 Ladies and gentlemen, I'm delighted to welcome you to today's professionalism seminar that will be given by a dear friend of all of us, but a dear friend of mine, Dr. Wendy Levinson. Some of you remember Dr. Levinson, who is the Chief of General Medicine here at the University of Chicago. When Wendy left about 10 or 11 years ago, she went to take over as Chair of Medicine at the University of Toronto. Some of you may not know that the Department of Medicine at the University of Toronto with over 700 full-time faculty is probably the largest Department of Medicine, at least in North America, if not, if not beyond North America. So Dr. Levinson is the Chair, and I just love her title. You're not going to stop me, but I get to say the title. Dr. Levinson is the Sir John and Lady Eaton Professor of Medicine at the University of Toronto. Dr. Levinson is a former Chair of the American Board of Internal Medicine's Board of Directors. She continues to work closely with Holly Humphrey on activities of the American Board. Wendy is also the incoming Chair of the Association of Professors of Medicine. That is the Chairman's Club of U.S. and Canadian Chairs of Medicine, and Wendy will be taking over in that role next year. Wendy has for a long time been a national leader in internal, general internal medicine, has been an expert on doctor-patient communication, the doctor-patient relationship. I think of that preliminary study you and I did in Oregon listening to tapes of primary care encounters with patients to see if we could hear elements of conflict or disagreement in the give and take on those tapes. But since then, Dr. Levinson has written spectacular stuff, the large movement on disclosing medical errors probably originated with Dr. Levinson's work over the last five or seven years. She's worked also on how surgeons negotiate informed consent with patients, an area of particular interest to me. Today, Wendy is going to speak on a behavioral and systems view of professionalism, a practical approach for physicians and organizations, and Wendy, I can't tell you how happy we are to have you back. Thank you. I'm really delighted to, I have to say a few things about Mark. Well, first I have to tell you that my title that he talked about is the First Chair in the British Empire. But I have affectionately tried to reverse the title to the lady and Sir John, Chair, because it really was the lady who put it in place and I know that. And I also have to say that we haven't, we've been friends for a long time. In fact, we were, I used to live, I used to say one firewall south of Mark and Anna because we actually lived in the attached house. That's right. So we have been friends and neighbors for a long time. So anyhow, it's really fun to be here and I'm really informal in conversation. So I really would like it if you interrupted me. I know that many of you have experience in this area, have ideas about it. I'm sure that you're doing really innovative things that I haven't heard about and I'd love to hear about. So I would be very happy if people just stop me and we chat it along the way. So I don't have any disclosures. I'm one of the few physicians who's never worked with pharma. They never had any interest in what I do. So I can always put this up. And I want to just share this framework. And it's actually something I've worked with. Holly, I just saw Holly Humphrey walk in through the ABIM. But I can tell you that I've done a lot of writing about communication. But this is actually something that I have found really useful to me, really exciting to work on. Because I think I never really understood how to take the concepts of professionalism and make them practical. And so this framework that we worked on through the ABIM Foundation really helped me shift my thinking. And what I want to do is share this framework with you and illustrate it using two examples. I have a third example if we have more time. But I'll use the example of patient-centered care as one. And the second stewardship of finite resources. Really to illustrate how I think this different model and way of thinking about professionalism I think is potentially helpful to both individuals working in the healthcare system. Not just physicians, but all healthcare professionals. And also for the systems in which we work, which are not just the passive contexts, but shape and influence our ability to be professional. So I'll share with you my thinking about it. So I'm sure all of you have seen the charter that came out now 10 years ago, which is pretty remarkable, by the American Board of Internal Medicine, the American College of Physician, and the European Society of Internal Medicine. And as you all know with this charter, I think it was a step forward. It laid out a clear concept of what professionalism in this millennium was about. And it had these three principles that were well-known, patient welfare first, patient autonomy, and put on the radar I think social justice as a third core principle. One I think that's had still less attention up until now. And it also laid out a series of commitments. They were not surprising professional competence, honesty, confidentiality. But at this time 10 years ago, I think it also put on the radar screen things that weren't talked about a lot at that time. Improving the quality of care, which physicians had not overall maybe thought about as their responsibility, improving access to care, also not necessarily on their radar screen, and the just distribution of finite resources. So it is interesting to reflect. This was sort of a foundational document. It wasn't a how-to. It didn't provide practical approaches. But it did articulate what the present commitments to professionalism should be. And it put these, I think, in shone the light on some concepts that we weren't talking about a lot. But it is interesting to reflect how much progress have we made? How much are we enacting this? What do we really need to do to take this from theory to practice? And I think that's challenging. And I myself have often felt not sure how to do that. Is it just a concept? Or can we make it more practical? And that's where I want to share this. Some of the old