 So that goes back. So let's see. I think it's just here. Here. Okay. The one. All right. Great. All right. Up and down. Okay. Up and down. All right. So we'll, we'll just give people a few minutes. Oops. So. Are you so. So we actually just last week, we saw that. Um, and, uh, what do you mean? This is. This is. Yeah. And so. Yeah. So, so I just decided that. So the daughter is married. She has a son. So we have a great family. So. Our youngest is my good daughter. So. So. Yeah. Yeah. Really. Yeah. Yeah. Um, and Dr. First, man. Okay. Okay. So. It's like the movie, wow, so he's doing stuff, that's great, yeah, well I have to say, I've been a little sad about the whole song. But I think, you know, it sort of makes sense. We had bought us one of the Instrater Bells, we were selling part of it in the city, so it has to make sense, we had to sell it face and face, and it was in the house. There's nothing on the report. So our house. of my life. This is not a thing. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. So I think we're going to go ahead and get started. I think we're going to get started. Yeah. So I think we're going to get started. It is now a few minutes after the hour, which seems to be the appropriate time to start. So welcome to the. Our next. Interdisciplinary seminar series lecture. It's a real pleasure for me to introduce the speaker today. Who has known me. George Sibolski is a neurosurgeon. Currently at Humboldt Park. I'm sorry. Humboldt Park Health. George. As I said, long time faculty member at Northwestern, we overlapped as faculty together for 10 years. But he's a neurosurgeon. He's a neurosurgeon. He's a neurosurgeon. But he recently has moved to Humboldt Park. George has a BS from the University of Illinois and MD from the University of Illinois, Chicago. He has been not only associate professor at Northwestern, but also chair of neurosurgery at Stroger hospital. He has an MBA from Loyola, which he obtained in 2010. And he's been involved with the technological platform development to improve safety and surgery. And disrupt barriers and inequity in spine care. And George is a long time neighbor of mine. We live in the same town, river forest. But I actually haven't seen him. I don't think in like 18 years about. But it's really, he hasn't aged at all. It's amazing. We're not sure what he's doing. But it's truly a pleasure for me to welcome George. So thank you. Thank you very much, Peter. And it is a great privilege and a pleasure for me to be here. I have sat in those seats. When I was at Northwestern, I would come down here for presentations, which were always good. And so I want to assure you that I have worked very, very hard to put this together and I hope, I hope you enjoy it. Congratulations, Peter, to you and your success and being the director of this fantastic center. I was behind you, even though you were behind me as a resident, I was a junior attending. I was behind you and really thinking about, even though I'd come here to hear some great talks, I was behind you and really kind of focusing on the ethical issues that we encounter in taking care of patients. But as time passed and experiences added up, I became more and more aware of disparities that are occurring in our healthcare system. And so that's what brings me here today. So I am, I'm going to assure you that as I said, I've put a lot into this. I am an old school person in that I send letters actually to people who I am impressed with and their work. And I've received shocking letters back and I'll, so some of the people I'm going to reference today, you will know some of them. And after today, you will know them better have responded. And these are people who are like-minded as ourselves and, and are, you know, attempting to make the world a better place. And some of these people were one person I didn't receive a reply, a reply from was a first century rabbinical scholar for obvious reasons, but we're guided by his work. But I've received replies from Nobel prize winning economists, Don Burwick, who most people know as the former director of Medicare CMS, the Center for Medicare and Medicaid Services, and started the Institute for Health Improvement. I have a funny story about just talking with them last week about this, what I'm going to do. And he has my slides and then I'm going to talk about some United States Marines and how they figure into this and, and share with you my experiences with them, which are very, very personal. So we have a tough challenge in taking care of patients. And in 2019 I left Northwestern and had a couple years there where I was in business and working on technological platforms and helped start a business to sterilize instruments for the operating room. And that was all very interesting. But I missed taking care of patients because of the heart of, you know, those of us who are here, you know, whether we're doing it from the front lines or whether we're supporting or whether we're interested in the background of taking care of patients, it is something that's, that's in us. So, fortunately, I was able to return to clinical medicine when one of my former fellows called me up