 Good afternoon to all of our participants and attendees. I'm delighted to welcome you. It's an honor and a pleasure to introduce you to Ken Ludmurer. Dr. Ludmurer is a professor of medicine of history of medicine and the Mabel Dorn reader distinguished professor in the history of medicine at Washington University in St. Louis. And Dr. Ludmurer is recognized by many people for his outstanding dedication to residency training. Ken Ludmurer is perhaps best known as a master clinician and a teacher. His passion for system improvement has earned him the role of the country's leading ambassador of the principles and values of graduate medical education. His recent book called Let Me Heal provides the definitive account of the evolution of the graduate medical education system and defines the principles of educational excellence and defines the path to realizing these principles. That book, which came out around 2015, provided the intellectual foundation of the new set of common program requirements that govern all residency and clinical specialty training programs in the country since 2017. Professor Ludmurer is working on a new book called Medicine, and did I get this right, Medicine and Black and White? Medicine and Black and White. Which will be the next book that he will be completing in a while. Ken Ludmurer's research interests have been in the history of American medicine with particular reference to the 19th and 20th centuries, and his work is focused on understanding medicine in a broad intellectual, social, and cultural context. I mean, some of the older and great books, also called Time to Heal, the one in 2005, was Time to Heal American Medical Education from the turn of the century from Oxford University Press. In 1999, Ken wrote Time to Heal American Medical Education from the turn of the century to the era of managed care. Ken Ludmurer's honors include the Distinguished Medical Alumnus Award from the Johns Hopkins University School of Medicine. The Association of American Medical Colleges Abraham Flexner Award for Distinguished Service to Medical Education, and his election to the American Academy of Arts and Sciences. Just in the last day or so, so Dr. Ludmurer received the John A. Guy Nip Award for the ACGME for Distinguished Service in Graduate Medical Education. I think that arrived yesterday. Did I get that right, Ken? Right. Well, I could go on about Ken having earned his bachelor's degree from Harvard in 68, and his master's and MD degrees from Johns Hopkins in 1971 and 73, and his training at the Barnes Hospital postgraduate training at Harvard, chief residency at Barnes, and joining the Washington University faculty in 1979. Today's talk is entitled Reflections on Medicines, Social Contract, and we're encouraging our attendees to submit chats or to raise questions when the talk is over. Ken says he would love to have that sort of interaction from our attendees. Thank you very much. And Ken, it's an honor and delight to welcome you. Well, thank you, Mark. Can you hear me? Beautifully, yes. Good. Well, thank you. It's a great pleasure and privilege for me to be here with you today. I've long admired greatly Mark Siegler and Mindy Schwartz and all the work that they've done and defined wonderful people that they are. And I've also long been a great admirer of the University of Chicago, the McLean Center, the Department of Medicine, the Medical School, the whole university. So it really is very meaningful to me to have the opportunity to talk with you today. As you see, I'm going to be reflecting on medicine, social contract. As I pursue this, I hope to portray the complexity of the many issues that we encounter. There are no simple problems or simplistic solutions. And if I can convey this complexity, the presentation will have been a success. And as Dr. Siegler mentioned, we'll have plenty of time for the discussion and questions and comments and nothing should be considered off-limits in terms of the questions. There's no subject or topic that should be considered out of bounds. Next slide, please. No disclosures. Next slide. And speaking of the social contract between medicine and society. It's important to recognize that this is implicit contract. There's nothing explicit about it. It's not a legal document, but implicit understanding that the medical profession and academic medical centers in particular have to serve society and to society to serve medicine. And society has a responsibility to the other. The medical profession has the responsibility to serve to do everything it can to improve the public health, as well as the health of the individual patients, and to be a serving altruistic and highly competent profession. Society has the responsibility to allow the doctors to do their good work, assuming the good work is documented. And to provide the material and psychological and psychic support necessary for the profession to do its work, academic medical centers in particular. I would point out the academic focus to this conversation, because we speak of the social contract with as it emerged with the emergence of the modern medical school and academic medical center. There was really no need for society to provide academic medicine, lots of funds and support before there was academic medicine and something to support. So this, the social contract emerged with the emergence of the modern medical school teaching hospital academic medical center and scientific medical professor. It might be helpful to point out that the social contract is not the same as professionalism, the word that we use very frequently today. The social contract is institutional, it doesn't pertain to the actions of individual physicians, rather, it relates to the responsibilities of academic medicine in particular and the profession as a whole to do this good work. In addition, as I indicated before, the social contract is a relatively recent event in the evolution of medicine, perhaps 120, 140, 150 years old. I had the, the responsibilities of individual physicians to their patients, going back to the times of Hippocrates and before, but the idea of an institutional or a professional responsibility is a much more recent development. Next slide please. To understand the social contract, it might be useful to put into