By Paul Henry / in , , /


MARCIA DAY CHILDRESS:
Good afternoon. [INTERPOSING VOICES] Great to see all of you here. I’m delighted to welcome you
to today’s Medical Center Hour. This is also UVA’s 2019
Alpha Omega Alpha Lecture sponsored by the Medical
Student Honor Society, AOA. In addition, this
particular venue on this particular day,
as many of you know, is part of our fourth year
medical students’ Residency Readiness course– two weeks of practical prep
for the intensive medical and surgical specialty training
that the newly minted MDs from the Class of 2019
will start this summer. Residency Readiness includes
a focus on leadership. So what a lovely and powerful
coincidence that our AOA Visiting Professor is herself
a distinguished leader in medicine with
leadership experience across the full spectrum
of the profession. And what a coincidence
and a joy that she’s here to talk with us and
especially with members of the Class of 2019 about
“Leadership in Medicine 2020 and Beyond– What Will Doctors Be?” Dr. Christine Cassel is
Presidential Chair and Visiting Professor this year at the
University of California at San Francisco where she’s
working on projects in aging and longevity,
technology and health care, environmental efforts. She is a geriatrician and a
biomedical ethicist by training and an expert in health
policy and quality of care. But over an influential
career spanning decades, she’s been so much more Most recently, she
led the American Board of Internal Medicine
and its Foundation, was President and CEO of
the National Quality Forum and served as Planning Dean
for the new Kaiser Permanente Medical School in
Pasadena, California. She’s also been, along the way,
a Department Chair, a Medical School Dean, a Medical
Specialty Society President, and Presidential Science
and Technology Advisor, a member of the National
Academy of Medicine, and a board member for many
foundations and organizations, and also a champion
for physicians’ social responsibility. You’ll find a thumbnail
summary of her career and accomplishments
in your handout. Even as UBA and
other medical schools prepare to graduate a
new wave of physicians, we find ourselves speculating
about these new doctors’ place and possibilities in a
health care system that’s had tremendous organizational,
sociocultural, political, and financial pressures. We welcome Dr. Cassel’s
perspectives on what should be expected of
you young physicians as leaders in your practice,
in your communities, in government and
policy circles, and in the public square. What will you new doctors be? Let me quickly say
that Dr. Cassel has no financial conflicts
of interest to disclose. And also that because
the fourth year students need to progress to their next
class session by 1 o’clock, we’re going to aim to wrap
up the formal presentation and a couple of
questions by 12:50 PM. And so we’ll pack a lot
into this not quite an hour. So all of you please join me in
welcoming Dr. Christine Cassel. [APPLAUSE] CHRISTINE CASSEL:
Thank you, Marcia. And thank you, everyone,
for being here. This is a great
opportunity for me. I always love talking
with medical students and future physicians. As you’re going to
be hearing, I’ve been thinking a lot about
the future of our profession lately. And so the title for
this talk might equally be “Bioethics and
What Lies Ahead.” So you might think
of it like that. So I’m going to start with
a kind of brief reflection on where I’ve been and then
have us shift our focus and look forward. And I will keep an
eye on the clock and very much try to allow us
to have some time for questions before folks have to leave. So my story. I was a philosopher before
I became a physician. And so it always led
me to be thinking– sometimes in the
background, sometimes more in the foreground– about
the role of a physician, and the idea, the
whole idea, of being a diagnostician and
a healer, and how do values determine the
answer to that question. I was a graduate
student in philosophy without health insurance,
hiking with some friends in the Pacific Northwest
and I fell and broke my arm. I went to visit the
local community hospital and they wouldn’t let me
even sit in the waiting room because I didn’t have insurance. My dad had been a Navy officer. So there was a Navy base
nearby so we went there. And I’m like this,
my arm hanging. And there was a
doctor on duty and he said, oh, yeah, come on in. And I had no right to be there. I wasn’t a military officer. I was no longer a dependent. He took an X-ray. I think he was probably a family
physician or a generalist. I know he wasn’t an orthopedist. But we got out– this
was before the internet– and we got out a the book of
fractures and looked together. This was before we called
it shared decision making. Looked together at the
X-ray and said, which one? It looks– I think it
looks like this one. No, maybe it’s– anyway, it
turned out to be a rather unusual fracture inside
the elbow capsule. He set it. I went on my way. And he asked me to come back. And the corpsman
said, very upset, Captain, how should I file this? Because this was obviously
highly irregular. Without skipping a beat, the
man said, file it under H for humanitarian. Well, I fell in love. I said, wow. Can people really do
this in real life? This is not philosophy. This is like morality in action. So while I was waiting
