HeartBeats Episode 7: The Future of Healthcare

 Good morning hello and welcome to HeartBeats I'm Cathy Murtaugh-Schaffer and I'm your host for this episode of HeartBeats. This podcast is brought to you by Shipley Cardiothoracic Center, an educational series dedicated to providing our patients and the community with information and education about our cardiothoracic surgery program, Lee Health, and matters affecting your health. Today I have the great pleasure of talking with two physicians that I hold in the highest regard, Dr. Scott Nygaard, our Chief Operating Officer for Lee Health, and Dr. Brian Hummel, one of the founding surgeons of Shipley Cardiothoracic Center. Today's topic is the future of health care. Gentlemen welcome, I am so happy to have you here today. I think you'll both agree that healthcare has undergone some tremendous challenges in the last year and I would venture to say that some of these challenges have really pushed the envelope. But, before we talk about the future, I think we need to acknowledge our present-day challenges because they are what will shape the future. COVID-19, a failing economy, an armed insurrection in Washington, a new president, COVID variance, environmental calamities, skyrocketing drug prices, advancing genomic and robotic technology, vaccine distribution, continued need for social distancing, the mental health toll on Americans, masking, hospitals rationing care, millions of people without healthcare coverage and/or jobs and the very existential thought that this is just a taste of pandemics yet to come. to say these are unprecedented challenges is an understatement. But these are the challenges that will shape hospitals and healthcare for the foreseeable future.

I am curious Dr.Nygaard, what is your process for thinking through these very complex matters and arriving at a plan that will help Lee continue its mission to provide exceptional care to the people of Southwest Florida?

(Nygaard) I think you raised a lot of good points there in your opening comments and often we have to find ourselves having to react to many of the different changes that are upon us, and respond to those. The harder part is to figure out what our strategy should be for the long term and how do we prioritize what will have the greatest impact on our community. And so, we go through a process where we do get input from other stakeholders across our community, our board, our management staff, and physicians and try to really come up with the priorities that will make the biggest difference in our community and for our healthcare system here in southwest Florida.

(Host) one of the things I think COVID has brought to the forefront is the challenge of bed management and we dealt with that for a good part of this year. I am wondering what role you both think robotics might play in providing opportunities that we might not have had in the past. For instance, we know that using the robot when possible leads to decreases in length of stay, surgical site infections, blood loss, and readmissions, which of course opens up beds. Are there opportunities in the future to utilize robotics in outpatient surgery centers and keep beds open on the inpatient side? I remember a time when doing laparoscopic surgery was limited to a hospital operating room, and now most laparoscopic procedures are done in an outpatient surgery center. Dr. Hummel your thoughts?

(Hummel) Well, I think we touched on one aspect, in that robotics, while it's kind of a novel and a unique device that we can use for a multitude of illnesses and problems that patients have. The real key is the outpatient setting and minimizing in-hospital days, which comes at an extremely high cost; The bricks and mortar of hospitals, the care needed, the technology whether in radiology and labs, that sort of thing, must be present for the sickest of the sick that utilizes these four walls. I think those things that are migrating to the outpatient center, whether it's robotically assisted procedures or simply were devising better ways to care for patients. One of the things is pain management, the other is recognizing and dealing with issues before they become such devastating consequences that require a hospital setting to manage them. I think the recognition by primarily specialists but also primary care physicians. A lot of these issues can be managed as an outpatient and as you said, laparoscopic is one, hernia repairs, all of those things that used to be 2-3-day minimum in the hospital are now done in outpatient and home within 6-8 hours. I think we're going to see more and more migration to that. It's going to be a savings overall to the health system of the country, robotics are certainly going to play a role in that. I have no way of predicting what sort of thing we will be using robots for in the future, that's a pretty big list right now. Some are advantageous for the robot and some of the robotic things are not much different than a simple laparoscopic procedure or a minimally invasive procedure done in a different format.

(Host) Dr.Nygaard, any thoughts on robotics and efficiency?

(Nygaard) I think Dr.Hummels commented on the use of robots in the operating room, I think there are many other uses of robots, just before we started this we were talking about the use of robotics in the pharmacy industry and distributing medicines. We do have some robots in our facilities, at Lee Memorial that actually deliver medicines to the floor and are able to do that effectively. I think you will see more and more uses where they can do repetitive tasks, things that don't require necessarily concentration of human effort. I think we're going to see it outside the operating room, in terms of how it impacts healthcare delivery and makes us more efficient.

