Good morning. I assure you that being director of oncology anywhere so is and no preparation whatsoever for the talk. I'm going to give you this morning. I guess I best lists of my credentials for being here this morning as I somehow like all of the rest of you and I having grown up as part of a larger society than just Physicians and patients. I would hope that my presentation this morning comes more across to you as an anthropological one rather than one of medical expertise as they were commenting earlier if I had to look at myself as of a person through time, I would see myself as Having learned to think of you having learned to manage and lead in the Marine Corps and learned how to drive nails and saw Wood Medical School. That was my trade if you wouldn't. I'm trying to look at the physician trying to look at Healthcare and trying to look at a place in society. I think I might point out to you that about the 1972 80 some odd years ago. It was well documented that there was a man in time who was known by all of his contemporaries and shortly thereafter as both a Healer and a priest the many people disagreed with him at that time, but it was singularly clear from all the writings of biblical days that there was no separation between the concepts of healing and priesthood or a faith. This is not unique to Christianity. It is singularly to the judaic tradition before Christianity and it can be found in essentially every culture that is studied. Other than the Christians you jack off. Sure. You will find that the shamans The Magician's the people who have the magic of the tribes are not only respected but they are feared and held as though they are in communication with some power which transcends and is beyond the capacity the native characteristics of the humanity of the remainder of the tribe. If you think that this is all old history, I might point out to you that until the current century prior to the year. $1,900 was essentially only one medication that worked. The only medication in the entire farmacopeia that work was digitalis and weathering got that from a witch. A wet should had it passed down through a family for centuries and how weathering Came Upon it and got it away from her. We do not know. But it gives you some concept of the depth of scientific inquiry available to Medicine prior to the 1900s. Prayer to the 1900s there for medicine was characterized by caring. not by Keurig Physicians were known for their concern for their patients. In fact, I was once on a Podium with an attorney who in leaving the podium and turn it over to me said I'm now introducing Richard you to off position who I would like to remind that him in before he gets off the his professional ancestors were busy bleeding their patients with all manner of devices while my professional ancestors were writing constitutions. A point well taken but then I was able to remind him that the singer thing we know about George Washington's physician was at the physician cared was available stayed at the bedside and knew when a great man had died and knew that he had ministered to him. There was then that Union of priesthood and that Union of caring which we called medicine the introduction of scientific medicine changed a few things. We sought out the highest performer in high school and we said to him smart young thing. You ought to go to medical school. And so we want you to go to college and we're going to get you a scholarship and you get them off to go to college in the first thing you remind him is it if you're in a pre-med car, she's got about one chance and 13 of getting into medical school. And then you say them if you don't get an A in organic chemistry the first year you were here just forget anything about medical school and then we saved them if you're a top performer if you're a 3.4 3.7 a 3.9. You're still only got one chance and four of getting into medical school. A woman just took suit in, California. She had a straight-A average. She was a Russian immigrant. at age of 16 she got turned down in medical school and she couldn't believe it not Native American woman and straight a average what they find out they had more qualified people for so you take that group of people who have totally isolated themselves from playing football or basketball or cheerleading or being socialized tackle traded people participants in society. You don't get into medical school by singing on the site Olaf choir used to get it by sitting down there and grinding out that straight 4.0 average you throw me into medical school and every Professor stands up there and says, I'm going to give you the wisdom of the ages and you've got to know everything I know about pediatric hematology. Well, you only need a couple of pediatric hematologist in the entire world. No less having every physician it ever comes up be a pediatric hematologist. Why you can change it? You could make it a burn Specialist or whatever. Every person has got to know what what makes the ganglion that lies on top of the salivary gland different from every other ganglion in the body that I've yet to meet many Physicians that no weather makes a damn difference. somehow the pressure of everybody doing their thing leads each position to believe it has to be totally competent totally prepared invulnerable and incapable very make a sandwich clinical years in the clinical years some unique things happen. He doesn't ask every ridiculous question and hasn't ordered every ridiculous testes demeaned in front of the face of all of his peers because somebody thinks of a test they forgot to answer or thinks of a disease that they