in 2000, late 2020, Daniel Ivankovich. And he asked me if I was really retired and I said, well, I guess kind of I'm doing some things. He said, well, come to Norwegian American hospital, which is in Humboldt Park and has since been rebranded as Humboldt Park Health, come, come and work with me and see some patients and let's do some spine cases together, which he was our spine fellow at Northwestern. And so it's been a really a great blessing for me to return to see patients. I see patients every week. And in the interim, though, it became very apparent to me that it's really even just with a hiatus of maybe a year and a half and from clinical medicine, the barriers that have that grew during that year and a half were astounding to me. And I'm talking about ordering an MRI for a patient of their spine, obviously. I'm talking about getting clearance for surgery. I'm talking about a lot of work that I'm at a small place. I don't have a lot of help that I have to do in order to get people taken care of for their spine conditions. And I find it even more ironic because I used to be at Stroger hospital, which is about five miles away, one of the biggest public hospitals in the country. Right next door is Rush Medical Center, a huge academic medical center. I've trained the head of that Department of Neurosurgery. I've trained some of the fellows when I was at Stroger and they'll do me a favor and get my patients in there for complex things. And so that's helpful, obviously, for me to break down some of these barriers. But when it comes to etna and Cygna and Illinois, Blue Cross and Blue Shield, managing Medicaid, which I don't know how that happened all of a sudden, it's been a struggle. And so it really emphasized for me, the ethical barriers that now exist in taking care of patients at the area that is surrounding us here in Chicago. So I'm going to talk about the following three things. These are the objectives. They roughly mirror what Aristotle and talked about with a rhetoric and that is I've already given you a little bit about myself and my credibility. And then I'm going to talk about the logic of my pursuit. And then we'll finish up for discussion. I want to keep going backwards. There we go. Amazingly, and I say this because I will get into it in regard to spine. I have never been a paid consultant for any spine instrument company. Never done that. I may have gotten a dozen golf balls from Striker somewhere down the line, but I've never been a paid consultant is never influenced my use of implants in the spine. And ultimately, we're not talking about brain surgery here when we're talking about spine care. But it is a huge business. And it dwarfs actually now any brain surgery. The good news about brain surgery is that in a metropolitan area that we're in, who has an urgent brain problem would be denied care. That's, it's a law obviously. For spine, that's a whole different thing. And it involves really some loosening in my opinion of the morality of taking care of patients. Healthcare, and I'm gonna differentiate, and I wrote a book on this and it'll be out by the end of the year called Can We Manage to Save Healthcare? Healthcare is a business, make no mistake about it. It's to be differentiated from patient care. What we do in the hospital here in the clinics is patient care, all the rest of it maintaining this lovely auditorium, the buildings, parking, on and on and on, the implants, et cetera. That's all business. And it's exceedingly complicated. It makes our work very complicated. And so despite decades, and I have had the privilege, I've been lucky, first I've had the privilege but I've been lucky enough to be around since the late 1970s as a medical student. The technical and scientific progress that we've made in taking care of patients still is not distributed in a way that is equitable. And getting back to Humboldt Park Health, advancing health equity, that's our mission. So everyone who's involved with it, I don't think the nice man who is in, what I would call an orderly back in the day knows what that really means, but it's there. It's there for people to at least see that that's something that we're aiming for. We waste and we spend and we waste an inordinate amount of money on healthcare, the business. A lot of it is siphoned off from actual patient care. And we're in a fantastic medical center here, top of the line training program I've been in others. And the fact that we have this ability on the one hand to train people and to provide any type of technical apparatus to take care of a patient and still not able to get that to all the people that need it is it's mystifying innocence. And in my opinion, borders on the criminal. It talks about what we value as a society. And unfortunately, ethical lapses punctuate the delivery of healthcare because of what we value. And I'll get to more of that in a minute. And so if in thinking about today, if we wanted to think about an ethical dilemma of healthcare, of the greatest magnitude, we need look no further than do we uniformly provide access to safe, high quality healthcare, patient care that is across our region and across the