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tv   Blair Sadler Pluck - Lessons We Learned for Improving Healthcare and the...  CSPAN  August 15, 2022 2:00am-2:51am EDT

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>> officer to discuss his new book. lessons we learned through improving health care around the world.
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a senior fellow at the institute and a member of the faculty at the university of california. from 1980 to 2006 was the president and ceo here in san diego. he has served on the board of the hastings center for 12 years and is a member of the board of health care without harm, environmental association. a doctor and a lawyer who are also twin brothers worked together on the early laws concerning organ donation and heart transplant. they were called where there have been multi-generation impacts. they described their roles and helping to lead and accelerate the case and scale of needed
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change. they bring together the spirit of courage, taking roads less traveled and living with the mindset that we can all call upon to improve everyday life. it inspires hope and collaboration, as well as meaningful change. please welcome blair sadler. [applause] >> thank you. i think you just heard my talk. so i think we will do two minutes of q&a and then we will go drinking. is that it? we -- this is such a special place. it has been here since 1977. it is memorable -- and his memorable pollen, the road not taken by robert frost, many of you know, to be of roads
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diverged in a wood and i took the one less traveled by. that has made all the difference. 55 years ago, my brother, a physician and i took a chance. we took a road less traveled to work together as a medical legal team. at age 26, levered together on organ donation and transplantation. bioethics at the hastings center , emergency medical care at the medical school, and taking emergency care to scale. to paraphrase robert frost, taking those untroubled roads has certainly made all the
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difference to both of us, but since then, our professional careers have diverged. we are both engaged full-time in health care. we find ourselves reflecting on these experiences and we realized that they had enduring value for each of us, personally , and it might be of value to others. he wrote this book with the hope that it might inspire others to action on the drawing on the lessons that we learned through our experience during those nine years but why pluck? the answer is, it took 18 months to figure out what the title should be and working through multiple drafts, the word serendipity kept coming up, but somebody had just grabbed it, so
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that was done. we were lucky with certain things that just seemed to appear, but we were keenly aware that nothing was actually handed to us. we had to go find opportunities with no assurance that they would need anywhere. the plug is about tenacity, persistence, courage, risk-taking. when combined with luck, it can lead to surprising results. our story goes -- it begins in philadelphia. i had completed law school at the university of pennsylvania and was clerking for a superior court judge in pennsylvania. fred was in his fourth year of medical school in philadelphia and doing a six week rotation at the hospital. each student had to give a
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presentation on a particular topic. fred asked if he could make a presentation with me on the legal and ethical issues. his proposal to boston. we made the presentation. the chair of surgery said this was one of the best presentations we have had pluck and lock. the positive experience lit a spark and we decided to pursue the idea of legal we developed a paper describing a variety of medical legal issues like -- informed consent from euthanasia and definition of death. i called one of my favorite law professors and a real mentor of mine who argued cases before the supreme court, and i asked if we could meet with him about our
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idea. he said sure, let's have dinner. a week later, we were having dinner. we had two questions. did this make any sense at all? and if it did or should we finish our career and get more training, either in law firm or he completed his residency. he reviewed the bar in addition to making corrections, said the idea is to good you should get going now. that gave us a major booster shot. the next question, how and where . we were aware of the u.s. public health service had opportunities to become commission officers, they were mostly for mds and phd's in science. so he took a chance and called dr. luther terry, the former
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surgeon general who become very famous by fighting the tobacco industry on cancer risks for 30 years and have placed a warning on every pack of cigarettes, smoking may be hazardous to your health. he was now the dean of the medical school and the vice chancellor for the university of and sylvania of all places. think of that. he explained when we met with him, this is a great idea, i wish i had a doctor lawyer team working with me when we were dealing with a cancer tobacco issue. he put us in touch with the current surgeon general and the current director of nih. we ran from three days of interviews with bethesda and washington and received invitations to apply for jobs, we did. four months after and we had heard nothing. i was running out of time, i was
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getting kind of anxious because my judicial clerkship was ending in july. i had to decide whether to accept an offer at a law firm in philadelphia. i called the associate director of this nih, with whom we have met months earlier. i asked could i see him. the secretary said, you have got a really full day but come on down and we will try to fit you in. i drove from philadelphia from bethesda and waited several hours later, he had a opening. he said come on in. he remember the conversations we had months ago. he made two phone calls and immediately rings were looking up. a month later, my 26th birthday, which unfortunately i have to share with my brother, one of the problems of being a twin. we received the best possible