for my arm to heal, I went to the local library and
got out some chemistry books and said, I guess I
could probably do this. You know? And one thing led to another
and I applied to medical school and never looked back. It was the best
decision I ever made. I only wish I could
remember that guy’s name and find him and thank him. Well, so as I came into
medicine, and training, and in my fellowships,
I decided to try to work in the field
of ethics and actually to try to identify ways that, as
a clinician and as an academic, I could apply
philosophy to medicine. And in those days,
doctors and nurses were just beginning to
talk about medical ethics. And there were barriers. Most clinicians thought ethics
and morality were private. You didn’t talk about them. And medicine was
scientific and objective. And there was a big sort of gap. And yet all around
us, there were moral questions and challenges
of the day like end of life decisions, reproductive
choices, distribution of organ and
transplant, allocation of limited [INAUDIBLE]. Many of them are
still very familiar. And at the time, there
was this new discussion that was happening between
legal scholars, philosophers, and doctors and
nurses in other areas. Now it is true
that people do have personal, religious
and moral views. And this is exactly the reason
why in our society, especially a multicultural society, we
need a language and a dialogue to deliberate about these
difficult questions that inevitably come up and are
going to continue to come up. We need not only to
discuss the issues, to disagree, to explore those
disagreements or deliberate, we also, because it’s medicine,
we also need to decide. And we need to
make the bioethics as a scholarly disappointing
and clinical specialties come together at this
moment of decision in weighing of the pros and
cons, different perspectives, making a decision
in a clear sense, even when there’s disagreement,
that everyone was heard, this is what we’re going to do. And most important, this is
why we’re making this decision. Now, lots of these decisions
are made at the bedside, or in the clinic, or in
one-to-one interactions with patients, kind of like that
military physician who inspired me to go to medical school. And we’ve even gotten better
at a lot of these things like learning and respecting
patient’s views, advance directives, setting
up a national system for redistribution
transplantable organs, establishing guidelines
for informed consent, and research with
human subjects. All of that is progress. And another kind of
progress is also occurring. 20 years ago, in 1999 and
2002, the Institute of Medicine published “To Err Is Human.” And [INAUDIBLE] a member of
the committees that wrote this reports. In 2002, the ABIM Foundation
published the “Physical Charter on Professionalism.” And I was with the
ABIM at that point. These documents, all of them,
just about 20 years ago, laid out a clear
and urgent sense to strengthen other aspects
of professional responsibility like being a part
of a system of care, making quality and
safety data transparent, improving quality and safety,
not just for the patients in front of you, but
to avoid errors that might happen to other patients. The Charter demanded of us
to improve access to care and to be thoughtful
stewards of resources for patients and society. Now, some issues in
biomedical ethics, like reproductive choices,
will continue to be debated. Some issues, like
medical aid in dying, or what we used to call
physician-assisted suicide, we once had a social
consensus about this. And that consensus
is now changing. Eight states have now
legalized some form of medical aid and dying. California did this just last
year, the huge and diverse state of California. Now, the fact that the laws
have changed in those states doesn’t change the
fact that people will continue to disagree. People will continue
to be troubled. And yet it creates a new
social and legal construct in which that discussion
needs to continue. So some of these perennial
questions– might point is some of these
perennial questions will continue to be asked. But there are also
going to be new ones. There is new
scientific knowledge, new capabilities that
we have, new technology, and changing social
and economic landscapes that continue to challenge us. So physicians will need
to have the skills to deal with ethical issues that we
can’t even imagine, certainly that we can’t predict. So what I want to
do with you today is to identify some of
these future questions and, in the process
of that, think with you about the future
practice of medicine and what your lives and
your professional work might look like. And in doing this, I want to
sort of turn our attention to the past, to the
future, when all of you are actually going
to be practicing. So I got to thinking about
this very intensely about three years ago when I
had the opportunity to join the efforts of a
huge delivery system, Kaiser Permanente, to start their
own new medical school. My role was planning here. So it was all about
setting the stage, doing all the sort of background
work to get it set up. The concept here, the KPSOM, as
we called it, Kaiser Permanente School of Medicine, is not
affiliated with the university. It’s a medical school based,
embedded, in a health care delivery system. The only other medical school
