GOOD AFTERNOON, I'M ELISEO
STABLE-PEREZ, DIRECTOR OF
NATIONAL INSTITUTE ON MINORITY
HEALTH AND HEALTH DISPARITIES.
THANK YOU FOR JOINING US FOR THE
NIMHD DIRECTOR'S SEMINAR SERIES.
THIS NIMHD DIRECTOR'S SEMINAR
LECTURE WILL BE UNIQUE FOR
SEVERAL REASONS.
FIRST, THE FOURTH AND FINAL
LECTURE OF 2023, SECOND WE'RE
CO-SPONSORING WITH THE NIH
OUTCOMES AND EFFECTIVE RESEARCH
INTEREST GROUP.
WE'LL ALSO HAVE THE NCI DIVISION
OF CANCER CONTROL AND POPULATION
SCIENCES DIRECTOR, WHO WILL
SERVE AS MY CO-MODERATOR AND
MONICA WEBB HOOPER WHO WILL JOIN
US ON THE PANEL AND BE A
CO-MODERATOR, DEPUTY DIRECTOR OF
NIMMED. -- NIMHD.
OUR SPEAKER IS MARTIN SHAPIRO,
PROFESSOR OF MEDICINE AT WEILL
CORNELL MEDICAL COLLEGE,
PRACTICED GENERAL INTERNAL
MEDICINE FOR MANY YEARS AT UCLA,
ORIGINALLY FROM CANADA, ATTENDED
MCGILL UNIVERSITY FOR COLLEGE
AND MEDICAL SCHOOL, OBTAINED A
MASTER'S IN PUBLIC HEALTH,
Ph.D. IN HISTORY FROM UCLA.
HE'S ALSO A DEDICATED RESEARCHER
WHO STUDIED MANY TOPICS, ACCESS
TO CARE, HEALTH DISPARITIES,
SCIENTIFIC MISCONDUCT,
PHARMACEUTICAL ADVERTISING,
SCIENTIFIC AUTHORSHIP, AMONG
MANY OTHERS.
PRIOR TO JOINING CORNELL, MARTIN
SPENT THE BULK OF HIS CAREER AT
UNIVERSITY OF CALIFORNIA LOS
ANGELES, WHERE HE WAS
DISTINGUISHED PROFESSOR AT
MEDICINE AND PUBLIC HEALTH,
CHIEF OF THE DIVISION OF GENERAL
INTERNAL MEDICINE, AND HEALTH
SERVICES RESEARCH, AND FOUNDER
OF THE UCLA T32 TRAINING PROGRAM
IN PRIMARY CARE RESEARCH.
MOST NOTABLY HE WAS THE
PRINCIPAL INVESTIGATOR OF THE
HIV COST AND SERVICES
UTILIZATION STUDY, ENROLLED A
PROBABILITY SAMPLE, NATIONAL
SAMPLE OF PERSONS WITH HIV,
WIDELY RECOGNIZED AS AFFECTING
POLICY IN HIV CARE THROUGH
STUDIES OF ACCESS, MENTAL
HEALTH, DRUG USE, RISK BEHAVIOR,
BIORESISTANCE, HEALTH OUTCOMES,
CLINICIANS PROVIDING HIV CARE,
AND IMPACT OF THE RYAN WHITE
CARE ACT ON PATTERNS OF CARE FOR
HIV.
MARTIN IS AN ELECTED MEMBER OF
THE AMERICAN SOCIETY FOR
CLINICAL INVESTIGATION AND
ASSOCIATION OF AMERICAN
PHYSICIANS, A PAST PRESIDENT OF
THE SOCIETY OF GENERAL INTERNAL
MEDICINE, WHICH IS AWARDING HIM
HIGHEST HONORS IN AWARDS.
PUBLISHED 200 PEER PEER
REVIEWED PAPERS AND AUTHORED
SEVERAL BOOKS.
HE HAS BEEN A TERRIFIC MENTOR OF
STUDENTS, RESIDENTS, FELLOWS,
JUNIOR FACULTY MEMBERS.
HE SERVES AT CORNELL AS
ASSOCIATE DIRECTOR OF THEIR T32
TRAINING PROGRAM AND STUDENT
RESEARCH PROGRAM.
HE'S AN AUTHOR, , HIS TALK ABOUT
BE A BROKEN SYSTEM, AMERICAN
HEALTH CARE NEEDS COMBINATION
THERAPY.
PLEASE JOIN ME IN GIVING A
VIRTUAL WELCOME TO MARTIN
SHAPIRO.
>> I'M THRILLED TO BE HERE.
I'M GOING TO SHARE MY SCREEN, IF
I CAN DO IT CORRECTLY.
THAT SHOULD BE MY SCREEN NOW.
CAN YOU SEE IT?
>> NOT YET, MARTIN.
>> SO I DID SOMETHING WRONG, DID
I?
I DIDN'T -- DID I NOT SUCCEED?
SHARING MY SCREEN.
>> DID NOT, MARTIN, DID NOT.
>> OKAY.
HOW DO I GET OUT OF THIS THEN?
SORRY.
I DID NOT GET ANY ACCOLADES FOR
MY TECHNOLOGICAL STRENGTHS ON
COMPUTERS.
SHARE SCREEN, DID THAT HAPPEN?
NO?
>> NO.
>> THERE WE GO, I THINK.
YES.
>> OKAY.
>> PRESENTATION MODE.
>> YES, OKAY.
I HAD TO DOUBLE CLICK.
>> IT'S PERFECT NOW.
THANK YOU.
>> OKAY.
GOD IS STILL WORKING ON ME.
THE GOD SUCH TECHNOLOGY.
THANK YOU VERY MUCH, ELISEO, AND
ALL OF YOU FOR INVITING ME HERE.
IN 2017, I MOVED TO NEW YORK.
I DETERMINED TO USE A GOOD PART
OF MY TIME WRITING A BOOK ABOUT
THE PROBLEMS OF HEALTH CARE IN
AMERICA.
AS I WORKED THROUGH, IT BECAME
CLEAR THE MAIN QUESTION TO BE
ANSWERED WAS WHY WE HAVE NOT
MANAGED TO FIX THE VERY OBVIOUS
PROBLEMS IN AMERICAN HEALTH
CARE.
MY EFFORT TO FULLY UNDERSTAND
THE PROBLEMS, PROCESSES, THE
PHENOMENA THAT STAND IN THE WAY
TOOK ME ON A JOURNEY INTO
SOCIOLOGY, PHILOSOPHY, HISTORY,
AND OTHER DISCIPLINES IN THE
SOCIAL SCIENCES AND HUMANITIES,
ESSENTIAL TO UNDERSTANDING THE
MESS THAT WE'RE IN.
I WON'T DWELL LONG ON THE
WELL-CHARACTERIZED
MANIFESTATIONS OF OUR HEALTH
CARE SYSTEM'S DREADFULNESS.
LACK OF INSURANCE FOR MANY, EVEN
AFTER PASSAGE OF THE ACA,
UNDERINSURANCE FOR EVEN MORE.
OUR HEALTH EXPENDITURES FAR
EXCEED THOSE IN OTHER COUNTRIES
AS A PERCENTAGE OF G.D.P.
BACK BEFORE 1970 THE U.S. WAS
NOT SUCH A SPEND THRIFT,
EXPENDITURES WERE RELEVANT TO
CANADA, THAT CHANGED AROUND THE
TIME IT ADOPTED NATIONAL HEALTH
PLAN.
OVER THE SAME PERIOD OF TIME AND
OMINOUSLY THE U.S. HAS FALLEN
BEHIND OTHER COUNTRIES WITH
ADVANCED ECONOMIES AND LIFE
EXPECTANCY.
WE LIVE 78.9 YEARS, AND NOW
TRAIL OTHER COUNTRIES WITH
ADVANCED ECONOMIES IN THIS
METRIC BY 5 TO 6 YEARS.
AS YOU ARE ALL AWARE THERE'S
CONSIDER CONSIDERABLE
DIFFERENCE ARE RACE AND
ETHNICITY.
IT GOES BEYOND PROPOSALS AND
HEALTH SERVICES RESEARCH.
RATHER, THE WAYS IN WHICH THE
VARIOUS GROUPS OF ACTORS
CONCEPTUALIZE HEALTH AND HEALTH
CARE PURSUE THEIR INTERESTS AND
PERCEIVE NEEDS, AND INTERACT
BASED ON THESE
CONCEPTUALIZATIONS, CREATING
IMPEDIMENTS TO A SYSTEM THAT'S
RATIONAL, JUST, EFFICIENT.
LET'S LOOK AT THE GROUPS OF
ACTORS, I ARGUE ALL STAND IN THE
WAY OF EQUITABLE, EFFICIENT,
EFFECTIVE CARE, THESE ARE
PHYSICIANS, MEDICAL SCHOOLS,
CORPORATIONS, INCLUDING
HOSPITALS AND HEALTH SYSTEMS,
DIALYSIS, NURSING, HOME AND
PHARMACY COMPANIES,
MANUFACTURERS OF MEDICINES,
MACHINES, MEDICAL RECORDS,
INSURERS, INVESTORS, ALSO
SCIENTISTS AND THE NIH,
GOVERNMENT, EMPLOYERS AND
EMPLOYEE GROUPS, AND, YES, ALSO
PATIENTS, FAMILIES, AND MANY
COMMUNITY ORGANIZATIONS.
I BELIEVE THREE PHENOMENA SHAPE
THE CIRCUMSTANCES AND EXPERIENCE
OF HEALTH CARE IN CONTEMPORARY
SOCIETY.
THE TREATMENT OF HEALTH CARE AND
HEALTH AS COMMODITIES BY ACTORS
WITHIN AND WITHOUT THE SYSTEM.
THE CONSCIOUSNESS OF THESE
GROUPS OF ACTORS, MEANING THEIR
ATTITUDES, VALUES, PERCEIVED
NEEDS AND EXPECTATIONS,
INTERESTS AND CAPACITIES WHICH
SHAPE ATTITUDES AND BEHAVIOR, IN
RELATION TO HEALTH CARE, AND THE
COMMUNICATION AND RELATIONSHIPS
AMONG THESE ACTORS WHICH
REINFORCE EXISTING ARRANGEMENTS.
FIXING HEALTH CARE IS SO VERY
DIFFICULT BECAUSE OF THESE
PHENOMENA.
LET'S CONSIDER THESE GROUPS OF
ACTORS IN TURN.
MAJOR HEALTH SYSTEMS INCLUDE
ACADEMIC AND NON-ACADEMIC ONES,
THOSE FOR PROFIT AND THOSE
SUPPOSEDLY NOT FOR PROFIT,
BEHAVIORAL DISTINCTIONS BETWEEN
THEM IS FAR FROM CLEAR.
THEY CONTRIBUTE TO THE PROBLEM
IN A NUMBER OF WAYS.
EARLY IN MY CAREER AT UCLA, MY
DEPARTMENT HAD A RETREAT.
THE KEYNOTE SPEAKER WAS A SENIOR
EXECUTIVE AT HENRY FORD HOSPITAL
IN DETROIT.
HE SAID WHAT YOU REFER TO AS
HOSPITAL ADMISSION AND
OUTPATIENT VISITS, SALES, WAS
CLARIFIED.
THESE SYSTEMS ARE INDEED
INTERESTED IN SALES, MAXIMIZING
MARKET SHARE OF COVERED LIVES,
MAXIMIZING REIMBURSEMENT AND
MINIMIZING RISK MEANING POOR
PEOPLE WITH MEDICAID OR NO
INSURANCE.
CONTRACTING WITH HEALTHY
POPULATIONS AND PROMOTING
LUCRATIVE PRODUCT LINES AND
PROCEDURES.
THEY SEEK NINE FIGURE SURPLUSES,
PAY EXECUTIVES SEVEN TO EIGHT
FIGURE SALARIES WHICH NATIONALLY
30% ARE FINANCIAL PERFORMANCE
BASED.
COULD WE ALTER THE INCENTIVES
FOR THESE CLINICAL CORPORATIONS
AND THEIR LEADERS?
NOT EASILY.
BUT SOME STARTING GESTURES MIGHT
BE TO NOT PAY CEOS SALARIES UP
TO 50 TIMES WHAT SOME DOCTORS,
TO END BONUS PAYMENTS BASED ON
FINANCIAL PERFORMANCE, REQUIRE
FULL PARTICIPATION OF ALL
CLINICIANS IN MEDICAID, FOR
HEALTH SYSTEMS TO MAINTAIN
NON-PROFIT STATUS.
AS FOR OTHER CORPORATE
INTERESTS, THEY TOO ARE
INTERESTED IN SALES AND ARE IN
THE BUSINESS OF INDUCING DEMAND,
PHARMA AND BIOLOGICS ADVERTISE
SHAMELESSLY TO PATIENTS AND
PROVIDERS TRYING TO CONVINCE
FORMER PRODUCTS WILL EXTEND LIFE
OR IMPROVE QUALITY WITHOUT
REGARD TO HOW MUCH OR WHAT COST,
RAISE PRICES AND RECRUIT
ECONOMISTS TO JUSTIFY PRICE
POINTS, EXTEND PATENTS WITH
MINOR MODIFICATIONS CALLED
EVERGREENING, AND PREVENT
NEGOTIATION OF PRICES.
EQUIPMENT MANUFACTURERS HAVE THE
SAME STRATEGY.
THE MARKET FOR INFORMATION
SYSTEMS IS AN OLIGO PATHY,
INCREASE COST OF PRIMARY CARE
PROVIDERS FOR BENEFITS THAT MAY
NOT BE FORTHCOMING.