country. We're part of this system. So this dilemma rests also solely with us. Not solely, it also rests with us. As I said, I will not hesitate to fax information to an insurance company in order to get a patient's surgery approved. I mean, if that's what I need to do, that's what I do. But it's way beyond that. These reviews that occur to get a MRI or to get a patient reviewed is really, and even yesterday in my clinic, a patient could not get post-op patient Norco 10 milligrams because he was in some Medicaid managed care plan where they only approve five milligrams. So the prescription that I authored for him had to be purged and we had to go to five milligrams and they told me how many I could prescribe. And it's just, to be it's criminal that there's that degree of oversight in a relationship that they have no idea I have with this patient. And it's just differential accountability and really the accountability rests with us ultimately in taking care of a patient. But we have to make do sometimes as I said with what is allowed by particular insurance plans. So Thomas Paine, to be frank here, toleration is not the opposite of intoleration but it's the counterfeit of it. Both are despotisms. It really is that significant. Compromising patient care based on the mechanics of the system of finance. Pogo had a, in the comic strip, the following saying and so we are to blame to a degree it's differential accountability. We put up with it. And some people not only put up with it, some providers, and I use that word very loosely some people who take care of patients are more adaptable is not the word but more, they'll let things go more than others. But it strikes at this inequality, this inequity of patient care. So again, with Aristotle putting together a talk, ethos, logos, pathos. So for me, the ethos was reading this book when I was about 12 years old I still have my copy up here somewhere I brought it along today. And I can't say that that's what made me want to be a brain surgeon, but it definitely made me want to be a doctor. And that's what separates us from the other branches of support that are in this business of healthcare. Yet we're under fire. And so I got an MBA a few years ago because I want to understand what was going on with the finances and the economics and the ethics of business. And it was very interesting and it just kept me researching and researching and brought me to where I am today. This inequity of patient care, it's not just for spine care, it occurs every day with countless other types of illnesses that are confronted or not confronted or not directed to where they need to be managed best. So the story goes that Rabbi Hillel was asked what is the, so there was a man and he asked two rabbis or another rabbi and Rabbi Hillel if he could convert to Judaism. And the man said, and I'm paraphrasing, but I want to understand it in the quickest way possible. And so the other rabbi beside Rabbi Hillel said, this is going to take you years, you're not going to be able to do this. So Rabbi Hillel, as the story goes, said here's what it is. That which is hateful to you do not do to your fellow. He said, all the rest is commentary. Now go and study. So that's my talk. So far healthcare is a business. It's a big business. Medical care treatment of patients is not a business. It's a relationship. It's a humane service. It's a connection. And it's being assaulted by the business aspects of healthcare. So that's it. We've got to go. We got to make a difference and let's get cracking on it. So understanding the economics of it starts with a guy named Adam Smith, the father of economics. He was a Scottish philosopher. And even back then, and he wrote the book literally on the first book of economics. And literally back then he was conflicted because before he wrote the book on economics published in 1776, he had written a preceding book in 1759 on the morality of how we treat each other. And so he understood on one hand that morality is a huge part of motivation for economics. And so since the 1700s, we've been grappling with this sense. And I think right now in healthcare we're really struggling with it. Adam Smith is famous for the invisible hand, the motivation, these virtues and ethics and things that we utilize when we interact with others. We emphasize that in our training in the healing arts. This competes, if you will, with the visible hand that is what is happening for us to be able to do our work and what do we need to do our work? Robots and spine surgery, et cetera, et cetera. He invented economics as part of political economy and that's the background for what we are dealing with with healthcare in the United States and the world today. It's political science and politics meeting economics and how they interact to provide social services. So on the face of it, with Adam Smith's background as a moral philosopher and the first economist, we should have a well-balanced approach to providing patient care services. And in fact, Edmund Phelps has written a book on this which he talks about economics aim as being mass flourishing. Now, Professor Phelps is 93 years old and I'm happy to say I wrote