(Host) one of the thoughts about improving care, I am still discovering what it all entails, but one of Lee’s new entities Innovatus, as a mission of moving LeeHealth into a value-based care strategy, which will require more focus on interventions that are not really reimbursable for example, nurse navigation and case management. Do you see this as an effective strategy to improve patient care and contain cost at the same time? Is this the future of healthcare?

(Nygaard) it is very complex, I think when we look back in medicines history for the longest period of time, we talked about being paid at a fee per service basis which is really, you know, for the units of service for the things that we actually provide. In a value-based world you would say, well you're going to collect all of the money upfront and then determine what the right services are so it's not being reimbursed on a per unit of service, its being reimburse in total. Which is really what the payers do when they charge a premium on an annual basis. They're appraising their risk, they're looking at the population, and they're saying for this much money collected over the course of the year, we can adequately cover our own cost, provide care to members were trying to serve, pay all of the different people you need to pay and have a small margin left over for profit. internal to our own thinking that is a huge change in terms of the way we think about delivering care, I do think we capture that in one of our strategic pillars we will be talking about this broad concept of right care. To me, right care is understanding that it’s not more care is better care, although we kind of have a consumption mindset in our US economy, but that the care that really matters that's evidence-based that would add value is the care we should be providing. There are certain things that, you know, are not helpful or may not benefit the patient and those are tougher decisions. When in reality we are being paid on a fee per service basis think we need to get out of the excuse mindset and into how do we accomplish that. It is possible in other areas of the country where we've had a capitated payment system with the health plan and it does things pretty differently, but it's a shift, and it's not an easy one. I also think CMS is tried to do 54 different demonstrations, trying to figure out how to change the culture in our healthcare delivery system in the United States and they're still trying. They've learned some things; some things have been partially successful. I applaud their efforts to try to innovate but we still have a long way to go in this country to figure out how do we get from this model to a more value-oriented model, then makes healthcare ultimately affordable.

(Hummel) I think one aspect that is really difficult to predict and to manage is the interface of all the players that go into this system that we have, that we've slowly evolved in in this country and that's- we have the politics in medicine, we have the cost of medicine, we have the patient encounters, we have the physicians providing care and then we have these insurance arms, if you will, or who’s covering/who's paying for their care. Some of that is federal, some of it's private, some of it's none at all, and how we navigate this interface, this complex interface is really what's going to determine how we move forward. I think there's going to be a tremendous focus probably over the next four years on the political side of things, there's going to be a push towards reviving and reinfusing enthusiasm into the Affordable Care Act, which I must comment that honestly, it's first iteration was not a fan. I have come to believe that something like that has to be done. We can't afford where we're going now and as a provider, it makes no sense to continue to repeat the same things we've done in the past. As Dr.Nygaard has said the issue ought to be quality and it ought to be timely care for the right reasons at the right price. Nobody wants to bankrupt physicians or hospital systems that are providing care. But at the same time, inordinate profits shouldn't be taken by any one of these entities that are involved in this and how we get control of that, how we act in that, is going to ultimately determine how we as a society deal with ourselves.

(Host) So as a follow-up question to that, what happens to the accountability piece? What I mean is were constantly fighting the rising cost of healthcare, but there doesn't seem to be any burden on people taking responsibility for their own health. For example, smokers, obesity, sedentary lifestyles, and now we're seeing people refuse vaccinations and I'm not talking about just COVID vaccinations, I'm talking about measles and polio which for a short time went extinct in America because of our vaccine programs. Now it seems everything is some contentious issue, even something as simple as wearing a mask. In the future do you think we're going to hold people accountable for the negative consequences of their behaviors, is that even possible?