assumptions of professionalism and I think what has shifted. And I'm drawing heavily on Catherine Lucy's work who wrote an article a number of years ago that I referenced in a minute that I really would commend to people. I think it was very helpful. But I think we've had the attitude about professionalism that is an admittional competence. It's based on character. You're kind of born to be professional. You have the right stuff. It's kind of inherent in you. That physicians or other health professionals who lapse are unprofessional. Kind of a bad apple. The person who refers to their own MRI machine or has sexual relationships with patients or are the outlier bad professionals. And then we need to figure out ways to punish them, teach them that they should be different. And we've had this sort of responses to elapse or punitive as a kind of underlying theme. We've also sort of thought, I think, in an old way that these challenges are infrequent. That we would go through our careers and be really good. And then occasionally we would encounter a challenge to a professionalism. And I'll share with you that I think a different framework is much more helpful. The healthcare systems, so a university and academic medical center like here, they're the places that healthcare professionals work. And they're the setting in which these lapses occur. But they're not part of the problem or the solution. They're passive places where the work goes on. And I think most important to people like you and like me is that medical schools and residencies are responsible for selecting and training professionalism. I think there's been an underlying kind of view that admissions committees should be able to do an approach which will pick people who are inherently, based on their character, professional. And then they should train them some in professionalism. But really, the medical school should shape us, but that you should get the right protoplasm in place, shape them a little bit during residency, and then they will be set to practice in a highly professional way. And even if not explicitly stated, I think, Holly, these have kind of been a bit the underlying assumptions that we've approached professionalism. And what I think is the different world view that I think really, I would say this has really helped me and my thinking is to shift my thinking in these ways. That it's really a multi-dimensional competency. That it's a competency like other competencies that we are training over time. And that it's a more complicated competency actually than some. That lapses occur in physicians who are good professionals. That it's not bad apples. That we all make mistakes, just as we would make mistakes in medical diagnosis or care. That we can kind of have an error in judgment in the professionalism realm. And that these challenges are not just once in a while, but we confront them actually pretty much on a daily basis. That we talk about teamwork, and then we see disrespectful interaction on the word, but we're not in a position of power, so we kind of ignore it. That really, if you step back and think there's small lapses and professionalism and things we see negative ones, there are also lots of positive ones every day in our workplace that we kind of take for granted. That responses to professionalism as opposed to the let's punish the person and teach them how to do it right should be based on a coaching and a root cause analysis. That we could figure out just like an error disclosure, what really went wrong in the system that led to this challenge in professionalism resulting in something? I mean, I was in a residency and not long ago and a cardiology resident told me that they all knew the cardiology trainees that one of the cardiologists did a lot more invasive procedures that they felt put patients at risk than the other cardiologists. And all the fellows knew it, but they didn't know what to do about it. Because really they didn't have the construct about how they could do a root cause analysis on that. That it wasn't just, there were many factors that allowed that to happen to the cardiologists. And another concept of this is that the sanctions are really reserved for those who fail to respond. That if giving feedback and coaching doesn't work, then sanctions might be required, but that they're not the way we handle professionalism as a routine basis. And that the healthcare system, and I'm going to talk quite a bit about this, really isn't the passive place in which these happen, but by the way we shape our policies and philosophies and culture, and I'll talk about that in the healthcare system that we very much either enhance the opportunities for us all to work in a highly professional way, or we inhibit the professionalism of our colleagues by creating incentives in the healthcare system that are not aligned with us doing what we believe. Like access to care issues, which a healthcare system can clearly inhibit us being able to live up to what we think is professionally responsible. And then healthcare leaders should support ongoing professional development of physicians throughout their career. That we're not selected at the beginning of medical school, baked during our residency, and then set for life in terms of the skill set, but that we're always working on developing them. So it's a really different approach of thinking about the concept of professionalism. And what Catherine Lucy says further in the article, and I'm not going to go through it in it, but this is the reference that was enacted in medicine in 2010, is that you can teach the people to have professional resiliency, that when you develop, when you encounter these challenges that what we need to have is skills and self-awareness in understanding the values that are at play in the situation, just like a differential diagnosis and therapeutic options, thinking about what there are, what are the options for managing the situation, how should that cardiology fellow, what are the options he might have for how we might approach this problem with the faculty member, a perceived problem with the faculty member overusing tests, communication skills that would allow us to think about