perspective where medical education began in this country. If one goes to the Civil War, or immediately after the Civil War, medical education was a very simple and easy process. And medical school everywhere consisted of two four month series of lectures with the left with the second term, being an identical repeat of the first instruction was wholly didactic lectures textbooks memorization. There was no practical experience of any sort. What little science was taught was taught without the use of laboratories. And similarly in the clinical work instruction was wholly didactic there was no meaningful contact between students and patients at that time. So when the physician graduated and went into practice that individual was literally going into practice that person is not seen a patient as part of his medical training. It was easy to get into medical school because entrance requirements were non existent. Even literacy was not necessarily requirement. There's a famous anecdote from Harvard Medical School, when in 1870 the faculty for the first time considered having written examinations and weren't the professor of surgery stood up locally objected. We can't have written examinations 60% of our students cannot read or write. The schools were very unimposing places, the second floor above a bank, or a corner drugstore was suffice, the school that had a simple building of its own is considered amply endowed. And the function of the school was teaching alone there was no research or investigation or any movement to try to make the medicine of the future better as part of this. And things began to change in the 1870s and this is a story I told my first book and medical education, learning to heal. And there were changes at Michigan and Harvard and Pennsylvania. And this culminated with the opening of the Johns Hopkins Hospital in 1889 and the Johns Hopkins Medical School in 1893, which was a fully mature modern medical school with rigorous admissions requirements for years of instruction of nine month terms rigorous scientific training, clinical clerkships at the Johns Hopkins Hospital faculty of scholars who are involved with investigation research not just teaching medicine. And the system by the opening of Johns Hopkins was in place. Another generation for the system to become generalized because the medical schools needed money and resources and clinical facilities and labs and buildings and etc etc. And that took a generation or so to accumulate, but by 1920 the system was in place. And as the system was being put together, the social contract became very clear and was adhered to, and it worked. The reason was that it became very clear that how a doctor was trained mattered to the results of that physicians patients became clear that medical research made a difference to making medicine better in the future. And it also became clear that with this reshaped medical school that much more money, physical resources and clinical resources were needed and required help from outside this is not a lot of expenses that medical schools to reach from tuition a lot. The money initially was private. It came from large donors. Robert Brookings at Washington University, John Rockefeller University of Chicago. During this period assumed a major role with the most notable being the General Education Board, which provided in its lifetime close to a billion dollars of 1910 1920 money into medical schools. This was the largest philanthropy of John Rockefeller senior. In the ironic area. Andrew Carnegie whose foundations sponsored the flexional report never became a major funder of medical schools. He said that flexors were convinced him that medicine medical schools were businesses, and he wasn't going to contribute to the support of anyone else's business. So Carnegie was one of was an exception and not being a generous funder. And the states got involved with the support of their individual public medical schools whether University of Michigan University of Maryland, whatever. And then after World War two. The federal government entered the picture in a very large scale and became the dominant funder of academic medicine. The NIH evolved into its present form after World War two, and its billions of dollars became vital to research and also vital to the medical school, because through indirect payments medical schools receive. Much could be funded in terms of further capital expansion and other costs of supporting medical school. After 1965 Medicare and Medicaid entered the picture of major funders. Their impact has been primarily on graduate medical education, because it's through Medicare funding that the salaries of our residents are paid. But in addition, the private support remain very significant so the government is an add on to ongoing private support not a replacement of it. And we think today of major institutions such as Howard Hughes Welcome Trust Robert Wood Johnson Foundation, or very wealthy individuals such as Michael Bloomberg who last year endowed 150. Yes, 150 endowed chairs at Johns Hopkins. In addition, the foundations and private individual philanthropy has the ability to punch above its weight by funding exploratory projects or innovative areas that the government may be unwilling to take a chance on. So for example, as Dr. Siegler mentioned my new interest has been racial equity in medicine. The largest supporters and advocates of this have been the foundations, since even before the civil rights legislation, the Macy Foundation was a major funder of all sorts of programs and public policy development. That Robert would Johnson Foundation entered that arena in the 1970s. So the role of private philanthropy, in my view, remains extremely important, even though quantitatively, the federal government has become the largest single sponsor. Next slide please. Well the social contract has resulted in many successes. In essence medicine has delivered. And here it's helpful to have the perspective of history to many medical students and I was among them medicine seems to have begun today he or she enters medicine medical school. But in fact, medicine has been evolving for a while, and even mid career doctors have witnessed extraordinary change and development and have had to relearn medicine at least once. If you move to