forgot to appreciate and take into account and then they're thrown into a great pit called the clinical past pathologic conference and the game of a clinical pathologic conference is to give you all the data in a vast array. And then you and you alone must find out what's wrong with the patient and cure that patient Fortune answer paper exercise. What is a paper exercise because unfortunately in medical school no one ever tell someone that the proper answer door nor logic problem is to know the telephone number of your friendly neurologists, since you're going to be a general surgeon or a pediatrician or whatever. That's an accepted you flunk. So you work your way through a residency and suddenly you get out and you walk up to a patient and you say to that patient. They know I just found a lump in your colon your breast of your lung and I'd like to take your breast off your colon out your long out. And I'd like you to sign this little paper that says you may that I may use my appropriate judgment to conducting a reasoned operation to best provide you with cure for this particular procedure and at that point in time. The patient suddenly gets a vested interest in the physician. Is there a one of you here who would sign a paper like that thinking that your doctor was a dunderhead? Could you conceivably sign a paper allowing me to operate on you to that extent thinking that maybe I'd never seen anything like that before? Then maybe I didn't know what I was doing course not and so by virtue of signing that piece of paper you get a vested interest in my being infallible. It's all you say to me. I'm so lucky to have such a great doctor. Tell me you're great. I hear your name on the page system all the time. There must be lots of people to want you. I am so glad that my family doctor sent me to. Because expectations. I got a lot of just you I just building up everything that's happened to me since I got it in the high school, you know. Then along about two days later. I walk out of the operating room. And your family says did you get it all? Am I going to say I'm going to say 4 years of pre-med four years of medical school five years of residency 10 years of experience and I can do a thank you mother. She's going to die every cancer anyway. How do I go about telling the whole bunch of that? I'm a fraud and a failure that my that I'm a 250 hitter. How do I tell you that for cancel the line that the whole bunch of you can cure yourself of? I'm a 90 hitter nine people out of a hundred. We have remedial attention to for cancel the long and yet everybody flekstore a door and says cure me of my cancel the long. I've saved my Rollie coupon since I've been 12 years of age. And now I'm ready to pay off. You have a vested interest in my being more than a human being. And so if I try to come to you as an adult by try to come to you as a patient as a correction as a human being flawed and capable of erring. You'll turn away. We have a system that's poorly used. We have a legal system that should be able to constrain punish or incarcerate egregious and criminal Behavior among any persons. man, or woman doctoral common laborer if I as a physician Commit a crime against any of you. If I assault you with an operative procedure unwarranted. and without reason criminal Manor the criminal system should be used but why do I have to look at every one of you as a potential malpractice litigant? Because if I fail to cure you you may say I broke a covenant or a promise with you a promise to cure. Can't I tell you that my real interest is to heal you and that you can dye successfully, but I've never kept anyone from the appointed. That's that's waiting than one day. that if I cure you of your cancel the breasts longer colon your only to die of something else and it may be my best role is to try to help heal you Helia, so you have a better understanding of yourself as a human being of your relationships with your family and friends and your relationships with myself as another human being. Who will try to do as best I can on your behalf, but proves prevent you or present you with no illusions of omniscience and total confidence. The real problem then is it we really have two languages being spoken the first language starts with feelings. In from feelings we go to opinion and Trump opinion we go to persuasion and from persuasion we go to subjective opinions. And that is what's happening when the person says there's got to be a cure for cancer. But nobody knows what it is a conspiracy conspiracy to withhold that cure from cancer. I have had repeatedly patients tell me. This and I'd say, why is it President's Ford's wife still had a mastectomy when he was president and that all the wisdom we want to draw and then she ended up on chemotherapy. Why is it that rockefeller's wife is all the money that he can generate still ended up having to have a mastectomy an additional therapy. And repeatedly I've had people say to me that's because they're members of The Establishment and they rather sacrifice their wives then their commitment to The Establishment and when I hear that I begin to realize the roots. disenchantment but many people hold with people who function as authority figures in your life people who come from another whole discipline and speak another language a language of scientific inquiry that starts with data from data goes to an evaluation step in from the evaluation step goes to step that looks into the Evaluated material and develops an objective decision. intellectual inquiry objective emotions subjective These are the people that I'm going to try to tie together for