(Nygaard) We've wrestled with that for a long time, in terms of how to hold people accountable. The primary mechanism of doing that is trying to shift the cost or some of the cost burden to them. In some cases, what we see people simply do, even for small increases in payment they avoid care and quit seeking care. In the long term is that a better or worse outcome? And we don't know all the time, the long-term effects in short-term decision making. I think a lot of that has to do with our culture in the United States. We've gotten very me focused and everyone should serve me, so it's much deeper than healthcare. I still think if we were honest with the best predictor of your health outcome is difficult in your socioeconomic status and has lots to do with the accountability, I'm not saying it's not important but it's a bit of a distraction. We have a lot of inequities that are still in the country and we have a mindset that we sub the healthcare system for the haves and the have-nots. It's a shame that for the most productive nation in the world that we can't find a way to provide a basic healthcare benefit to people because without your health it's very hard to be a productive member of society. And so, that remains a challenge I think, again, more of culture mindset challenge. We have the idea that competition is going to solve all of these things, I haven't seen that. I think we have a lot of challenges with that because as we compete, I think what's often forgotten is that we build all the facilities and set up all the different tests on every corner, the MRI imaging. That cost is simply passed back into the community, soon or later the community has to pay for it. I think because healthcare is complex people lose track of what's really happening, they live in a different business world.

(Hummel) I totally believe that that's the issue. I think that there is an inequality of healthcare. One of the things that also drives it and that we're seeing more and more of is what is "the best practice". The best practice in a very affluent society where you can- cardiac disease, which I am intimately familiar with says well you need to have a nuclear stress test if you've had any presentation of chest pain then followed by a possible catheterization and then when is the treatment or management of those patients appropriate. Whether it's continued medical therapy or intervention of catheters or even surgery. In an affluent hospital system, those things can be delivered pretty efficiently but at some extreme cost. Whereas that same person or patient living someplace else with less affluent availability to a healthcare system is going to suffer and they will not receive "best practice" and I think somehow we have to reconcile the regional differences of what best practice represents. It's hard to hold the physician in accountability if he doesn't have at his disposal, those tests that the society says- this is what you need to be doing for this disease process. Well, there's diabetes or cancer or whatever, he or she can’t be held accountable for the care they can't deliver, and yet we are. Unfortunately, the litigious nature of our country also impacts that and brings a different pressure to bear. You know you got to do all these tests and if you don't do these tests you're committing malpractice. a great majority of some of the scans and radiologic procedures and some of the blood test are probably unnecessary, and if we were allowed to step back and say ok let's really look at the results and the outcomes, we could change behavior. But were afraid in this country because quite frankly malpractice is still the hidden elephant in the room for a lot of things.

(Nygaard) In addition, there are ways to create incentives that are positive, like where people can generate, like we've done in our health plan for our employees, if you get a preventative exam you get a healthy premium or you do get an immediate benefit and so people see that as an advantage because they're getting something of value to themselves and the incentive is saving them some dollars. It's a belief mindset, do you believe that it brings value over time. I think at LeeHealth that it does bring value over time. We would rather have our employees get enough screenings and things done to prevent disease, which is a lot more expensive down the road. Even that's a mindset shift; When a lot where we fund healthcare is on an annual as opposed to looking at it as a long term investment. I'd say the last thing I think from an accountable perspective, I'm not even sure that we all have any agreement across the country on what does success look like for the health system. Everybody kind of makes it up in their local marketplace, so do we really even have a shared vision? How will we know we're successful? We tend to focus on the money but Dr. Hummel brought up a lot of good points on quality and outcomes of care and other aspects that we should be contemplating much more about the scorecard approach as opposed to just the economics.

(host) Do you think we will get there?

(Nygaard) Well, I remain optimistic. I try to say "did we leave it better than we found it?" that's always my hope, I think we're on the right road of thinking her at LeeHealth, in my mind. Obviously, I'm biased but I think we've come a long way in terms of our quality performance and safety performance. Our hospitals come into the top 250 top 100, so I think were focused on the things that we think mate to our community and to tour patients.

(host) Dr.Hummel, I'm wondering if you think the last four years of political upheaval has damaged us on a global stage in regards to healthcare, particularly given the laissez-faire attitude of the initial COVID response in this country and the turbulent rollout of the vaccine. Do you feel the United States can remain a respected leader in thought and innovation worldwide?