why not a reasonable person-actist way using skills of active listening and empathy instead of judgment and peer coaching skills in terms of what's the best way to prevent a colleague from having a lapse and how can I handle this. So it's a really different framework, I think, than we might have thought about, in terms of how an individual might develop the skills, the multi-dimensional competency that you develop over your career in encountering and thinking through how to handle these situations. So what we said in this article that I thought really helped shift my views and goes to what David talked about policy is that professionalism happens in multiple settings. The behaviors which demonstrate professionalism happen in the physician-patient encounter, the interactions with the team, the practice settings and training environments in which these occur and those are set in the broader environmental external environment that has payment, the policy regulations, and the socioeconomic factors, etc. that determine health and that this environment, these environments, as I alluded to before, they're not passive. They influence how physicians express their professionalism. If the institution which we work has a very high bar for accepting patients that have good insurance, this affects this interaction very directly. But that also physicians and health care workers, they have a responsibility to exert influence on these environments to encourage them, influence them to make the policies ones which support our being professional. So if we're working in an environment that has undue pressures on us, for example, to see a lot of patients in a short period of time for productivity measures and we think it's not, it's surpassing a threshold which is in the best interest of the patient, we have a responsibility to influence the practice settings, the training environment and the external environment that is putting that undue pressure that we think is influencing our doctor-patient relationship. So it's a system that interacts with one another. So I want to use the example of patient-centered communication to illustrate this and talk about what are the challenges to individual physicians and teams really delivering patient-centered care and then what are the institutional challenges and I'll show you how I think this framework can help us think about what are the ways we can influence the system to make it function to optimal professionalism. So, you know, this is the area I've done my research in. I really think physicians and teams are, their challenges are challenges are that active listening and educating patients takes time. I mean we all know this, you know, you cannot have a really fully informed decision-making conversation with a patient if you're a surgeon in lightning speed, you know, it's just too complex. So there is, you know, we can do things to make visits efficient but ultimately listening, caring and compassion and informing patients takes time that we have in our system in many settings perverse incentives to be efficient, to be, that drive efficiency sometimes beyond where I think we can do this task well. That there's certainly multiple transitions in care, you know, the challenges in, as you know increasingly in handing off care between settings between individuals and in that handoff understanding and passing on patients values and wishes because the next team may be there when the patient has a dilemma or a crisis and the team needs to understand how they understand, how they view their, their care and their wishes. We've all for many years talked about the hidden curriculum in medicine, the curriculum, I think everyone knows that term right, the hidden curriculum of model saying we do this and then in on the words or in practice showing something else especially around compassionate care and respect where I just earlier mentioned the example that you, we teach about team-based care and then on the words we see someone interacting with a staff member in a way that doesn't demonstrate that respect and I think we worship technology. You know, it is just true that, you know, trainees get, we work in an environment where sophisticated medical care and technology is often viewed as the real stuff of medicine and that communicating and sitting down and talking to patients is sort of the soft stuff. I mean, I, I have long experienced in my career the view that I do research on, you know, this soft stuff that doesn't matter as much as the real work of medicine and I think, you know, we, we really do look to technology as the solution for things, thinking that sort of the time with patients is nice but not as important. So, I mean, I think that these have been challenges and the institutions have had challenges, long-standing cultures that don't change easily. The hidden curriculum itself, I mean, a faculty member said to me recently, I said, we talk about respect and caring that she had this dilemma because she was on a search committee being chaired by a very senior member of the faculty but that it was clear that the junior people were not supposed to speak their mind, that they were on the committee but they were encouraged to be silent and she said, you know, what should she do about this? And of course, this is also the hidden curriculum but it's the institutional hidden curriculum around communication and respect. Institutions have huge competing priorities these days, you know, are they going to trade off, giving more time with patients and making the schedules less or, you know, generating that extra revenue? We often have a lack of champions in teaching doctor-patient communication. Our measurement of teamwork and communication is pretty fledgling, you know, where we really talk about teamwork but it's hard to actually have really good metrics of how to measure that or measure trainees competencies in it although we're, I think, working on developing it. And teaching, you know, patient-centered communication skills requires time and resources. It needs simulated patients, direct observation. It's not something you teach in a lecture and then trainees have the skills. It does require feedback. So these are