Massachusetts Medical Society: 2011 Interim Meeting: Annual Oration Speech

2011 Interim Meeting: Annual Oration Speech

Presented by: Sean Palfrey, MD, FAAP, Pediatrician and Professor of Clinical Pediatrics and of Public Health at Boston University.

I am a general pediatrician, and I love practicing medicine ...still. I love the science. I love working and playing with children, well or ill, talking with and teaching parents how to keep them well, and helping them heal.

Within my lifetime, our profession has changed profoundly. The practice of medicine is exciting but extremely complicated …scientifically, technologically, financially and academically. And, we are at a breaking point. The fact is that in order to address and take advantage of all the new elements in the practice of medicine - we, (you and I) - have to rethink how to learn and utilize all the new science, treat all our patients, orchestrate  and finance our practices, and train and work with a new constellation of health professionals.   

Every generation faces new challenges. I came into medicine when most doctors worked in solo practices and general hospitals. Just 40 years ago, most of us had only rudimentary understanding of micro-biology, immunology, and pharmacology. The genetic code was a brand new concept. Doctors treated patients in the context of their families, diagnosed illnesses on the basis of the patients' histories and physical exams, and treated them with a small formulary of inexpensive medications.

As a young pediatrician, it was possible for me to have a fair grasp of pediatric medical science, diagnostic procedures I needed to use, and available medications for children. In fact, as a chief resident at Tufts, I ran the PICU and NICU, and knew the condition of every child in the hospital. My colleagues and I felt fairly confident that we were providing the children with the full range of services then available.

Several generations later, residents and young physicians, who have grown up in a world of exploding science and technology, cannot begin to know it all. They are surrounded by specialists and subspecialists in scores of fields, and research is feeding us new information every day. These young people have grown up in a digital world. They were, as our son John Palfrey says, "born digital", and are "digital natives". They see the practice of medicine in a whole new way.

I practice and teach every day, and when I walk onto the wards, I find the students and residents sitting in a conference room, working feverishly at computers, typing in orders, checking blood and imaging results, requesting consults and reading reports and recommendations for more tests and procedures. During rounds, even in the guise of "family-centered" walk rounds, they spend most of their time in the hallways or huddled around the foot of a bed (near the wheeled computer), talking in impersonal and medical terms about 31-B (really a child or young adult).

But it is not just the young physicians. In this new world - on the wards and in the ICUs, in clinics and practices  - all of us, to varying degrees, hurry past our patients toward the bottom line, more results, more tests. Almost everything important to us is on-line, in a box or in the cloud. Despite huge reservoirs of human warmth and dedication, doctors are distancing themselves from their patients. We take histories and do physicals and transcribe them into an electronic template. That's where the patients live. They are stored, their data arranged and rearranged, like avatars of their child-hosts, sometimes almost real.

Within our lifetimes, science and technology have redirected our focus away from the patients themselves. Daily, scientists are discovering the most basic mechanisms of normal physiology and pathophysiology at the molecular level. Often, within months, these findings are translated into tests, images, and new procedures, each one more expensive than the last. This is so fantastic that we all want to know it all, and take advantage of the new knowledge - well before it's clear how useful this information might be for our patient management.

Unfortunately, over these past decades, our health care system has permitted, even encouraged, all of us to alter our practice of medicine to embrace these new options without the necessary discipline.  Because manufacturers and insurers are by and large competitive, for-profit companies, incentives, and few disincentives, have been created for doctors to access new products and see them as essential to good practice, and consumers look for every benefit they can get covered, without knowing the risks and benefits, or fiscal consequences.

Similarly, our fee-for-service system pays us and our hospitals better if we order more tests, consult more specialists, and perform more procedures. There are few counter-balances to doing more, and we and our patients have become seduced into the misconception that "more is better", and "more expensive medicine is better medicine". Large quality studies have shown, however, that by practicing this way, we have achieved few improvements in health outcome. By adopting such an expensive style of practice, so much money is spent on covered patients that there is not enough to provide any health care at all for millions of Americans, and the health care sector is jeopardizing the financial health of our country's economy.

US health care costs twice as much per patient as the next most expensive country in the world, and 3 - 5 times more than most other first world countries. Yet we generate poorer health outcomes year after year. The US ranks 50th in the world in terms of life expectancy, 23rd in the world in terms of overall child health measures, including neonatal mortality, quality of life years, teen pregnancies, gun violence, and others.