(Hummel) well, I think amongst medical professionals, yes the US is still going to lead the way around the world and be a really contributing partner to major medical advances in the developed world and providing needed facilities and care to a third world. That being said, I think the general populations in the world now have a different perspective of what the US really means. As you said, the way the world views how we managed our COVID issue. Everybody had a different approach, every country, every society. But frankly, wore all the wealth and benefits we had, we were unwilling or unable, politically or whatever, to come out with very strong mandates, that quite frankly could have saved a lot of lives and certainly could have saved a lot of hospital days. The cost of not doing the right thing, in this particular instance, was tremendous and we as a society have paid the price. There is no question, there's a balance between individual liberties and individual choice. But, when the choices are detrimental to your neighbor or your community, that choice has to be looked at in a different light and I think we dropped the ball there, I really do. I think its unfortunate, and the world saw it and quite frankly a lot of the world took our lead- to their own detriment. You mentioned the anti-vaccine crowd and it's hard for me to say that that's an ok approach. I get people being nervous about new vaccines and the untoured consequences that maybe could arise. But in light of the COVID vaccine, it was the most heavily tested vaccine to ever come on the market before it got released. Even though it was in a short period of time. Because it was all based on prior research and they had these gene codes stored and they had the ability to break it down very quickly and say ok what's different about this versus one of the over viruses- the SARS virus. That's how these vaccines were able to get to the market so quickly. But there were years and years of research behind them, and it's unfortunate that people are choosing not to be vaccinated. The variant that's smoldering viral load if you will, that's out in society, promotes mutations amongst the virus, and unless we get on top of it, unfortunately that's going to mean vaccines, to establish enough resistance to the virus. We are setting ourselves up for this slow slow slog through illness I don't know how you get people to do that, I don't know how you politically can push them, but I would certainly like to see a more centralized approach and more education to people so that they would act appropriately.

(Nygaard) Adding to that, I think we still have the ability to lead. We have to be conscious of making medicine an attractive profession and something people can be a proud partner to contribute to. That's not just physicians, that's all clinicians and all staff, I think we do have a lot of opportuny to contribute to problems in the world. I think there's a lot of time and energy volunteered from many physicians in the United States across many different (untranscribable)...that do give their time and talent and help people with any number of different medical and surgical problems. I think we tend to want to give back. I think that the challenge that we face in terms of maintaining our leadership position is, 1. again we become distracted by lack of truth, I call that, kind of, the social media were running the whole country on fragments of information and not really looking at the science. The science has just been lost in so many instances, whether it was the masking issue, (untranscribable) was it a perfect solution, no. It was a solution that would buy us some time to try and have time to innovate, learn more about the virus and come up with better treatments. I think over time you've seen us do those kinds of things. Whether it's trial and error in different drugs, trying to learn what's effective. There definitely has been a progression in a relatively short time, we would be proud about the things that have come forward short order. Instead, we begin to be focused on, again kind of this culture of "you", where there is more interest in dividing people rather than uniting people who weren't prepared as a world for a pandemic. Even though there were many signs well in advance to this that pandemics have occurred and have come. We didn't have adequate supplies worldwide, we didn't have adequate public health messaging worldwide, we let variation become the enemy against solution.

(host) my next question kind of alludes back to something you said earlier, Dr.Nygaard. Can we really maintain elite status in the world if we don't address the collateral issues that influence healthcare, the environment, poverty, racism, etc. for instance the United States still has a maternal mortality rate that is the highest among developed counties with wide racial and ethnic gaps. How can healthcare influence these factors?

(Nygaard) so I think I throw that in the bucket of what I call a social determinant of health and there are many of those out there. I think what we provide in traditional medicine fixes about 20% of those things, the other 80% have something to do with these social determinants of health. Have we built a collective infrastructure, it's the burden of that on us as the healthcare provider. Again, back to shared vision and clarity and what's our role and responsibility and if it is our role and responsibility then how is it funded so that we can actually try to do that work. I don't think people aren't willing to do the work but we need a mechanism to fund us to do that but, if not, then who's taking a lead on a given service? So in our own community we've tried to translate that, most recently into saying how do we more effectively partner with agencies that are actually funded to do some of these things. Whether it's food, housing, clothing, a substance use disorder. there are agencies that already have funding but I think, because again, the fragmented nature of the delivery system and all the different assets out there, you know it's difficult for us to understand how to access them. a couple of years ago we brought a bunch of people together around to discuss behavior health. I went to the meeting and there were 60 different agencies, and I thought "oh these people know each other and they know whats going on and about an hour into the meeting I'm realizing, they don't even know." and it kind of was like eyes open, "oh I didn't know you did that, I didn't know you provided that service", and through that collaborative, we've kind of been trying to take that back and engage people in much more of a collaborative approach across the community. its not easy but I think it's starting to pay some dividends in terms of better solving in that particular case all of the mental health issues we have

