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  • I am a palliative care physician

  • and I would like to talk to you today about health care.

  • I'd like to talk to you about the health and care

  • of the most vulnerable population in our country --

  • those people dealing with the most complex serious health issues.

  • I'd like to talk to you about economics as well.

  • And the intersection of these two should scare the hell out of you --

  • it scares the hell out of me.

  • I'd also like to talk to you about palliative medicine:

  • a paradigm of care for this population, grounded in what they value.

  • Patient-centric care based on their values

  • that helps this population live better and longer.

  • It's a care model that tells the truth

  • and engages one-on-one

  • and meets people where they're at.

  • I'd like to start by telling the story of my very first patient.

  • It was my first day as a physician,

  • with the long white coat ...

  • I stumbled into the hospital

  • and right away there's a gentleman, Harold, 68 years old,

  • came to the emergency department.

  • He had had headaches for about six weeks

  • that got worse and worse and worse and worse.

  • Evaluation revealed he had cancer that had spread to his brain.

  • The attending physician directed me to go share with Harold and his family

  • the diagnosis, the prognosis and options of care.

  • Five hours into my new career,

  • I did the only thing I knew how.

  • I walked in,

  • sat down,

  • took Harold's hand,

  • took his wife's hand

  • and just breathed.

  • He said, "It's not good news is it, sonny?"

  • I said, "No."

  • And so we talked and we listened and we shared.

  • And after a while I said,

  • "Harold, what is it that has meaning to you?

  • What is it that you hold sacred?"

  • And he said,

  • "My family."

  • I said, "What do you want to do?"

  • He slapped me on the knee and said, "I want to go fishing."

  • I said, "That, I know how to do."

  • Harold went fishing the next day.

  • He died a week later.

  • As I've gone through my training in my career,

  • I think back to Harold.

  • And I think that this is a conversation

  • that happens far too infrequently.

  • And it's a conversation that had led us to crisis,

  • to the biggest threat to the American way of life today,

  • which is health care expenditures.

  • So what do we know?

  • We know that this population, the most ill,

  • takes up 15 percent of the gross domestic product --

  • nearly 2.3 trillion dollars.

  • So the sickest 15 percent take up 15 percent of the GDP.

  • If we extrapolate this out over the next two decades

  • with the growth of baby boomers,

  • at this rate it is 60 percent of the GDP.

  • Sixty percent of the gross domestic product

  • of the United States of America --

  • it has very little to do with health care at that point.

  • It has to do with a gallon of milk,

  • with college tuition.

  • It has to do with every thing that we value

  • and every thing that we know presently.

  • It has at stake the free-market economy and capitalism

  • of the United States of America.

  • Let's forget all the statistics for a minute, forget the numbers.

  • Let's talk about the value we get for all these dollars we spend.

  • Well, the Dartmouth Atlas, about six years ago,

  • looked at every dollar spent by Medicare --

  • generally this population.

  • We found that those patients who have the highest per capita expenditures

  • had the highest suffering, pain, depression.

  • And, more often than not, they die sooner.

  • How can this be?

  • We live in the United States,

  • it has the greatest health care system on the planet.

  • We spend 10 times more on these patients

  • than the second-leading country in the world.

  • That doesn't make sense.

  • But what we know is,

  • out of the top 50 countries on the planet

  • with organized health care systems,

  • we rank 37th.

  • Former Eastern Bloc countries and sub-Saharan African countries

  • rank higher than us as far as quality and value.

  • Something I experience every day in my practice,

  • and I'm sure, something many of you on your own journeys have experienced:

  • more is not more.

  • Those individuals who had more tests,

  • more bells, more whistles,

  • more chemotherapy, more surgery, more whatever --

  • the more that we do to someone,

  • it decreases the quality of their life.

  • And it shortens it, most often.

  • So what are we going to do about this?

  • What are we doing about this?

  • And why is this so?

  • The grim reality, ladies and gentlemen,

  • is that we, the health care industry -- long white-coat physicians --

  • are stealing from you.

  • Stealing from you the opportunity

  • to choose how you want to live your lives

  • in the context of whatever disease it is.

  • We focus on disease and pathology and surgery

  • and pharmacology.

  • We miss the human being.

  • How can we treat this

  • without understanding this?

  • We do things to this;

  • we need to do things for this.

  • The triple aim of healthcare:

  • one, improve patient experience.

  • Two, improve the population health.

  • Three, decrease per capita expenditure across a continuum.

  • Our group, palliative care,

  • in 2012, working with the sickest of the sick --

  • cancer,

  • heart disease, lung disease,

  • renal disease,

  • dementia --

  • how did we improve patient experience?