According to the Congressional Budget Office, 5% of US gross domestic product - $700 billion - goes to tests and procedures that do not actually improve health outcomes, and the CBO further states that future health care spending is the single most important factor in determining the nation's long term fiscal condition. And despite spending 2.7 trillion dollars each year on health care, approximately 51 million Americans have no health insurance at all.

We are at a very difficult juncture - a point where we have an embarrassment of scientific and technological riches that we need to learn to use optimally, yet we provide health care outcomes that compare poorly with the rest of the world. Yin and Yang. So this is a moment of huge opportunity as well as serious crisis.
 When I wrote a Perspective entitled, "Daring to Practice Low Cost Medicine in a High Tech Era" about all this last March in the NEJM, within a few days we got 150 responses agreeing with my point of view, not just from this country but from around the world as well. These observations hit a nerve.
One doctor summed it up this way:  "It is extremely revealing that not a single response to this important article has disagreed with its central premise - not a one! We ALL know what is going on, but we seem helpless in the face of financial incentives and pressures, political currents, legal threats, and our increasingly impersonal and technophilic culture."

Physicians, both generalists and specialists, admitted that they were ordering clinically unnecessary tests and procedures, even when their clinical judgment urged them not to. They agreed that most of these excessive and costly practices were caused by their own medical curiosity, the easy availability of the tests, lack of knowledge of their costs and cost-benefits, community expectations, need for personal reassurance, and desire to protect themselves from possible law suits. Many, from the US and Europe, from India, Brazil, Thailand, Mexico, and other countries, reported that they practiced one form of medicine in one setting and another in other settings, but that the outcomes were little different.

 What can we do?

It seems to me that there are three major categories we need to address: First, we need to teach ourselves and our trainees to balance the huge benefits inherent in the new science and technology in this digital age with the age-old wisdom of basing all we do on the patients themselves, and learn to incorporate science into patient-based clinical judgment. Second, we have to take cost, cost-benefit and genuine long-term benefits into account with every patient at every level of practice. Third, we have to restructure our Medical Homes,  -  re-configure the incentives and priorities of our current health care system, train and re-staff our medical homes, both outpatient and inpatient, focus on prevention and minimizing the costs of our care, and plow the savings back into our practices in order to empower them to optimize the health of all patients.

Establishing balance in patient care:

 All the new science, technology, and digital communications we are being offered create remarkable opportunities for the advancement of medical care. We all want to put them into practice immediately, but it takes years to confirm the findings, perform the translational research and measure cost-effectiveness and long term outcomes. Then it takes more years before they are incorporated into "best practice" guidelines.

I was taught that 80% of diagnoses could be made on the basis of history and physical exam. This is still not so far wrong in terms of acquiring  the knowledge we need to know in order to help a specific patient's body heal.
When students and residents first come onto a new service, their supervisors focus on teaching them the new technologies - the lab ordering systems, the note and discharge summary documentation, the way to order consults and retrieve lab results and xrays.  Much more emphasis is placed on those tasks than on the thinking processes they will need to use to evaluate and treat the new types of patients on that particular service. As attendings, we need to redirect some of their attention away from their computers, to help them make as great a cognitive shift as a technical one, to prepare them for treating their patients…not just the test results.

On rounds, in primary care clinics and practice apprenticeships, it is crucial for us to model the invaluable hands-on skills our masters taught us, and pass on to our residents and students, in a disciplined fashion, the ways we learned to diagnose appendicitis, pyloric stenosis, hydrocephalus, the differences between different forms of cellulitis, the secrets hidden in rashes and murmurs, how a child walks, the breathing pattern of an infant - disappearing arts and techniques that give those who remember them critical information the moment we see a child even across a room. I still use the texture of a liver, prolongation of a respiratory phase, transillumination of a scrotum, subtle variations in an optic disc, even fun things like the response to my tickling an abdomen, or having a child hop or play with a toy. These skills provide us short-cuts to get the patient home, to the OR, or to the ICU, but week to week I discover how little of this our students and residents actually know, and how rarely we take the time to teach them.

Another lesson is the importance of gaining social and cultural understanding. We need to demonstrate the art of listening to our patients and gaining their trust in order to discover details of their illness they might not otherwise share. We wonder why some people just can't break out of a cycle of disease. If you ask a patient to take a medicine, but it contains something their religion says cannot be consumed, no wonder the patient does not heal as we expect. If they live in an apartment with ten cats and their brother smokes in the closet, no wonder their asthma stays bad despite so many changes in controller meds and courses of steroids. If they have drug dealers hanging outside their door, they may cling to the couch and the TV. No wonder they are obese.