to him and he wrote back. And he said, and I shared this philosophy with him and he said exactly, he said, the problem is, is that we lack a bridge between the two disciplines. So that's the homework assignment for all of us to work on that bridge. And no one would argue that access to safe, high quality, efficient healthcare is critical for mass flourishing. So when we talk about political economy, it gets, if it's balanced, that's good. If it's not, it gets to be a distraction and at worst it can take away, it can corrupt, it can corrode how we propagate appropriate care for each other. And the Romans, and I hope we're not in that era as well here in the United States, but in the Romans in the dying days of the Roman Empire, they used a lot of bread and circuses to distract people from the downward spiral of their society. And so we need to be aware that history does repeat itself. So what are these barriers to mass flourishing through healthcare? It's a conflict we have now between politics and economics. We have the ethics of business driving economics, in my opinion, corroding the ethics of the healing arts. What are the components of the policy or the politics of healthcare? Well, we have a lot, probably too numerous to mention in just one slide for sure. But we have the obvious federal programs that we deal with Medicare, Medicaid, Accountable Care Act, AKA Obamacare. We have the federal healthcare system, take care of veterans, veterans administration. We have Indian healthcare service. We have right here in Chicago, a number of federal urban qualified healthcare networks. We have other state and local county healthcare systems. I mean, Cook County Health and Hospital System is bigger, has a bigger hospital than most mid-sized cities in the United States. Unfortunately, my experience with it is politics drives it and it's lost some of its key mission focus due to that. We have lobbyists in Washington, DC that work on behalf of CVS and Aetna and other health insurance modalities. And then we have this concept of the commanding heights. So Lennon, father of communism, he said to his followers in order for us to take over Russia, we have to follow the military principle of taking the commanding heights, not physically, but ideologically. And so when politics and business work together in that regard for power and control, they have the commanding heights. And so that's what we are facing in terms of healthcare here in the United States. And then there's an excellent book called Kleptopia that I just read about the oligarchs that were spawned by the collapse of the Russian, the USSR, which also uses that same principle. For supply, right? Where we are now, clinics, freestanding surgery centers, freestanding MRI facilities, medical schools, academic medical centers, training providers, nursing and allied healthcare professional training. And then we have the other middleman, like now is Medicare Advantage season. So, you're watching the World Series last night, and there you go, you're bombarded with Medicare Advantage programs to sign up for. I guess they think most old people such as myself are still watching the World Series, although they said it was only watched by nine million people last night where it used to be watched by 100 million. So it's a real change as well in our culture. Demand or microeconomics is based on these one-to-one interactions that we have or one-to-our-phone interaction with Amazon or whomever. But I've always had great mentors in medicine and learned a lot about interacting with them and observing them with people and how to interact in a way to gain the trust of people. That's a value that is, you can't put a dollar amount on that. Transactional is more like business in general. And so we have a force and a counter force in taking care of patients. And more and more, I have seen the influence of this transactional type of mindset for ordering an MRI or approving surgery, et cetera, et cetera. A healthcare insurance, it introduces to some degree moral hazard in that if you are insured, you may not be as careful with how you proceed in life, like car insurance, you know? Okay, I dented that other car, I am insurance, you know? I'm not gonna sweat it, but either you or someone else will pay for that for sure. And then tragedy of the comments is in regard to us really not paying heed to our resources, the sustainability. And we hear this term, you know, the national debt is unsustainable. Spending on Medicare is unsustainable. Well, no one really talks about what that really means, you know? If something's unsustainable, that means something will have to be cut. And that's why Medicare Advantage advertising is very devious in my opinion, because it offers a lot of different services that they say are at no extra cost to whoever signs up for it. Well, someone is gonna bear that cost. And then right around here somewhere is the University of Chicago Department of Economics and Richard Valor has, and others obviously who have also received Nobel prizes have distinguished what aspects of biases and more deviously nudges if you will to make people behave in certain ways. And so