you today with a group of slides as we look at my purview of these people functioning and Healthcare System want to turn on the light. First of all, I'd like to show you how I think the average healthcare system looks The average Healthcare System is a composite of vastly different diverse multi shaped pieces carefully balanced hung together and interrelated one to the other. And when you move one all the rest move and then when you stabilize one all the rest continue to move. They're all hung together from a common point. The problem is not that we're so totally interdependent. The problem is what is that common point and I'd like to look at that common point with you from a few different eyes. This is the way the physician looks at that common Point The Possession having had four years of Premed four years of medical school five years of residency. Now as a pediatric surgeon or a cardiac surgeon or a cardiologist or neurologist and the positions interest discipline is in his training and so that position Stands up and starts Define Healthcare in terms of how many coronary artery bypass procedures were done last year how many radio therapeutic procedures were done last year? In seeing Healthcare with a total of 14 15-20 years of training. Very costly training talked into the person wear that person's whole being is wrapped up in a single discipline. That person can only respond by defining that Healthcare System in terms of their experience. In terms of their training for the pernicious situation up initial situation in which Healthcare is defined in terms of the training of the people available to deliver Healthcare. The meaning of you immediately say that's what's wrong with doctor says nothing is wrong with doctors. That's the natural product. of Excellence and lack of management of a component parts of Excellence. It's always turn around and look at what the management systems does. Send Libre comeback to a group of people who he might call hospital administrators. What a hospital administrator singing is Central in the Healthcare System. Azizi the buildings. I've got 65,000 square feet of bed space. I have to keep filled and you chase them all out with a utilization review program. That's alright Richard you though. We're going to go find some other use for those 65 thousand square feet of wheel will create a whole new program. Should we do something for alcoholics, now that everybody wants to do something for alcoholics. I set up an alcoholic payment center in a good idea, but it's not a good idea at the purpose of the whole unit is to use up for five thousand ten thousand fifteen thousand square feet of a bricks-and-mortar if it's pernicious to Define Healthcare in terms of my training. I submit to you that it it's morally repugnant to me to start after Define Healthcare in terms of the already existing buildings pipes tubing's and heating plants. The people we've already got employed at all levels of the institution. If you think I'm over blowing this you might look at the Covenant that is grafted into every person who's asked to serve on a board of a hospital. They're asked to commit themselves to the fiduciary responsibilities of the hospital fiduciary Integrity the financial soundness of the hospital has anyone ever? Seen a study where a hospital look where it looked at the medical care in the community and found there were five hospitals in the community and it was the poorest prepared to deliver Healthcare and the s in the community only needed for and someone out of business. No, it's spend 70 million dollars to create another hospital and we don't need any more hospitals. You don't have to leave the Twin Cities to look at that model. over bedded Excess bricks-and-mortar drive around town and look at the new structures being built. We're just waiting for the edifice complex to appear the Guthrie stage. I think there is a reason dancer though. There's a reason to answer that can be worked out not by doctors not by administrators in an Institutional level. But by a community of carers and a community of servers in a larger frame purpose and front purpose, I believe that we could bring you together today and the people who deliver Healthcare and start to Define why in the world we're all here together and what it is we expect and then having put together some basic statements about purpose and Healthcare. I think we can start to Define functions. What is it? That should be part of the medical establishment. What is best out of the hands of positions what functions are best handled in an ambulatory mode and for what functions should we establish create and perpetuate institution and 150 find those functions. I think now we can make a structure which is responsive to the Define functions. We've all agreed upon now we go out and put together some programs. I haven't used any new words. I just giving you a basic logical approach to looking at everything that happens and ask yourself as you look at Healthcare. Are you responding to the position? Are you responding the institution or? Is your activity directly derivative of the purpose that all the people joined together? I'd like to look then at this at this whole activity in another way. I'd like to look at what a Healthcare System should be doing as it starts to relate to patients. I'd like to raise questions of availability. I think that we cannot ask the neurosurgeon what should be availability of Neurosurgical services. I don't think we should ask the cardiac surgeon. What should be the availability of cardiac services. I think it's a reasonable unified Community Activity 2 together