One of the things I love about my practice at BMC is that my patients come from all corners of the earth, with many different concepts of health, illness, prevention and treatment. I have to, first, understand what they think, want and are afraid of, and tailor my approach and therapy to those realities, and help them understand the things my science and technology can offer. I have, on occasion, let families coin or cup a dying child's back, because if they don't, they feel they have not done everything they could have according to their culture or religion.

Do these things improve the physical condition of a child or adult? Who knows? Sometimes. But they certainly help the family's sense that together we are doing what needs to be done. Children and adolescents will relax and I can get a better physical exam because I've learned how to settle them down and get them to trust me. The parents will tell me more because I ask them a question framed in a personally appropriate way. We see them as anxious, but they may care much less about what I am interested in, the blood gas or aortagram, than in some other question, and I can get good compliance by addressing their concerns before mine. We need to teach our residents and fellows these things by story and by our example.

Excellent clinical care also requires the wise use of time. We and our residents are perpetually in a hurry. They consider everything urgent, even when it's not. They feel pressed to make decisions rapidly and that that ability is a sign of skill, knowledge and maturity. In fact, we want them to learn to think, wait, watch, and learn to use time as a diagnostic tool. A general surgeon in the US wrote, "We need to maintain the courage to let some time determine the clinical course of investigation." A pediatric endocrinologist  wrote:" The "test of time" will usually separate those with real disease from the normal variations and self-limited problems if we have the patience to limit tests and see the patient back."  Time so often gives us answers as to the direction an illness is going. We need to impress on trainees the value of not treating or testing right away, slowing the pace of decision-making a smidgen or more, examining their patient again in a few hours or days, asking them new questions, reconsidering.

I was told I would never know more stuff than after my years as chief resident, and that was true. But I hadn't seen dozens of HUS or Reyes or sickle cell crises or even serious asthma attacks, so I needed a Sydney Gellis to tell me to jump or to wait. I still need Paul Rosman to warn me that this is not the way a child should be moving or walking or shaking.

Apparently the Stanford 25, a computer-based education program, tries to impart a little of this type of wisdom to its students and residents, but what we really want them to gain, through their own experience and that of others, is "clinical judgment".

 With all the microbiology and pathophysiology our students get taught, they do not understand how effective most bodies are at healing themselves. One of our most important challenges as physicians has always been to decide when, how, and even if, we should do anything at all to help this process. It is sometimes difficult to reassure everyone, (including ourselves) that intervening too soon or too intensively may not give the body the time and opportunity it needs to do its own work, and learn from it, to gain immunity for instance. More medicine is often not better medicine. More expensive medicine isn't either. We have often seen that treating with broad spectrum antibiotics is not a wise choice for instance, and by treating things that may not need to be treated, like H. pylori, appendicitis or otitis media, our patients may do worse rather than better.

Our ability to heal our patients depends both on our clinical skills and on our understanding of science and technology. Our patients are not simply the sum of their data, as vast as that might be, they don't really exist inside a computer, and we need to keep reminding ourselves that it is our cognitive skills as physicians that really make us good healers.

Taking cost, cost-benefit and established long-term outcome measures into account at every step of practice

We order too many tests and procedures for a number of reasons: uncertainty of clinical understanding, academic or personal curiosity, fear of not knowing or doing the right thing, practice incentives or disincentives, money, or perceived community expectation of standard practice.

My use of the word "daring" to practice low cost medicine in a high tech era clearly touched a nerve. Many people pointed out in response to the Perspective that it does take courage not to order lots of tests, consults and procedures, for a variety of reasons.