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news. telegrams? you remember those things? the u.s. public health service offering us commissions to start in the director's office at nih at the on july 1. but our graduate education programs have -- being in the public health service,'s opportunity to serve our country in a meaningful way. on our first income i will never forget. remember their new boss, joe. the director of officer program planning. he looked every bit like hollywood's definition of a career civil servant. white, short-sleeved shirt, thin black tie, black rimmed glasses, short hair, nonstop high energy and turned out to be a brilliant writer. his stewards words after saying hello were, johnson -- his two words after saying hello were,
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gentlemen, we have a problem. the l.a. times corners -- for . i want you to find out everything there is to know about the laws relating to the use of cadaver tissue for medical purposes and figure out what we need to ensure our guarantees comply. his reason for concern, nih and other medical centers to extract pituitary glands from cadavers to study how a human growth hormone could be synthesized. the ultimate goal, was to give newborns who are suffering with dwarfism to have a chance, and noble purpose for sure. it seems like some people in
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some offices were not following the law. we were complete rookies on this issue. whether it is medicine or law, when you're confronted with a new issue, first thing you do is research. step one. we went to the georgetown law library and reread everything we could get our hands on and at our state laws relating to autopsies and donations. we got advice from the leading authorities in the country and visited them in pittsburgh. we also met with the leaders of every relevant medical association and funeral directors. during our research, we discovered the commissioners on uniform state laws, now the former la commission had created a committee that had been at work for an entire year drafting a model state organ donor law. we met with professor from of
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the former dean of the michigan most will who was at the committee. we reviewed the many connections we had made to make health care organizations and we had a mandate to nih to help solve this problem. he asked us to serve as the official consultants to his committee. what an opportunity. two months later, christian bernard david the first human heart transplant in south africa that changed the world. tremendous public interest and concern. 70% of people would say, yes, i would be an organ donor. on the other hand, you would see things like sending a different message. one of the patients in embed with a big --in a bed with a sign over him saying, patient
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asleep, not a hard donor. or another one, a bumper sticker, drive carefully, dr. bernard may be watching. while humorist mother was a concern under that that my people -- while humorist, there was a concern that my people if up on you if they thought you were a organ donor to someone else down the hall. we work on multiple drafts and reviewed them with the committee. they approved it. the whole committee. they said we are ready to send this on to the full commission. at its core, the uniform act is a gift in the statute. facing involuntary consent that provided for in individual who could decide to make a donation effective upon their death, for transportation or research. and if the family of the individual of made the decision, the family was identified in the order of priority that they
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could make that legally binding decision. but also say that the donor's decision has to be separate from the recipient decision to deal with the conflict of interest concern, and at a time when brain death was being widely discussed, we wisely based on advice from many did not put a definition of death in the law because it was going to be changing over time. it has in june 19, 1968, less than one year we had started work at nih, we presented the uniform anatomic to the entire body of 100 commissioners at a hotel in philadelphia, and they approved. the very next week, all numbers of the american bar association approved it. now we have to get to work. it was time to move into action. the monologue was enacted in 41
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states the next year. 50 states in just three years. that has never happened before in the history of the uniform law commission, that is over 128 years old. we testified before probably 10 different state legislatures, senate hearings, conducted by walter mondale, remember him? before we knew it, we were getting presentations all around the world. to be sure that physicians and lawyers were aware of the law we publish leading articles in the journal medicine. the uniform donor card. the law specifically provided that a card be a valid legal document. forward if they were different in conflicting? -- but what if they were different and conflicting?
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we convene a pivotal meeting of 21 organizations with one goal, develop a donor card that could be used by all organizations. the meeting was a success and produced a simple legal document , the size of a drivers license. a potential crisis of confusion and conflict had been avoided. bernards headline making first human heart transplant catapulted medical ethics to the forefront of medical discourse. in 1968, 2 leading activists began a series of discussions on the ethics of a variety of health care issues. , including organ transportation. we were invited. over the next year, we were invited to be two of its founding fellows.