like that in the United States is the Mayo Clinic. And they did that 40
years ago, but for many of the same reasons,
wanting to train doctors in a whole cultural
different way of having specialists interact and
information flowing out to patients. So here we are now
40 years later, and Kaiser has this amazing
system of care that is– has been 70 years for a
prepaid model what we– the rest of American
health care is trying to aspire to
value-based purchasing. Kaiser has been doing
this for 70 years. It’s full of data because they
have an enrolled population. So they have all– and, you know, early to
adopt electronic records. So they have a rich database. And their members have a lot
of trust and– and retention of the members. So they have really
good longitudinal data and much of it actually
genetic at this point. The physicians practice
with real-time visibility of their own quality
and safety metrics, as well as comparative data
across the whole system. They work in teams. They’re recruited by this
primary care model, where primary care physicians
are really at the center and really respected by the
specialists and everyone in the system. They’ve focused early on
intervening and patients’ care, close communication, and
coordinating, especially with– and a very strong relationship
with the community because if you can
intervene upstream, you can reduce the cost of care. You can reduce unnecessary
hospitalizations and emergency visits. So what I did there was I helped
to create a new legal framework for the school and to
recruit the founding board of directors. This board included leaders in
medical education, of course, but also leaders in the
innovative technology, two in particular,
Anne Wojciki, who is the creator and
CEO of 23andme, one of the online genetic
mapping organizations and Peter Lee, who is the
vice president, executive vice president of Microsoft
in charge of innovation. Don’t you love that
title, innovation, you know, for Micro–
all of Microsoft. He’s got this amazing sandbox
I can only just imagine. Anyway, the two
of them asked me, why would you want us to be on
the board of a medical school? You know, we don’t know anything
about medical education. This is what I told them. I said, do this
thought experiment. The first class will start
in 2020, next year in 2020 before they graduate. Then they do a residency,
three to five years. So our challenge
is to figure out how to prepare physicians to
practice for 2030 and beyond. So remember now,
we’re in California, so it’s that Silicon
Valley world. People know that,
you know, Google started barely 20 years ago. Facebook only really got
started 10 years ago. What is going to be the next
thing 10 years from now? We really, I think, have
no way of knowing what– what technology
changes, but also what social changes
are likely to occur. So by the way,
both Anne and Peter signed on enthusiastically and
have been very effective board members. And they ask a lot of
really important questions about the future. One of the most important
things they point out is that we won’t know
exactly what the changes are going to be. The one thing we can be sure
of is there will be change. And the question is, are
we preparing our students for change? So more on that. But it leads to this title, you
know, what will the doctors be, and what will be their
role in health and illness? What will be their
role as citizens? And what will they be doing
every day 10 years from now? So while I’m talking
a lot about change, I want to sort of express my
hope, one constant that I think we should strive for, which
is that I hope that doctors continue to be
trusted professionals, even though our role and
how we work may change. If anything, there’s going to be
an even greater need for trust in the humane
interface, if you want to think about it that way,
of science, of humanism, and health, and the relief
of suffering with science. And that that’s
going to continue, and it’s going to be up to us. It’s going to be up to you
to navigate these changes and to make that
fundamental value endure. So here’s a few of
the changes that I’ve learned to think about, and
I’ll bet the people in this room have a lot of ideas
about others as well. So the first, which is,
of course, already upon us is organized systems of care. Physicians are
practicing in groups and larger organizations. There’s lots of data about
this, and it’s not just about control of the
lifestyle models, which as important as that is, it’s
also because we’ve learned that that’s really– a system
of care around a patient is what delivers better
care for that patient. The second thing is the growing
roles of other disciplines, and in particular,
nurses increasingly are working in independent
practice settings and in the larger teams
in different kinds of relationships with medicine. Pharmacists, you don’t probably
think as much about that, but this whole model of retail
clinics is allowing one of– I think, one of the
most underutilized areas of expertise,
the pharmacists, to come out from
behind the counter and become part of the team. As a geriatrician,
I can tell you that the medication
interactions, and now, we’re going to
have pharmacogenetics, which is going to be essential
to prescribing and reducing those medication adverse events. There’s no way any physician
or advanced practice nurse is going to be able