senior doctors, the transformation and improvement of medical knowledge and practice becomes even more apparent. If one compares the early 20th century with the early 21st century. The differences are simply astonishing in terms of the capacity of medicine to understand and to heal. And significant developments of medicine, in my view, are on this list I consider the most important development from the basic sciences, identification and physical structuring of DNA. And the most important diagnostic development to be the emergence of non invasive imaging. And I would argue that the most important therapeutic development has been the creation and development of antibiotics. I would also add to the success of medicine that as part of the emergence of academic medicine, medical education became launched and embedded in the university. It's a university enterprise the goals to provide university level, professional education, and not mere vocational training. And this is a very important difference to understand and a huge achievement that we have made medicine, a university enterprise. By university enterprise I mean acquiring the ability to adapt to the future, not merely to learn for the here and now. It's an emphasis on the higher order cognitive skills of analysis synthesis and problem solving, not the lower order cognitive skills of recall and recognition. It means reading to build knowledge explore problems and deep and understanding, not just to acquire isolated facts. It means understanding why something should be done, not just knowing what to do involves the cultivation of critical skills. A distressed of authority, a recognition of what is not known and the ability to tolerate manage uncertainty. University education requires education requires inquiry and curiosity to be part of the daily learning environment in contrast to vocational training, which could occur in isolation from research. Education also requires learners to teach in contrast to training where learners learn, but rarely taught. Education is value laden involving a reflection on the values of the profession, the type of doctor or training one would be the role of the doctor in the profession and the community, and responsibilities of the profession to create a better healthcare system and a healthier all in contrast to the training, which is much more content driven and value neutral. In short, university professional education of intellectual intellectual inquiry, not merely practical training for the forthcoming job. Now, as medicine has matured and demonstrated its value to society. Society, by and large has executed its end of the social contract is provide provided abundant abundant financial resources. And clinical resources for academic medical centers to do their good work and for hospitals to carry on the application of knowledge to the care of patients. It's also resulted in considerable respect and autonomy for the medical profession. There's autonomy and medical education and practice. The medical profession and the last 150 years has benefited with and enjoyed an enormous increase in social prestige and an income. Next slide please. Nevertheless, the social contract has never been fully executed and there remain ways in which both medicine and society have not fulfilled their end of the bargain fully. In terms of medicine and its success in serving society. It's not done a good job in terms of costs. And the origin of soaring costs and medical inflation are multifactorial. But we should recognize that the way we educate doctors and practice medicine is contribute to this. We profess to be scientific. We teach and practice in a very non scientific fashion. We're considering testing procedures because they are indicated by the patient circumstances we've always had a tendency to get everything is there. See what the data show them shows and then goes from there. That's obviously a very expensive and non parsimonious way of practicing medicine. So we had an emphasis on treatment rather than a prevention or public health through social determinants of health. In my view, the issue of prevention is an issue of morals and values. In other words, the reason to be concerned with prevention is because it's the right thing to do, not because it will necessarily save money. The economic benefits of preventive medicine or unclear and some medical economists argue that on balance, there may not be any gains if we do an excellent job with prevention. The reason is that the data that shows prevention reduces costs applies to populations of patients under 65. So an insurance company that is ensuring a large corporation and is able to put into place various wellness and prevention programs that company may end up paying less in terms of payments for its population. This considers retirees and the population over 65, the cost amount greatly, the cost of end of life care, the cost of cancer treatment, coronary artery bypass or whatever it may be. The cost of old age and dying extremely high and these have to be taken into account as well. So, these are reasons that I suggest that the emphasis on prevention is in and it should be underscored because it's the right thing to do not, especially because it might save money, that aspect is unclear. Another area that the medical profession and academic medicine has received criticism is in not producing the types of doctors that society allegedly needs. This has to do with doctors having the human qualities and the cultural understanding and ability to comfort and to advise and to be anchors of support that our patients need. This has to do with specialty type and physician distribution. We regularly hear the charge that there are too many specialists, not enough generalists and physicians concentrating certain areas but not in other areas. These charges are regularly made. And a final deficiency in terms of how well we have served the social contract comes from the attention of academic medicine and medical profession on individuals, our historic mission, but not on the system itself. So we have a system that is enormously wasteful, that is expensive, that is very inefficient and sometimes insensitive and the delivery of healthcare. Next, considerable concern about the greed and self-serving behavior that has