that's utilized by marketing of healthcare services. And we see that all the time on any program that you will watch on regular cable TV. And so unfortunately a lot of the services that are offered that way, what is the value of them? And are they really just eyeglasses for free or great? People should not be without eyeglasses in the United States, but what are you trading off for that option? And Thomas Sowell, who is a really a remarkable economist, he distinguishes as I have tried to between healthcare and what medical care is. And they're not the same. Unfortunately, they're packaged the same way. And right now they're managed to a big degree, at least with the majority of healthcare, even Medicaid is managed by insurance companies. And they restrict if a patient can come and see me at a little safety net hospital even, that they maybe can't, that they have to go and wait in line at Stroger Hospital in the clinic with a herniated disc and severe sciatica. I mean, that's just cruel. And Henry Aaron, I haven't written to him recently, but I have written to him because about 20 some years ago, I took care of his mother at Northwestern and touched base with him about, he's retired and I touched base with him about Medicare and some questions about its sustainability. And he has studied it his entire career like 50 years. And he basically, I'm quoting him from a paper, but he basically said the same thing to me that there's so many factors that detract from the actual care of patients. And I said, what's the solution? He said, after 50 years, I have no solution. I'm not gonna be dismayed though, we can come up with a solution. Uwe Reinhardt, an amazing scholar, he looked at cost as well and demonstrated that we have a lot of waste in our healthcare system. When it comes to spine care, more is less. These are a number of the specialties that are involved with treatment of spinal disorders. Most spinal disorders do not need to be treated actively, that is, they do not need injections, they do not need anything more than maybe a short course of medication. They need a change in lifestyle and really a analysis of the factors that are causing it in each person. That involves speaking to the actual patient, and taking that time to figure out what is going on in their life. So pointed out as I am that when you have neurosurgeons and orthopedic surgeons seeing people for degenerative disc disease, and the only thing you have as a hammer, well, that's gonna look like a nail to them. And they're gonna wanna do surgery, replace discs, put in a lot of metal into the spine, fuse the spine. I'm operating on a nice lady who has not been able to get care elsewhere because she had in 15 years ago, I'm operating on her in two weeks, 15 years ago she had a, I don't know why, but she had a instrumented fusion, we have five lumbar vertebrae for the non-spine surgeons here, from L3 down to her sacrum, fuse that whole part of her spine. So she can only move at L2, 3, and she is in severe pain because that's the only segment of her spine where she could move, and she has built up degenerative thickening of a ligament that's squeezing her nerve roots. And because she's had previous surgery, and it's a Medicare patient, she's been seen and told to do some ridiculous things that would not give her more room. So I take care of patients like that and I'm gonna do a simple laminectomy above the level of that fusion to make more room for her nerve roots. And she's 76 years old, we don't need to do an extension of our fusion or anything like that. So now we're seeing the results of these increased fusions that have come about due to the perverse economic incentives for spine surgeries. We need to think about in every patient, the value equation should involve risk and analysis of the conventional thinking like every person with degenerative spine disease needs a fusion and what is the risk of that? And now we need to recognize the inertia that's been created by these bureaucracies of government and insurance companies. It involves this concept of entrenchment and it's driven by economic factors that are influencing the decisions that are being made. And the tragedy is that we continue to pay for things that we probably don't need to pay for. We don't need to even do is what I'm trying to, what I should say that was in our phone. Not everyone needs a fusion for degenerative disks in their spine. And it's this inequity is a result of this struggle and the inability to change. Overcoming it, it's gonna require on our part self-resilience. We've heard a lot about this after the COVID pandemic and that's for another discussion. I'm gonna skip ahead a little bit. So while medical care has been called an art to which science is applied, it's foremost an ideal, it's a humanistic pursuit to comfort first and foremost, give people information and help them to understand why they're having pain, especially in regard to the spine. Dr. Peabody, anyone familiar with this paper? Yeah, this is a classic paper everyone should read here. So Dr. Peabody, that's his famous saying and he was giving this paper knowing that he had inoperable cancer and he