challenges. So this is the framework that's been, I think, very helpful to me and I'll show you using compassionate care how this has helped me change my thinking. So if we think about these values of professionalism that kind of are categories of the values, compassionate care, integrity, accountability, the pursuit of excellence, and fair and ethical use of resources, which you kind of can map onto the charter if you look at the competencies that I talked about earlier and then say, okay, well, for compassionate care, what is needed to express compassionate care at each level of the system? How could we build a system that really drove us to deliver this kind of care by all of the players playing a role instead of just, you know, because I have to just pause for a minute. I mean, the problem with the old model of professionalism that depends on the healthcare professional alone is I've often said to myself, it's like a hero fighting to be professional against all odds. Or Hallease has said, sometimes residents feel bludgeoned by professionalism. I remember your words. By which I think you meant all of the responsibilities on the professional to do this right. Thou shalt do this, and thou shalt do this, and thou shalt not do this. Instead of this more systems approach to professionalism. So what's nice about this is it helps reframe this as a competency at all levels of the system. So for the individual, and this is just a brief kind of way of thinking about it, to deliver compassionate care, we need to develop our communication skills of patient-centered care. We need to know how to actively listen, to express empathy, to hold silence, to talk about tough things like end of life care, breaking bad news, disclosing medical errors. Those are skills of informed decision making. We need to develop those sets of competencies to express compassionate care. But the team also needs to develop collaborative skills of communication, demonstrate respect amongst team members. Because otherwise there's the hidden curriculum, that we might do it here, but not here. And have skills of, like I alluded to before, handoffs. So that we can share information about what a patient's values and wishes are as we transfer care between us. But the practice setting has to support that. So examples of how the practice setting could support that is ongoing communication skills training. In some, I'd say, settings like Kaiser. Kaiser is a good example. I'm, Park Nicolette in Minnesota. There are some healthcare systems that have for a long time felt that physicians need, you know, can benefit by training and communication. They run workshops on it. Kaiser embeds communication training in all their other education CMEs. So if they do things on low back pain, they talk about communication about low back pain. And so we're engaging families and patients in management. So in some settings, like you know about, I don't know how it is here now, but Dana Farber, for example, after that, the Betsy Layman case has patients and families on every committee in the hospital. Every single committee in the hospital. So it is a way of this practice setting, engaging families and patients in how can we deliver compassionate care. And I'm going to, in a minute, talk about, I'm going to the next slide, I'm going to turn to academic medical centers and the ways that setting can influence this competency. And then there are professional organizations. So, you know, professional organizations can advocate for payment reform to support time in working with patients. If time is so eroded that this is not a fashion, this is partly a payment issue. And it can promote competencies and teamwork. I mean, professional organizations like American College of Physicians and the other medical societies can help teach this in their continuing medical education programs. So this framework, I'm going to turn to academic medical centers, but the point I'm trying to make is this set of values around compassionate care can be supported, nurtured by all levels of the system. And I think that's needed to develop the environment that allows us to express our professionalism. So I'm going to share a little bit more about the practice settings of academic medicine on this theme. And then I'll pause and I'll talk about another one. So I think academic medical centers are critical to developing this competency in all of the people that work there. The leader signaled what's valued. I mean, like I said, that search committee told this young woman, we tell you to be respectful and listen to people's views, but she didn't see it in action. So it was the hidden curriculum. Curricular changes in education, I think we've done pretty well in medical schools over the last number of years introducing communication skills training. But we are absolutely not there in residencies. They vary a lot. Some of the medicine residencies, primary care residencies in particular, family medicine residencies, geriatrics, palliative medicine, I'd say those are the exceptions. But I can tell you in our place, the surgical residents do not get much training in communication skills. And I think that we have a long way to go actually in residency training. I'll be interested in hearing your perspective and faculty development. I mean, you know, these if these are skills to be taught, they're role modeled and, you know, when in intending rounds, you know, do we comment, do we go to the bedside, watch trainees and give them feedback? We ourselves have to have skills to analyze communication and to give that feedback effectively. So it's an area that needs faculty development. I think faculty feedback on their performance and 360s to faculty. I don't know whether you routinely, David, get 360s. But this drives change. A lot of the feedback from patients. You know, I'll tell you, for example, on the at the ABIM in the practice improvement modules that are part of the maintenance of certification process, the one of the most popular modules has been peer and patient feedback. And faculty and people in MOC tell us that the they required to submit a quality improvement plan. And they tell us that the most frequent thing they submit back to