Define what Healthcare Services shall be available within an instant within a community? Now you may say that's easy. Let's do everything for everybody. If you really believe that I promise you that we those of us who are trained and Healthcare can spend your gross national product. In the Bureau of Health Services Research meeting in Annapolis, Maryland, December 1st and 2nd in 1975. statisticians working with good solid data were able to identify an unmet need of 25 billion dollars per year in cardiac bypass surgery alone That was in a year. in which the federal government had spend 39 billion dollars in direct Health Care Services They had 41 billion dollars worth of requests for end-stage renal disease programs. Assuredly, if you're the one on the it with end-stage renal disease you're willing to spend any anything and everything. Right suggested maybe we should read collectively a book by a Stanford Economist by the name of Fuchs called who shall live. Maybe it should be titled who should die. No reason title it is because the answer is obvious. We all one day we'll die and it being a death fearing death denying culture where a seemingly prepared to go down a path that will spend our entire resources. half of all of our medical resources in the last year a person's life Well, we've evolved now develop the commonality of interests you decided what it is that we're going to make available. How do we guarantee access? How do we guarantee that the people get into the right hands? How do we guarantee that when your child's white blood count goes from 5,000 to 50000 to 500,000 you're in the hands of a pediatric oncologist. You just decided you going to treat childhood leukemia, then let's make sure that when a child gets childhood leukemia there in the hands of someone who knows how to discipline themselves with childhood leukemia. Let's build access points based on informed knowledgeable entry into the healthcare system. This means that the patients have to participate in being informed and their role and their relationship in the Healthcare System. The third role of the interface between patient physician and Healthcare System deals with acceptability. Unfortunately acceptability of Health Care is usually defined in terms of the care. I give I guarantee you with the length of training I've had in with the amount of experience. I've had I couldn't possibly deliver anything but acceptable Health Care to my patients. People believe that Tony I do the same thing with my spelling. I flunked the first 8 out of 9 years of grade school. Fortunately, they sent me on to the next year because no one to keep me another year but they always conditioned me on because I couldn't spell I had 13 to 4:15 ways of spelling that this is the house that Jack built like you have to do that every night in third grade. My father couldn't understand it. high school and left me alone except for one Latin teacher She gave me 50 on my Latin exam. That's a perfect grade for translation. That's a zero for grammar. Call me and she said somebody slip to the translation. Did they You couldn't possibly was zero on the grammar and get a perfect translation paper ice is no problem. I can read Latin. She's a how'd you learn to read Latin? This isn't a simple I went down and I took out all of the parallel translations. I can find all of the local libraries and I read the Latin I'd read the English. And by the time I was done I found I could read Latin like to read sister like to read Virgil without the parallel translations and we went through her library and we went through the heart of the high school's library and she pulled books at random off the shelf and I could read Latin I could read sight translation stuff. She's never seen before and I couldn't decline a single word. And so she left me alone and I got to yell on a full scholarship. and I full scholarship by the the English Professor comes up and says there's nobody but nobody you can be at this prestigious Tower of learning and spell like you spell your papers are a catastrophe the Hallmark of a learning person is the way they spell and write and you can't spell and I'm going to teach you how to spell 200 words twice a week. I can memorize 200 words in Chinese. I can learn 200 words in. Kanji. I've done it. 20 words find a hundred hundred on my test twice a week, but 36 weeks later x 400 words like at 18% I got the got to medical school late and a hassle me too much. Nobody else could spell their and then I got to Bellevue Hospital. That's where I got back into the real world again, because there was a student nurse who would learn to spell and she picked up my chart. She said my God, you can't even spell Benadryl I said you want to list I sent you down in the bees. I haven't even started with the A's of the words. I can spell I said at least I can spell my name. You don't y a t e a u and I said most nurses get that wrong. I learned to spell at 43 years of age and I haven't made a mistake since I did it exactly the way Physicians to fine acceptability Healthcare. Inow Define proper spelling the way I spelled it. I've spent my whole life. Doing it your way now. I'm doing it my way. Acceptability in healthcare is only effectively handled if there's a broad interface relationship activity between the recipient and and give her a healthcare. And the reason it doesn't work is because the concept of servant or to serve. Has gotten lost in the scientific inquiry has gotten lost because we're speaking those two different languages of scientific inquiry and emotion that I spoke to you about as they open today. I do however