to understand that, even with the best decisions
at your fingertips. So the pharmacist,
I think, is going to be a key new
emerging strong force. All of these folks are going
to be practicing in what we now call top of license. So that’s really– that’s
a really important use of a limited resource, which
is the medical workforce, the health care workforce. But what does it mean
about physicians? What does it mean to practice
at the top of your license if you’re a physician? I think one of the things we say
very easily that physicians are going to be involved in the
most complex issues, the most complex cases, maybe as leaders
of complex systems of care, and you know, I welcome sort of
your thoughts about that too. So I mentioned decision support. The other big change
on the horizon is artificial intelligence
and machine learning. That’s an area I’m working
on while I’m at UCSF now. You know, in Silicon Valley,
some of the futurists there are predicting that we
won’t need doctors in 30 years because artificial intelligence
will be so smart that people will be just able to go
online, put in their symptoms, and get– get their prescriptions,
and there’ll be some, maybe some– maybe
surgeons– there’ll be still some work for surgeons,
but certainly any, you know, analytical diagnostic care can
be delegated to an algorithm. Well, I don’t think
doctors are going to be obsolete in
20, 30 years, but I do think we have to think very
carefully about how do we– how are we going to interface
with artificial intelligence? There is an
already-published report that AI outperforms
radiologists and pathologists in a number of diagnostic–
common diagnostic areas. Retinal scanning– they get
much better diagnostic accuracy from artificial intelligence
and machine learning models. These areas are
image recognition, and that’s kind of
low-hanging fruit for AI, but radiologists
themselves acknowledge– I’m not going to ask who
is going into radiology, but you know, some people
predict we won’t need radiology anymore. Radiologists
themselves acknowledge that there’s going to be
dramatic changes in the role of radiologists, not
in 10 or 20 years, but in three to
five years from now. So I think, in general, we
anticipate dramatic changes in how we interact with
information– how we interact with information
systems, also how to chase specialty practice,
and how consumers access this very same information. So that’s the only consumer. Even right now, people who are
uncertain about whether they really need to go to the doctor
or go to the emergency room can go online to one of a
half a dozen different chat services that are free,
similar to advice nurses, that will check
your symptoms, let know what the most likely
diagnosis is, and refer you sometimes to the most
appropriate types of cares, all kinds of new apps that
are offering to do this. There was medical
expertise in developing the content and often the people
who created the companies, but the voice that interacts
online is not a human being. It’s an artificial
intelligence that’s very smart, and it even can joke about it. One of them says, hi, I’m
a bot, how can I help you? And people are
getting more and more used to this and this kind, of
you know, game that they play. So this kind of
information can also be used to extend what we
think of as telemedicine. So sometimes, you know,
there is a physician there at the other end, and
many health systems are now investing in this
because it’s a much more efficient way to deliver care. I know that that’s
happening at KPU, and I suspect you’re
doing some of that as well in a rural [INAUDIBLE] state. So these new innovations
are already upon us. There’s real questions about
the quality of the information in all of them. But it’s getting better, and
who’s to say and how are– are there going to be
ratings of the quality. Is it going to go by Yelp. Is it going to go by– you know, the FDA going
to regulate these things. All of that remains to be seen. But a question for you is, what
is your day going to look like, and what is the work
that you’re going to do? How is it going to have the
greatest impact on the greatest number of patients? And how in the process
of that can you maintain that humanity at the
center of this profession? So as we watch these new
products enter the market and widely get adopted
by consumers, employers, and others, it’s clear that a
lot more are going to emerge. So in doing this, we free
our physicians, nurses, psychologists
psychiatrists, and people who really are scarce to spend
their time on like the 20% of people who really need
that face-to-face interaction, that more complex interaction or
who, for one reason or another, don’t have access to
or are uncomfortable with the online interaction. So this is going to dramatically
reduce the traditional hospital base, and by the way,
has lots of challenges for our current payment
models, and I’m not really going to address that here. But in some ways, that’s why
many of these innovations have already been widely adopted
in many European countries because they have global budgets
for their health care system. And they have to deliver
care within a defined budget. And this is a much more
effective and less-costly way of providing care. All right, let’s switch
gears for a minute. Genetic information–
I mentioned 23andme. There is also Ancestry.com