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point and luck. produced results that we could not have imagined when we started. we experienced firsthand the power of several lessons, start where you are, grow from rookie to expert cannot find and develop your voice, use the power of collaboration and partnerships, include all stakeholders, leave it with transparency and develop trust. as our two-year commitment to nih comes to a close, we wondered how would would continue our partnership. our time in washington had changed each of us. we did not imagine returning to practice in a law firm in philadelphia or resuming a surgical residency. the uniform act had shown the power of collaboration across disciplines and we would want to continue it. our next project found us. dr. roger, the assistant
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secretary of health for h e w was putting together a team dealing with what was then and now a workforce public health care crisis. how do we get more doctors and nurses and other health fractional? medicare and medicaid had adjustment enacted in 1965, increasing access to care but also increasing demand for care. we were asked to focus on exploring some highly new programs that were being tested. because of the medical legal work how to explore. our first step, research. we went and looked at all of the different kinds of theories out there and helped strategies, talked with leaders across the country and we met with the federal programs that were actually funding allied health programs around the country. we visited the three prior new -- pioneering programs. the first at duke,
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colorado, the medics program in washington. we discussed these programs in their visionary leaders in detail in the book. three, threats emerged in one to share with you tonight. all of these pioneers were pushing the envelope of helping resolve the help workforce shortage. there were also all struggling for the same question, how to license these new practitioners in a safe and expeditious way. they were all in a hurry, why? graduates of these new programs needed to be able to practice in the next six to nine months. there were no licensing laws replaced. warmer trip back to the library and reviewing all of the laws, it turned out for allied health professions, they were all over the place. there was no uniformity at all. all have some form of a medical
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practice act that defined what a position -- physician, only a position could do. if we go back to the uniform law of commission, do we develop a model of law? good idea but it would take 30 to 40 years. we met a talented physician and lawyer during our duke visit. we came up with an idea. how about a one sentence amendment to the state medical practice act were smart they all existed in every state at all. nothing in that language shall prevent a physician from delegating into a specially trained nurse or physician assistant that they are qualified to carry out certain tasks. as long as they are carried out under the supervision control and responsibility of the license physician. we completed our hundred page report to the director of health manpower in hew and got the
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endorsement. with that, we rallied health care leader starting with the presence of the ama and the aha, federation of state medical board to encourage state legislators to act immediately. they did. by 1973, within three years, states had amended their medical practice act to a qualified assistance to work in collaboration with and under the supervision of physicians. the lessons again on collaboration seeking matters, including all stakeholders had paid dividends. this experience taught us another endearing question, when solving a complex problem, sometimes the simplest solution is the best. during the third year of the public health service, oversaw the renal disease grants program, which included sitting universities that applied for or received grants from nih. in addition to a scheduled visit with the leaders of the renal
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disease program idea, he decided to meet at what this medical school professor, who is now the chair of department surgery at yale. dr. jack welcomed into his office that he had a copy of the medicine article on his desk, he said, i had been following you lads and the wonderful work you had been doing. that is when the meeting turned from a reunion to a job interview. i just recently obtained a $2 million grant from the commonwealth fund in new york. to study, and emergency care. i want a yells department of to do something about our country's unlawful state of emergency. we do quite well once the patient's get to the operating room, the question is, whether they can get there alive because the prehospital system is laid iron need up operating.
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-- outside of the hospital. i interviewed several other surgeons, he said, senior surgeons, but i think the two of you would be a great team to run this. you can directly trauma program out of the department of surgery . with that interest you? absolutely. i would member getting a call from fred discovering what had just occurred. it was a great opportunity. we also said we would like to develop a pa program at duke and emergency care. dr. cole agreed. we started a new odyssey, new haven on july 1, 1970, to conduct the conference of study of emergency care using the state of connecticut as a test case, sort of as a laboratory. we would design and launch a program as well, the fourth one in the country. talk about luck.