HEALTH INSURANCE INDUSTRY SEES
SINGLE PAYER AS EXISTENTIAL THE
THREE AND EXISTS EXPANSION OF
PUBLIC COVERAGE AND PROD ALLIES
TO PRIVATIZE LUCRATIVE PUBLIC
PROGRAM.
THEY SEEK TO MINIMIZE RISK OFTEN
BY DENYING COVERAGE FOR
PROCEDURES, OFFERING PRODUCTS
WITH LARGE CO-PAYMENTS AND
DEDUCTIBLES, M AN ENORMOUS
BURDEN ON MANY AND SADDLE FAR
TOO MANY WITH INSURMOUNTABLE
MEDICAL DEBT.
OTHER CORPORATIONS SUCH AS
NURSING HOMES, PHARMACIES,
DIALYSIS COMPANIES ARE
INTERESTED IN MAINTAINING OR
VASTLY INCREASING REVENUE
STREAMS.
HEDGE FUNDS MOVE INTO THE MELT
SECTOR, THEY SEEK TO INFLATE
VALUE THROUGH UPCODING REVENUE
AND CUTTING CORNERS AND SELLING
AT PROFIT, SOME TALK ABOUT
VALUE-BASED CARE.
WHEN ONE WAS RECENTLY ACQUIRED
BY CVS, THEY SPOKE OF, QUOTE,
OFFERING SIGNIFICANT VALUE TO
OUR SHAREHOLDERS, UNQUOTE.
LEGENDARY COMEDIAN AND PRODUCER
MEL BROOKS LIKES TO TELL THE
STORY ABOUT A MAN WHO GOES INTO
A DELI TO BUY BAGELS, PLACES HIS
ORDER AND STOPS AND SAYS, SALT,
ALL OF YOUR SHELVES ARE COVERED
WITH RED BOXES SALT.
YOU SELL A LOT OF SALT?
THE OWNER RESPONDS.
IF I SELL A BOX OF SALT A WEEK
I'LL THROW A PARTY, IT'S A
MIRACLE.
I DON'T SELL A LOT OF SALT.
BUT THE GUY WHO SELLS ME THE
SALT, BOY, CAN HE SELL SALT.
THESE GROUPS OF CORPORATIONS ARE
VERY GOOD AT SELLING BOXES OF
SALT, AND POLICIES ARE UNLIKELY
TO HAVE MUCH IMPACT.
WHAT ABOUT DOCTORS?
PRACTICINGCLINICIANS AND
PROFESSIONAL SOCIETIES HAVE
ECONOMIC INTERESTS, PAYMENT
SYSTEMS REIMBURSES, PROCEDURAL
SPECIALTY SOCIETIES APPLY 70% OF
SEATS ON RVU UPDATE COMMITTEE
THAT ADVISES MEDICARE PRODUCE
GUIDELINES THAT JUSTIFY THEIR
ACTIVITY, MINIMIZE RISK BY
OPTIMIZING INSURANCE TYPE, WHEN
THEY RUN THE TILL AS LONG AS
THEY CAN.
AT UCLA THE RESIDENTS USED TO
JOKE THE CARDIOLOGIST HAD TWO
INDICATIONS FOR HEART
CATHETERIZIZE, LUB AND DUB, THE
HEART SOUNDS.
THE WAYS THE SYSTEM PAYS FOR
SERVICES SHAPES PHYSICIAN
BEHAVIOR.
THE INCOME DIFFERENCES BETWEEN
PROCEDURAL AND COGNITIVE FIELDS
ARE STARK.
IN FACT HAVE GROWN SINCE THE RVS
WAS IMPLEMENTED IN MEDICARE.
AT THE SAME TIME, DOCTORS
WEREN'T SELECTED INTO MEDICAL
SCHOOL PRIMARILY TO BE EMPATHIC
AND CARING.
MANY PHYSICIANS HANDLE
UNCERTAINTY POORLY, ARE NOT WELL
TRAINED TO LIMIT CARE, ARE MORE
COMFORTABLE WITH NARROW TASKS
LIKE PROCEDURES THAN BUILDING
RELATIONSHIPS WITH PATIENTS.
ACCORDINGLY THE CHOICES MANY
MAKE OF SPECIAL SPECIALTIES ARE
DRIVEN BY INCOME GENERATION.
DAVID WAS A THIRD YEAR MED
STUDENT WHO I SUPERVISED IN
INTERNAL MEDICINE CLERKSHIP.
HIS KNOWLEDGE OF DISEASE AND
TREATMENT WAS AT HIGH LEVEL.
HE RELATED EXTREMELY WELL TO
MEMBERS OF HIS TEAM AND NURSING
STAFF.
WITH PATIENTS HE WAS SENSITIVE,
OPEN, CARING AND COMMITTED.
I TOLD DAVID HE WOULD BE AN
OUTSTANDING RESIDENT AND HE
COULD IMAGINE HIMSELF IN
INTERNAL MEDICINE BUT HAD BEEN
ADVISED NOT TO DO THAT.
QUOTE, YOUR TEST SCORES AND
GRADES ARE TOO GOOD, IT WOULD BE
A WASTE, UNQUOTE.
THEY WERE SAYING HE WAS IN LINE
FOR A HIGH-PAYING SPECIALTY.
NONETHELESS HE PROMISED TO THINK
ABOUT WHAT I SAID.
THE PROPORTION OF RESIDENCY
PHYSICIANS FILLED BY USMGs
BEARS A LINEAR RELATIONSHIP TO
SPECIALTY INCOMES.
SEVERAL MONTHS LATER DAVID CAME
BY MY OFFICE AND ASKED IF I'D
WRITE A LETTER OF RECOMMENDATION
FOR HIM FOR RESIDENCY.
I WAS HAPPY TO PROVIDE ONE BUT
DISAPPOINTED TO LEARN HE CHOSE
TO GO INTO ANESTHESIOLOGY.
IT'S LIKELY HE WILL BE A
TERRIFIC ANESTHESIOLOGIST BUT
AWARENESS FINANCIALLY WAS A
CORRUPTING INFLUENCE ON HIS
CAREER DECISION.
WHY DOESN'T SOCIETY VALUE COG
ANITY SPECIALTIES?
IT'S NO LESS COMPLEX AND
DEMANDING AND LIFE ALTERING FOR
PATIENTS.
I CAN RELATE STORIES FROM MY
EXPERIENCE.
A PATIENT WHO NEEDED CONSTANT
COACHING AND REPEATED DISCUSSION
OF THE EVIDENCE, EMOTIONAL
SUPPORT TO STICK WITH TREATMENT
FOR HODGKIN'S DISEASE.
A PATIENT WITH SEVERE
HYPERTENSION, SERIOUS MENTAL
ILLNESS THAT MADE IT HARD FOR
HER TO ADHERE TO TREATMENT AND
SHOW UP FOR APPOINTMENTS, BUT
NEEDED A DOC WHO WOULD STICK
WITH HER AND KEEP HER ALIVE IN
SPITE OF ALL THAT.
A PATIENT WHO WAS DISSPIRITTED
BY MULTIPLE MORBIDITIES AND
NEEDED A DOCTOR NOT ONLY TO
MANAGE HER COMPLEX REGIMEN BUT
ALSO TO KEEP HER SPIRITS UP.
SOME DOCTORS DO ATTEND THESE
VITAL ISSUES, THE PROBLEM IS
THERE'S A DISINCENTIVE IN THE
CURRENT SYSTEM TO SPEND TIME
DOING THAT.
WELL, CAN WE CHANGE CLINICIANS'
PRIORITIES?
HERE ARE SOME IDEAS.
PAY DOCTORS FOR THEIR TIME, NOT
FOR PIECE WORK.
SPECIALLY PAY SHOULD DIFFER
MODESTLY TO ACCOUNT FOR TIME AND
TRAINING ONLY.
INCENTIVIZE TO SEEK
PSYCHOTHERAPY TO HELP THEM
BETTER RELATE TO PATIENTS' NEEDS
AND VALUES.
ALL PHYSICIANS SHOULD HAVE
PERIODIC TRAINING IN
COMMUNICATION, NEGOTIATION WITH
PATIENTS, ETHICS, MORALS, SOCIAL
RESPONSIBILITY.
AND MANDATE PROCEDURALLISTS AND
ADMINISTRATORS MEET AND SET
TARGETS RATHER THAN THE
OPPOSITE.
WHAT ABOUT EDUCATIONAL
INSTITUTIONS?
UNIVERSITIES AND MEDICAL SCHOOLS
ARE PART OF THE PROBLEM.
MEDICAL SCHOOL ADMISSIONS ARE
LIMITED WITH THOSE WITH GREAT
SCORES AND PAY LITTLE ATTENTION
TO VALUES, ABILITY TO EMPATHIZE
AND COMMUNICATE EFFECTIVELY, NOT
SURPRISINGLY THE GREAT MAJORITY
OF THOSE ADMITTED STUDIED THE
BIOLOGICAL AND PHYSICAL SCIENCES
AND RELATED DISCIPLINES AND
OVERWHELMINGLY REPRESENT THOSE
FROM PRIVILEGED BACKGROUNDS
WHILE UNDERREPRESENTING BLACKS
AND HISPANICS, SCHOOLS DO A POOR
JOB OF IDENTIFYING STUDENTS WITH
COMMITMENT TO SOCIETAL
BETTERMENT.
THE UNDERGRADUATE CURRICULUM IS
SCIENCE BASED, BIOLOGICALLY
REDUCTIONIST, HUMANITIES AND
SOCIAL SCIENCES WHICH SHOULD BE
A CORE REQUIRED COMPONENT OF
MEDICAL EDUCATION IS AT BEST AN
AFTERTHOUGHT.
THE WHITE COAT CEREMONIESY ARE
EXERCISE IN TRIUMPHALISM BUT
PEOPLE THAT ACCOMPLISHED NOTHING
YET AND GO THROUGH A NEGATIVE
SOCIALIZATION AND LOSS OF ANY
IDEALISM THAT MEDICAL SCHOOLS
DON'T SHOW INTEREST IN
ARRESTING AND DON'T LEARN HOW TO
RELATE TO PATIENTS AND NEXT TO
NOTHING ABOUT ETHICAL
OBLIGATIONS AND SOCIAL
RESPONSIBILITIES.
SOME WHO ARRIVE INTENDING TO
FOLLOW IN FOOT STEPS OF MOTHER
TERESA DECIDE TO PURSUE HIGH
PAYING SPECIAL TILs.
DEBT IS SUBSTANTIAL DID YOU NOT
PRECLUDE LIVING IN COMFORT BUT
PROVIDES RATIONALIZATION FOR
THOSE DECISIONS.
WHEN I ENTERED MEDICAL SCHOOL,
MY UNCLE COMMENTED THAT I WOULD
HAVE A CHOICE BETWEEN FIGURING
OUT HOW TO MAKE A LOT OF MONEY
OR HOW TO BEST SERVE HUMANITY.
ON THE BASIS OF MY CHOICE PEOPLE
COULD JUDGE MY WORTH AS A HUMAN
BEING.
THAT WAS A PROVOCATION AND GIFT.
IN POST-GRADUATE, AND CLINICAL
TRAINING IT'S THE EXCEPTION, NOT
THE RULE, COMMITMENT TO
DIVERSITY POPULATIONS, THAT
MIGHT MAKE AMERICA LESS
EXCEPTIONAL.
AGAIN, AS LITTLE EXPOSURE TO
HUMANITIES AND SOCIAL SCIENCES,
FEW OPPORTUNITIES TO ADDRESS
PERSONAL CHALLENGES OF DOCTORS,
STAND IN THE WAY OF EFFECTIVE
RELATIONSHIPS WITH PATIENTS,
LITTLE EFFORT TO ASSURE THEY ARE
ABLE TO COMMUNICATE EFFECTIVELY
WITH PATIENTS, SOME INSTITUTIONS
TRY TO PROVIDE POSITIVE
OUTPATIENT EXPERIENCES, BUT IN
MANY PROGRAMS THEY ARE AWFUL.
RESIDENTS WHO ARE PRESSED FOR
TIME ARE ASSIGNED PATIENTS THE
FACULTY DON'T WANT TO SEE
THEMSELVES.
PROMOTE CHOICES OF PROCEDURAL
CAREERS.
CLINICALLY, MEDICAL SCHOOLS ARE
NO LESS INTERESTED IN THE
PRIVATE SECTOR IN GENERATING
REVENUE, THE HEALTH OF THE
PUBLIC IS NOT MUCH OF A PRIORITY
BEYOND THE OCCASIONAL LECTURE ON
SOCIAL ASPECTS OF MEDICINE.
PRACTICES ARE OFTEN SEGREGATED
BY INSURANCE TYPE, BUSINESS
PLANS REFLECT PRIORITY OF
REVENUE GENERATION, MARKET
SHARE, MAXIMIZED REIMBURSEMENT,
MINIMIZED RISK, RUN THE TILL,
THE HIDDEN CURRICULUM.
STUDENTS GROW UP TO EMULATE THE
PRACTICE PATTERNS AND VALUES OF
THE FACULTY.
WHAT CAN WE DO ABOUT MEDICAL
EDUCATION?
THERE ARE LOTS OF POTENTIAL
STRATEGIES.
REPLACE PRE-MEDICAL SCIENCE
REQUIREMENTS IN TOTO WITH
ETHICS.
THIS WAS PROPOSED BUT IT HASN'T
HAPPENED.
SELECT APPLICANTS ALTRUISTIC,
EMPATHIC, PSYCHOLOGICALLY OPEN
AND HAVE SOUND MORAL AND ETHICAL
FOUNDATIONS.
MEMBERS OF UNDERSERVED
COMMUNITIES SHOULD NOMINATE
MEDICAL SCHOOL MA TRICULUM, AND
SHOULD PROVIDE HALF OF THE
CURRICULUM AND BE INTEGRATED
INTO CLINICAL TRAINING.