and, now, millions and millions of people have gone online
and gotten both their ancestry information and, in many cases,
their medical information in various kinds of forms. Some of it is even
FDA-approved now. So what does that mean? It means more and more
patients are going the internet and then coming to your
office with questions about the significance
of these changed areas. Well, I don’t know about you,
but as a general internist and geriatrician, no
matter how well trained, physicians are not geneticists,
and are not specialists, and are not going
to be comfortable answering these questions. So you could do
what my doctor did, and sit down
together, and google the results to see what you
could learn together and figure it out. Or you can find other ways
to direct the patient. Maybe there will
be a new specialty that will emerge about how
to interpret these things. But one of the most
important things is that it’s no longer
just academic interest because many of these
disorders now can be treated. Alzheimer’s disease,
one of the hugest challenges– we still don’t
have a good treatment. But there is more
and more reason to think that whatever
treatment when that does finally come on
the market, you’ll want to start it as
early as possible. So wouldn’t you want
to know if you had some genetic predisposition? But there is also
the gene editing. So this, just within the last
five years, and Jennifer Doudna is at the University
of California. So we actually have
some interaction with her and her team there. She’s the one who discovered
this model or created it. So you probably heard recently
about this Chinese physician who used gene editing to create
these actual twins, not one baby, but two, under,
some people feel, sort of a spurious idea
that they would then be immune to AIDS going forward. And that there– you
know, he did this in the middle of a pretty
global scientific consensus that there needs to be
a moratorium on using gene editing at this stage
of the game in the germ line. There’s lots of gene
editing research going on that’s really fantastic
about various other kinds of illnesses. But there is this fundamental
queasiness, I think, about the idea of making
heritable changes in the genome because people have kind of deep
moral forums about the nature of human identity. And well they should. And well we should
be discussing this. But– but– what if you
could end sickle cell disease forever? What if you could end
Huntington’s chorea or Tay Sachs? What price would
be worth paying? And what risks would
be worth taking? And who decides? In five years, not
10 or 20, I think, these questions could
be in front of you to figure out
whether they should be offered to your patients. So those are just a few
in science and technology, but there’s also
changes before us outside of biomedicine
and technology, changes in our society. Most dramatic is the
gap between the rich and the poor, that is
forever increasing, has been growing for the past 30
years, and it’s getting worse. While our economy is
growing, the top 10%, to be the top 1% of people,
are increasingly doing better. And everybody else
is doing worse. As citizens, we
should be concerned about the social and political
instability this creates, but for health care, it creates
a fundamental challenge. Our costs continue
to increase, continue to be unaffordable for
people, and continue to– to prevent wages from rising
because health care costs by employers are so enormous. And then the other
thing that lies ahead is that baby boomers are going
to double in the next 20 years. People are living longer. That’s a good thing. Is it a boon for geriatricians? Maybe. But one thing that we don’t
talk about, many people– we talk about this all the time. We don’t find about 40% of
people now over the age of 65 and coming into the baby boom
have zero savings and zero pension, meaning they are
going to be completely dependent on very small
social security payments if that persists. So even Medicare has
high out-of-pocket costs. So what we’re going
to be seeing is working people and
elders alike, patients, who are extremely poor. And, meanwhile,
biomedical science will continue to
advance, and there will be dramatically effective
new drugs and other treatments, many unaffordable by
a majority of people. And these economic
and social disparities result directly in
health disparities that we now call the social
determinants of health. What is our role in addressing
these issues as physicians? How does medical ethics help
address these questions? What can you, the
students of 2019 and 2020, be doing in this world
that lies ahead of us? So some of you will develop
innovative approaches to using technology to
improve quality and access. Others may take inspiration
from Virchow, a 19th century pathologist, who told politics
is medicine writ large. He was a doctor, but he
went into political life. He got himself elected as
a legislator in Austria because he saw that poverty
was such– even then, that poverty was such a
driving cause of illness. And some notable physicians
in the United States have taken both
routes, actually, the scientific
search for answers and the social-political search. Health is about social
and political issues, so bioethics has
to be there too. So at the Kaiser Permanente
School of Medicine how do we think