First, we are by nature intensely risk-averse. We don't want anything to go wrong for our patients, and want to know everything that might be relevant. We feel that doing everything is the best practice and the best way to prevent harm. We test to explore and reassure ourselves, and in some cases the patient or the family, instead of trusting our clinical judgment, and ordering no, or only the obviously necessary tests and interventions, watching our patients, giving them signs and symptoms to watch for, and seeing them again in a matter of hours, days, or months. 
We need to teach students and residents the subtleties of differential diagnosis that focus on the likely, and how to use history and physical exam to clarify probability before we roar off chasing zebras. Our residents and students tend to chase zebras right out of the starting gate, because the tests are there, and they want to show us that they've thought of everything and covered every base. We need to give them our permission, instruct them, to focus on common conditions first, uncommon presentations of common things next, and only, when the likely causes seem unlikely, should we focus on the uncommon conditions.  A doctor from Belgium noted: "This has indeed high consequences (and not only in the US) on costs and quality of medicine and it keeps young doctors from becoming good and reasonable physicians."  
In primary and urgent care practice, I urge residents to order almost no studies year to year. One of my respondents wrote: "I talk people out of CT and MRI scans all of the time. They appreciate being set free from the lunacy that has overtaken the practice of medicine."  If a child has pneumonia by history and physical, treat it only if it looks bacterial, and watch. In hospitalized patients, I urge residents to be disciplined, to decide when the most informative time would be to do a test. It's a matter of pride not to repeat them if at all possible.

Our specialist consultants are in the same bind we are, perhaps worse. They seem to feel required to address every possible diagnosis our patient might have. One ID specialist wrote: Nowhere in medicine is the pressure to over-treat more evident than in the area of infectious diseases. The development of practice guidelines which have been developed in the spirit of zero tolerance for failure is forcing us to leave no stone unturned, medical homes and overtreat. There is no room for "watch and see".   Those are certainly not "best practice" guidelines, and need to be reframed.

Another specialist commented: "I (a practicing Neurologist) could not make a living if I didn't routinely perform EMG testing in my office for example. Only 10% of EMGs are necessary."  If I ask a cardiologist for their opinion on a murmur, most feel an obligation to perform an EKG and echo regardless of their clinical opinion (it's covered by insurance after all, and if the patient should turn out to have some obscure disorder which they missed because they didn't do an echo, or cardiogram, or CT scan, they might be sued). It's the same for the pulmonologists or the geneticists .

In reality, what I want first from a subspecialist is their balanced, professional opinion, based on the knowledge and experience they have that I don't: "Your patient is most likely to have this, though these other things are possible, but much less likely. What would you like me to do?"  It's the same with a surgeon. Given the choice, I look for surgical colleagues who respect my, and their, history and physical exam and will give me well-considered advice, someone I know who would rather examine than image, who will talk to my patient and use his or her clinical judgment before performing some procedure. I choose surgeons who won't take every tonsil or appendix out, who has expert examination skills, and doesn't insist on imaging before they see a patient.

The second reason we order too much is that we are scared that if anything should go wrong, we will be sued, and colleagues might look at us as being careless or irresponsible. We feel pressured to test and treat more aggressively because guidelines for "reasonable care" and "reasonable outcome" are so difficult to define in the almost infinite spectrum of human illness. Our practices have become increasingly influenced by fear of "malpractice" and less by the inspiration to heal through "best practice".

Our cornerstone of "first do no harm" has crumbled into a pile of self-protective tests and procedures.

We, the scientists and clinicians, need to establish the boundaries of scientifically, personally and fiscally responsible practices for our profession, or others will do it for us, as they have. We need to define "excellent practice" more broadly and flexibly, and build what we consider to be optimal metrics of high quality performance and reasonable expectations for health outcomes, taking into account the full range of issues including patient comfort, feeling of well-being and respect, appropriate use of technology and available resources, and the constraints of personal and pubic finance.

A generalist wrote us: A young patient of mine recently suffered a ruptured appendix while the surgeon waited eight hours to obtain a CT scan, even though the clinical history and physical findings were absolutely typical. We are wrong if we don't speak out critically, both as individuals and as a profession, of this kind of practice. Our patients would thank us for it. If we were more honest and self-critical, we could argue more effectively against the malpractice system. We need to defend practice guidelines that help us practice better medicine, not more expensive medicine. One doctor in India wrote a long response with many cogent comments. In one section he said: Only when we stand together, and start to re-place the emphasis on talk to the patient, look, feel, move, think and then investigate, will we actually improve the practice of medicine and actually have satisfied patients with good health care for all at a reasonable cost. We can then direct the money to the needy patients and not waste it."

You and I do need to advocate for tort reform, probably a no-fault system, such as is being experimented with in Vermont. It is hubris to believe that we can prevent illness or death in any particular case.  We need to establish the standards and support each other in following them. It is hugely important for physicians to work with lawyers and legislators on such a new system so that it can truly serve the best interests of our patients and the public health.