WHAT ABOUT MEDICAL RESEARCH?
THINKING ABOUT SCIENCE IT'S
WORTH CONSIDERING ROBERT
MURTON'S CHARACTERIZATION, LET'S
LOOK AT THE SECOND ONE.
COMMUNALISM.
THE FINDINGS OF SCIENCE ARE
PRODUCTS OF COLLABORATION,
ASSIGNED TO THE COMMUNITY.
THIS ETHOS IS INCOMPATIBLE WITH
TECHNOLOGY DEFINED AS PRIVATE
PROPERTY.
DOES THAT CHARACTERIZE MEDICAL
RESEARCH TODAY?
CERTAINLY NOT ENTIRELY.
BASIC SCIENTISTS TEND TO BE
EXCITED ABOUT DISCOVERY, GET
LITTLE EDUCATION ABOUT SOCIAL
RESPONSIBILITIES OF SCIENTISTS,
PATENTS CAN BE LUCRATIVE TO
SCIENTISTS AND THEIR EMPLOYERS
AND FOR SOME THESE PRIORITIES
ARE APPARENT TO THEIR STUDENTS.
AND AFFECT THEIR ATTITUDES TO
WHAT'S IMPORTANT IN SCIENCE.
CLINICAL RESEARCH IS ESSENTIAL.
BUT WHEN IT'S FUNDED BY
INDUSTRY, PAYMENTS CAN BE
GENEROUS BUT THE PRIORITIES MAY
BE THOSE OF INDUSTRY.
THERE CAN BE LIMITATIONS ON
INTELLECTUAL READING.
AS FOR LATE TRANSLATIONAL POLICY
RESEARCH SUCH AS I'VE DONE IN MY
CAREER AND ELISEO TOO, MOST
SCIENTISTS TEND TO GENUFLECT,
MOST FOCUS ON SMALL CHANGES.
LET'S LOOK AT THE NIH MISSION
STATEMENT IN PART.
TO SEEK FUNDAMENTAL KNOWLEDGE
ABOUT THE NATURE AND BEHAVIOR OF
LIVING SYSTEMS AND APPLICATION
OF THAT KNOWLEDGE TO ENHANCE
HEALTH, LENGTHEN LIFE, REDUCING
ILLNESS.
THEY DO NOT TREAT ALL ASPECTS OF
THIS MISSION STATEMENT EQUALLY.
SCIENTIFIC ORGANIZATIONS AND
FUNDERS SUCH AS NIH OVERPROMISE
BENEFITS OF BASIC RESEARCH.
THE RELENTLESS PURSUIT OF
MOLECULAR SOLUTIONS TO HEALTH
PROBLEMS AFFECTS PRACTICE AND
ENCOURAGES PROFESSIONAL AND
PUBLIC ATTITUDES TOWARDS
DISEASES BEING LARGELY A SOCIAL,
PRODUCING NARROW VISION OF WHAT
SIGNS COULD BE TO KEEP MONEY
FLOWING THROUGH THEIR
PRIORITIES, CERTAINLY NOT
TOWARDS OTHER KINDS OF RESEARCH
THAT MIGHT HAVE A LARGER IMPACT
ON POPULATION HEALTH SUCH AS
STUDIES, PROGRAM TO IMPROVE
BLOOD PRESSURE CONTROL, WEIGHT
MANAGEMENT, SMOKING CESSATION
AND THE LIKE.
WHEN I WROTE MY FIRST R01 GRANT
PROPOSAL, HIV OUTSOME STUDY, I
GOT EXCELLENT SCORE BUT WASN'T
FUNDED.
THE PROJECT OFFICER WAS
ENTHUSIASTIC ABOUT MY PROPOSAL
BUT TOLD ME NOT TO RESUBMIT
THERE BECAUSE THE DIRECTOR DID
NOT CONSIDER SUCH RESEARCH TO BE
HIS RESPONSIBILITY.
REDIRECTED ME TOWARD WHAT IS NOW
AHRQ.
YOU CAN SEE THE BREAKDOWN OF THE
2021 NIH BUDGET ALONG WITH AHRQ
AND PCORI.
SOME LARGE INSTITUTES DO SUPPORT
SOME HEALTH SERVICES AND
BEHAVIORAL RESEARCH.
IN MANY, YOU THE FLUCTUATES OR
WITH CHANGE OF DIRECTORSHIP SOME
YEARS AGO THE LEVEL OF SUPPORT
FOR THIS KIND OF RESEARCH
PLUMMETS.
OTHERS ESSENTIALLY NEVER SUPPORT
SUCH RESEARCH, A FEW
CONSISTENTLY DO, BUT MOST OF
THOSE HAVE BUDGETS THAT ARE LESS
THAN 1% OF THE BUDGET OF THE
OVERALL NIH.
SO, HOW DO WE MAKE SCIENCE MORE
RESPONSIVE TO SOCIETAL NEEDS?
TRAINING IN SOCIAL
RESPONSIBILITY SHOULD BE A
SUBSTANTIAL FEATURE OF
SCIENTIFIC EDUCATION.
REVENUE FROM INVENTIONS FUNDED
BY FEDERAL GRANTS SHOULD ACCRUE
LARGELY TO THE GOVERNMENT AND
NOT TO SCIENTISTS, INSTITUTIONS
OR CORPORATIONS.
RESEARCH ON BRINGING EFFECTIVE
CARE SHOULD HAVE THE NIH HIGHEST
PRIORITY, HALF OF THE MEMBERS OF
ADVISORY COUNCILS OF INSTITUTES
SHOULD BE NOMINATED BY MEMBERS
OF DIVERSE COMMUNITIES.
GOVERNMENT CAN BE PART OF THE
SOLUTION BUT IT'S OFTEN PART OF
THE PROBLEM.
THE U.S. GOVERNMENT AVOIDS
POLICIES THAT NECESSITATE
RAISING TAXES.
SUSCEPTIBLE TO CORPORATE
PRESSURE, THEY FAIL AS
WASHINGTON POST REPORTED TODAY,
THEY FAIL TO EXERCISE MARCH-IN
RIGHTS TO CONTROL THE
EXTRAORDINARILY EXTRAVAGANT COST
OF NEWER DRUGS.
THEY OVERPAY FOR PROCEDURES
RELATIVE TO COGNITIVE SERVICES.
THEY PROMOTE OVERSPECIALIZATION
IN TECHNICAL FIELDS THROUGH THE
DISTORTED FEE SCHEDULE AND
EDUCATIONAL SUBSIDIES AND PREFER
MOONSHOTS THAT ARE ASOCIAL.
OUR PATIENTS, ARE THEY INNOCENT
VICTIMS?
I THINK NOT.
JUST AS SCIENTISTS, CLINICIAN,
PHARMACEUTICAL COMPANY, HEALTH
SYSTEM SEE HEALTH CARE AS A
COMMODITY, SO DO MANY PATIENTS.
THEY WANT THEIR SHARE.
18 TO 19% OF GDP, WHO WANTS TO
WORK 7 1/2 HOURS A WEEK TO PAY
FOR MEDICAL CARE BUT THEY WANT
BLOOD TEST, SCAN, BED IN ICU AND
MANY TREAT LIFE ITSELF AS A KIND
OF COMMODITY WANTING MORE DAYS
AND WEEKS AND MONTHS OF LIFE,
WHATEVER THE COST OR CONSEQUENCE
TO OTHERS.
THERE'S NO MORE THOUGHT OF THE
COMMON GOOD AMONG MUCH OF THE
PUBLIC THAN AMONG THOSE WORKING
IN THE HEALTH SECTOR.
WHY WOULD THAT BE?
WELL IN PART IT REFLECTS A WORLD
IN WHICH ALMOST EVERYTHING IS
COMMODIFIED, SOME PEOPLE FEEL
ENTITLED TO GET WHATEVER THEY
WANT, AND MANY WHO ARE NOT
WELL-CONNECTED TO OTHERS,
REPLETE WITH LONELINESS, BEATEN
DOWN BY THE WORLD, THEY COME TO
HEALTH CARE LOOKING FOR COMFORT,
COMPANIONSHIP, A HEART OPEN TO
THEM IN THE WAY THE LARGER WORLD
IS NOT.
UNLIKE THOSE DEMANDING CARE OUT
OF ENTITLEMENT, WHO GET WHAT
THEY WANT, THESE INDIVIDUALS
ENCOUNTER PROFESSIONALS NOT
EQUIPPED TO GIVE THEM WHAT THEY
NEED.
BELIEFS AND ATTITUDES MAY BE
SHAPED BY A MEDICAL PROFESSION
THAT DOESN'T KNOW HOW TO SET
LIMITS, SCIENTIFIC ESTABLISHMENT
THAT HOLDS UP CONQUEST, LACK OF
CLARITY ABOUT WHAT LIMITS
REASONABLE AND DOGMA FROM SOME
RELIGIOUS LEADERS ABOUT WHEN
LIFE BEGINS AND HOW IT SHOULD
END.
I COMMEND TO YOU THE WONDERFUL
BOOK BY ROBERT BELLA AND
COLLEAGUES, HABITS OF THE HEART,
WHICH PROVIDES INSIGHTS.
THEY WRITE IN PART, AMERICAN
INDIVIDUALISM HAS BECOME
AUTONOMY DISASSOCIATED FROM
MEANINGFUL SOCIETAL INTEGRATION,
THERE'S BEEN A DESTRUCTION OF
SUBTLE TIES THAT BIND PEOPLE
LEAVING THEM FRIGHTENED AND
ALONE.
MANY ABANDON ANY NOTION OF
FINDING MEANING IN RELATION TO
SOCIETY AND THE IDEA OF THE
COMMON GOOD.
EDUCATION BECOMES AN INSTRUMENT
FROM INDIVIDUAL CAREERISM AND
THERE'S A FRACTURED IMBALANCE
BETWEEN INDIVIDUALISM AND
COMMUNITYISM.
UNDERLYING ACTIONS ARE VALUES
AND CONSCIOUSNESS OF SOCIETY,
LACK OF COMMUNAL CONCERNS,
MISTRUST, GREED IS GOOD, POVERTY
IS WEAKNESS, DECLINE OF RELIGION
IS A SOURCE OF SUPPORT, FAILURE
OF PUBLIC DISCOURSE TO ADDRESS
THESE ISSUES, HEALTH CARE
MANIFESTS IN ECONOMIC AND
POLITICAL BEHAVIOR OF ACTORS AND
IN THEIR INNER LIVES.
HEALTH CARE IS COMMODIFIED.
SOME SEEK GREATER MARKET SHARE,
STILL OTHERS RUN THE TILL AND
NEVER SAY KNOW TO PATIENTS AND
FAMILY MEMBERS.
SOME INTERESTED IN INVENTIONS.
AL OF THESE GROUPS ARE PUSHING
FOR HEALTH SYSTEM DO MORE, SPEND
MORE.
ON THE OTHER HAND, INSURERS, THE
GOVERNMENT, LAWYERS, EACH WITH
THEIR OWN REASONS TO LIMIT CARE
AND COST, COVERAGE IN A WAY NOT
NECESSARILY CONSISTENT WITH
OPTIMAL HEALTH.
(INDISCERNIBLE)
WHEN CARE IS COMMODIFIED THERE'S
DISINCENTIVE TO KNOW THEM, TO DO
MORE PROCEDURES, GREATER
CO-PAYS, EXACERBATING
DISPARITIES, CONSUMPTION OF
RESOURCES, LIMITING ACCESS TO
NEEDED CARE, AS WELL AS
DIVERSION OF RESOURCES FROM
SOCIAL SERVICES AND EDUCATION
AND INFRASTRUCTURE.
CAN HEALTH CARE EVEN BE
OPTIMIZED IN A COMMODIFIED
MARKETPLACE?
PELLEGRINO OFFERS PUTTING
PHYSICIANS AT FINANCIAL RISK CAN
(INDISCERNIBLE) WHICH HAS GRAVE
CONSEQUENCES IN MEDICINE AND
ONLY THE GOVERNMENT WILL PLACE
PUBLIC GOOD ABOVE PRIVATE
INTEREST.
ECONOMIST KENNETH ARROW WROTE
HEALTH CARE CAN'T BE A PERFECTLY
FUNCTIONING MARKET BECAUSE OF
UNCERTAINTY ABOUT QUALITY OF
PRODUCTS THAT PATIENTS PURCHASE,
INJURY TO SOME CAUSED BY
UNCONSTRAINED MARKET MAY NOT BE
OFFSET BY BENEFIT TO OTHERS.
WE KNOW MARKET-BASED U.S. SYSTEM
IS PERHAPS THE LEAST EFFICIENT
WHILE PRODUCING POORER OUTCOMES.
HOWEVER, CONSCIOUSNESS OF
ACTORS IS NO LESS POTENT.
CLINICIANS DOING THINGS CONCRETE
AND SHORT TERM HAVE TROUBLE
RELATING TO PATIENTS, SAYING NO,
AREN'T GOING TO LIMIT CARE AND
CHANGE PRIORITY.
MEDICAL SCHOOLS CAN'T TRAIN MORE
SUBSPECIALISTS, THEY DON'T KNOW
HOW TO BREAK WITH PROPENSITY FOR
MERIT RATHER THAN CAPACITY TO
CARE, LACKING INTEREST TO
PRODUCE SOCIETAL OBLIGATIONS,
SCIENTISTS LIKE IT FIGURE THINGS
OUT, OBLIVIOUS TO PROBLEMS.
POLITICIANS HAVE MOONSHOTS AND
PROGRAMS BUT DON'T WANT TO
OFFEND THOSE THAT MIGHT DRIVE
THEM FROM OFFICE.