about future proofing the curriculum in a way? We did adopt some
new technologies, holographic ways of teaching
anatomy, and integration of AI, and machine learning into
the curriculum on diagnosis, and those kinds of things. But most important, in addition,
a deep core of teaching on ethics. But in addition, probably
the most important thing was leadership skills,
including change management. We can’t anticipate
every change that’s ahead over the course of the
next 10 to 20 years, certainly over the course of your careers. But we can equip you to
understand the change, to be headed of it, on top
of it, not victims of it, perhaps even agents
of some of the changes that we would like to see. So I want to close
now because I want to leave some time for your
thoughts and questions. But in doing that, I want
to repeat the thought to leave with you. Whatever lies ahead,
I hope that doctors will continue to be the
trusted professionals, even know though the definition
and the role may change. That need, the
need for trust, is in the interface of all
of this science that’s going on around us, all of
the questions that it raises, all of the social
disruption and change that we witnessed in the
last decade, especially– and I’m sure we’re going
to be seeing ahead of us. But health problems
and suffering are part of the human
condition, and we have unique tools that can help
people in those situations. And if the definition
of our profession is going to be sustained and
going to be something more than just a vendor or online,
then it’s going to be up to us to navigate those
changes to make sure that a central trust survives. Thank you, and I hope to get
some ideas and challenges from this fabulous audience. Thanks very much. [APPLAUSE] MARCIA DAY CHILDRESS:
Thank you so much, and we have a few minutes for
some comments and questions. We’ll have a couple
of mics on here and one in that aisle to take
your comments and questions, and I’d like to start with– right next to me here. Please identify yourself. AUDIENCE: [INAUDIBLE]. I am one of the directors of
the leadership curriculum here. So Dr. Cassel, thank you first
of all for being here today. A lot of this talk was
very important to me, especially around,
you know, how we should think about the future. And I’m seeing a
few themes here. Two of them being
manage and be ready. And another one being
sort of leadership agility in a sense
and the mission for changing some of the other
things that you mentioned. I guess my question is
from a practical sense, a lot of these students
are going to their– off to residency to do some other
things after medical school. How do you keep up if
we’re trying to, you know, sort of residency for me was
a vacuum just trying to keep on learning about my patients
and trying to do some [INAUDIBLE] out there– probably failed on that front. But how do you keep up with
these future innovations in a practical
sense [INAUDIBLE]?? CHRISTINE CASSEL:
So this is keep up with what’s
happening in science? AUDIENCE Yeah, or the world
around you, like what are– CHRISTINE CASSEL:
Like the world? AUDIENCE: Yeah, even
the world around you, how do you keep when
you’re a resident and even beyond that
as physicians we work a lot– trying to
take care of our patients. Maybe we’re reading journal
articles specifically about, you know, sort of patient care. Are there resources
out there that can help us just keep up with
what’s going on outside–? CHRISTINE CASSEL: Well, I’m not
going to recommend a single– that is a really good
question because I’m not going to recommend a single resource. I think– I think
the bottom line is, and we’ve all
heard these things. There’s something like
17,000 new articles and clinical trials are
released every month. And there’s just no
way you could possibly keep up with all of that. So that’s where
AIML is really going to be our friend in better
and better waves all the time. And you’re already
seeing that from the NIH websites and some other places. I think one of the– sense– sense consumers
and physicians are going to have access
to the same information, I think there is going to be
more of a level playing field. And one of the things we can do
is help to curate and identify which of those information
sources are really reliable and really the highest quality. But I think I think that’s going
to be a great source of help. I think the other thing is that
since I made the point that health is also political, and
we live in this very, you know, echo chamber of noise about
political perspectives, and points of view,
and proposals, to think about a way of
streamlining your attention if you’re– you know, if you
want to pay attention to that stuff. And I think on some
level, we sort of have to. We have to find ways of
cutting through the noise and really paying
attention to what matters. I find, personally,
that sometimes the most trusted sources– two things, one is some
of our specialty societies continue to really advance
and provide that service. So for me, and the American
College of Physicians, for example, is a good– a good example of that. But I think people are going
to find their own through it. But I think that the most
important thing maybe is to be conscious of the fact that you
need to do that and that some of the old ways of doing it
aren’t– aren’t going to be as effective. MARCIA DAY CHILDRESS:
Other questions, comments? CHRISTINE CASSEL:
Here’s one right here. MARCIA DAY CHILDRESS: Oh, hi. CHRISTINE CASSEL:
And also anything I missed that I should
add to this list. So– AUDIENCE: Hi, thank
you so much for coming. I thought this was a
great talk as well. One of the– kind of a
bunch of central themes, but with the emergence of AI and
these health care innovations, there is kind of an entrance
of new players into the health care system. I think one of the unique things
about these players is, A, we don’t have the
same knowledge base when we’re talking
about pharmacy, you’re talking about
pharmacy, other specialties, we can somewhat,
nursing, you can somewhat have the same conversation. But with the health
care innovations, you literally just like
a fish out of water talking about what’s going on. If we’re trying to do this
in an evidence-based way, so we’re actually
only introducing innovations that are good, how
do you recommend we do that? You know, health care
is usually regulation, but how do we regulate
something we don’t understand? CHRISTINE CASSEL:
Well, you know, the FDA is asking itself
that question right now, and so I think there is– you know, there was a discussion
that even the electronic health record could be categorized
as a medical device and needed to be
approved by the FDA. They decided not
to take that on. But I think some of the– I think we are– I think there is role for
regulation more, actually. But in the absence of that,
we don’t have that now. We live in a society where
people don’t want regulation. But here’s– you know, I think
sometimes it’s a good thing. I think some private sector
organizations can do rating systems and sort of
can say, here’s– these have legitimate purposes,
and I know that some of them are starting, you know,
to try to do that, and I think that
would be helpful. But I– I think
for just in terms of even the previous
question, the same thing is, we just have to
be alert to this. It means to be– you know, it’s kind of like
diagnostic uncertainty. There needs to not be chasing
zeros all of the time, but always keep that thing
in mind that headache might be meningitis. It’s probably not
just, you know– so the same thing with this,
you just be suspicious, but don’t cut it off. We need to use
these tools, but we need to have a healthy
skepticism about it. MARCIA DAY CHILDRESS: It just
occurred to me we don’t usually work in this room in the medical
center, but you all have mics. [LAUGHTER] For those who are accustomed
to being in this room– CHRISTINE CASSEL: See,
this is technology– MARCIA DAY CHILDRESS: You
need to press the button to make it go, but raise
your hand and use your mic. CHRISTINE CASSEL: There’s one. MARCIA DAY CHILDRESS:
Tell us who you are. AUDIENCE: I’m Dr.
Baldwin from Lynchburg, and I’ve been interested in low
socioeconomic communities who don’t have any doctors,
and I’m wondering if you’ve run into the idea that
we need doctors on salaries, some sort of a way to get
doctors into these communities and to establish the
relationships it takes to be on an effective position. And in our
free-enterprise situation now, our doctors
and hospitals are moving towards the
[INAUDIBLE] patients. But you mentioned 40%
of people 65 and older won’t have the funds. To address that, I
don’t see any other way than to have
doctors on salaries. CHRISTINE CASSEL:
Yeah, well, and I think by doctors on
salaries, the question is, again, that was kind of– I went over it very quickly. But the first point
about doctors being part of large organizations. And I think we’re going to
see more and more of that because the
fee-for-service model just doesn’t work to try to get the
most efficient systems of care, where you spread the care
around all the care providers and you get nurses
on the front lines. And you use telemedicine, or
you use email, or you use, you know, video conferencing
to get those very remote– we have a wonderful program
called Project Echo that started in New Mexico that– that gets care in
very rural parts of this very big western
state, entirely remotely and very effectively. But it only works because
the doctors are on salary because, otherwise, you can’t
bill for this kind of service, right? And there’s a whole
lot of other reasons why I think that’s a good idea. If you look at the data
on quality of care, the systems of care in which
the physicians are salaried actually have always
consistently produced the better outcomes
overall for patients. So I think it’s– it’s a model
that we’re heading towards as a country. And I think it– it will also
help along with a lot of other things that we need to do to
really address the quest– the combined challenge of rural
and poverty that, you know, faces so much of our country. MARCIA DAY CHILDRESS:
Any other question? CHRISTINE CASSEL: There
is one over there. MARCIA DAY CHILDRESS: There’s
one in the back, yeah. AUDIENCE: Yeah, I’m
curious about what role you think that medical
professionals should play in the end deciding the
amount of rules that govern innovation, simply because
the financial interests that the professions have in the
system has driven [INAUDIBLE] in the way of, you
know, innovation. CHRISTINE CASSEL: You mean,
the sort of vested interest in the status quo? AUDIENCE: Exactly. CHRISTINE CASSEL: Yeah. I think it does. I mean, I’ll give you– I’ll give you some really good,