the board is on issues that have been raised by patients. So for example, if patients say, well, the office staff made them were rude, or I didn't get enough information about the instructions, these are the most frequent things that physicians often say, oh, I didn't know that was happening. And so feedback from patients often drives quality improvement. Transparency of patient ratings. I think, you know, there are mixed feelings about the impact of transparency, but in competitive health care systems, if patient satisfaction ratings, of course, you know, this is mainly happening on the internet with all the other forms of feedback about docs. And we talked about the hidden curriculum. I want to say that large medical groups, it's not just academic medical centers, you know, they large medical groups can assess their culture. This is one thing from the the AMA, a communication climate assessment tool, where people can, you know, a group could assess what their culture is about this. There's large scale trainings, like I mentioned, it's a required part of MOC and a lot of large groups. So we do require in all the maintenance of certification for all of the boards, not just the American Board of Internal Medicine, that patient satisfaction. This has not been fully implemented yet. It has to be implemented, I think, in the next year, that there's some feedback from patients as part of the maintenance of certification process. And, you know, we can reframe things and really, I'm very interested in whether we could use techniques like root cause analysis to understand communication breakdowns in groups and try to drive quality improvement from the things that we see that might not be working. And just quickly, you know, there are other things that other people in that last box on the external environment can also influence compassionate care. You know, CME providers could incorporate it into their learning. For example, I've never understood what, you know, in Chicago, the Orthopedic Surgeon Association, the AOS, has a big learning center here that people come to to learn how to put some new joint in, you know, and new things in. Why don't they have a standardized patient there and have the surgeon need to tell a standardized patient about this procedure? It would be a way of driving this. Accreditation bodies clearly play a role, and we talked about maintenance of certification, but, you know, MOL is another place, and hospital standards that are getting involved in communication, like Jaco and disclosing medical errors, and payers we've talked about, and malpractice companies, too, in the external environment. I can tell you that the way I, my work got going, that my very beginning research was on the relationship of communication and medical malpractice, and two very large insurers, the insurance company in Colorado and Portland and the Oregon one where I was living, worked with me and we did some research together, but in the end they started workshops on communication and offered all the physicians who took them premium reductions in their malpractice premium, because they realized that it was breakdowns in communication that led to malpractice. So what I'm trying to say is, if we want to deliver compassionate care as one of the planks of professionalism, there are a whole lot of different places that we could build a system if we thought system-wide of how do you foster this competency across the entire continuum. So I just, I'm not going to take much longer, I want to make sure we have time for questions, but I want to demonstrate it quickly just with one other, and the reason I want to is because I think this is the area we've paid the least attention to, and you know, we all know we're like really in deep trouble as a country if we don't get our act together, and you know, you have to hear Glenn Hackbarth who's the head of the ABIM Foundation and is the head of the head of MedPAC stand up in many venues, and he basically says that when his kids who are now late teenagers want to start a family, every federal dollar that the government collects in taxes will be going to the entitlement programs and paying down the deficit, and that does not leave much room for other things, and that the only place that really can be significantly cut is healthcare. It's just such a big part of the budget. So we have to think this line through together, and you know, what let me just, what I want to do is talk about stewardship for a minute, and I want to tell you about this choosing wisely campaign, which is down in that box at the far side in what systems can do. So we all know this, that the healthcare expenditures are just not sustainable. We know there's waste in the system. This is Jack Wenberg saying that it's estimated about 30% that's waste. Waste meaning if we did away with it, no harm would come to patients, quality would not suffer. It's just taken up cash. One-third of all physicians say that they acquiesce to patient requests even when they know they're not necessary. This is a article by Campbell. That's the MRI for headache, sure. I'll order it for you. And physician decisions account for a very large part of the healthcare expenditure. You know, David Melser is sitting here, so, you know, I'm on thin ice, but it's okay, he can correct me and add. And Dom Burwick recently published this slide in JAMA talking about the billions of dollars in waste and the different wedges he called them of where they come from over treatment, excess administrative costs, failures to coordinate, and that we could look at all these places that there is theoretical waste in our system and ask what we can do about it. So, obviously, physicians are challenged. As we talked before, we care for the patient in front of us. We have patient expectations who want that MRI. We really don't know how much tests cost. In fact, frankly, it's quite impossible to know how much tests cost, because it costs a different amount. It's like sitting on the airplane. How much did you pay for your ticket? How much did you pay for your ticket? No one knows how much it costs. And it's really difficult to discuss these cost issues with patients. We are not skilled in having