(host) I think we saw a bit of that Dr. Hummel when we had our endocarditis round table and all of these different agencies and people showed up and we're all just looking at each other so surprised that, oh I didn't know you did that and I didn't know you were out there and how do we connect and this was I think D. Nygaard's point is well taken

(Hummel) oh I totally agree I had a similar experience when we did the roundtable and for our listeners in the issue of IV drug abuse and substance use disorder in our community like every community quite frankly is way beyond what people recognize or acknowledge and we as heart surgeons were faced increasingly, frequently with the patients who had developed valvular heart problems or as a result of IV drug use and it got to the point where we recognize the tremendous economic impact that was having the resources of the hospital system and so just kind of educate everybody in the community we did call around table and thinking as Dr. Nygaard said everybody would know each other and that they just didn't know how big this problem was and once we brought everybody in the room it was very apparent nobody was talking to anybody else and again I applaud you Cathy for continuing to take that lead I kind of stepped back but the reality is we now have addiction medicine specialists in the community and then the whole system. But the health system recognize that it's primarily an un-imbursable reimbursable event but they hired these specialists which have been tremendously helpful to our patients. We've seen the need for our intervention in these in stages to come down some despite the fact that we know IV drug use and overdoses have increased in the last year. It's not translating quite as frequently to the need for surgical intervention that being said I saw a patient just before I walked in here but it is a tremendous problem and it is a one of communication and that's how we're going to solve most of these things it's going to start with communication to let people know OK here's the problem how do you see it or how do we see it or how do they see it? You need the input of everybody that's involved and once you have that input you can at least formulate a plan that the kind of have a basis in some common sense before we were just scatter shooting and not doing a very good job.

(host)From what you both are saying it sounds like what we really need is a central hub to organize all of these various fragments that are out there so that everybody is on the same page and knows that oh I could call Dr. Nygaard for this or I can call Dr. Hummel for that well Cathy can you put me in touch with whoever in that central hub and I'm wondering is healthcare the central hub? Is that the place where that central hub lives and I'm not sure?

(Nygard) Yeah I don't know if it is the central hub or not I mean there are other agencies like in our own community like the United Way that thinks of themselves as a hub and a connector but you know I think we can play a role in there because I think we see the needs when people do end up in our care and you know many of the things they're seeking care for of all of these needs, so can we become aware and can we connect them I'm not we sure get to solve every problem from them but can we connect them to the right resource and get them plugged in. Sometimes that's half the challenge people just don't know how to navigate through the complexity of a community. If any one of us have ever had to navigate that you realized a lot harder than you might have thought it was.

(host) Dr. Nygaard it seems that there have been a lot of health care mergers this past year and I assume many of them occurred for financial reasons but also there's been some new kids on the block as well trying to get in on the healthcare action so to speak including Amazon, Walmart, CVS and alike. How do you think these new retail-focused entities are going to impact the traditional healthcare structure and does that type of competition help or hinder cost? Can they really provide value based care?

(nygaard) You know I think that evolved out of this consumer mindset and what do I want in terms of self service and ease of access and if you look at the Amazon model and how many people have tried to copy their home delivery system or you know kind of, now you've got a lot of retailers in the pickup business perhaps partly as a result of COVID, but I think also as a result of competitive pressures from other people who got into different ways of distributing product to people. Targets growing their online business and you could look at almost any retailer and we're seeing vacancy in a lot of the retail facilities as time goes on, its starting to close up because people realize I can get this at my doorstep when I get when I get home. I think we're, we have to do a better job of understanding what the people in our communities really want and what a value add to them. I think for years and we've kind of gotten away with it I've always felt like we've been able to say to our communities not just here but many places I've been you know here's what will give you take it or leave it and all of a sudden the boundaries are being erased and the ability to get things I don't have to take it or leave it I can go somewhere else. Expense is valuable to me, you know we all spend money on things that using bring value to us and then I think again it's a frameshift. I think it's also disrupting or challenging the way we construct relationships with our patients it's always interesting for years we've said you know that's my patient and ever since I started practicing medicine I thought, no I serve at the pleasure of you I'm your doctor and it's your choice not mine and so if they yeah we need to just again change some of our thinking. I think if it's out of pocket dollars that were growing in these different sectors you know could be a growth model for the entire industry and there could be more available revenue streams for all of us to compete effectively in that space for patients

(host)Dr. Hummel do you see these retailers impacting the subspecialties of medicine, what I mean is do you think that referrals to subspecialties will be slowed by this type of medical practice?