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he develop a curriculum for the pa program based on lessons learned from other pa programs. with cole's support, they felt was extremely supportive of teaching a new cohort of pa students often in combination with medical students. first class began in january. he also help find opportunities to expand our impact, he introduced us to a consortium with five leading foundations that have supported a program we visited. they ask us to write a position paper that analyzed the crucial organizational and challenges for the new professions and recommended next steps further funding. with our nursing colleague, we completed the lengthy paper that at their request was expanded into a book, the physician's assistant today and tomorrow. it was to sue.
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two federal and state officials throughout the country. in addition to legal foundation, all health care professions rely on four pillars to get started. in association to the program that educates them, association for the practitioners, system of accreditation, a system that document is that the practitioners are confident for health professionals. the growth of the pa profession has been remarkable. in early 2002, there are actually 284 pa programs that are credit in the united states. 150,000 pas who are certified in the practice. based on criteria, including job opportunities, job satisfaction and income come on in january 21, u.s. news and world rank the pa profession as the first among all job categories, as well as a
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first among jobs and health care. at the same time, we were emerged in the pa world we were designing and launching the trauma program. as hard as it is to believe today, in 1970 in america, there was a note 911 number to call. there were no emts. no paramedics. the ambulances were glorified his station wagon, sometimes doubling as hearses. there was no residency programs. there was no system of trauma centers. the battlefields of birmingham, well-trained medics were taking wounded soldiers. the cardinal rule was the golden hour, get the patient to a well-equipped trauma center within an hour. ironically, no such goal existed back home in the states. it was scoop and haul. pick up the patient, take them
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to the nearest hospital, hope for the best. no wonder that in 1966 study by the national -- called accident of neglected disease of modern society. we begin learning everything we could about ems in the state. we supervised and deployed nine yale students. we gather data from interviews, questionnaires, will confirm that no real system actually existed. there were 35 hospitals in the state of california and 179 ambulances. there was no coronation. in 1968, a presidential nominee had recommended the telephone number, 911 p or at&t declared it was now available within connecticut. very few 911 systems existed, only covered 14% of the
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population. we created and cochaired the first state ems advisory committee consisting of all of the key stakeholders. to these monthly meetings we developed for respect, a detailed report, boil it down to 50 page document that we submitted to the governor, called emergency medical services for blue prints for a. fortunately, -- has just developed and purchased a training manual for any category of medical professionals, emergency medical technicians, emts. between 1971 and 1976, in connecticut, 6000 ambulance attendants were trained as emt. on a sunday morning in may, new york times headline, wealthy
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johnson foundation maps plans. the article said that the foundation, which of until then was a small family foundation in new jersey, had received $1 billion in j&j stock in the will of the late robert foundation. it would be dedicated to inventing health care in united states, beginning with investments of $52 million in 1972 along. overnight, it became the country's second wealthiest foundation. -- was appointed the foundations first president. fred handed me the paper and said, maybe we should look into this. absolutely david has already recruited two of our close foundation collects in new york to princeton, they encouraged us to connect with roger, who was
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so happening giving a ground talk at a place called gail. after his presentation, we had a excellent discussion, soon we were heading to princeton with discussions with them and other senior officers at the foundation. roger said, i want you to join my team as senior officer, can you start tomorrow? we have some serious soul-searching to do. was this the right time and opportunity to make another big leap? knowing that the trauma program was based on a three year grant, we decided maybe it was. the advantage of working as to partners was never more important. for the next few months, fred remained at yale directing the pa and trauma programs, i began taking the train to princeton where i stayed a few days in between deriding my time. one of the first meetings with david rogers and other members of the senior team, we were discussing how best to improve
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citizen access to health care in america. we should start with an idea we have been working on in connecticut for the last three years. that might be a good place to start. we were developing a single seven digit phone number for every region in connecticut, that will be highly publicized and appear in the front of every cover. i explained that the 911 emergency number was being tested in several communities and would he widely available. of course, the people who handled these calls needed to be trained in how to handle medical emergency, not just police and fire. further, i'll ambulances would need radios to connect them directly to hospital emergency rooms, so people at the scene could receive guidance from physicians or nurses. i described the excellent emt training manual that we were already using. after a meeting with outside
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experts, who confirmed the wisdom of this approach, we presented a proposal to launch its very first national competitive program. it was approved unanimously. we announced the program, indicating that $15 million was available to regions if they follow certain guidelines. from 250 one applicants, we selected 44 grants in 32 states in puerto rico. i was appointed to run it. it was exhilarating to see the tremendous progress made in three years and in addition, the foundations money was leveraged with over 250 million of federal dollars from hew to support mortgages throughout the country. rw jay had demonstrated how a single foundation can take a good idea to scale. in evaluating the program 25 years later, authors james
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buffer, concluding emergency medical services are embedded and secured in medical communities to a degree, that planning this in the 70's could only dream about. from train 911 dispatcher, two highly trained him to use in paramedics, to thousands of care physicians and nurses, sophisticated ambulances that transport patients to designated trauma centers, emergency medical care is now a tool in america's health care crown. as i reflect on the lessons fred and i learned during this nine year odyssey, i realize that they had created a platform for all of the work that i subsequently done at children's hospital. collaboration and partnerships were central to our philosophy. i would like to say, we do not inhale or exhaled without talking to our physicians.