afflicted the medical profession. There's no question in my mind that doctors should be well paid, but how much is enough? Ophthalmologists are happy if the payment for cataract extractions are sufficiently high, and if they're not, they'll just lower their threshold for how much of cataract is needed before surgery is performed. Ophthalmologists are happy if dialysis payments are sufficient, care about little else. The blame C is happy if NIH budgets and research support are large enough, but has traditionally not thought about many other issues. So what about the size of academic medical centers? It's essential that an academic medical center be large because we need plenty of patients for students for research, for residents and fellows to learn with. We need patients to be involved with clinical research and trials. The faculty also needs to see patients to keep their clinical skills sharp so they can continue to be seen as our nation's best clinicians and to serve other docs by being sources of referrals for tough cases. However, academic medicine has always been existed to support the system of medical practice, but not to be the system of medical practice. And this is what we've lost sight of in recent decades. And that to Abraham Flexner, as he endorsed the full-time system for American medical schools, defined full-time as sex full-time professors in the entire medical school. Well, clearly we need more than that. But how large do we need to be? We've moved into an era in which the goals has often seemed to be to see more and more patients for the sake of generating revenue as opposed to doing any academic work. Clinical productivity is a term often used, and it doesn't refer to the quality of a physician's work, but the dollars that that physician brings in through practice. Promotions are often made for the dollars brought in, even to physicians who do not engage in serious teaching or research. And then a third issue is the question of how we measure ourselves. Once upon a time, success at an academic health center was defined by the quality of the work. The teaching hospitals were traditionally the least profitable hospitals in the country. Community hospitals without teaching research were much more profitable. But the teaching health hospitals took pride in that because it meant that they were doing good work in investing resources back into making medicine better. This is a view that we've lost today. We're even at the allegedly most academic medical schools and teaching hospitals. The goal seems to be how much money can you generate as opposed to what you were doing. Next slide please. Society has not fully met its end of the social contract either. It has responded positively, as I indicated before, with an enormous amount of financial support, but this support is irregular, irregular, particularly in research and education. Because one never knows if next year's NIH budget will be larger or smaller, and that makes planning and long-term projects much more difficult. In addition, many hospitals have been very cordless supportive, and I'm referring particularly to municipal hospitals, which have long been greatly underfunded. They've contracted or closed, leaving lots of economically and socially disadvantaged individuals without much care. When I arrived in St. Louis as a resident, we had three public hospitals in St. Louis, and now we have zero. Society has also in recent decades imposed enormous regulatory burdens and administrative costs on our academic medical centers and on to profession. I'll say no more about that at this time, but those are very important and real problems today. In recent decades, we've developed an academic business model of quality and not a professional model. We have come to define quality as how many patients we see, how quickly we do, not the quality of care that we provide. This is a subject that I focused on intensely in my book, Time to Heal, because we have been losing the time to heal. Time is necessary for learning, for reflection. Time is necessary for the practice of medicine to be reflective, to be able to provide the education and the counseling and the comfort patients need. But time has been a very short supply in the last couple of decades within increasing as physicians are increasingly on a treadmill that says, see more and more patients faster and faster. And you will be judged by how many patients you see and the revenue you generate, as opposed to the quality of the work. And in my view, this is the most serious challenge facing the practice of learning and medicine today. Next slide please. Who leads going forward? Medicine or society. In the area of undergraduate medical education in the medical school, leadership clearly came from the medical profession. The creation in the modern medical school was directly related to the creation of that of academic medicine as a profession in the United States and the emergence of the research university. And later, the medical profession provided leadership in the creation of our system of graduate medical education, residency and clinical fellowships. In terms of the standards of care, that has been and remains largely an internal issue. No one's going to tell a neurosurgeon how to take out a blastoma or import. And external agencies are not going to try to define standards of care. But everything else. Leadership and direction has come from society. The evolution of our healthcare system, the organization, the fine rights thing has clearly come from society, not from the medical profession. More recent leadership in terms of gender, religious, ethnic equality. Medicine has gotten better, but we've been responding to external forces. The leadership has not come from within. This is true of racial equality today, which is stuck to the point it out is a subject of my ongoing investigation and a new book that I'm reading. Every step forward in the attainment of greater racial equity and medicine has come from outside the profession is not come from within, whether it's the desegregation of the war. Whether it's the various affirmative action programs. It has all come the integration of hospitals. This is all come in medicine's response to the forces of society. It's not reflected internal leadership from within