with the problems that we know are in front of us. I think Representative Salinas, your points on, what I took away from your points is the need for persistence in this space. Persistence, timing, and continuing the educational process so that policymakers have a better and better understanding both of what the problems are and what the potential opportunities are. Jane, I thought your explanation of existing law and regulation being a real barrier to states took me back in time to when we used to talk to each other when I was still a puppy lobbyist on Medicaid Best Price. Thank you for saying that. It's never a complete meeting for me until we have some kind of dialogue around Medicaid Best Price. So thank you for that. But you also made the point on having the creativity to address the holistic around all of this. Amy, thank you for reminding us that the pharmacists are the ones who are actually there with the patients, and there's an absolute need for that all the time. And, Rena, both the comments that you were making today and the conversation that we had offline, one of the things that I do think is underappreciated and demanding far more attention is whether the system that we have developed to finance drug development is leaving a whole lot of stuff on the table that could be of value for society and for individual patients and the economic expectations, in my view, and at some point you and I will go and sit down and argue out our varying perspectives over some period of time. But I think we're actually in pretty close alignment. The way the system is set up now is targeting investment in a relatively small number of potentially extraordinarily profitable innovations and leaving a whole bunch of stuff off the table. And so we need to really, and this goes to pricing, but it goes beyond pricing, to thinking about how will we get back to bringing the pharmaceutical industry to being as innovative in reality as it potentially could be. And that is at the core of much of the problem, and I think you described it as re-engineering the system to serve this true masters who are the people who live in our country and the people who are responsible for taking care of. So there's a whole, I made a list of many other things, but I don't have time for all those things. But I do think that, again, our time today did reflect how valuable it is to pull us together periodically to talk about problems that we see, things that we mutually are all very concerned about, and I think this will just be a continuation of a dialogue that we will have. The team had pulled together a couple of slides in the interim showing it's not just when we sit down together. There's plenty of virtual conversation to have, so I urge you, if you're on social media, to try to continue that conversation. And overall, I just want to thank everybody for so many of you sticking with us for the whole day. Clearly, we have more work to do, more conversations to have, and as Norm Ornstein told us, there is some light at the end of this tunnel and we should keep driving at it. So thanks everybody for being here. Take care.