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we claim our role as being the switzerland of health care for children. while the big adult systems were competing for market share, we said let's be neutral and work with everyone. i also planned another lesson we have learned, times persistence is the only option. in light 2001, after 18 years children in ucsd's find long-term affiliation agreement to combine pediatric programs in teaching and research. it was a win-win for both organization, more importantly a win-win for children today and children of tomorrow. in closing, i want to comment of those. probably the elephant in the room question. it is a very fair question.
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today is a very different world. is there any possibility that any of these lessons in this polarized environment, alternative facts? in 1960 it was not a walk in the park. there were riots throughout the entire country. some people at the vietnam war split the country in half. then a watergate was starting. there were parallels. they are not the same kind of viciousness that we see today. fred and i believe that the lessons that we learned, those 15 lessons are as relevant today as ever. maybe more so. the importance of hope, collaboration, taking action, starting where you are, most importantly living with a mindset of possibility, we can't
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give up. we have to save democracy. we have to roll up our sleeves and do what we can. and for the opportunity to share this journey with you. i would love to take questions. [applause] yes? >> i am curious thinking about the organ transplant, werther werther organized constituents that seem to come to mind for both of those? could you comment on what they were? say one in time. then everyone here the question -- that everyone here the question? in the transplant world, there were religious groups that were opposed to mutilating the body as they saw it.
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it was voluntary. we talked with them, met with them, we never really had any organized opposition. the one debate that occurred, without getting into the weeds on this, it became prominent, it still goes throughout europe, is it a voluntary gift statute. or is a presumed consent? most people would be a organ donor, we are going to presume you unless you object. we have a lot still going on in england and other places that that does not get you anywhere. on the nursing pa side, organize nursing, national league for nursing, the american nurses association absolutely thought this was the worst thing in the world to have. at the dean of the nursing school at el, nothing to do with it. we learned from duke at the same
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experience, he started with the nursing school, he said he wanted to bring all of these military -- because they have not gone to medical or nursing school. can we work together? they said unless you go through that, so they created their own. there was that. the growth in nurse practitioner programs has also been substantial. they are terrific. my only concern about some of the instances, a lot of this is on research and not as much as care. if you compare the curriculum of the p8 with the curriculum of masters nurse practitioners, there is an imbalance. we need them both. we need them both.
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>> i don't know where i could do that in any thoughtful scientific way. we just seem to get along. he is a recovering tennis player, so mi. when we were 14, 92 degrees humidity, we were playing tennis, just learning the game. we realized, if we helped each other and collaborated rather than trying to beat the crab out of each other, we could both went -- trying to beat the crap out of each other, we could both win. inks not always the same as we get older. sometimes relationships, like every other relationship takes work. that was seized and. -- that was c-span.