died a few months later, but he devoted his whole career to this aspect and it's a great read, it's a classic, it's reprinted in JAMA, many other places. You can get it for free, you don't have to be hostage to a PubMed or one of the other services that wanna charge you $51 for a three page paper. So what are the ethical and moral principles of medical care? First, do no harm. The other four are this privilege, recognize this privilege that we have for helping someone, potentially helping someone with a condition of their life that's causing them pain or inability to work or whatever. We have to be aware of the risks that we're putting people through if we do recommend a surgical procedure and we have to remove ourselves as much as possible when we do recommend treatment that we are not recommending a fusion because I'm paid by Zimmer Biomet as a consultant to use their pedicle screws for using their degenerative condition of the spine. And justice, that's the most difficult virtue in my opinion to be aware of. So what about the diagnosis and treatment for spinal conditions at last? As part of this trillion dollar industry for healthcare, instrumentation of the spine is a forever growing, every year growing part of these expenditures and the majority of the instrumentation of the spine and why is instrumentation of the spine done when for this patient I'm just gonna do a simple laminectomy you can charge more money for the procedure by adding a fusion to it. And as more and more businesses get involved with this, that's where the decision-making process becomes corroded on the part of the relationship we have with the patient. It muddies these ethical waters for sure and it makes taking care of patients more transactional rather than a relational encounter. It's all about economic self-interest and the invisible handmade visible by doing something. So last week, last Tuesday, it was 80 degrees and full disclosure, I usually have clinic on Tuesday but for last Tuesday, I had something I was supposed to do and it was canceled and I was on the golf course. So I had written Dr. Berwick and this is the other paper that you must read. This was in JAMA very recently and Salve Lucrum was in his lead paragraph. This is an awesome paper. Salve Lucrum is a Latin phrase that means hail profit and he points out that ironically that phrase was in a mosaic floor at Pompeii and so it was below like 16 feet of volcanic ash. So here was in an atrium of a beautiful building. So and he goes on to talk about really the amount of money that is expended on Medicare Advantage and the amount of money that's expended on excess unneeded surgery, et cetera, et cetera. So it's an awesome paper. So I'm on the golf course and I get a call and it says, Don Berwick. So I said, Dr. Berwick, he goes, oh, Dr. Sibolski, he goes, thank you for your letter. I wish you well on giving your talk. He said, give him hell because he said we need to enliven ourselves with the conflicts that are just eroding how we take care of patients and therefore why patients don't trust us as much as they have in the past. So that was fun and so he's an amazing guy and it was a fun interaction to have with them. And so the inequity of surgical specialty care involves all of these components. Access, as I told you, I'm at a small hospital within five miles of three huge hospitals in Chicago. I can get a patient over there if they have a complex surgery, I think should not be done in a small hospital but then they're a victim of the system of whether their healthcare plan will actually cover the care that can occur there. The quality, quality is not such an issue. People are well trained in taking care of spinal problems but we're biased in terms of taking care of spinal problems in terms of what are our solutions and do we think of solutions outside of our particular subspecialty and efficiency. Can we get patients seen quicker and we need to work on that. And so more and more instrumentation procedures have been performed in 1986 or neurosurgeons were performing close to zero instrumentation procedures. Nowadays, spine surgery and spine instrumentation procedures in neurosurgery probably takes up at least 75 to 80% of what neurosurgeons do. And whereas we would do laminectomies, I was trained by classical neurosurgeons to do a laminectomy to decompress the one or two levels of the spine for degenerative stenosis. Now everybody gets a laminectomy plus pedicle screws. They'll get that and some of them will then get also a, that's from the back and then turn them over onto their back and go through the front and put in cages to open up the disc space. If you can decompress from behind and you're fusing them, you don't need to go in front. You can make enough room for those exiting nerve roots. You don't need to jack open the disc spaces but you get paid more money for that. And as a consequence, sad case there was a neurosurgeon down in Florida who was a consultant for one of the major spine implant companies about 20 years ago now and was coming to lecture us here and there and everywhere. And he was making so much money, he had his own jet but tragically he crashed