I realize that we have a very difficult road ahead. There is obviously an enormous vested interest in the legal profession, and many benefit from such a lucrative system. Nonetheless, we must try. I wrote a follow-up piece to my Perspective in the Massachusetts Medical Law Report advocating this, and in contrast to the huge response I got in the NEJM, there was thunderous silence. But as one doctor had written: "Until the financial and legal incentives are aligned with good care, bad care will continue."

The third reason we order too many tests is that we don't know the cost, the cost-benefit, the accuracy, or the relevance of the tests or procedures available to us. There are no obvious disincentives to excessive test ordering and many incentives. Data on the specific costs and the serious consequences of ordering unnecessary tests, are rarely publicized by our hospitals or health plans, yet in the hospitals and regions that have begun to do this, like the Intermountain Group in Utah, the programs have resulted in remarkable savings due to uniformity of well-reasoned and consensus-driven community practice.

A doctor in Ireland sent in this anecdote: "When new practitioners join our private practice, having left the state systems where allegedly 'no-one pays', invariably they order maybe 10-15 thousand euro of laboratory tests in their first month or so and are shocked when they are confronted with the costs of their actions and the realization that the patients will actually have to pay for these tests. Their behaviour does modify as a result and they will invariably order quarter of the cost in tests in the subsequent months."

 We need to have much easier access to the research on the costs, outcome measures, accuracy and clinical relevance of these tests and procedures. The AAP, and I'm sure the AMA and MMS, are constantly being asked what members get in exchange for our dues. Building such national, or even regional databases and making them available to us all through our practices, and in our EMRs, would provide the membership, and the country, a great service..

Building a universal Medical Home System, inpatient and outpatient -

 A fully-functioning out-patient and in-patient medical home should be centerpiece of high quality, comprehensive, cost-effective, patient-centered care. This is where all the scientific and technological advances we have been discussing are blended together with our clinical judgment to greatest advantage, and where the benefits of such a system are most obvious.

The focus of all efforts in the medical home is on the patients at the center. It provides the incentive to practice the best possible medicine at the lowest possible cost since all the gains should come back to profit the patients and the operation of the center itself, to make it as high functioning, coordinated, responsible and effective as possible.

The Medical Home concept actually emerged in the late 1960s as general pediatricians realized they needed a way to centralize all the scattered information that was being generated about their most complex patients by the new breeds of specialists scattered about in hospitals and elsewhere. Generalists, soon to be called primary care physicians, started to organize centralized record systems and medical passports to collate all the information in one place, and urge all clinical providers to communicate more effectively with each other through the center.  Similarly, as the medical care of these patients became increasingly complex, and as clinician groups started to serve the needs of a wide variety of patients, from the healthy young to the resource-poor, to the complex elderly patients, and children with serious special health care needs, twenty four hours a day, it became clear that many different types of staff professionals were needed in the primary care sites.  

The goal of a good medical home is to integrate primary care, emergency care, consultative, and inpatient care, and enable patients and involved clinical professionals to access all appropriate health information and create a coordinated, individualized health plan for each patient. Our young physician colleagues, tech-savvy and well-trained as they are, are enormously important to medical home development because they live in this world, and can help us build in the most effective communication and information systems.

At this moment, though, we don't have anywhere near enough doctors, nurses or other personnel to offer medical homes to all patients who need them. The shortage of generalists has been recognized for some time by the federal government, and a multi-billion dollar new initiative has just been announced to recruit and train new primary care providers.  However, the way we are training residents, at least in pediatrics, offers them disproportionately little outpatient training since their rotations are  too often driven by service needs of the medical center, not by appropriate educational needs.

In addition to physicians, though, we need to develop and train whole new categories of health professionals. We have struggled to extend the old roles into the new paradigms, but are now realizing that we need make fundamental changes. Medical Homes need clinicians with various sorts of training, call them what you will, nurses, patient care coordinators and support staff.

For decades, I have had the pleasure of working with a wide variety of trainees, clinicians and health practice professionals. For instance, I often have community health undergraduate students working with me in clinic. It is a wonderful way for them to learn medicine while assisting my practice. They join me with patients, enter the visit data into our EMR and retrieve information for me. This is an emerging profession called "scribes". I have worked with primary care nurses who knew my patients as well as I did and could assist them and me with almost every element of practice. Our patient care coordinator is one of our most essential team members. Our social workers not only help with family problems but coordinate much of our basic mental health care. For a decade I have worked with lawyers from the Medical Legal Partnership to advocate for our patients legal needs. I have also worked with nurse practitioners for decades, and know that they do many things better than I can, just the way residents know more than I do and medical students can teach me the most current basic science.