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>> that was really lovely to hear the history that you described. the u.s. has often regarded as not having the best, we pay the most but we actually have in regard to not having the best health care. could you put your forward-looking glasses on and tell us where do you think we need to emphasize, or would we need to do to actually up our game on the health care front. >> i think that is the day that -- i completely agree. i think it is a question where you start. european country start with the university of access, that is like public education in america. we are schizophrenic about where the health care in america is a privilege or a right. we say it is a right. if you ask a person on the street, it is a yes. then you ask, should the
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government run its and oversee it? then you get the pushback about competition. that is let made america great. then you get the divide. you do not get that universal coverage unless you commit to universal coverage. it has to start with the universal coverage. we do not. we do not have near that. because of lack of access to a lot of basic things, when you look at the 12 indicators the people are measuring against, infant mortality rates and others, we are way down. if you look at the very complicated high technology high-tech services for which you get paid a lot for the way you reimburse, we are off the charts number one. it depends on what part you want to look at. you have something on your mind? >> we just can't make it public.
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remember those negotiations? >> i just talked about the last paragraph. >> there were a lot of personalities. indeed. >> tom mullen, connecticut people, come on, we were talking about connecticut. >> thank you for your work at yale, that is great. are you and your brothers donors? >> we are. >> he is much older. he is four minutes older. he is aging badly. he is slipping. he is slipping. >> shouldn't be an assumed plan that everybody wants to be an donor? what is the downside? i heard you about that you do not want to take it too soon. >> the downside is, with an opt
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out system, in each case when the event occurred, you ask the family. if he asked the family, you're basically having the same question. we would like permission for a donation, as opposed to, we are going to take the kidney unless you object appeared to us, this seems like a less successful and effective conversation. you have to have the conversation in either case. what we did with a lot of our ethics, if you really opt out to the extreme, than it is basically public ownership of the dead body. there are countries that do that. that is a different model. if you look at spain, which typically gets the best transplants per thousand population year after year. there are -- they are even with
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us, overall. even though they have a opt out law, they do not even have a opt out register. the core of its training superb icu physician and nurses to be very skilled and empathetic of having conversations with families every single time. even though that is the law of the land, they basically do not follow. >> what is our data on donors? do you know? >> the numbers i checked mostly, how many lives do we save through transplantation last year? 40,000. that is a heroic experience with tremendous difficulty. the bad news, how many died on a waiting list? 8000. depending on -- it is not sort of eight b plus.
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-- it is not a b plus. there is tremendous variability. we will not tolerate in any other area of medicine. there is varying degrees of oversight. i think we need to up the game of expectations and those that are not performing, we need to -- a hospital who was not performing adequately, you have six or nine months to get your act together and you would be out of business. that is a political issue. it is a good system. there are a lot of great components to it. it is very uneven. >> carolyn wants to ask me a question. idiotic nurse extraordinaire
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children has pediatric nurse exy children . one of the best ever. >> my successful hip replacement, what do you have to say? >> you have not mentioned california. >> does the east coast own this history, or was california at all involved in the early history of -- . >> let's talk, centers appeared a lot of surgeons are based in the east coast. in 1984, i haven't been in children's for four years, re-created the trauma system in san diego county. there were probably six or eight
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in the country then. five adult trauma centers. one pediatric. one of the best in the country. people visit from all around the country and the world. there are definitely places that are leading the way. ucsd is about to be the first one. we can be doing more in creative areas of helping manpower than we are. there is a lot to be proud of. >> i want to emphasize that your importance of the nurse practitioner. it it has dramatically improved our health care. we do not have the position capabilities of managing all of the problems.
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a major complaint in our system is we cannot see the doctor fast enough and we can't get to the surgeon fast enough. these people have changed their lives for us. now we have in our own system, 18 pas, we would like to have 18 nurse practitioners. he emphasized the importance of that. thank you. >> great to hear. >> what are your thoughts on the reimbursement system? >> the reimbursement system is upside down. it is procedural oriented.
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specialists oriented. it is way out of balance. until we correct that, it is going to be an uphill battle. it is tough as hell. the various surgical gills, anesthesia have enormous power. they are not going to share the pie. i am being purely frank. back to the earlier question, if we had more of a universal system, were other countries do not have the single there, but they have the single payment level, which is essentially decided. the disparities between what specialists make an pediatricians and family physicians make is much narrower. you are a lot younger than i. i think we are ready to go. thank you very much.


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