PATIENTS RUN DOWN BY LIFE WITH
PAIN LITERAL AND FIGURATIVE,
DON'T TRUST MEDICAL AUTHORITIES
FROM WHOM THEY ARE DISTANT,
CONFUSED BY MISINFORMATION ABOUT
WHAT MEDICAL SCIENCE HAS TO
OFFER, LOOK TO MEDICINE FOR THE
HEALING TOUCH.
DISCOURSE IS DISAPPOINTING,
DOCTORS SELLING PROCEDURES,
PROVIDERS ADVERTISING MIRACLES,
PROFESSIONAL SOCIETIES GUARDING
THEIR INTERESTS, MEDICAL
EDUCATORS PROMULGATING VALUES OF
THE STATUS QUO, SCIENTISTS AND
NIH MAKING EXTRAVAGANT PROMISES,
CORPORATIONS INDUCE DEMAND AND
BLOCK PROGRESS, POLITICIANS
PRIORITIZE MOONSHOTS, MEDIA
SENSE TAIGSALLIZE REPORTS OF
LATEST ADVANCES, NOT REPORTING
VERY OFTEN ON SYSTEMIC PROBLEMS
IN CARE.
HEALTH POLICY RESEARCHERS DON'T
THREATEN THE STATUS QUO, PUBLIC
INTELLECTUALS WHO MIGHT TRY TO
BALANCE DISCOURSE ARE DROWNED
OUT.
ACOURTING TO THEORY OF
COMMUNICATEIVE ACTION PROGRESS
IN SOCIETY DEPENDS ON COMMON
UNDERSTANDING ACROSS THOSE WHO
CONTROL CAPITAL, THOSE WHO MAKE
POLICY, INDIVIDUALS AND GROUPS
WHO SEEK TO HAVE INFLUENCE, AND
VALUES AND BELIEFS THAT MEMBERS
OF SOCIETY, ARGUES IN GENERAL
CAPITALISTS AND POLICYMAKERS
COMMUNICATE VERY WELL WITH
ELEMENTS SHUT OUT IN HEALTH
CARE, CAPITALISTS HAVE THE
POWER, AND ABSENT COMMON
UNDERSTANDING ADVERSARIAL
SITUATIONS LIKE MALPRACTICE
SUITS, INSURANCE DENIALS,
COLLECTION AGENCIES, MISDIRECTED
PRIORITIES IN RESEARCH, CLINICAL
PROGRAMS, MEDICAL EDUCATION,
POOR COMMUNICATION AND CLINICAL
ENCOUNTERS ALL ENSUE.
SO, WHAT CAN WE DO?
POLICY CHANGE CAN'T BE SUSTAINED
WHEN ALMOST EVERY ACTOR WANTS IT
TO FAIL.
PHILOSOPHERS AND OTHERS,
SOCIOLOGISTS WHO THOUGHT ABOUT
THIS, LUKACS, KORSCH, CONTEND
PURSUING SOCIETAL CHANGE JUST BY
POLICY WITHOUT ADDRESSING
CONSCIOUSNESS WILL LEAD TO
FAILURE IN THE END.
IN HEALTH CARE THERE ARE SO MANY
MATERIAL GOODS AT STAKE AND
NON-MATERIAL FACTORS THAT ALL
GROUPS OF ACTORS ARE INCLINED TO
BEAR THOSE ILLS WE HAVE THAN FLY
TO OTHERS THAT WE KNOW NOT OF.
SO, THE CHARACTERS IN THE
PAINTING OF THE ASSASSINATION OF
CAESAR COULD BE ALL THE ACTORS
IN HEALTH CARE WHO SEEK TO KILL
REFORM.
A MODEST INTERVENTION SUCH AS
INCENTIVIZING CASSPISA AND
BRUTUS WOULDN'T HAVE CHANGED THE
OUTCOME ON THE IDES OF MARCH NOR
WILL THAT BE ENOUGH IN HEALTH
CARE.
MEANINGFUL CHANGE, IS IT
POSSIBLE?
THERE ARE SO MANY ACTORS CAUGHT
IN THIS MAELSTROM OF
COMMODIFICATION OF CARE.
IT'S A DAUNTING CAST, WE CAN'T
IGNORE CHALLENGES.
WE NEED TO TAKE THEM ON.
WE NEED TO THINK HOW MANY
PROBLEMS CAN BE TAKEN ON IN
THEIR INSTITUTIONS AND IN THEIR
OWN BEHAVIOR.
GOVERNMENT CAN'T COUNT ON
MINIMALIST INCENTIVES TO CLEAR
THE WRECKAGE, SCIENTISTS CAN'T
BURY HEADS IN SCIENCE AND TRIALS
IF THEY ARE COMMITTED TO
IMPROVING THE HEALTH OF THE
PUBLIC.
THEY NEED TO FUND STUDIES NEEDED
TO DEVELOP AND EVALUATE
INTERVENTIONS THAT ADDRESS THE
MANY PROBLEMS AND PERHAPS
POTENTIAL STEPS THAT I'VE
SUGGESTED TODAY.
CHANGING POLICY WON'T BE ENOUGH.
WE NEED TO TRANSFORM
CONTEMPORANEOUSLY POLICY
CONSCIOUSNESS AND COMMUNICATION,
POWER RELATIONSHIPS, COMBINATION
THERAPY IS NEEDED, OTHERWISE
INNOVATIONS WHICH REPRESENT REAL
PROGRESS ARE LIKE TREATING
LYMPHOMA OR HIV WITH ONE DRUG,
WILL MAKE SOME DIFFERENCE BUT
WILL BE UNDONE BY THE UNDERLYING
MALADY.
IN ADDITION TO WHAT WE'VE
DISCUSSED OTHER CHANGES ARE
ESSENTIAL.
EVERYONE NEEDS THE SAME
INSURANCE, SEPARATE IS NEVER
EQUAL.
NEW TREATMENT SHOULD BE APPROVED
AFTER ONLY CAREFUL ASSESSMENT
AND COST.
THE NATIONAL ACADEMY ALSO SHOULD
CONVENE A PANEL TO PROPOSE A
RADICALLY REVISED BUDGET
PRIORITY FOR NIH THAT GIVES FAR
MORE EMPHASIS TO POPULATION
HEALTH.
IF WE CAN'T DISBAND THE FEE FOR
SERVICE SYSTEM, WE SHOULD
DISBAND THE RUC, WHICH POISONS
IT AND RADICALLY REVISE THE
MEDICARE FEE SCHEDULE.
IN TERMS OF COMMUNICATION, FIND
A WAY TO LIMIT HEALTH SYSTEM
ADVERTISING TO PROMOTION OF
PUBLIC HEALTH, NOT THEIR PRODUCT
LINES.
STOP OVERSELLING IMPLICATIONS.
STOP SELLING PATIENTS WITH
THINGS THEY DON'T NEED.
PROVIDE GREATER TRANSPARENCY
ABOUT ALL MEDICAL DEVICES
INCLUDING AN INDIVIDUAL
DOCTOR/PATIENT ENCOUNTER AND
ESTABLISH MEDIA STANDARDS FOR
MORE BALANCED REPORTING ON
IMPLICATIONS OF NEW RESEARCH.
FINALLY, FOR PATIENTS AND PUBLIC
PROVIDE THE SOCIAL SERVICES AND
FINANCIAL AND PSYCHOLOGICAL
RESOURCES NEEDED TO ADDRESS
PROBLEMS BEST DEALT WITH IN
THOSE CONTEXTS, EDUCATE THE
PUBLIC AND PATIENTS ABOUT THE
C█OMMON GOOD, FAIR DISTRIBUTION
OF LIMITED MEDICAL RESOURCES,
LIMITS ON WHAT MEDICINE CAN
ACCOMPLISH, TRAIN CLINICIAN WHO
IS CAN RELATE TO DIVERSE
COMMUNITIES AND INCORPORATE
COMMUNITIES INTO ALL LEVELS OF
DECISION MAKING AND RESEARCH
EDUCATION AND CLINICAL CARE.
SO, SOME WOULD SAY YOU CAN'T
SOLVE THIS IN HEALTH CARE ALONE.
I AGREE.
ACTORS IN HEALTH CARE WON'T
UNILATERALLY DISARM IN TERMS OF
COMMON -- COMMON FUNDED.
WE MUST ACT IN PROFESSIONAL
CAPACITIES AS CITIZENS TO
PROMOTE CHANGES.
SILENCE IS ASSENT, AS WAS
WRITTEN.
SO, WHAT NEEDS TO HAPPEN IS THAT
EVERY ORGANIZATION INCLUDING
INVOLVED IN MEDICAL EDUCATION
RESEARCH AND PRACTICE NEEDS TO
ADDRESS THESE PROBLEMS WITH
UTMOST URGENCY IN THEIR OWN
ACTIVITIES IN BROADER SOCIETY,
CHANGE CONSCIOUSNESS, TRANSFORM
DISCOURSE, PURSUE A CONSENSUS
WE'RE IN THE SAME BOAT, AND
PRODUCE THE EVIDENCE NEEDED TO
OPTIMIZE POPULATION HEALTH.
WE SURELY SHOULDN'T GIVE UP WITH
EACH FAILED EFFORT AT REFORM.
TWO MILLENNIAL AGO IT WAS
WRITTEN IT'S NOT YOUR DUTY TO
FINISH THE WORK BUT NEITHER ARE
YOU AT LIBERTY TO NEGLECT IT.
WE DIDN'T TALK ABOUT ALL THESE
BALLOONS TODAY.
BUT THERE IS A LOT WE NEED TO
DO.
THANK YOU VERY MUCH.
>> THANK YOU, MARTIN.
I'M GOING TO REACT AND PASS TO
EITHER KATRINA OR MONICA TO HAVE
COMMENTS.
SO, YOU PRESENT A RATHER I WOULD
SAY PESSIMISTIC VIEW OF WHERE WE
ARE, MAYBE THAT'S NOT YOUR
INTENT BUT THAT'S CERTAINLY THE
MESSAGE I HEAR.
YOU KNOW, A LOT OF WHAT YOU
COMMENTED ON, YOU KNOW,
RESONATES WITH MY OWN VIEWS, AS
TO WHERE WE ARE.
BUT IT MAKES IT ALMOST SO
DAUNTING THAT YOU SAY, WELL,
WHERE DO WE START?
WHAT DO WE DO?
I MEAN, ONE OPTION IS TO, YOU
KNOW, QUOTE/UNQUOTE BLOW
EVERYTHING UP AND START OVER BUT
THAT WE KNOW IS NOT VERY
PRACTICAL.
SO, YOU KNOW, WHERE DO WE GET
STARTED WITH INCREMENTAL CHANGE?
>> WELL, YOU KNOW, I THINK ALL
OF THESE THINGS NEED TO HAPPEN.
AND THERE'S NO ONE ENTITY OR
INDIVIDUAL WHO CAN WORK ON ALL
OF THEM.
BUT WE NEED TO RECOGNIZE THEM
ALL.
MY VERY FIRST SLIDE, I QUOTED
MAX WHO SAID THAT THE
DENUNCIATION OF EVERYTHING THAT
MUTILATES MANKIND AND IMPEDES
ITS PRE-DEVELOPMENT RESTS ON
CONFIDENCE IN MAN.
I WOULD HOLD THAT LAYING ALL OF
THIS OUT, ALTHOUGH, YES, IT'S A
LOT OF STUFF, IS AN OPTIMISTIC
VIEW BECAUSE WHY WOULD WE DO
THAT IF WE DIDN'T THINK WE COULD
SOLVE PROBLEMS?
SO, WHERE WOULD WE START?
I THINK INSURING EVERYONE AND
GIVING THE SAME INSURANCE IS ONE
ITEM.
CHANGING MEDICAL EDUCATION BOTH
BY CHANGING WHOM WE SELECT INTO
MEDICAL SCHOOL AND WHAT GOES ON
IN MEDICAL SCHOOL WOULD BE
ANOTHER KEY THING TO DO.
AND CHANGE THE INCENTIVES AND
PRACTICE.
AS I SUGGESTED, PAYING DOCTORS
FOR THEIR TIME AND PAYING PEOPLE
ONLY A LITTLE BIT MORE IF THEY
HAVE TAKEN AN EXTRA YEAR OR TWO
OF TRAINING.
ALL OF WHOM WOULD BE QUITE
HELPFUL.
AND I THINK THAT WOULD BE A GOOD
STARTING TRIPLE REGIMEN.
>> ALL RIGHT.
THREE AREAS AT LEAST.
KATRINA, DO YOU HAVE --
>> YES, THANK YOU SO MUCH FOR
THIS PRESENTATION.
IT'S ABSOLUTELY FANTASTIC.
AND I THINK WE'RE SPEAKING TO AN
AUDIENCE OF PEOPLE AT NIH TODAY,
AND SO I'D REALLY BE INTERESTED
IN DIVING A BIT DEEPER INTO SOME
OF THE CHALLENGES THAT YOU THINK
SPECIFICALLY HOW SCIENTISTS ARE
CONTRIBUTING TO THESE PROBLEMS
AND WHAT WE CAN DO AT NIH.
AND YOU HAVE A CHAPTER IN YOUR
BOOK ABOUT SCIENTISTS AND OUR
CONTRIBUTIONS TO THE PROBLEMS.
AND SOME OF THE THINGS THAT YOU
MENTIONED ARE BIASES IN PEER
REVIEW, LOBBYING, OVERSTATEMENT
OF THE BENEFITS OF OUR RESEARCH
THAT WE OFTEN SELECT RESEARCH
THAT HAS MARGINAL OR INCREMENTAL
ADVANCES VERSUS HIGH RISK
ADVANCES.