believe that there is a role that is specific and unique for scientific inquiry and I call at appropriateness of healthcare. Appropriate is a healthcare is where you take your best word opinion using all of the knowledge you have is to what Healthcare should be centered around a given disease. And then you find out whether or not the system reached up and met and was measurable for that system for that leveled care. And then you find out if it was not met. What should be done. And that is what Physicians Hospital medical staffs and physician Community is all about having charge them with the care. The scientific delivery of care having charge them to reach out. For people with cancer or heart disease now you hold them responsible do within themselves organized themselves in such a way that that organization guarantees that the care is appropriate to that charge and the way that you are assured that this happens is called accountability. And it is only one thing you take home from my talk today. It's a hope of my part, but I will convince you. That the best relationship that can be developed between the server and the serve the healthcare professional and those who are receipt of healthcare. Is an accountability system. Accountability system that is capable of ensuring that Health Care is delivered appropriately at the time that it occurs so that you don't develop accountability through malpractice. That is to say you wait until you're hurting and you're convinced there for the doctor must have done something wrong. And so you assume every malpractice equation ends up with the person who is either aggrieved or believe they were grieved and a person who feels that he either did his best or did to his best. I don't also I also firmly convinced that the government regulation. Is probably going to be a failure and accountability for those who believe that the government can regulate anything. I'd like you to read Rodger Knowles book called reforming regulation. From The Brookings Institute for I fear more adventuresome read the ad Council reports about this long talks about the ability of the federal government to regulate the quality of TV your kids. Look at on Saturday morning the quality of the maritime industry. How about Amtrak? How about the quality of the postal service's and the able the ability of most of you to just barely remember we once had a 3-cent stamp and twice a day delivery and daily delivery in town within 8 hours. Federal government has one successful regulatory efforts. However, it's called the FAA the ability to regulate the ability of the pilots to fly. 74/7. What does might be another reason they're too it's very possible that the pilots in the passengers have the same interest. Accountability has to be constructed therefore in such a way that it's an ongoing system that there's a guarantee that the organization. In which Health Care is delivered. Is responsive and responsible I'm going wild care is delivered and the only person who's available for institutional care today to do that online is an organized Hospital medical staff. It is disciplined internally, but it is held accountable to society. The reason why I asked you to take this approach is because we really only have two Alternatives and quality assurance quality assurance with respect to hell when and where Healthcare is delivery delivered those two alternatives are accountability that is holding me responsible for my professional Behavior or the alternative defining in advance how Healthcare should be delivered. I don't see two faces here that look alike. There's no two of you were that ever going to get the same disease identically, I like there's no two of you will respond exactly like to any of the drugs we use this note to of you was gallbladders prostates lungs are breasts look the same and behave the same. Your faces are different. Your body is biochemistry a different but somehow we constantly end up with a cookbook. We called definition of practice it somehow I was going to tell everybody how to treat everybody. And if you want the worst example, I know of that I point out you to three weeks ago. I was visiting Dr. Lumen on Malachi and had occasion to go down to the leprosy Colony there and find at the Public Health Service the United States of America's Define leprosy see if defeated disease is appropriating no more money for it. That's absolutely true. What do you do for the 56 people are blind and have no fingers who can't tell where their feet are so they can't walk fortunately there are four nuns down there in the most ramshackle painted buildings you ever saw in your life trying to care for those people. Because the Public Health Service says we can't put any money into a defeated disease. That's what happens. When you start to Define care in terms of disease systems alone. That's what happens when the scientific inquiry goes so far that it fails to go full circle back to what George Washington's position singly did for George Washington made out of cutest ammonia, but he cared and was present. Caring can be part of healthcare and people can be held accountable for the extent of their caring. I'm submitting to you. Therefore that indeed there has to be discipline there has to be control of medicine, but it should be controlled not. 5 years or 3 years later in an adversarial relationship in the courts. It should not be controlled by a regulation that tells us how we treat everybody's heart attack alike and how they make everybody's in a surgeon for gallbladder operation. So like but rather that should be controlled online at sight in a system that affects