the profession. These are extraordinarily complex issues. And this slide illustrates some of the ways in which that is true. Consider geographic and specialty distribution. We say that we need more generalists and fewer specialists. Number one, how do we know that manpower projections have been extraordinarily inaccurate and incorrect over time with an aging population, you can argue that we need more specialty cancer care gerryactics. We need urologists to do more and more prostate procedures and so forth. And as we achieve a specialty distribution. We always was done because various fields have always been a competition with each other. And medical students have chosen careers based on the intellectual attractions of the fields. For example, in the 1960s there was statistics and this remains true today. Ophthalmology was a very hot field. Ophthalmology was not this had nothing to do with incomes or lifestyles the two were and remain very similar. It has to do with the perceived attractiveness about an excitement about themologies of field vis-a-vis or the laryngology. Radiology once upon a time was the least attractive field of all and had difficulty attracting enough residents until the 1970s. And that was the name among the very hottest. And that was a reflection of the arrival of non-invasive imaging. We talk about the need for more doctors in rural areas. But incentives for living in cities have long been present in our society, even more so in the profession. The first census was the first census in which 50% of the population lived in cities rather than rural areas. But by that time already 80% of the physicians were in cities and there were distinct attractions of cities to doctors because of the professional support that was available. As I mentioned, doctors as a group being a cultivated group and the attractions of the cities were very conducive to those interests. What the issue of specialty in geographic distribution really comes down to in my view is the need for us to deal with traditional American individualism. In the last few years had the ethic that individuals can decide their own future. So medical students will decide where they want to go to practice or what area to go into. This is in short difference to England, for example, where these decisions are made by the government. There are only a certain amount of residencies in a particular field per year. And if you don't get a residency in that field, you can't go to a second or third or fourth care program you have to do a residency in somewhere else. And similarly, once you obtain your specialty training you go where there are openings. So if you're a urologist, you go to communities that at the time need urologist. Go anywhere you wish you can but you would be a general physician not a urologist. So this American tradition of individualism and individual liberty is very much intertwined with geographic and specialty distribution. We have frequent charges that we need more physicians in primary care. So who's responsibility is this and how are primary care physicians obtained. It goes beyond paying primary care physicians more. It has to do very much with the respect that our society gives them, because the same foundations and, and policy groups that argue for more primary care. It's called primary care physician professions providers, and there is no distinction between a primary care physician or nurse practitioner physician assistant. They're all considered providers. So this type of diminution of the respect of the field. It can be more track difficult to attract people to it. Disclose beyond payment and more about how a field is value is valued in the eyes of society. Another example of complexity is the assumption of responsibility. It is axiomatic in a medical education that residents assume responsibility and make decisions and do things on their own. But it is also this also raises a question who are the patients and how much supervision there is. In fact, the patients that we learn on historically and even today have been those of lower social economic status, and not everyone. And then we have the issue of primary preventive care, because the much preventive care is beyond the capacity of a physician to administer. We can educate her and counselor patients, but it takes much more to motivate a person to lose weight, get exercise, stop smoking and so forth. And the farther you get from that doctor patient relationship, the more difficult it is for the individual physician to intervene. We can tell complain that our patients are non compliant news that disparaging term, but if the patient doesn't have the financial means to pay for medications that puts in a whole different category. We can talk about good nutrition, but if you have a single wealth mother and welfare gallon of coke is much less expensive than a quart of milk. So these sorts of social issues start appearing and further we get from the media contact of the patient the more powerful these issues are. We have many opportunities to improve the social contract and to do better work. We need to not only appreciate the progress that we've made, but to use that understanding to identify what is transient and what is constant to defend our core principles and values, even as everything around it changes. And what are these core values. Well, the need to strive for profession not just competence to work continually to produce better doctors for in the future through education and expand medicines capacity through research to develop the problem solving skills and ability to manage uncertainty and encourage curiosity among our trainees and our doctors reinforce alters of dedication to hard work service to society, remembering that medicine exists for society, not society for medicine, and that medicine is a public trial trust, and to be very vigorous in our defense of medical education is a university level professional education, and not to allow it to devolve into vocational training. I will say, for now that my view there are very profound forces in our society that would have medical education devolve into vocational training, and I think that's the next existential threat that needs to be prevented. That's right. Solutions, in my view, come largely from within. There's within