AND REALLY WAYS THAT WE
PRIORITIZE BIOLOGICAL
REDUCTIONISM AND KINDS OF
RESEARCH AND HOW WE SELECT
RESEARCH TOPICS WERE SOME AREAS
WAY WE CONTRIBUTE AS RESEARCHERS
AND SCIENTISTS AT NIH.
I'D LIKE TO HEAR MORE YOUR
THOUGHTS ON WHAT CAN WE BE DOING
FROM OUR NECK OF THE WOODS.
>> WELL, AS I IMPLIED AT ONE
POINT IN MY TALK, I THINK THAT
THE IDEAS THAT WE HAVE ON HOW WE
FIX THINGS ALL NEED TO BE
EVALUATED.
AND THE NIH SHOULD BE INVESTING
SERIOUSLY IN -- CERTAINLY I MEAN
IN I THINK THE NIH ISN'T OFTEN
INTERESTED IN STUDYING MEDICAL
EDUCATION BUT MEDICAL EDUCATION
IS ONE OF THE POISONS IN THE
WATERS OF HEALTH CARE IN
AMERICA.
AND NEEDS TO BE STUDIED AND
ADDRESSED AND IMPROVED AND
CHANGED.
A LOT OF OTHER ISSUES THAT I'VE
TALKED ABOUT SIMILARLY.
BUT WHEN YOU THINK ABOUT WHAT
THE NIH INVESTS IN, FORMER
DIRECTOR OF NIH JUST WRITING
THIS PAST WEEKEND IN THE
"WASHINGTON POST" I THINK WROTE
ABOUT HEPATITIS C, WROTE THAT
THE CORRECT NUMBER OF DEATHS
FROM HEPATITIS C IN A YEAR IN
THE U.S. RIGHT NOW SHOULD BE
ZERO.
YOU KNOW, BUT THERE ISN'T A
SYSTEM IN PLACE TO GET US THERE
WITH UNDOING ONE PROJECT, YOU
KNOW, THERE ARE A FEW OTHER
PROJECTS WHERE PEOPLE ARE
LOOKING AT ACCESS AND
DISPARITIES AND WHAT DO YOU DO
AND SO ON IN THIS DISEASE.
BUT IF -- YOU KNOW, IF 16,000
PEOPLE WERE DYING FROM A
TERRORIST ATTACK, YOU KNOW,
THERE WOULD BE A LOT THAT WOULD
HAPPEN TO TRY TO MAKE SURE THAT
DOESN'T HAPPEN AGAIN.
BUT IN MY CAREER, MY FIRST
PROJECT IN MONTREAL WAS STUDY OF
PROBLEMS IN CONTROLLING
HYPERTENSION IN THE COMMUNITY.
THEN I SPENT A LOT OF MY CAREER
STUDYING HIV AND ITS CARE.
WE HAVE TREATMENTS THAT CAN
ALLOW PEOPLE TO LIVE A NORMAL
LIFE WITH HIV BUT THERE'S STILL
15,000 A PEOPLE YEAR DYING FROM
HIV IN THE UNITED STATES.
WHY ISN'T THE NIH INVESTING SOME
OF -- MUCH MORE OF ITS $50
BILLION LOOKING AT THESE
DISORDERS AND THESE POPULATIONS
AND THESE PROBLEMS, AND THEN THE
UPSTREAM STUFF THAT LEADS TO
THAT.
IT'S NOT ENOUGH TO SAY, WELL,
LET'S DEVELOP A BETTER DRUG.
YEAH, SURE.
SOMETIMES IT'S GOOD TO HAVE A
BETTER DRUG.
MAYBE IT'S GOOD IF SOMEONE CAN
TAKE AN INJECTION INSTEAD OF
GETTING A PILL EVERY DAY.
BUT THERE IS SO MUCH NEGLECT OF
POPULATION HEALTH.
I REALLY THINK THE PRIORITIES,
SURE, WE NEED BASIC SCIENCE, WE
NEED TO DEVELOP VACCINES AND,
YES, IT'S GREAT TO HAVE DRUGS
THAT ARE GOING TO GIVE PEOPLE
ANOTHER TWO OR THREE MONTHS OF
DISEASE-FREE SURVIVAL, YOU KNOW,
WITH THEIR LUNG CANCER, AS
REPORTED IN THE NEW ENGLAND
JOURNAL THIS WEEK.
BUT THERE'S SO MUCH MORE THAT WE
NEED TO DO.
THERE'S SO MANY PEOPLE THAT ARE
DYING EARLY.
IT IS A CATASTROPHE.
YEARS AGO, I REMEMBER READING AN
ARTICLE ABOUT DECLINE OF LIFE
EXPECTANCY IN THE SOVIET UNION,
IN THE 1980s.
I SAW THAT AND SAID MY GOD, HOW
CAN THAT COUNTRY SURVIVE?
WELL, THIS IS A FIVE-ALARM FIRE.
LIFE EXPECTANCY IS DECLINING,
PEOPLE ARE DYING OF DISEASES
THEY SHOULDN'T DIE OF.
PEOPLE ARE GOING INTO MEDICAL
SCHOOL, 10% OF STUDENTS IN THE
FIRST YEAR OF CLASS HAVE ALREADY
SELECTED ORTHOPEDIC SURGERY NOT
BECAUSE OF LOVE OF BONES, THEY
MIGHT TELL YOU THAT'S WHY THEY
ARE DOING IT, BUT BECAUSE THEY
CAN MAKE SO MUCH MONEY DOING IT.
OUR MEDICAL STUDENTS, SOME ARE
VERY IDEALISTIC.
WHEN YOU GET A COMMUNICATION
LETTER A LOT HAVE A SIGNATURE
BLOCK THAT LISTS PREFERRED
PRONOUNCE, WHICH IS GREAT, AN
ACKNOWLEDGMENT OF DIVERSITY.
BUT SOME YEARS FROM NOW, THEY
WILL HAVE -- MAY STILL HAVE
PLEASED PRONOUNS BUT WILL HAVE
PREFER INSURANCE AND IT WON'T BE
THE INSURANCE 90 MILLION
AMERICANS HAVE, MEDICAID.
WE GOT TO SOLVE THESE PROBLEMS.
THE NIH SHOULD GO ALL IN WITH
POPULATION HEALTH.
SOMETIMES WHEN I GIVE TALKS
PURSUANT TO MY BOOK, I QUOTE
JOHN DUNN.
ANY MAN'S DEATH DIMINISHES ME
BECAUSE I'M INVOLVED IN MANKIND.
THAT SHOULD BE THE MANTRA OF THE
NIH.
ANY MAN'S DEATH, ANY PERSON'S
DEATH, ANY PERSON'S DEATH.
AND THEY SHOULD INVEST ACCORDING
TO WHAT'S GOING TO DO THE MOST
TO PREVENT THOSE DEATHS THAT CAN
BE PREVENTED.
>> ELISEO, YOU'RE ON MUTE.
>> I WANT TO TURN TO A QUESTION
IN THE CHAT.
ALTHOUGH I DO THINK THERE'S MORE
BEING DONE AT THE NIH THAN YOU
GIVE US CREDIT FOR, MARTIN,
WE'LL COME BACK TO THAT.
REGARDING YOUR PROPOSAL FOR
MEDICAL SCHOOL ADMISSIONS HOW DO
YOU SCREEN FOR THINGS LIKE
MORALS, ETHICS, SOCIAL
RESPONSIBILITY AND ALTRUISM AND
HOW DO YOU ENSURE THAT
APPLICANTS ACTUALLY BELIEVE IN
THESE THINGS, IN THESE VALUES,
RATHER THAN SIMPLY LEARNING THE
CORRECT THING TO SAY OR TREATING
THEM LIKE, YOU KNOW, BOX
CHECKING EXERCISE FOR THE
PURPOSE OF THEIR APPLICATION?
SEEMS LIKE THERE'S A RISK THAT
THOSE WHO ALREADY HAVE THE LEG
UP COULD JUST ADAPT BUT NOT
TRULY GROW AND FIX THE PROBLEM.
>> I WOULD AGREE BUT SOCIAL
PSYCHOLOGISTS SPEND THEIR
CAREERS DEVELOPING MEASURES OF
THINGS LIKE THIS.
OF COURSE THEY HAVE TO BE TESTED
FOR THESE PURPOSES.
BUT WE INVEST A LOT IN PEOPLE
DEVELOPING MEASURES OF QUALITY
OF LIFE, THIS, THAT, AND THE
OTHER.
WHY NOT INVEST IN DEVELOPING
RELIABLE WAYS OF MEASURING OR
DETECTING THE VALUES OF PEOPLE?
NOW, MEMBERS OF THEIR
COMMUNITIES, I SUGGESTED
COMMUNITY MEMBERS SHOULD BE ABLE
TO NOMINATE.
THAT COULD GET POLITICIZED TOO
AND COULD GET DISTORTED.
THEY WOULD HAVE TO THINK ABOUT
HOW TO NOT HAVE THAT HAPPEN.
WHAT HAPPENS WHEN PEOPLE COME DO
MEDICAL SCHOOL, THE ETHOS IS NOT
WHAT IT SHOULD BE.
I TALKED ABOUT THE WHITE COAT
CEREMONY, CELEBRATING WITH
FAMILIES, REFERENCE TO ETHICAL
RESPONSIBILITY, MIGHT BE BETTER
TO DO WHAT POPE FRANCIS DID ON
HIS FIRST DAY, WASHING THE FEET
OF THE POOR REMINDER WHAT HE WAS
SUPPOSED TO BE ABOUT.
NOW, THERE COULD BE ANALOGOUS
THINGS THAT ONE CAN DO.
AND I THINK WE COULD GET THERE.
I THINK WE COULD GET THERE.
BUT, YOU KNOW, DANIEL MARKOWITZ
WROTE A GREAT BOOK ON
MERITOCRACY, BASICALLY THE
CURRENT PATTERN OF SELECTION
JUST PROVIDES MORE EQUITY TO
THOSE PEOPLE AND THEIR FAMILIES
WHO ALREADY HAVE LOTS OF IT.
>> ALL RIGHT.
MONICA, ARE YOU ON?
DO YOU HAVE A COMMENT OR
QUESTION FOR MARTIN?
>> I AM.
HI.
THANK YOU, ELISEO.
I DO.
I APPRECIATE THE THINGS YOU
BRING TO THE TABLE IN YOUR
DISCUSSION BECAUSE IT'S VERY
THOUGHT PROVOKING.
I THINK MANY PEOPLE HAVE TALKED
ABOUT THIS TO SOME DEGREE.
YOU BRING IT TOGETHER IN
INTERESTING AND, YEAH, THOUGHT
PROVOKING WAYS.
MY QUESTION, SOME PEOPLE REFER
TO THE U.S. HEALTH CARE SYSTEM
AS REALLY MORE OF A SICK CARE
SYSTEM VERSUS HEALTH CARE.
YOU KNOW, IT'S INCREASINGLY
DIFFICULT TO GET AN APPOINTMENT
TO SEE YOUR DOCTOR FOR MONTHS
SOMETIMES AND AS YOU SAID, TIME
WITH CLINICIANS IS JUST VERY
LIMITED.
I THINK OTHER THINGS,
PREVENTION, MENTAL AND
BEHAVIORAL HEALTH ARE JUST NOT
PRIORITIZED IN FAVOR OF THE
BIOMEDICAL MODEL.
AND RESEARCH HAS SHOWN THAT
ATTENTION TO THESE ASPECTS OF
HEALTH ARE NOT ONLY CRITICAL FOR
REDUCING PREVENTIBLE DEATH AND
DISEASE BUT ALSO REALLY COST
EFFECTIVE.
SO FROM YOUR EXPERIENCE, WHAT
ARE SOME OF THE MOST EFFECTIVE
STRATEGIES TO BRIDGE THE GAP
BETWEEN RESEARCH FINDINGS AND
THEIR IMPLEMENTATION IN CLINICAL
PRACTICE FOR THESE AND OTHER
CLINICAL PRACTICE KINDS OF
ISSUES?
>> WELL, I'M NOT A GREAT
IMPLEMENTATION SCIENTIST.
I WOULD DEFER TO OTHERS.
BUT I THINK INVESTING IN LOTS OF
EFFORTS TO FIGURE OUT HOW TO DO
THIS, PUTTING LOTS AND LOTS OF
RESOURCES INTO DOING IT IN
PRIORITY AREAS IS GOING TO
IDENTIFY THE STRATEGIES FOR
DOING SO THAT ARE MOST
EFFECTIVE.
I THINK JUST SAYING, OH WELL,
THIS IS A PRIORITY, LET'S MAKE
THIS A PRIORITY AND GO OUT AND
DO STUFF, WE WOULDN'T DO THAT
WITH MEDICATIONS.
WE NEED SCIENCE AND WE NEED MORE
SCIENCE.
ELISEO, I KNOW THERE'S STUFF
GOING ON AT NIH.
I'M ARGUING THAT IT'S NOT NEARLY
ENOUGH.
WHY CAN'T $20 BILLION OF THE $50
BILLION BE DEVOTED TO THESE
KINDS OF THINGS?
>> CAN I ASK A FOLLOW-UP
QUESTION ABOUT HOW WE SHOULD BE
THINKING ABOUT WHAT HAS THE MOST
POPULATION HEALTH IMPACT AT NIH
AND SO JUST AS AN EXAMPLE, ONE
OF THE AREAS I STUDIED IN MY
PAST IS PEDIATRIC HEREDITARY
CONDITIONS, WHICH ARE FAIRLY
RARE.
SO IF YOU'RE THINKING ABOUT
THESE CONDITIONS OUT OF
POPULATION IMPACT LEVEL IN TERMS
OF THE NUMBERS OF INDIVIDUALS
WHO HAVE EACH OF THESE
CONDITIONS, THERE AREN'T THAT
MANY PEOPLE.