  • "I want to be at home, Doc."

  • "OK, we'll bring the care to you."

  • Quality of life, enhanced.

  • Think about the human being.

  • Two: population health.

  • How did we look at this population differently,

  • and engage with them at a different level, a deeper level,

  • and connect to a broader sense of the human condition than my own?

  • How do we manage this group,

  • so that of our outpatient population,

  • 94 percent, in 2012, never had to go to the hospital?

  • Not because they couldn't.

  • But they didn't have to.

  • We brought the care to them.

  • We maintained their value, their quality.

  • Number three: per capita expenditures.

  • For this population,

  • that today is 2.3 trillion dollars and in 20 years is 60 percent of the GDP,

  • we reduced health care expenditures by nearly 70 percent.

  • They got more of what they wanted based on their values,

  • lived better and are living longer,

  • for two-thirds less money.

  • While Harold's time was limited,

  • palliative care's is not.

  • Palliative care is a paradigm from diagnosis through the end of life.

  • The hours,

  • weeks, months, years,

  • across a continuum --

  • with treatment, without treatment.

  • Meet Christine.

  • Stage III cervical cancer,

  • so, metastatic cancer that started in her cervix,

  • spread throughout her body.

  • She's in her 50s and she is living.

  • This is not about end of life,

  • this is about life.

  • This is not just about the elderly,

  • this is about people.

  • This is Richard.

  • End-stage lung disease.

  • "Richard, what is it that you hold sacred?"

  • "My kids, my wife and my Harley."

  • (Laughter)

  • "Alright!

  • I can't drive you around on it because I can barely pedal a bicycle,

  • but let's see what we can do."

  • Richard came to me,

  • and he was in rough shape.

  • He had this little voice telling him

  • that maybe his time was weeks to months.

  • And then we just talked.

  • And I listened and tried to hear --

  • big difference.

  • Use these in proportion to this.

  • I said, "Alright, let's take it one day at a time,"

  • like we do in every other chapter of our life.

  • And we have met Richard where Richard's at day-to-day.

  • And it's a phone call or two a week,

  • but he's thriving in the context of end-stage lung disease.

  • Now, palliative medicine is not just for the elderly,

  • it is not just for the middle-aged.

  • It is for everyone.

  • Meet my friend Jonathan.

  • We have the honor and pleasure

  • of Jonathan and his father joining us here today.

  • Jonathan is in his 20s, and I met him several years ago.

  • He was dealing with metastatic testicular cancer,

  • spread to his brain.

  • He had a stroke,

  • he had brain surgery,

  • radiation, chemotherapy.

  • Upon meeting him and his family,

  • he was a couple of weeks away from a bone marrow transplant,

  • and in listening and engaging,

  • they said, "Help us understand -- what is cancer?"

  • How did we get this far

  • without understanding what we're dealing with?

  • How did we get this far without empowering somebody

  • to know what it is they're dealing with,

  • and then taking the next step and engaging in who they are as human beings

  • to know if that is what we should do?

  • Lord knows we can do any kind of thing to you.

  • But should we?

  • And don't take my word for it.

  • All the evidence that is related to palliative care these days

  • demonstrates with absolute certainty people live better and live longer.

  • There was a seminal article out of the New England Journal of Medicine

  • in 2010.

  • A study done at Harvard by friends of mine, colleagues.

  • End-stage lung cancer:

  • one group with palliative care,

  • a similar group without.

  • The group with palliative care reported less pain,

  • less depression.

  • They needed fewer hospitalizations.

  • And, ladies and gentlemen,

  • they lived three to six months longer.

  • If palliative care were a cancer drug,

  • every cancer doctor on the planet would write a prescription for it.

  • Why don't they?

  • Again, because we goofy, long white-coat physicians

  • are trained and of the mantra of dealing with this,

  • not with this.

  • This is a space that we will all come to at some point.

  • But this conversation today is not about dying,

  • it is about living.

  • Living based on our values,

  • what we find sacred

  • and how we want to write the chapters of our lives,

  • whether it's the last

  • or the last five.

  • What we know,

  • what we have proven,

  • is that this conversation needs to happen today --

  • not next week, not next year.

  • What is at stake is our lives today

  • and the lives of us as we get older

  • and the lives of our children and our grandchildren.

  • Not just in that hospital room

  • or on the couch at home,

  • but everywhere we go and everything we see.

  • Palliative medicine is the answer to engage with human beings,

  • to change the journey that we will all face,

  • and change it for the better.

  • To my colleagues,

  • to my patients,

  • to my government,

  • to all human beings,