conversations about what we're not ordering. It's just not part of what we do. And we also have perverse incentives in some settings. And, of course, the system has many challenges. Expensive tests and procedures generate revenue. We have competition in a medical place, so if we're not going to do it, someone else is going to. We really have very limited incentives to limit certain kinds of expensive procedures. And there are all the political issues that as soon as you start to talk about this, everybody goes rationing and, you know, killing granny. And, you know, it's very hard in our society to talk about cost constraints. So, I just want to tell you about choosing wisely because I think it's really exciting. And I want to actually ask you to think about what are you going to do with this at your institution? Maybe some things are underway, but I think this, the ABIM Foundation started a major project to help physicians choose, physicians and patients to choose wisely. And we did a lot of research about what language was right for this because we didn't want to bump into the same issues of rationing and, as I mentioned earlier. And so, the ABIM Foundation launched a campaign with medical professional societies and nine societies participated in the first wave. This was just public about two weeks ago. So, ASCO, the American Society of Oncology, the ACP, American College of Cardiology, et cetera. And they each picked, here are the societies, they each picked five things that patients and physicians should question. Five procedures for which there was good evidence that it was probably waste, like routine EKGs before surgery or MRIs for low back pain, et cetera. Some very ambulatory, some very inpatient, where we live and breathe in academic settings. They partnered with a variety of consumer groups, particularly consumer reports, who agreed to do partner patient side education at the same time so that patients would be informed about these five things. And so, just to go back, so that they announced these five things. And probably, did everybody, most people see the press about this? That really got a lot of attention. And, you know, if you think about it then, and what they really wanted was the dialogue. You know, our hope is that we could start talking about these things more as physicians. And the key to this campaign is that it's physician-led. It is not the government or an insurance company saying we shouldn't be ordering MRIs for low back pain. It's physicians themselves, the spine surgeons are participating now, or the cardiologists saying we shouldn't be doing this. This is leading to waste. And so, this is an example of this part of the, this square that we have professional organizations advocating for effective care and looking at how we can choose wisely. And if you then think about it, each part of the system similarly can develop competencies to drive this aspect of professionalism. We can do no harm, not provide unnecessary and unwarranted care in our relationships. And I'd add to this, develop communication skills to talk to patients about these choices related to cost. The team could work to improve efficiency in the delivery of care and to look at where they can optimize care or where, you know, think about it on the wards where we check off an order set where, you know, everybody gets everything because, and in fact, when I talked to our faculty about this recently, they told me that some of these order sets were so old that people had, you know, been doing research back then. And so the order set in rheumatology clinic just got to be like this. And then people added to the order set, but no one ever went back and said, oh, you know, that's on there because Dr. So-and-so used to do research on that. I think we can take it off. And so, you know, we can look at, and in the practice environments, of course, we have all kinds of ways that we could influence it, including providing information about the costs to providers in our system and looking at population-based ways in the practice setting. So I don't want to belabor it because I want to leave time for questions, but that was a second example and just briefly of how we could look at finite resources again in the same model. And how do we have the, how can we as physicians in the case of choosing wisely interact with our patients, but in this case have our professional organizations start to stimulate a dialogue about how we choose wisely, which in turn can influence us and change the way we live up to that set of professional values. And, you know, what I did in our department is brought the choosing wisely campaign to our executive leadership. And, you know, we're now engaging in a discussion. We're not finished it. How can we integrate this into our training program? And how can we start to do this in each of the divisions? And so I think that just that beginning that dialogue can help us to create an environment where we can all live up to that value of finite resources in a way that we maybe haven't been in the past. So really, I've tried to talk about refining profession, redefining it from a character trait to a lifelong learning process that lapses and challenges are common. And there are complex situations like Daniel brought up earlier. This is not, these are not simple solutions, but that maybe we could use some of the techniques we've learned in the medical errors and patient safety movement applied to this and help to have the systems in which we work support our being able to live up to our professionalism, both as individuals, as physicians with patients, teams, and in the settings in which we work. So I'll pause there. I'm really interested in your reactions. What's going on here that you think speaks to this, what you're trying. Thank you very much. One comment that comes to mind, particularly with this recapitulation that you offered near the end, is that at the moment, the moment you want to do professionalism, you can do it through the medical student dean's office. You can work with your faculty to gain control of parts of the curriculum and to develop modules in professionalism. But the model that you're proposing, the much more