HOWEVER, THESE CONDITIONS ARE
RESPONSIBLE FOR A SUBSTANTIAL
FRACTION OF HOSPITALIZATIONS
AMONG CHILDREN, AS WELL AS A
SUBSTANTIAL FRACTION OF THE COST
FOR PEDIATRIC CARE.
AND SO I'M JUST WONDERING, YOU
KNOW, HOW WE PRIORITIZE, WHAT IS
THE MOST IMPACTFUL PUBLIC
HEALTH-RELATED TOPIC NIH SHOULD
BE STUDYING, MERELY BASED ON THE
NUMBER OF PEOPLE IMPACTED OR
WHAT MEASURES WOULD WE USE?
>> THAT'S A GREAT WAY OF FRAMING
THE QUESTION.
I WOULD SAY IT'S NOT FOR ME TO
SAY.
BUT WE CAN'T BE IGNORING THE BIG
THINGS THAT ARE KNOCKING OFF
LOTS OF PEOPLE.
BUT THERE OUGHT TO BE ROOM TO
STUDY THE KINDS OF THINGS THAT
YOU ARE TALKING ABOUT WHICH ALSO
HAS IMPLICATIONS FOR DELIVERY OF
HEALTH CARE AS WELL AS THESE
OTHER KINDS OF THINGS THAT ARE
NOT GETTING NEARLY ENOUGH
ATTENTION.
AND HOW DO WE DO THIS?
WELL, I THINK LARGE SWATHS OF
THE BUDGET COULD BE MOVED INTO
STUDYING DELIVERY AND STUDYING
NEED AND STUDYING STRATEGIES FOR
IMPROVING UPTAKE OF TREATMENTS.
WHEN I DID THE WORK ON HIV WE
HAPPENED TO GO INTO THE FIELD
JUST AS HIGHLY ACTIVE AND
ANTIRETROVIRAL THERAPY BECAME
AVAILABLE.
WE TRACKED DIFFUSION OF
TREATMENT IN THE POPULATION IN
THE UNITED STATES.
PEOPLE WHO WERE IN CARE.
AND AMONG PEOPLE WITH ADVANCED
DISEASE IT SHOULD COME AS NO
SURPRISE THAT WHITES GOT TREATED
MORE RAPIDLY THAN BLACKS, THAT
MEN SOONER THAN WOMEN, THOSE
WITH PRIVATE INSURANCE SOONER
THAN PEOPLE WITH MEDICAID MORE
LIKELY UNINSURED, AND SO ON.
AND THOSE ARE UNACCEPTABLE
PATTERNS.
AND ALL OF THAT NEEDS TO BE
ADDRESSED.
YOU KNOW, YES, TREATMENTS ARE
IMPROVING FOR VARIOUS
CONDITIONS.
LET'S MAKE SURE THAT TREATMENTS
THAT ARE GIVEN PRIORITY IN THE
SYSTEM ARE AVAILABLE TO
EVERYONE.
LET'S MAKE SURE THAT IF THE
UPTAKE ISN'T EQUITABLE WE FIGURE
OUT WHY IT ISN'T EQUITABLE.
SO ARE THERE SMART PEOPLE AROUND
WHO CAN FIGURE THIS OUT?
THE ONE THING I DROPPED IN, I
REALIZE NIH CAN'T JUST DO THIS,
BUT, YOU KNOW, A FRIEND OF MINE
WHO IS A REPUBLICAN COMMENTED
THAT FOR THE NIH TO FUND A
STUDY, THAT LEADS TO THE
DEVELOPMENT OF A DRUG AND GET
NONE OF THE REVENUE IS
SCIENTIFIC MALPRACTICE.
AND THIS WAS SOMEONE WHO WORKED
IN THE TRUMP ADMINISTRATION.
AND I THINK THAT'S TRUE.
WHY NOT BRING A LOT OF THAT
REVENUE BACK INTO THE NIH AND
USE THAT FOR STUDYING
DISSEMINATION, STUDYING
IMPLEMENTATION?
IN A FAR MORE SERIOUS WAY.
>> FIND A WAY TO REDUCE OUR BASE
BUDGET IF WE DID THAT, JUST LIKE
WITH FDA.
I THINK IT IS A TOPIC OF
DISCUSSION, PARTICULARLY AROUND
THE RIDICULOUS HIGH COST OF
DRUGS FOR PEOPLE PAYING BOTH OUT
OF POCKET, NOT JUST FOR RARE
DISEASES OR UNCOMMON BUT ALSO
FOR COMMON DISEASES LIKE HEART
FAILURE, DIABETES, ET CETERA.
SO LET ME GO TO AN AUDIENCE
QUESTION.
CAN DR. SHAPIRO CLARIFY WHAT HE
MEANS BY "GOVERNMENT."
>> I THINK THAT'S A FAIR
CHARACTERIZATION, YES, WE'RE
PROBABLY NOT GOING TO GET A
SINGLE PAYER SYSTEM WITHOUT
ELECTED OFFICIALS PARTICIPATING.
IN TERMS OF THE AGENCIES, LOOK,
I MENTIONED HOW WE SHOULD MAKE
SURE EVERYTHING IS COST
EFFECTIVE.
THEN YOU HAVE PEOPLE IN CONGRESS
WHO WILL NOT ALLOW PCORI, FOR
EXAMPLE, TO DO COST
EFFECTIVENESS ANALYSIS.
WHICH IN THE U.S., NOT TO DO
COST EFFECTIVENESS ANALYSIS IS
LIKE WHAT ARE THEY THINKING?
OR AS YOU PROBABLY -- MANY OF
YOU WILL KNOW, WHEN OF THE
PRECURSOR OF AHRQ I DON'T KNOW
FUNDED AND SUPPORTED A STUDY
THAT SUGGESTED CERTAIN BACK
SURGERIES WERE NOT BETTER THAN
MEDICAL TREATMENT, THE
ORTHOPEDIC LOB LOBBY GOT THE
HOUSE TO ZERO OUT THE BUDGET.
OTHERS TOOK AWAY THE GUIDELINES
PORTFOLIO AS WELL.
THERE ARE REALLY PROBLEMS IN THE
POLITICAL PROCESS BUT WITHIN
AGENCIES THERE ARE PRESUMABLY
THINGS THAT COULD BE DONE.
THE APPROPRIATION WITHIN THE NIH
BUDGET OBVIOUSLY THERE IS SOME
MANDATE WITHIN THAT BUDGET.
BUT THERE IS MORE DISCRETION.
AND --
>> THERE IS BUT JUST TO MAKE
SURE WE ALL UNDERSTAND, NIH IS A
FEDERATION OF 24 GRANT-GIVING
INSTITUTES AND CENTERS, AND SO
IT'S REALLY THE PRIORITIES ARE
SET BY EACH OF THE INSTITUTES.
IT'S NOT LIKE WE IS MOVE LIKE
MONICA BERTAGNOLLI CAN SAY $10
BILLION INTO THIS OR $8 BILLION
INTO THAT, IT DOESN'T WORK THAT
WAY AT NIH.
IT'S ONE OF THE UNIQUE
STRENGTHS.
LET ME GO BACK TO HEALTH SYSTEM
SOLUTIONS PERHAPS.
I THOUGHT THAT DOING THE
AFFORDABLE CARE ACT
IMPLEMENTATION ONE OF THE
DRIVERS, AS YOU PROBABLY KNOW
NOW THAT YOU'VE BEEN AN EAST
COASTER FOR A FEW YEARS, THERE'S
A DRAMATIC DIFFERENCE IN HEALTH
CARE ORGANIZATION IN SOME WAYS,
NOT ALL, NOT IN MANY BUT SOME
BETWEEN EAST AND WEST,
PARTICULARLY AROUND THE VALUE OF
PRIMARY CARE AND PARTICULARLY
AROUND THE ISSUE OF HOW PEOPLE
LOOK AT POPULATION HEALTH.
THAT ASIDE, THERE WAS A MOVE, A
DIRECTION TOWARD ACCOUNTABLE
CARE ORGANIZATIONS WHERE THE
IDEA WOULD BE THAT HEALTH CARE
SYSTEM WOULD SAY I'M RESPONSIBLE
FOR THESE PEOPLE WHO ARE UNDER
THE SYSTEM AND THEN WE WILL
COVER EVERYBODY AND DO WHAT WE
CAN WITH ALL THE SERVICES AND
RESOURCES THAT WE HAVE, AND WE
HAVEN'T FIGURED OUT BUDGETS,
STILL DRIVEN BY FEE FOR FEE FOR
SERVICE OR A LOT THROUGH STAFF
MODEL HMO OR HMO-TYPE SYSTEMS
PAYMENT PER MEMBER PER MONTH.
THAT SEEMED TO END OR AT LEAST
WAS I WOULDN'T SAY END BUT WAS
PAUSED COMPLETELY IN 2017, AND
HASN'T REALLY BEEN REIGNITED, I
HAVEN'T SEEN IT AT LEAST, ANY
THOUGHTS ON THAT AS A POTENTIAL
INCREMENTAL STEP?
>> WELL, YOU KNOW, MY
UNDERSTANDING, AGAIN I'M NOT AN
EXPERT IN THAT, IS THAT IT
LOOKED LIKE IT HAD TINY EFFECTS,
WASN'T HAVING MAJOR EFFECTS.
AND MY SENSE IS THAT THE --
THERE WAS ALSO AN EFFORT TO GET
MORE DOCS TO TAKE MEDICAID
PATIENTS AND I THINK LIKE A 2%
JUMP FOR A WHILE.
WHILE INCENTIVE WAS THERE BUT IT
WENT AWAY.
THAT IT REQUIRES BIGGER KINDS OF
INTERVENTIONS THAN LITTLE
ECONOMIC MANIPULATIONS, NOT WITH
STANDING PERSPECTIVE OF
ECONOMISTS, BEHAVIORAL
ECONOMISTS ON ALL OF THIS.
THE MOVIE JURASSIC PARK, YOU MAY
REMEMBER THE EXPRESSION, NATURE
FINDS A WAY.
RIGHT?
WELL, I THINK THAT'S LIKE THE
RESPONSE OF THE PROCEDURALLISTS
TO THE RELATIVE VALUE SCALE, OH
MY GOD, THIS IS A CATASTROPHE.
BUT TURNS OUT THEY ARE DOING
EVEN BETTER THAN THEN BECAUSE
THEY FOUND A WAY TO WORK AROUND
THE SYSTEM.
WE NEED A SYSTEM THEY CAN'T WORK
AROUND.
WE NEED A SYSTEM THAT DOES NOT
OFFER THE POSSIBILITY OF
BUSINESS AS USUAL.
AND AGAIN I DON'T PRETEND TO
HAVE THE SOLUTION.
BUT LOTS OF RESOURCES NEED TO --
YOU GUYS DO IMPORTANT WORK.
I REALLY BELIEVE IN WHAT NIMHD
IS DOING.
AND THERE'S A LITTLE BIT OF WORK
SUPPORTED BY OTHER INSTITUTES
BUT IT'S NOT NEARLY ENOUGH.
WHY CAN'T YOUR INSTITUTE HAVE $2
BILLION A YEAR?
YOU COULD DO MORE WITH $2
BILLION A YEAR THAN YOU DO WITH
FOUR OR FIVE HUNDRED MILLION.
>> I'LL PRETEND I DIDN'T HEAR
THAT.
LET ME TURN TO MONICA TO SEE IF
SHE HAS A QUESTION OR COMMENT.
>> YOU KNOW, ONE OF THE THINGS
THAT YOU MENTIONED WAS ABOUT THE
MEDICAL SCHOOL ASPECT OF THIS,
AND THAT'S SOMETHING THAT REAL
NEEDS TO BE ADDRESSED.
AND I WANTED YOU TO SAY MORE
ABOUT THE CURRICULUM CHALLENGES.
I CAN REMEMBER BEING FACULTY
MEMBER AT A MEDICAL SCHOOL, AND
I RAISED A FEW ISSUES IN TERMS
OF RACISM IN THE MEDICAL SCHOOL
CURRICULUM WHICH WAS IMPLICIT
BUT FOR ME IT WAS JUMPING OUT AT
ME.
I REMEMBER GETTING PRETTY
SIGNIFICANT PUSHBACK FROM SOME
OF THOSE ON THE CORE CURRICULUM
TEAMS ABOUT MAKING THOSE
CHANGES.
INTERESTINGLY ENOUGH FAST
FORWARD TO 2020, I WAS GETTING
E-MAILS, APOLOGIZING SAYING
YOU'RE RIGHT, WE SHOULD CHANGE
AND WE WILL.
EVEN IN THE WAY PEOPLE ARE
TRAINED IN TERMS OF DISPARITY
REDUCTION, AN IMPORTANT PART OF
THIS BROKEN SYSTEM, IT'S
INTERESTING IF YOU COULD COMMENT
ON THE CURRICULUM CHANGES
SPECIFICALLY AROUND ADDRESSING
UNDERSERVED POPULATIONS.
>> YOU KNOW, IT'S HARD TO KNOW
BECAUSE MEDICAL STUDENTS WHO I
ENCOUNTER NOW AT CORNELL, YOU
KNOW, WILL OFTEN EXPRESS
POSITIVE SOCIAL VALUES ABOUT,
OH, WE'RE AGAINST RACISM, WE'RE
FOR JUSTICE AND ALL THIS.
BUT WHEN IT COMES TO CHOOSING
THEIR SPECIALTIES A LOT ARE
STILL CHOOSING HIGH-PAID FIELDS,
A LOT ARE STILL GOING INTO
PRACTICES WHERE INSURANCE
CHOICES ARE QUITE LIMITED.