the core of medicine, defending our core principles, scientific reasoning and management, critical thinking that that is a key element in my view of reducing the problem of exorbitant medical costs. Expanding our four principles for contemporary situations, consider admissions. There's always been the goal of medicine to have the best people enter medicine, but to do so we need to draw from all segments of society. Yes, just particularly privileged group. We actively work today to make medical medical careers more available to those from less affluent groups or more underprivileged groups were actually acting in a fashion consistent with our core values. And to do so will be to better refine our abilities of assessment and judgment. We know the types of doctors that we wish to have, we can talk about their intellectual curiosity or aptitudes or human qualities. It's not easy to actually recognize those qualities in a particular applicant before you. We are working to do so with the new MCAT examination and holistic admission practices. But there still is a long work to be done to actually be able to identify those applicants who really are the people we wish to have as future physicians. And then, lastly, I think it's very important to maintain our optimism as we do about the work, our work. Medicine has never been without problems. It's always had its messiness and its complexity and its challenges. On the other hand, we have overcome our problems with time. And there is no field of my view that is more exciting today or has greater potential to contribute to society or has greater promise for the future than medicine. And as I look to the audiences to which I speak and I saw photos of some of you, there are a lot of students and residents and fellows and, and, and junior physicians in the audience, and I would say to you that I'm jealous. I'm rounding the third base in my own career. You're beginning yours. I'm envious. I wish I could be back where you, where you are. There is simply no professional human activity, in my view, more exciting and better able to serve the public that did medicine. Well, those observations I'll conclude and thank Dr. Schwartz and Dr. Stigler for the opportunity of being here with you today. And I'm glad to entertain any comments or questions that there might be. Well, I want to thank you so much for giving that talk. You, you highlighted all the challenges and now we're left with where do we go from here. Let me just pick up one of the comments in the chat. I think that was a propo. It says, as the regulatory burdens that society places on medical education and practice increase the ability of medicine to lead in those areas and or self police diminishes greatly. In other words, the cause of death of medicine as a fairly autonomous and exceptional profession will be by paper cuts. So, and it is interesting because there have been, you know, efforts from within the profession like there have been resident strikes, there have been lawsuits against the NRMP for, you know, violating competition. So, I'd like to hear a little more of what you think about those. Well, regulation is a huge problem today. Number one, this is not unique to medicine. We're in a regulatory bureaucratic society now. So the problems that we face are in some, in this sense, microcosm of the problems that our society has as a whole faces. As we come back to medicine in particular. I think to answer the question that was raised, we have to go back to who establishes those regulations and why and what are the regulations attempting to accomplish. I think the solution going forward would be more vigorous discussions among medical leaders and policy leaders about the idea of regulation, what is a reasonable regulation to have because we do need to be accountable and responsible. We become unnecessarily onerous. And to the degree we as a profession are doing outstanding work that is clearly recognizable to out to all than our position in this was increasingly stronger because the public would likely side with the medical profession. And doing good work and going back to the table at the time where regulations are being created. I think it's the direction to go. Okay, Carolyn you want to take it away. Thank you so much for this talk it got me thinking about a lot of things a couple different directions but I wanted to pick up on something you mentioned about how residents often work with patients of a lower socioeconomic status who have maybe less access to primary care or even preventative care. I was just thinking about how that the structure of that probably isn't going to change anytime soon so I wondered if you had any thoughts about what would be required at the undergraduate medical education level to sort of prepare students to better understand those circumstances. In my own work I think I've been thinking recently about this idea of vulnerability and that sort of usefulness of that term, maybe there are some some limits to it so it certainly if you have thoughts about that I'd love to hear it. Thank you. The fundamental principle of undergraduate medical education is learning by doing, which is why the clerkship became such a powerful and innovative structure in medical education. The fundamental principle of graduate medical education is the assumption of responsibility, doing things without someone immediately looking over your shoulder, they're doing it within an appropriate safety net, so that there are people nearby and immediately available if you need help So the question of who the patients are becomes a more pertinent one with residency than it does with medical students because the residents are doing things themselves or making decisions themselves. And the system of medical education was created at a time we had a two tier healthcare system. And those were cared for without charge in our various teaching hospitals did so with the understanding that they could be, they would be cared for by the residents and in exchange they got free care or care that was significantly less than cost. And we have been moving toward a one class system of care. Ultimately, we need to do better in achieving that goal. And as we pursue this, we need to make certain that appropriate supervision is given our residents. We have