it flying to the spine headquarters where he was gonna have some meeting or do some consulting or whatever. And then we have other neurosurgeons who have invented some little piece that goes with a Medtronic spine fusion tray and he gets paid $17 million and goes on to bigger and better things. So it's not unusual unfortunately to see this influence. So I was trained by some great neurosurgeons and they would have in the classic people that they knew as well. And one of them, and this is obviously stuck with me as a spine surgeon must be a mind surgeon. We must look at and talk to the patient, find out what their expectations are and tailor customize our care to them. And unfortunately, that's getting lost in this shuffle for putting in instrumentation. Dr. Fowler of the book Nudge would, I think endorse that as a good nudge. So I'm always looking for ways to increase the value and in the Wall Street Journal three years ago now I saw this article. So this is Virgil Carter. Virgil Carter was my boyhood hero. He was a quarterback for the Chicago Bears. Back then, so this is in the early 70s, back then to be a pro football player he used to have to have a side gig and some of the most of them were salesmen but Virgil Carter was a very smart guy. He got his MBA, well he's playing for the Bears from Northwestern and right here he's using one of the few computers that was in action at that time. And that's his wife and he, and he took the plays from, in every football team and I've been on the sidelines as a Bears neurosurgeon. There's a person who is the quality control coach who charts every play. 20 yard line, run, gain 2.5 yards, they chart every play. So back then they were doing that. He took that and digitalized it and came up with the analysis they do now, the books they have now where you've got a guy sitting up in the booth. It's third down on the Bears 10 yard line. What's the, you know, it's not a book anymore but you know, back then what was the book say what's the best play? And you know, then you call it in right away, you know, run off the right side with Gail Saras, you know, there was a high percentage. So anyway, he did that. He's the father of NFL analytics. He's also the father, if you will, of, he went into the insurance industry after this and looked at, you know, lifespan of people and, you know, and if they had, you know, some interaction or some illness, what would happen to them? So at any rate, I saw this article and I Googled him. He lives in Flairmont, California. And I wrote him a letter and I said, Dear Mr. Carter, I've been a fan of yours since, you know, the early 70s. And I'm interested in expected value for you know, if I tell Mrs. Smith that we're going to do a three level laminatectomy, I'd like to tell her more than, you know, a doctor, you know, she asked me, you know, what's the percentage of success? You know, and I have to say, well, I've done a thousand of these and you know, blah, blah, blah, blah. But I want to be able to have these measures so we can tell people, you know, that you have a fusion, whatever. So long story, or it is a long story, but shorter, it's a long story. And so, you know, we had a great conversation about this. He thought it was an awesome idea. But he said, Doc, he said, you've got to get data from the insurance companies. I'm still waiting. Still waiting. You know, data a lot easier than you can now. But awesome and just fun, you know, to interact with people who think outside the box and create value. So it takes, you know, all of us to, you know, come up with these ideas and come up with this interest for how we can create actual value for patients. And for me, it's thinking about how I can optimize my decision making for my patients, you know, in this little hospital on the west side of Chicago, who knows where that will lead. We have to always bear in mind, I'm all, as I said, a spine surgeon, it must be a mind surgeon. We have to know what the patient's expectations are. And we can develop, you know, based on that, some technology which I'm also working on to improve safety of patient care in the operating room. Future challenges. I think AI will help us in this respect. It will allow us to create a frequency distribution for what happens when we do, you know, parathyroid surgery on, you know, different age groups. But we can, you know, we have to somehow also factor, and that's why I think AI will be helpful, but we'll still need the interaction. We'll need the, you know, the smart people that we are to translate that for our patients and help them with their decisions. AMAs, Code of Ethics, we alluded to a little bit of that. So I'm going to wind this down now. So I told you I would talk about the Marines. And fortunately, my son and my son-in-law are both Marines. My son, this was back in 2012. He had just graduated from Officer Basic School of the Marine Corps. And he's 22, 23 years old at that time. And their training is such, he's going to become the boss of 40 Marine infantrymen. And the training is such that the Marines have no problems. And the structure of their organization, they have no problems. You know, his sergeant was 