extensive model, requires extensive cooperation, I mean more than buy-in, but extensive cooperation from a whole range of powerful interests, including the institution, which may have its own questions about what is best in its terms of efficiency and its margins and stuff. It's obviously a more embracing model than the limited one, but I think a very hard one to implement. Maybe, but let's just look back at quality and safety. In the last 10 years, I'd say 10 years ago, no one talked about medical errors, like truly no one talked about medical errors. I gave a workshop at SGIM, like I think 10 years ago, on disclosing medical errors. I don't think anyone had done something like that with a colleague, Tom Gallagher, who's done really a lot of work since then. And we've changed the system. I mean, we really have changed the system. There have been external influences. The IOM clearly played a big role in that, like by the errors human, which was an external, then there were these high profile institutions, maybe in that practice environment, like the Dana-Farbers, like University of Illinois at Chicago. And I think it has led to changes in each part of that system. So I would say 10 years ago, we would have said the same. Nice. I mean, it's a good example and model that you're pointing to, that you can actually change it from multiple dimensions at once. And you know what, finite resources yet for the next 10 years. I mean, we are going to have to figure out finite resources. So like if we don't, we really have serious problems. And I really think so we're going to have the external pressure. We have it now, right? The government is telling us that. And what is the role we as physician leaders are going to play in this dialogue? How can we bring this, you know, it is a difficult and it's a culture change and, but we all know how much room we have to move on the finite resources. Every one of us every day knows stuff that's being wasted. But if we sat down at the end of the day and wrote down, where did I see waste today? It would not be a blank piece of paper. I mean, don't you agree with that? Yeah. I am. I have the luxury of being able to see a patient for one hour and enjoy it and a patient enjoys and everything. I really proud of myself. But then I saw a colleague of mine had to see 20 patient during the time I saw four. And all of a sudden I realized if he had to do like the way I do, he has to retire and get out of the system. So my question is, is there any need for professionalism for establishment, for those insurance companies, for the major hospital, for people who I think he meant to say that these are the people are extremely important? Your answer was it's very easy. But at least in U.S. so far it's not easy because this person that I'm talking about had been three times sued for simple things that it was in his problem. So he has to order MRI, he said. Otherwise, he said, I couldn't live. I couldn't stay with it. 10% of cost of the medical practice in U.S. is because of the lawyers. Now they say it is 2%. 10% of them or 20% is because of the unnecessary orders of back pain, cardiac arrest. But all these things are the consequence because 70% of the doctor says, I just can't trust the system. I have to order it. Well, I mean, it's a complicated issue. I mean, it is true that some tests are ordered because people are afraid of malpractice. But if we as a community work like on this five things and there's a standard that this is not really appropriate, then that would certainly help decrease litigation. But I can tell you it's so interesting because people say and I always hear litigation is the reason. So in Canada doctors are sued very little. I mean, it's like shocking. It's too little actually. But in research I've done with Tom Gallagher on the medical errors and attitudes to this, physicians say the same thing. They're just as worried about malpractice in Canada as here and that they ordered these tests for malpractice, but they're never sued. So I think it's more, there are many factors, but one is our attitude toward it. That we think that we have increased in our mind the psychological presence of malpractice and the need to order. And I think that we could work at many levels. We could have standards that show that it's not appropriate care, but we could also work on our culture which supports that belief that we have to order it. And we could work on communication because my earlier research showed that I looked at surgeons who had been sued and primary care doctors who had been sued multiple times and those had been never sued. We audio taped the encounters and we could predict which to some degree, which surgeons had been sued and which had not been sued based on both content and tone of voice. Yes? You spoke a bunch just now about changing the culture. I know that as a part of medical school and it's becoming more common as a part of residency training, this changing of culture is an active process, whether it's this discussion of appropriate standards of care, kind of like the things you were talking about that have recently been published and recently being popularized. But I think it's much harder to change the culture because as an active process, because the individuals who are the ultimate decision makers are certainly not the medical students, they're certainly not the residents. It's the people who are ingrained in the system and who are ingrained in the current culture. How do you recommend or how do you foresee the culture being changed before the next generation of medical practitioners, which could be 10, 15 years from now, the ones who are really making the culture? Yeah. Well, it's a great question, but I am remembering an example that Holly told me a few years ago where a group of your medical students analyzed the mammography. You can tell the whole story, but my memory is that by analyzing the mammography rates at the hospital that they were able to influence the center to open more capacity for mammography for underserved patients. Is that not true? That's correct. So when you said that, my head is full of, here is an example right here that Holly told me a while ago where the students