today, residency training is more closely supervised than it was when Richie Conner Bruce Byer and I went through. And I think that's a good thing because it provides security for the patient and for the public. And ultimately in an ideal society, all patients will be agreeable in under a certain circumstances to having residents make certain decisions or do certain things. The bank president, including the worker from McDonald's, and that maybe the chair of surgery might operate on an indigent patient and the chief resident of surgery on the chairman of the corporation. So these are issues of equality and justice and evolution toward one class system of healthcare, which is a reflection of the values that we have as a country, but these are the ways that we would need to go to accomplish that. And I think that by making certain that we do a better job of balancing the independence that residents need with appropriate supervision to provide maximum safety can be a useful device and strategy in that process. Anybody else have any questions or comments. Okay. Okay, so my question will be my experience is most of the regulation or the rules that's being implemented there basically focused on two things one, if, and to put it like lamely or loosely I feel like most of the organizations are helping us to protect the patient from the physicians now, so multiple time out multiples things all those things, and also on quality control. Like when, and that's indirectly to the money to the base on what you said or what you're in my thinking would be is part of the social contract is that the society is telling physicians that we don't trust you as much. And you're too greedy so slow down. So where do the system go wrong because most of regulation are basically to protect the patient now. We have in general, and that's why I do all the steps in place and the other thing is quality control like, which is basically compliance throughout the day CME for the year. What does it mean, along the line, the people that are being trained are not as good. So, did we not do a good enough job ourselves so society came and they're telling us what to do. Well thank you for those observations and for the question. In terms of regulations. I think one's values and perspective influence how that question is phrased. You can say this as you did that regulations are put in place to protect patients from the doctors. I would also say that the safety of the patient has always been paramount in the practice in the teaching and practice of medicine remains paramount today. That happens to be my personal perspective on it. So in so far as we can learn through research and documentation ways to practice more safely. And this is a good thing and consistent with their core mission and values. And what is interesting about this I think is that much of safety is a low tech type of thing, taking time outs, making sure that the appropriate limb or side of the body for surgery is marked. Things of that sort, which is one reason why it took a while for the safety movement to gain intellectual respect, respectability within the profession, because this is very low tech it's not creating new knowledge per se it's common sense and putting that into application. So I think more research and a greater respect for common sense and medical practice is something that we in medicine can do to facilitate the safety movement. But any all physicians from all times to my knowledge have have always endorsed the concept of safety and this is consistent with the core value. In terms of quality. There's a very problem we have in quality. This actually became clear to me when I attended a conference at University of Chicago many years ago on quality of care, and the keynote speaker was a philosopher who argued that we will never be able to measure quality, because this is essentially a qualitative concept not quantitative. How can one measure the beauty of the Mona Lisa or fear or any significant human emotion. So we end up measuring what's measurable, but not necessarily what's important. So we can look at the computer record and did the doctor prescribed baby aspirin to someone with coronary artery disease. We can look at those things off, but now the larger dimension of quality and care the ability to manage uncertainty to handle complexity to figure out and then known to do a procedure very effectively and safely and skillfully. These are things we're really not able to measure. And this is a huge challenge and I think the most important challenge in the area of quality research to have better hand. We know what we want by quality. If we see it we can recognize that it's hard to measure quality. Someone who could figure out a way to measure quality will deserve a Nobel Prize in medicine, my opinion. Let me just add another comment from the chat it said thank you for your insightful presentation as a follow up question. Does the relationship between regulation and medicine vary by specialty. And are there specialties in medicine where you feel that regulation might be more helpful to improve quality. Yeah, that's an excellent question. I am unaware of any significant difference among specialties in terms of regulations their regulations for all the specifics are going to vary from specialty to specialty. There are certain off hand that I could think of certain specialties that are much more highly regulated than others. I could be mistaken, but off hand, it seems to me to be a general issue. And the second part of the question was this regulation help. I'm not certain about this. Is there any. Are there any specialties in medicine where you think that regulation might be more helpful to improve quality. Is there anything that's kind of out there that regulations might be helpful. I'm not certain. I think that. I think that standards are needed. So in that sense, yes. We've had a lot of clinical education and practice in all specialties and in all in all specialties and at all levels whether trainees or practitioners, we need standards. And we've always had standards and they've been constructive. We've had regulatory bodies that make certain that individuals adhere to standards or that institutions adhere to standards. And I say regulation. And I'm just responding off hand. I