the ongoing assessment of the Care delivered and then develops a response to that assessment at the time is delivered that deals with educational changes if needed that deals with policy changes that has policies built-in in such a way so that we know that the care that we expect we delivered is delivered. We have to keep privileges to deliver care and keeping with training confidence and experience and finally have to have an online sanctioning system within the institution. I'd like to give you some pictures and of some of the people who are functioning in that institution. This is one of the positions that you will often see in the institution. And in fact, if I were to be sick today, this is the model of the physician I would want. This is a physician who is so totally committed to me as an individual that he sees himself as the only person that stands between me and total defeat by my disease. This person will admit that somebody puts arment in his plane and feels It prepares it for the next day's battle, but when it comes time to do battle with malignant disease, I'm the only one who does it. I'm the only one is up in the air all by myself. This is the fighter pilot model. This is the model to which most Physicians are trained don't demean them for it because it's this very total commitment to you as a patient and two serving your disease that will keep that person flying in your behalf. When you most needed with the toughest problem available, there are however some other types of positions as well. This would be the Destroyer Captain Destroyer Captain is a physician who recognizes that he's functioning as part of a Healthcare System only as long as that ship is under way. He recognizes that someone has to keep them for pedo Nets over the side keep the navigation going a keep the Armament demand and the all of the other ancillary Services going in and no way sees himself as capable of functioning as a total Destroyer himself, but rather sees himself as part of a component part and yet it has no problems understanding that he's captain of the ship. But recognizing that the ship is afloat only because of all of its component parts. Now, sometimes those two people are put together and when we put those two people together, we start to get an organized Hospital medical staff is an organization that's capable of making fighter pilot sit down with Destroyer captains in together recognize that the reason they're all functioning together is for the purpose of the entire unit. And I think I spoke to you earlier on enough about what I feel the purpose of a functioning unit of healthcare should be This means there for but I see a hospital medical staff. I see people are delivering Healthcare as basically being conglomerates. If I could use the corporate word, what is a conglomerate do a conglomerate holds its many subsidiaries corporations accountable for their ability to interact but yet allows them to be individual corporations. So too. I don't care what we were talking about the solo practitioner the partnership of two or three or four positions positions who are working in small groups positions who are working as corporations or people with thousands of positions at hand such as the Mayo Clinic or hundreds at hand such as a St. Louis Park Medical Center. I'm rather saying that these different models of care can be bound together, but they have to be bound together not out of fiscal interest not out of federal regulatory imperative butt out of the purpose of Joining together hand-in-hand between the server and the served and making sure that with open lines of communication the care that she'll be available should be accessible in an appropriate manner in an acceptable way and if they are held accountable to Society for their behavior on their behalf in order to do that the greater model of healthcare then has to do the following thanks. It has to be capable of defining the patient population. It serves. It has to have the resources to Define their medical needs and has to know what its available resources are and be able to correct any deficiencies in available resources. That's a very different model from model equates for whoever wants to show up at the hospital emergency room to show up that doesn't care about medical needs of the greater population. But guarantees is going to fill up another five thousand square feet with a new service that may or may not be needed and develops Resources by waiting to see What position shows up to apply for privileges on the medical staff? It means that the hospital medical staff and the organization that is going to carry medicine to the future is going to have to create integration of a ball Healthcare Services integrate the services that are handed handle institutionally with those that are handled in the ambulatory pattern. It means to healthcare is got to leave its episodic mode of practice. It's got to stop waiting for a person have a heart attack and then assume that they is one they walk out the door. They're cured forever in their heart will never bother them again, and it's got to have an online sequential relationship with people. Thirdly, we're going to have to in the future recognize that when you demanded of legislators and got the right to see such things as your credit record. You didn't go far enough. He didn't go far enough because everyone of you have a bank book and get a week or monthly statement of your fiscal Affairs. Every one of you have insurance know what the insurance policy reads you even allowed to participate in writing your own will and you're allowed to read it. How many