38 years old. And when he was assigned to his platoon. And they deployed. And I may become a little emotional about this, but they deployed. And for nine months, and they saw some action. And then he came back. And I asked the sergeant, you know, how did it go with Eric? And he said, oh, the lieutenant, he's a great guy. He goes, he would say, I was always concerned that he wasn't getting enough sleep. And, you know, he would sleep one or two hours a night, always looking at after his guys and all that. And I said, well, that, that sounds like internship, right? Right. One or two hours a night, but, but no one was trying to kill us that I know of at that time. But so the Marines, you know, they have something and unfortunately it's been written up by Simon Sinek. So for us to have the benefit, we have to learn so much in terms of, of patient care that I think we get slighted on the leadership of part of it. And it's taken me all these years and reading so many books and Peter, I know you're the same way. That we finally, you know, get, you know, a cotton, you know, we get a feel for what leadership is, but the, but I recommend that book. And, and Professor Karzy talks about, he's an amazing guy. He talked about finite and infinite games. So when we take care of a patient, we do a procedure, do it well, that's all good. But, but what we're doing is we want to create value for the future. And so that needs to, we need to consider that as well. And so one of my last kind of mentors from afar is, is a story of this country doctor in England. And I recommend, I recommend this book as well. And yesterday I'm in my clinic. And I have this week's JAMA. And I'm happy to say that it was written up about a fortunate woman. And so a follow-up of this doctor's practice in England and his, his credo, which she, which she follows. And so we all have a privilege here to do so much. It's hard because the work is hard. The sacrifice is great. But, you know, let's take inspiration from the Marines and a fortunate man and woman and continue to create value for our patients. Thank you. You're presenting us with a personal challenge to do good for our patients. And ultimately, I think that's where it all comes in. What it comes down to. Is there, is there some other set of economic incentives for regulatory oversight that can push us to do the right thing? Because, you know, we mentioned at the beginning where you want to get an MRI, but you've got to go to the hospital to get it done. In theory that's designed to prevent low quality care, low value care. But it does seem as though these are off roadblocks. But the ultimate question is, you know, is someone going to be recommended an operation? Often that doesn't happen a lot. Absolutely. So, so way Reinhardt talked about costs. So that, so that's what we're talking about. What, what we're interested in here is ethics of, of recommending something and the cost of it, not only in terms of dollars, but in terms of resources and the tragedy of the comments, you know, we sustain ability. So that's where Peter, you know, your center here, you know, writing papers that are, that get into health economics, you know, they get into other journals that force the issue. And, you know, I'd obviously be happy to collaborate with anyone who would, would want to do that. But we focus. So I've been to Mike Porter's course, the famous Harvard professor, brilliant man, made his way to fame with five courses of strategy. But, but kind of, I've been, I'm reverse engineering. He's like forward engineer. He is an engineer. So this is how they work. So then he said, you know, I've conquered strategy. I'm going to conquer health care. So he and his associate write a book. It's this, that I'm redefining health care value or redefining health care. And it is slow going. And, and, you know, I'm trying, I mean, hey, it's just my assessment as a practitioner. And I've had this discussion with them when you attend meetings, you know, you get to eat dinner with them and all this stuff, but they're missing the point. The point is, and, you know, and thank you all for your attention. The point is, is that the value of what we do in terms of interaction and, and value of decision making is really what no one else can take away from. That keeps me faxing stuff to whoever, because I know this patient needs an operation, you know, but it doesn't have to be that way. And so I don't know, health economics or whomever where we talk about the value of decision making or decision making under stress and uncertainty, which is surgery, you know, and any, you know, and ICU and, and ER and all this. We don't get enough. We don't get that message out there. No. You know, people, you know, they want something, they want us to do that, you know, in the city. And that's the way to do that is that's often every and whether that's 15 and you don't necessarily find the their goals need. They want to be fixed. So the case was send to the case and I look at it is it's struggled to get here to the hospital. I think it's very, very hard to get here. I was not able to get here. I was not able to get here. I was not able to get here.