see it as a double that sword, because you need standards and individuals or institutions that are not meeting standards need to be held accountable for the public good. And at the same time, standards could be onerous. They can be ill founded. They can be inadvertent consequences that outweigh the gain. And so I think that ultimately, one needs to become very contextual and specific and concrete what standard, are we talking about. I'm not certain it's possible to give one general answer that applies to everything. I think one would need to get particular and concrete, discuss a particular standard of regulation that issue. Yeah, I mean, I think on a practical level, you know, it's kind of as from where I sit in healthcare feels a little bit like the chicken and the egg because the more, you know, money drives medicine. You know, compresses the time we have with patients. It requires more supervision and more safety because we're putting people in a much more dangerous position doctors are going and all healthcare professionals are going faster than it is reasonable and we live in challenging times. I think it's good that you're telling us not to lose hope but I think a lot of times many of us feel a sense of we know that our practices would be better, patients safe would be better. The outcomes would be better if we had more time with patients and weren't like such hamsters on a wheel or, you know, going so fast in clinic or in the operating room that we've got to turn stuff over. Because we've got to keep, you know, this throughput and the language, you know, personally is been toxic, you know, patient throughput and there's a lot of things that I just feel like are just very demeaning and, you know, harsh, I guess from being a little older is, you know, you know, you know, and the metrics, I call it the mad metrics of medicine, the way you measure things. And right, it is hard to measure quality, but the one thing is you can experience quality just like you can experience those other ephemeral things like beauty and justice and other things. So, I'll let you end up on that and then we'll give you a little downtime before you do the. That's reply to that, indeed. What you're suggesting is a test testable hypothesis, just, just providing more time result in better care. For example, consider the leaky initiative in the Department of Medicine at Johns Hopkins. It's a matter of pride to me that this initiative came out of the book time deal because David Hellman at Johns Hopkins agreed with the idea that you needed more time to do the job right. And so he created the leaky initiative. Residents on their leaky rotations have half the number of patients as residents on the standard medicine rotations. This is an experiment in internal medicine. While they are in the leaky rotation, they have more time, not only to spend with their patients but for reading and reflection conferences, they make home visits to their patients and really get to know the patient as person. The main cost of this is that someone has to take care of the patients that are not seen by the leaky residents. So, David was able to get funding to support this from Mrs leaky that whose name is with the initiative. And the money is used to pay for the salaries of nurse practitioners and moonlighters or physician assistants to see the patients that the residents are not seeing by virtue of their reduced load. And the leaky program has been studied and there have been published results. But basically, the leaky residents are much happier and much more fulfilled and have much more self worth than other rotations. They are. They feel they learn more in the leaky rotation and testing results have shown that they can provide better quality of care because the time they take the time and attention to the job right as measured by, you know, hospital readmission rates within 30 days after pneumonia can just apart fail there are a number of crude measurements of care we have in the leaky residents provide better care and those standards and they practice more cost efficient medicine to because they take things out and get what's needed not just everything that's that's there to have it in case it might be needed. So the results are really very impressive. I've suggested to David that this study be continued to examine the practice patterns and habits of the residents five years 10 years into practice. And if you can show that those differences are persistent. You can demonstrate an import an impact on the trainees and that this is a better way to practice medicine. So data can be brought to bear. And the other issue is who will listen to the medical point of view and to the degree that medicine is greatly respected this profession, our word and our what we attest is given greater weight to part of the problem is that we have lost much of the public respect we once enjoyed when you and I began medicine, the medical profession was in public opinion polls, the second most prestigious and valued profession in the United States, second only to justices of the US Supreme Court. We've had a marked diminution in our status. Since then, because we've been greedy and self serving to the degree we can recapture the high ground that will be powerful making things better because the public will better more fully feel that we are speaking for the public good and not just for our own. And that's part of the solution to follow up. So one of the other in the other thing in the chat said, in addition to looking at your what you were talking about the leaky group, they said, we not only need to look at the outcome from the patients who were studied, but also not the patients that the physicians were studied, but also you have to see if the control group getting worse care than usual by having overburdened nurse practitioners, and you know physicians assistant so you'd have to look at the downside but I think what was one point. And so it's a it's a good thought so I think what we'll do is we'll wrap it up so you have a few minutes to just, you know, get a drink and stretch your legs before the afternoon session and on behalf of the McLean Center I want to thank you so much for coming and giving a very thought provoking and intellectually stimulating talk today we really appreciate it.