like, real-time examples is telemedicine, which to my mind,
is a very early first step is the one where you still
have the doctor or the nurse practitioner on the screen and
the patient on the other end, very effective in delivering all
kinds of care, including now, increasingly, mental health,
for a certain, you know, is very much needed. And many states have opposed
it, not the legislatures, but the medical
society of the state because they see it as a threat
to their model of practice. So that’s– you know,
that’s what, to me, is a real challenge of
professionalism that– you know, to rise
above your current– whatever your current financial
arrangements are and figure out, as this gentleman
down here said, let’s change how we get paid
so we cannot stand in the way of this kind of innovation. And I think physicians
traditionally have not been trained to think– that’s
why I’m talking about thinking more about ourselves as change
agents because the physicians, they think they’re
doing the right thing. They think they’re
protecting their way of life and their way of taking
care of their patients. But they’re not
looking beyond that. And that’s what I
think we’re going to need to do in the future. Yeah. MARCIA DAY CHILDRESS: Go ahead. AUDIENCE: Yes, Christa Kennedy,
fourth-year medical student. I’m just curious how you
can speak about issues like financial compensation of
physicians and vested interests when you were forced to resign
from your $200,000-plus annual salary from Kaiser Permanente’s
board while you were chief executive of the National
Quality Forum and while you also took down a $1.2 million
annual salary from the American Board of Internal Medicine,
while they were increasing rates for maintenance
of certification. CHRISTINE CASSEL:
So here’s an example of where what you learn
online isn’t always true. I never got a $1.2
million salary from the American Board
of Internal Medicine. So, you know, I– I know that that stuff is out
there because a lot of people are concerned about the
burdens of maintenance of certification. And I’m sympathetic
about those burdens. But I think it’s really
important to look at it, as one of the
previous people said, to look at the sources of
the information and what– where it’s coming from and what
the motivation is around that. AUDIENCE: So they’re coming
from 990 federal filings from the American Board
of Internal Medicine. CHRISTINE CASSEL: Yes,
but– but it was– it’s a longer
discussion, but that– that– those numbers
were not myself. They were represented from
a lot of other sources. So, uh, you know,
I’d be happy to talk with you one on one about that
because I think it’s important. But I think here’s the most
important thing about it is that the maintenance and
certification debate has been a real crisis of professionalism
because physicians have been really inundated
with requirements for all kinds of reporting,
and public scrutiny, and a certificate–
board certification is a big part of that. I’m actually now chair of a
committee for the National Academy of Medicine
about the burnout problem in not just the
medical profession, but in nursing, and pharmacy,
and other professions as well. So I’m– I am a– ABIM were and are
very aware of the need to make those requirements
more aligned with what all the other requirements
are and reduce the actual work time that’s involved. I think actually AI
is a tool that we can use to help us with that. But it doesn’t mean that we– but it’s kind of like
the doctors in Texas who don’t want to
have telemedicine. We can’t just keep
moving forward without acknowledging
the responsibility of our profession to be more
transparent with the public. And the ABIM is of the
profession, but for the public. So that information about
the quality of physicians needs to be out there,
and they need to– we all need to do what
it takes to make sure that that information is up to
date, that they are accurate, and that, you know,
whatever the technology is that puts the information
out there, that costs money, some of it. And that’s– you know, every
profession has a version of that. And so, you know,
if you’re a plumber, you spend $2,000 every
five years to get re– re-licensed or
certified as a plumber. So shouldn’t a physician
have some similar capacity? And because it’s medicine,
it’s much more complex. So let me just say that. And I– I do appreciate the
challenge because I think that’s another thing
that we have to be aware of in our field is with growing
transparency and the ubiquity of internet information, these– these echo chambers can
develop, and information that isn’t entirely true
or that is misinterpreted can get then used
for other purposes. And we need to be
constantly, I think, standing back and
saying, what does, you know, the profession
require of us? And what’s the best
thing for the public, which at the end of the
day, is the definition of professionalism. MARCIA DAY CHILDRESS: So
I’d like to thank you again. CHRISTINE CASSEL: Thanks. MARCIA DAY CHILDRESS:
And thank all of you for being here with us today. Thank all of the
other folks who’ve come for this medical seminar. I just want to let
you know that this is the last medical
seminar of 2018, 2019. We’ll be back with a series of
programs starting in September. Thank you all so much. And– [APPLAUSE] Thank you, Dr. Cassel.


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