AND I THINK THAT -- I SUGGESTED
HALF OF THE FIRST TWO YEARS,
PEOPLE EVEN TALKED ABOUT
DECREASING MEDICAL SCHOOL BY A
YEAR, BUT WHY NOT GIVE THEM A
YEAR OF -- OR YEAR AND A HALF IN
WHICH HALF OF WHAT THEY ARE
DOING IS HAVING POSITIVE VALUE
REINFORCED, ALL KINDS OF
EXPERIENCES THAT MIGHT HAVE A
POSITIVE EFFECT ON PEOPLE.
ALL OF THAT NEEDS TO BE STUDIED.
WHAT IS IT THAT'S GOING TO TAKE
PEOPLE, GET PEOPLE TO WANT TO
TAKE CARE OF POOR PEOPLE, TO
SACRIFICE SOME INCOME IF
NECESSARY TO TAKE CARE OF POOR
PEOPLE?
WHAT WILL LEAD PEOPLE IN THAT
DIRECTION?
WHAT WILL MOTIVATE THEM TO SPEND
MORE TIME WITH A PATIENT WHO
NEEDS THEIR ATTENTION AND WHO
NEEDS THEIR COMPASSION?
HOW DO WE GET TO THAT?
THIS IS ALL THE KIND OF THING
FOR WHICH 100,000 STUDIES SHOULD
BE DONE UNTIL WE FIND THE THINGS
THAT REALLY MAKE THE BIGGEST
DIFFERENCE.
IT MIGHT BE CLINICAL
EXPERIENTIAL THING, I'M NOT
SURE.
AGAIN, IT ALL REQUIRES
VALIDATION AND VERIFICATION.
I THINK SINCE THE CURRENT
ARRANGEMENTS CONTRIBUTE TO THE
PROBLEMS, CONTRIBUTE TO THE
DISPARITIES IN LIFE EXPECTANCY,
YES, OF COURSE THERE'S OTHER
THINGS BESIDES MEDICAL CARE.
BUT IN THE FACE OF ALL THAT, I'M
SITTING AT 91st STREET IN
MANHATTAN.
GO 30 BLOCKS NORTH AND PEOPLE
ARE LIVING 15 YEARS LESS.
THAT'S NOT OKAY.
THERE SHOULD BE FAR MORE
RESOURCES THAN THERE ARE TO
PEOPLE IN MY BUILDING AND MY
NEIGHBORHOOD.
AND IT WILL REQUIRE A VERY
DIFFERENT MINDSET FOR THE
PRACTITIONERS, AND ULTIMATELY
FOR THE HEALTH SYSTEMS TO TREAT
IT IN A DIFFERENT KIND OF WAY
TOO.
SO THE CURRICULUM, YES, THE
CURRICULUM NEEDS TO CHANGE.
THE CONTENT OF THE CURRICULUM.
I THINK THE SCIENCE BASIS, THE
FACT THAT STUDENTS TEND TO GET A
TASK EVERY TWO WEEKS OR SO -- A
TEST EVERY TWO WEEKS OR SO,
RAT-TAT-TAT THE WHOLE TIME.
THEY WILL HAVE THEIR DOCTORING
CURRICULUM OR THEIR SOCIAL
MEDICINE COURSE WHICH IS NOT
GREAT GRADED THE SAME WAY WHICH
DOESN'T AFFECT INTERNSHIP
APPLICATIONS THAT HAS VERY
LITTLE IMPACT.
ALL OF THAT NEEDS TO CHANGE.
IT'S A DIFFERENT THING THAT
NEEDS TO HAPPEN, I THINK.
YES, IT'S NOT GOING TO BE EASY
TO GET THERE.
BUT I THINK THE NIH COULD HELP
IF THEY REALLY DECIDED TO PUT
MONEY INTO TRYING TO IMPROVE
THESE.
>> ALL RIGHT.
LET ME TURN TO ANOTHER AUDIENCE
QUESTION.
DR. SHAPIRO, THANKING YOU FOR AN
ENLIGHTENING PRESENTATION.
WHAT KEY HURDLING BEYOND
POLITICS AND SUPERFICIAL
SOLUTIONS HAVE HINDERED
SUBSTANTIAL REFORM IN THE
AMERICAN HEALTH CARE SYSTEM, CAN
WE LOOK TO SUCCESSFUL MODELS IN
OTHER COUNTRIES FOR
INSPIRATION?
IF SO WHICH COUNTRY IS A
PROMISING MODEL FOR REFORMING
AMERICA'S HEALTH CARE SYSTEM?
>> I DON'T KNOW THE MODEL
THATTEDS SHOULD BE A-- MODEL
THAT SHOULD BE ADOPTED.
ALMOST ALL WESTERNIZED SYSTEMS.
THERE ARE PROBLEMS IN CANADA,
THEY COULD EXPAND TO A LEVEL
THAT WOULD SOLVE PROBLEMS
WITHOUT COMING NEAR WHAT THE
U.S. IS WASTING ON U.S. HEALTH
CARE.
I WOULD POINT TO THAT.
THERE ARE ISSUES BEYOND THE
ECONOMIC AND POLITICAL, AND SOME
IS REFLECTED IN PEOPLE'S VALUES
AND NEEDS AND EXPECTATIONS.
YOU ARE KNOW, THE PATIENTS WHO
CONTINUALLY DEMAND CARE AND
SERVICE AND TESTS, BECAUSE THEY
CAN'T DEAL WITH THE FACT THAT
GRANDMA IS DYING OR THEY ARE
ANXIOUS OR THEY ARE DEPRESSED
AND THEY WON'T -- AREN'T ABLE TO
GET THE CARE THEY NEED FOR THAT,
OR THEY ARE NOT PREPARED TO
CONFRONT THAT.
THE PEOPLE WHO GO INTO MEDICINE
AND HAVE PERSONAL PROBLEMS, YOU
KNOW, THAT MAKE THEM
UNCOMFORTABLE DEALING WITH
PATIENTS WHO HAVE INTENSE
PSYCHOLOGICAL NEEDS, I HAD AN
EXPERIENCE, A RATHER INTERESTING
ONE.
WE HAD A HOLOCAUST SURVIVOR ON
SERVICE WHO DIED, AND I CAME
INTO ROUNDS THE NEXT DAY, HEARD
ABOUT IT.
NO ONE WAS TALKING ABOUT HER.
I NOTICE SHE'S NOT ON THE LIST.
SOMEONE SAID, SHE CODED.
WELL, SHE WAS NOT CODED.
SHE DIED.
IT WASN'T TO BE RESUSCITATED.
I SAID LET'S TALK ABOUT HER AND
HER EXPERIENCE A LITTLE BIT AND
TALK ABOUT DEATH AND DYING.
SO WE DID THAT.
PEOPLE TALKED ABOUT THEIR
EXPERIENCES.
WE TALKED ABOUT HER.
AND THEN I PULLED OUT SOME POEMS
FOR PEOPLE TO READ ABOUT DEATH
AND DYING.
SOME FAMOUS STUFF.
AND ASKED EACH TO READ A POEM, I
READ A POEM.
WHEN READING MINE TEARS WERE
STREAMING DOWN MY CHEEK.
I WAS CRYING.
AND AFTERWARDS THE RESIDENT TOLD
ME THE STUDENTS HAD COME OVER
AND ASKED IF I HAD A COLD.
THAT IT WASN'T SEEN AS BEING
OKAY TO EMBRACE THE EMOTIONALITY
OF DEATH, OF DYING, OF HUMAN
EXPERIENCE.
AND I THINK ALL OF THIS NEEDS TO
BE ADDRESSED TOO IF PEOPLE ARE
GOING TO GET THE CARE THEY NEED
AND TRUST DOCTORS AND THE
SYSTEM.
>> LET ME TURN TO KATRINA.
>> YEAH, I WANT TO ALSO GIVE AN
AUDIENCE QUESTION.
SO, HE UNCOURAGED NIH TO FUND
MORE POPULATION STUDIES.
WHO IN AN INSTITUTE MAKES THAT
DECISION AND HOW CAN WE
INFLUENCE THAT PERSON OR GROUP
TO FUND IN THAT DIRECTION?
I WANT TO ADD MY OWN QUESTION,
WHICH IS, PART OF WHAT YOU WERE
CONCERNED ABOUT WITH SCIENTISTS
IS THAT WE LOBBY AND ADVOCATE
FOR OUR AREAS OF SCIENCE, SO IF
WE ARE HEALTH SERVICES
RESEARCHERS, ARE WE NOT GUILTY
OF THE SAME THING THAT OTHER
SCIENTISTS ARE DOING IF WE'RE
ADVOCATING FOR MORE OF THE KINDS
OF WORK THAT WE DO?
>> THEY ARE BETTER AT IT THAN
YOU ARE, CLEARLY.
WHO WITHIN AN INSTITUTE?
WELL, I TOLD YOU ABOUT HE WHO
MUST NOT BE NAMED WHO DIDN'T
THINK THAT OUTCOMES RESEARCH IN
HIV WAS IN THE MANDATE OF THE
NIAID.
PRESUMABLY, AT THAT LEVEL, THERE
IS SOME PRIORITIZATION THAT CAN
BE SHAPED.
BUT I THINK THERE'S ALSO THE
ISSUE ABOUT THE RELATIVE BUDGETS
OF INSTITUTES.
AND THERE ARE A NUMBER OF
INSTITUTES THAT SHOW INTEREST IN
THIS KIND OF WORK.
THE OPPOSITE THING, BY THE WAY,
WAS DIRECTOR OF NIMH DECIDING
ALL HE WANTED TO SUPPORT WAS
BASIC SCIENCE AND CLINICAL
TRIALS.
SO CLEARLY SOME OF THAT OCCURS
THERE BUT IT'S THE ABSOLUTE
LEVEL OF SUPPORT FOR DIFFERENT
KINDS OF WORK FOR DIFFERENT
KINDS OF -- WITHIN THE
INSTITUTES, AND I THINK IT
OPPORTUNITIES WITH SMALL
BUDGETS, THREE, FOUR, FIVE
HUNDRED MILLION A YEAR
INSTITUTES, THEY ARE HONORABLE
AND WORTHY.
THEY OUGHT TO BE ON THE SAME
FOOTING AS THE -- YOU KNOW,
NINDS WITH ITS $2 BILLION THAT
DOESN'T DO ANY OF THIS RESEARCH
AND SO ON.
SO, YES, LEADERSHIP WITHIN
INSTITUTES.
PART OF IT OF COURSE DEPENDS WHO
YOU APPOINT AS DIRECTOR OF BE A
INSTITUTE.
I SUSPECT THERE ARE OTHER PEOPLE
ON THIS CALL WHO KNOW A LOT MORE
ABOUT WHAT IT WOULD TAKE TO MOVE
MONEY AROUND WITHIN THE NIH
BUDGET.
>> THANK YOU, MARTIN.
THERE HAS BEEN I WOULD ALMOST
SAY A GENERATIONAL TRANSITION OF
INSTITUTE DIRECTORS WHERE YOU DO
HAVE A GROUP NOW THAT IS
PRIMARILY COMING FROM A
DIFFERENT SET OF DISCIPLINES AND
BACKGROUNDS ACROSS THE NIH.
SO, I'M SITTING HERE, EIGHT-PLUS
YEARS SINCE ARRIVING, I'M THE
MIDDLE OF EXPERIENCES.
YOU CAN GET A FLAVOR THAT PEOPLE
DO TURN OVER AND THERE HAVE BEEN
TRANSITIONS.
SO I REMAIN ETERNALLY OPTIMISTIC
THESE THINGS WILL GRADUALLY
CONTINUE TO CHANGE.
LET ME ADD ANOTHER QUESTION FROM
AUDIENCE.
IN WHAT WAYS CAN WE FOCUS ON
PRODUCING EVIDENCE NEEDED TO
OPTIMIZE POPULATION HEALTH AND
NOT JUST INDIVIDUAL
PATIENT-LEVEL HEALTH?
>> WELL, I THINK STUDIES IN A
LOOK AT POPULATIONS, YOU KNOW,
COULD BE REALLY HELPFUL.
YOU KNOW, YOU CAN'T ALWAYS DO A
PROJECT LIKE THE HIV STUDY THAT
I GOT TO DO, $25 MILLION OR SO.
BUT BY STUDYING A REPRESENTATIVE
POPULATION WITH AN IMPORTANT
DISEASE, NOT JUST LOOKING AT
MEDICAL RECORDS BUT ACTUALLY
TALKING TO PEOPLE AND SO ON,
PRODUCED EVIDENCE OF WHERE SOME
OF THE PROBLEMS WERE.
AND I THINK LOTS OF STUDIES LIKE
THAT COULD BE DONE OF LOTS OF
THINGS.
WHY AREN'T PEOPLE GETTING
BETTER -- GETTING DIABETES
BETTER CONTROLLED ON A
POPULATION LEVEL?
WHY ARE 16,000 PEOPLE STILL
DYING EVERY YEAR OR 14,000 OF
HEPATITIS C?
WHY ARE SO MANY KIDS IN POOR
COMMUNITIES WITH ASTHMA ENDING
UP HOSPITALIZED?
AND SO ON.
THAT COLLECTING DATA AT A
POPULATION LEVEL CAN BE
COMPELLING, YOU KNOW?
THE USUAL NIH GRANT WHERE YOU
CAN HAVE UP TO, YOU KNOW,
$500,000 A YEAR TOTAL, WELL,
DIRECT COSTS, TO DO A STUDY, YOU
CAN DO DECENT STUDIES BUT THEY
ARE NOT GOING TO PRODUCE
REPRESENTATIVE POPULATION-BASED
DATA.
SO I WOULD THINK TAKING ON BIG
PROBLEMS IN THAT KIND OF A WAY
WOULD BE A GOOD THING.
>> OKAY.