people in this room? carry their medical record Hey, we got one. Thank you. You've just to you just doubled my average performance. And usually I make that statement in front of Physicians two weeks ago. I was in a meeting of 375 positions. I didn't have to Physicians who had ongoing access to their entire on medical record. What in the world can be in it. What right do we have to do anything to you? I submit that it's time that in working together. We start doing things together or with you and I submit to you that you're responsible in large part for how much you smoke your failure to wear seatbelt your refusal to stop driving when you're drunk and creating all those accidents and fill up our emergency room. 50% of all of our actions are directly related to your abusive Collective drinking. And nobody ever hold you accountable for it. I'm seeing there for a greater interface between the future of the people who served and serve between the ambulatory and institutional sectors of healthcare between all personnel office syllabus and all funding if that interface is not built. Then the future is going to be very poor for us and beat. We have to have a willingness there for collectively to say yes, we are responsible and that means that the hospital medical staff not only is accountable to the people that serves but it has to be willing to be responsible for the medical needs of the Define population. The roles relationships are responsibilities of all of the healthcare professionals lending institution and the quality of the Care delivered and I think you could recognize that every one of those sub-points is worthy of an entire seminar in and of itself. I've said something which I have to admit many Physicians are not yet ready to agree to but I think in the coming 5 to 10 years, they will have to acknowledge and that is the recognition that the future of healthcare is one in which the delivery of healthcare will be managed, but it's not going to be managed successfully from the outside if we use the federal model for everything else, but you're going to have to be much more participatory and you're on Healthcare and the management of your own Healthcare record. I tried to paint their for a healthcare system and evolution Healthcare System is gradually switching from the parent child model where I spend all my time worrying about how you slept last night, whether your bowels move this morning, whether you brushed your teeth or not and instead started to develop an open dialogue with you where I started to tell you but as a physician, I can't hear you all the time that was cancer the Press time a 550 hitter with cancel the long of a 90 hitter. That more often than not when I see a person with ligma disease, my best hope is that I can help them die successfully with malignant disease that I am not a shaman and I'm not a magician and I don't have a crystal ball and I'm not going to tell him when they're going to die and I'm not going to tell him how long they're going to live. I can only say that with my 14 years of education and my additional 14 years of experience in healthcare. I will do the best I can for them. Sometimes I will do it. Right occasionally. I will air and I hope it is a human being from my own Humanity. You understand me for that. Healthcare System, therefore is not a physical system of doctors and people it's a system that addresses the Triune being the emotional psychological if you would spiritual and physical needs of the patient and Doctor alike. You'd like me to stand up here and talk about the needs of patients. I could talk as long about the needs of doctors. As people as human beings as people who can cry and feel emotions as people can care. There's only so many people I can care for who died day in and day out from malignant disease that I've done my best for that. I can carry on my shoulders by myself. as part of a larger carrying system, you've got to recognize that I need support to In summary, it was set Best Buy a presbyterian Minister from the marble Collegiate Presbyterian Church in New York City when he went to Fordham University to deliver the eulogy for John Courtney Murray a touring Jesuit Theologian. He said the history of mankind has too long been replaced with people who lived in an adversary relationship with one of the other people against people drives against tribe States against a city states against States nations against Nations and ultimately accesses against allies. They went on to say it's not enough to go to an Era of coexistence where you hate despise and are prepared to kill each other or injure or maim each other. Or isolate one from the other emotionally. Rather ultimately, the future of mankind is be based on the ability of mankind to rise to the level of pro existence. He was speaking about Nations, but I think that still holds true for a Physicians for patients for healthcare because patients and Physicians cannot function as adversaries. We cannot have Health Care Systems and Doctor systems and patient systems an HSA and government regulatory agencies in patient. Advocacy groups in Physicians groups and medical Societies in Hospital medical staff, coexisting side-by-side and distrusting and hating each other's indefinitely ultimately if we're really to help each other if we really to find our own Humanity really to find herself as people we've got to do a David Reed said to those Jesuits, we've got to learn to live for one another that's Pro existence a new message maybe but I doubt it because I think you'll find in Galatians. 6:3 Paul said it's time to Bear one another's burdens like