We all need each other and should not see ourselves as competitors.  Just as we should be partnering with lawyers to solve the huge malpractice challenges, we need to work with nursing and many other health professional administrations to solve the country's massive staffing and personnel shortages.  We should be welcoming and eager to partner with them so that each of us can be using our knowledge and training most effectively and be more satisfied in our clinical roles (unless you're totally happy with the balance now, which I doubt). This is not simply an issue of efficiency, or financial resources, or the national economy, it's the future of quality health care.

With the explosion of science and specialization, medical and health education needs to evolve as well. A century ago, the first Flexner Report transformed the education of physicians, creating specialties and specialty training. A few years ago a new Flexner Report was developed for the 21st century. There is also a massive new Future of Nursing Report. I don't think either of them is broad enough in scope or vision to create the professional training tracks or curricula we will need.
All health careers training curricula probably should start earlier than college and cross-fertilize each other. Students should share courses across disciplines (students in all tracks need more science early on, and more training in psychosocial and multicultural health elements). There needs to be a vastly greater emphasis, and money spent, on prevention. All of us know that if we can prevent infectious diseases, obesity, diabetes, asthma and dozens of other expensive and debilitating chronic illnesses, everyone would be better off.

More emphasis on prevention and practice efficiencies, including a better division of labor and the ordering of many fewer tests and procedures at every point, could save each practice many thousands of dollars a day while allowing us to see more patients. If we are pro-active, we should be able to build an affordable care organization system that allows us to keep those savings in our medical homes. This is one feature of ACOs that really makes sense to me. Thus a cycle of higher quality, more efficient, preventive care might take hold, making everyone healthier, possibly wealthier, and certainly happier. 

Advocacy for change in the larger system:

I am hoping that the new health care reforms we create over the next few years will dismantle the structural and economic constraints we currently practice under. You and I all need to make and advocate for change in the health care system. We're actually at a time when this can happen. Massachusetts is designing it's new health care system, and you and I need to be in there, with our administrators, our public health care colleagues, our lawyers and  legislators to redesign the incentives and disincentives built into this crazy pay-for-test, pay-for -procedure and document-all-day- long insurance system.

 We lost most of the last rounds because we, the health care providers who knew what our patients needed, either felt powerless or disinterested, and were reluctant to get involved. But the health plans and insurance companies, with their profit-driven priorities, forged ahead and set up systems and regulations destined, and subsequently proven, to produce more expensive, less effective care, and we all whined.

As long as the profits generated in the "business of health care" are directed into the pockets of corporate investors and administration, the costs of health care at every step, from the costs of medications to fees for testing, imaging and procedures, will continue to surge. Profit simply creates too many conflicts of interest to allow frugal practice. The incentives are all backwards. If a profit motive must exist anywhere, the money created needs to flow back to improve patient care. Otherwise, we will bankrupt the US health care system, which we seem well on the way to doing.

You and I have huge responsibilities as clinicians. Some of the most basic, day to day problems are ones only we can change. And we have to swallow our pride and work with others who can help us. We all want to be the best doctors in the world for our patients, but we are obviously failing in the current system. There was a well-known creature in our house as our children were growing up named "Not-me, Not-me".  But it is us. If the well-being of our patients is really our top priority, then we are the people who must make these changes through our own day to day practices. If we don't, someone else will make them for us, because the country can't go on like this for long. And then, no one will be happy.

I do a lot of legislative health care advocacy for children here in Massachusetts, and it is obvious that I am listened to because I advocate for my patients needs, first, and my own needs second. I tend to lead with: "this is what needs to change for my patients", and then, "In order for me to accomplish this in practice, the system needs to enable me in these ways." Legislators did sit up and pay attention when I published my Perspective, because I was able to point out to them how changing incentives in the crazy fee for service system in place now could change the face of health care financing.

A different Oration:

This is a very different Oration from the one I originally wrote. That one had graphs and slides to illustrate my points. But as I struggled with it, I realized that I don't like working from slides in a talk that is mostly a thought piece, so I decided to give this talk this way.

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