LET ME TURN TO MONICA.
WE'RE DOWN TO THE LAST TEN
MINUTES OR SO.
>> I MEAN, I THINK AS I'M TRYING
TO THINK ABOUT ALL THIS, IT IS
AS ELISEO SAID IN THE BEGINNING
JUST PRETTY DAUNTING.
ONE OF THE THINGS THAT I WANT TO
ASK I GUESS ABOUT LASTLY IS
DURING THE PANDEMIC EXPERIENCE,
THERE WAS A NEED, IT WAS CLEAR
THERE WAS A NEED FOR HEALTH
SYSTEMS AND PEOPLE WHO WORK IN
HEALTH CARE, AND THE PUBLIC
HEALTH SECTOR TO BE WORKING
TOGETHER IN THIS COUNTRY AND
PROBABLY IN OTHERS.
BUT I GUESS THINKING ABOUT THIS
COUNTRY SPECIFICALLY.
AND EVEN SOME DISCUSSION, YOU
KNOW, ABOUT THE THINGS THAT NIH
SHOULD BE FOCUSED ON, MORE IN A
PUBLIC HEALTH DOMAIN.
WHAT ARE YOUR THOUGHTS ABOUT HOW
PUBLIC HEALTH AND HEALTH CARE
SYSTEMS AND HEALTH CARE
CLINICIANS CAN BE MORE
INTEGRATED GOING FORWARD USING
LESSONS LEARNED IN THAT
EXPERIENCE TO IMPROVE HEALTH
CARE TO POPULATIONS AS WELL AS
OUTCOMES AND FOR ADDRESSING
GAPS?
>> WELL, HEALTH SYSTEMS FEEL
LIKE THEY NEED TO RESPOND TO THE
FRESHES ON THEM.
PRESSURES ON THEM.
LOOK AT NEW YORK OR L.A.
I REMEMBER IN L.A., UCLA AND
CEDARS-SINAI, AND A COUPLE OTHER
BIG SYSTEMS WERE SCRAMBLING FOR
MARKET SHARE.
I REMEMBER THINKING THAT THEIR
ATTITUDE TOWARDS ONE ANOTHER WAS
SOMETHING LIKE THE EXPERIENCE OF
THE PRESIDENT IN THE MOVIE
"INDEPENDENCE DAY IMTS" TALKING
TO THE ALIEN, WHAT DO YOU WANT
US TO DO?
DIE.
SYSTEMS WANT TO INCREASE MARKET
SHARE AND REVENUE, AND SO IT
GOES.
AND THEY ACT IN WAYS THAT ARE
CONSISTENT WITH THIS APPARENT
REQUISITE, AND ROSEMARY STEVENS
WROTE A GOOD BOOK ABOUT
HOSPITALS, DEVELOPMENT OF
HOSPITALS TOWARDS WANTING TO
EXPAND, EXPAND AND GROW AND
GROW, OF COURSE BEING ABLE TO
BUILD THEIR MORTGAGE COST,
ESSENTIALLY, INTO THEIR MEDICARE
RATES.
WHAT HAVE YOU.
THAT I THINK THERE ARE
STRUCTURAL THINGS THAT
CONTRIBUTE TO THIS KIND OF
BEHAVIOR.
BUT, YOU KNOW, I WOULD LIKE TO
SEE THESE CEOS OF HOSPITAL WHO
PRESENT PROBLEMS, DEANS OF
MEDICAL SCHOOLS, EVEN THOUGH
THEY ARE MISGUIDED A LOT OF
TIME, THEY ARE NOT AS MUCH OF
THAT PART OF THE PROBLEM AS THE
CEOS ARE BUT THE CEOS HAVE A LOT
OF SAY OVER WHAT GETS DONE AND
WHAT GETS PRIORITIZED IN TERMS
OF CLINICAL PRACTICE.
AND CAN YOU REEDUCATE THEM?
NOW, BELLA'S BOOK I THOUGHT
WHICH WAS OTHERWISE BRILLIANT
BUT A LITTLE NAIVE IN THINKING
THEY COULD ACTUALLY CHANGE
CORPORATE BEHAVIOR BY, YOU KNOW,
THROUGH EDUCATION, I THINK
YOU'VE GOT TO CHANGE THE
INCENTIVES.
WHY SHOULD THE -- I MEAN TWO
CEOS IN NEW YORK CITY WHO IN THE
LAST YEAR FOR WHICH DATA WERE
AVAILABLE, THAT HAD TOTAL
COMPENSATION AROUND $12 MILLION.
AND MANY LEVELS OF EXECUTIVES
BELOW THAT EARNING A LOT OF
MONEY.
THEY WOULDN'T BE EARNING THAT
KIND OF MONEY IF THEY WEREN'T
GENERATING LARGE SURPLUSES.
SO GETTING THEM TO CHANGE THEIR
PRIORITIES TO REALLY FOCUS UPON
OPENING THEIR DOORS TO A BROAD
POPULATION, MANY OF WHOM ARE NOT
GOING TO PROVIDE THAT LEVEL OF
REIMBURSEMENT, TO PUTTING
CLINICS IN ALL PARTS OF THE
COMMUNITY, INCLUDING PARTS OF
THE COMMUNITY WHERE A LOT OF
PEOPLE DON'T HAVE GOOD
INSURANCE.
IT WOULD TAKE A SEA CHANGE, BUT
IT'S NOT TO SAY IT'S IMPOSSIBLE.
THERE WOULD HAVE TO BE POLICIES
AND DIFFERENT PEOPLE IN
LEADERSHIP THAT WOULD MAKE THAT
HAPPEN, I THINK.
>> LET ME TURN TO ANOTHER
QUESTION IN THE CHAT.
I'M CURIOUS TO HEAR MORE
THOUGHTS ABOUT INTEGRATIVE AND
COMPLEMENTARY INTEGRATIONS LIKE
YOGA TO SUPPORT MENTAL HEALTH,
WELL-BEING, LIFESTYLE CHOICES
AND OR SOCIAL HEALTH CHALLENGES
WHICH BURDEN THE MEDICAL SYSTEM
AND OFTEN HAVE POOR OUTCOME WHEN
TREATED BY PRIMARY CARE
PHYSICIANS.
AND MEDICATIONS.
AS A YOGA PROFESSION THERE ARE
MANY CONVERSATIONS ABOUT
INTEGRATING YOGA INTO HEALTH
CARE.
WHAT ARE YOUR WARNINGS OR
ENCOURAGEMENT FOR THIS WHEN
CONSIDERING ACCESS AND
POPULATION HEALTH OR WORKING TO
REDUCE NEGATIVE SOCIAL
DETERMINANTS OF HEALTH?
>> IT'S INTERESTING.
I THINK THESE SORTS OF
ALTERNATIVE THINGS, YOGA, TAI
CHI, SOME IN V.A. PROVIDE THESE
TO VETERANS WITH PTSD BECAUSE
IT'S AN INTEGRATED SYSTEM.
THE PROBLEM WITH ALMOST ALL OF
THE SYSTEMS THAT PEOPLE, WHERE
PEOPLE GET MEDICAL CARE THEY ARE
NOT INTEGRATED, AND IS THE
GENERAL MEDICINE CLINIC AT UCLA
OR UCSF OR CORNELL OR COLUMBIA
GOING TO HIRE A YOGA INSTRUCTOR
TO WORK WITH THEIR PATIENTS?
THEY MIGHT, BUT MAYBE THEY THINK
WELL, WHY DON'T WE INVEST THAT
IN A NURSE, RIGHT?
AND THE POINT IS THAT YOU CAN DO
ALL OF THESE THINGS IF YOU THINK
THAT THIS IS -- IF YOUR MISSION
IS TO HELP ALL OF THESE PEOPLE.
AND THE REALITY IS OF COURSE
THAT MANY OF THE AFFLUENT PEOPLE
THAT GET CARE IN THESE SYSTEMS
CAN GET YOGA OUTSIDE THE HEALTH
CARE SYSTEM AND OFTEN DO.
SOME IS AN ORGANIZATIONAL
QUESTION, HAVING AN ORGANIZATION
COMMITTED TO COMPREHENSIVELY
ADDRESSING THE WELL-BEING OF AN
ENTIRE POPULATION, AS I SAID,
THERE ARE A LOT OF PEOPLE WHO
COME TO MEDICAL CARE AND DEMAND
SERVICES, THEY DON'T REALLY
UNDERSTAND WHAT'S WRONG BUT
OFTEN THEY ARE DEPRESSED OR
ANXIOUS OR THEIR LIFE IS JUST
NOT GOING THE WAY IT SHOULD.
AND THOSE ARE PEOPLE WHO WOULD
BENEFIT FROM HAVING ACCESS TO
ADDITIONAL RESOURCES.
>> KATRINA?
>> YEAH, I WANTED TO ASK ANOTHER
AUDIENCE QUESTION OF HOW CAN
COMMUNITY-BASED ORGANIZATIONS
PLAY PIVOTAL ROLE TO PROLONG
QUALITY OF LIFE SO THINKING
ABOUT OUR HEALTH CARE SYSTEM,
HEALTH SYSTEM AS A WHOLE, THAT
GOES BEYOND HEALTH CARE DELIVERY
SYSTEMS, AND REALLY BECOMES PART
OF POUR COMMUNITY.
>> OVER THREE TRILLION A YEAR,
MAYBE FOUR, THAT GOES INTO
HEALTH CARE, ALMOST NONE TO
COMMUNITY ORGANIZATIONS.
AND I REMEMBER ONE POINT WHERE
THEY WERE DISCUSSING AT UCLA
PUTTING CLINICS AROUND THE
VARIOUS PARTS OF THE LOS ANGELES
BASIN.
IT REALLY LOOKED LIKE THEY WERE
ONLY CERTAIN PARTS OF THE LOS
ANGELES BASIN WHERE THEY WERE
PUTTING THE CLINICS.
THEY WEREN'T PUTTING THEM IN
SOUTH CENTRAL OR EAST LOS
ANGELES.
I SAID WHAT ABOUT THE HISPANIC
AND BLACK PEOPLE?
WHO IS GOING TO TAKE CARE OF
THEM?
THE ANSWER I GOT WAS, OUR
AFFILIATES, MEANING THE PUBLIC
HOSPITALS.
THAT'S NOT AN OKAY ANSWER.
IT'S ALSO NOT OKAY TO SAY, WELL,
YOU COMMUNITY ORGANIZATIONS
SHOULD GO AND DO STUFF.
I THINK IF COMMUNITY
ORGANIZATIONS WERE FUNDED,
SOMETHING THAT EASILY COULD BE
STUDIED, ADEQUATELY, YOU KNOW,
TO HAVE PAID STAFF SUPPORTED BY
THE HEALTH BUDGET, THAT MIGHT
DECREASE OTHER MEDICAL COSTS.
OR EVEN IF IT DIDN'T DECREASE
COSTS IT MIGHT IMPROVE THE
HEALTH OF MANY PEOPLE.
SO I THINK IT'S A GREAT IDEA TO
HAVE COMMUNITY ORGANIZATIONS
INVOLVED.
ONE CAVEAT I WOULD OFFER IS YOU
SHOULDN'T HAVE PEOPLE IN THE
COMMUNITY BEING THE ONLY PEOPLE
IN THE SYSTEM, AROUND THE
SYSTEM, WHO ARE CULTURALLY CLOSE
TO THE PATIENTS.
YOU DON'T WANT YOUR DOMINICANS
AND YOUR AFRICAN AMERICANS AND
OTHERS TO HAVE A COMMUNITY
WORKER OR PERSON WHO COMES TO
HELP THEM OUT, AND WHO HAS A
DOCTOR THEY CAN'T POSSIBLY
COMMUNICATE WITH.
THOSE ARE PROBLEMS THAT NEED TO
BE ADDRESSED IN PARALLEL.
>> OKAY.
WELL, I THINK WE'RE ABOUT TO RUN
OUT OF TIME.
SO I'M GOING TO BRING THIS TO A
CLOSE.
I THINK THIS HAS BEEN VERY
THOUGHT PROVOKING, MARTIN.
I REALLY APPRECIATE YOU TAKING
THE TIME TO PRESENT HERE AT NIH.
WE'LL FIND OUT ULTIMATELY HOW
MANY PEOPLE ACTUALLY TUNED IN,
I'M SURE WE HAD MANY MORE
QUESTIONS LINED UP THAT WE COULD
ASK BUT I ENJOYED THE
PERSPECTIVES THAT KATRINA AND
MONICA BROUGHT TO THE QUESTIONS,
TO THE CONVERSATION WITH YOU.
AND SO AGAIN I WANT TO EXPRESS
MY APPRECIATION FOR YOUR
PRESENTATION, TO OUR COMMUNITY,
AT NIMHD, AND NCI, AND THE
OUTCOMES AFFECTING RESEARCH
INTEREST GROUPS.
SO THANKS AGAIN, MARTIN.
>> WELL, THANK YOU VERY MUCH.
IT'S REALLY BEEN A PLEASURE AND
IT'S BEEN VERY STIMULATING
DISCUSSION FOR ME.
IF ANY OF YOU DO GET THE CHANCE
TO READ MY BOOK, THE PRESENT
ILLNESS, PUBLISHED BY JOHNS
HOPKINS, YOU CAN DISSECT MY
ANALYSIS AND PROPOSALS LINE BY
LINE AND COME UP WITH BETTER
IDEAS.
OR MAYBE AGREE WITH A FEW.
BUT IT'S BEEN WONDERFUL.
>> THANK YOU, MARTIN.
>> IT'S BEEN WONDERFUL TO TALK
TO YOU.
THANK YOU.
>> THANK YOU.
BYE-BYE.
TAKE CARE.
>> THANKS, EVERYONE.
BYE.