saw a problem, analyzed the problem. That was a professionalism problem, right? In the access to care value and they drove the system to change. I think at a micro system, we all can have an impact even if it's small. So I wouldn't wait for the administrator to say we're opening a new mammography machine. I think that's part of what we need to learn. That's the evolution that we have to have in this field, I think. That's my view of it. That was right, right? That's true. Early in your talk, you talked about the importance of looking at this competence professionalism as a multi-dimensional attribute where there's this idea you can be really, really good, whereas we've instead focused on just the really bad apples. I wonder whether part of the reason that we focused only on the bad apples is because when you're a regulator, you really can't punish without cause. And so you lower the threshold at which you punish to the point that no one could argue. It's like you don't fail a student unless there's a really clear reason. So in other words, some of the problem that arose may have arisen because this was not an aspirational goal that was brought forward, but that it came from a regulatory body. And then to turn to the second part of your story about costs, I think there are lots of people and I might even be one of them who could argue that doctors are at least as much the cause of this problem as the solution to it. And will continue to be because there are fundamental conflicts of interests between what's good for doctors often and what's good for patients or society. And the only reason we're talking about this now is that we've pretty much killed the goose. Okay? And so I guess what I want to ask you and what I wonder about is should we really be looking seriously to professional societies to be doing this? Or should we really be looking elsewhere? Can the profession be professional? Well, I mean, so you're right. I'll give you. So in cardiology in the ACC, if you read the five things, they didn't start with echoes. Like the first thing on their list was we should cut down on all the echoes, right? No, I don't think so. They started with low-hanging fruit that wasn't as threatening to their finances. You know, would it be better in terms of cost if they started with the high ticket items? Yes. But I guess I really do think that starting somewhere and having the dialogue led by physicians, it's such a different dialogue if physicians are coming to the table. And I think that the professional societies can start there. It isn't the echoes. So I agree with you and I think I'm a little more optimistic. I don't have an opinion. I guess I'm just... Yeah, well, that's what I mean. And just about the medical regulators and, you know, if we can get out of the bad apple kind of philosophy, I think maintenance of certification, which we could talk about more. It's a perfect example. It's a more continuous quality improvement type of regulation rather than a bad apple approach. I'd like your comment on this. If you look at a lot of the academic medical centers, there have been significant changes in terms of productivity measures where faculty are just looking for RVU everywhere. And when you bring up the issue of self-interest, which David talked about a few minutes ago, I think it grossly undermines the effort for people to be professional using the metrics that you use in terms of the finite use of resources if you want to promote a time for effective communication. I think that's a major, major factor from all institutions that actually undermines the ability of people to be professional using that in a broad sense. I want to comment on that. The thing is this, these are not easy to change. I agree. But can we in a system in which we work agree on what our values are? I mean, if we had agreement that we wanted to develop compassionate care to the patients we took care of, and then said, well, let's look at all levels of our system at where we facilitate or where we create barriers to that. And what could we modify to, you know, if physicians sat down and said, this is the dilemma, and you know, but I think we have to have agreement on what we value. Like, I don't think we can drive change effectively unless we have some shared common bottom line that we are going to drive compassionate care. If we don't mean it, then it's hard to drive change. This exchange, these last, you know, your comments and David and Scholler's make me wonder if you don't have to broaden your model a little bit and get, perhaps, these two to contribute to it. What's desperately needed according to these questioners is an economic model to encourage professionalism. That is, in addition to the hordatory model of, you know, building on people's good intentions and laudable goals, if you can't actually think of economic incentives that would further the professional model. David? In some ways, we actually already are seeing that across the country as RVUs have increasingly shifted very recently into the bundled payments. So beyond our walls out in the community around us, private physician practices are joining, i.e., being bought by hospitals because of the way the payment is now lining up. So the RVU has become significantly devalued so that in order for private physician groups to capture those dollars, it is to their advantage to be employed by the hospital. So if the hospital and the physicians got together on the same page and said, here are our goals for patient care, and because I have a chance to see this in action, because my husband is now a cardiologist previously in private practice, now employed by a hospital, and that hospital administration and that cardiology group set the goals for patient care, and the payment from Medicare goes straight to the hospital and then to the physicians because of bundled payments. So I think that economic model again isn't perfect, but I think it's actually already happening. So I'm mindful of your time. I'm happy to stay and answer questions, but I also really want people to feel free to go back to what you need to do so that you're not feeling like you can't walk out. So I'm happy to stay. We're going to let you go.