(Hummel) I don't actually, I don't think so, I think these arose out of the need for these big companies to control their health care costs. They were providing insurance for their employees and as we have spoken to we're providing a fee for service and quite frankly the cost to provide health care insurance-wise into your employees, became exceedingly expensive. It was probably the biggest line item and every one of their budgets. So I'm not at all surprised by this. I suspect what will happen is that they're going to provide an early entry into a primary care setting where patients are seen regularly, blood pressures are maintained with normal ranges, well-baby checks are undertaken prenatal care, whatever. I think that we will see perhaps a turn towards more appropriate and timely primary care. I think the patients that are going to require some specialty care, now they may have their own panel are specialists that they refer to and it's not going to be as broad as maybe in our community or whatever but say if you lived in Seattle and Microsoft says OK here here's our cancer doctor and here's our cardiac surgeon and heres whoever, they are going to be directed there because they know there is a cost-benefit for them to use that. I think in a lot of the markets is going to dictate how it's done. I don't think it's going to ultimately alter the needs of the patients but hopefully with the patients will be coming to the system to the specialist earlier with the problems that can be addressed in a much more timely fashion

(host) one of the high impact areas from this past year is the incredible stress that's been placed on health care staff, Dr. Nygaard, you once wrote to me and I quote "we are here to serve and preserve the calling of medicine. Leadership is fundamentally about the stewardship of the heart souls and minds of people". To me it feels as if we've moved from the everyday stress of health care to trauma and a recognition that it's going to take more than resilience training to deal with secondary traumatic stress or vicarious traumatization. With a high rate of clinician burnout almost 50%

in one study. A national shortage of doctors, nurses leaving the profession, continued government cutbacks, a highly regulated profession requiring more and more time away from the patient. How do you preserve the heart and soul of medicine and ensure that the next generation of providers have what it takes to weather the burnout factors and the secondary traumatic stress?

(nygaard) so for me, I've always kept it very simple. I've always thought you know medicine first and foremost is about the patient and I can't think of a profession in which we get, I call the privilege to entering the hearts, souls, and minds of people, and when you make a personal connection with somebody whether it's a family member or if it's your patient or whether you reach out and touch somebody. I think we've gotten lost in the technical side of medicine over the years but that compassion and the need for human connection is great, we found that in the code pandemic isolation. The things that keep people apart, we are social creatures by design we need you know those interactions. So, I would say what's your passion and find it and find passion in a patient or be curious about their family make it personal. Because when it becomes personal it's not just a transaction or procedure or something beyond what you're doing you know then it tends to bring you joy, even if the end isn't what you'd like it to be. Sometimes we have to deal with the death but that's an opportunity to serve a family in transition to grieving and doing some other things and so you know I think we've lost that passion around profession. The last thing I would say we have to take care of ourselves you know you deserve time off you deserve the ability to kind of get out of the office. We do have colleagues and partners we should be able to trust to provide care and give us you know a breath in our in our week or in our month or whenever you need time off. I've had so many people come up to me and say oh i haven't taken a vacation in forever and i say well youre not doing any good for yourself, you're not doing any good for your patient and you're certainly not going to be helping in the long term by doing that. You know I've been in situations where we've seen the end result of that become a position suicide or staff suicide, that's unfortunately you know no profession is worth and so I think you just kind of got to get back to the basics and find that you know that human connection and celebrate you know there's lots of opportunities in a day to connect with somebody whether its a smile, or a handhold, touch on the back, or even a brief exam, hello to the family. There's so many ways we have opportunities still to connect .

(host)Dr.Hummel you take care of a lot of patients with very complex chronic problems. As we move into the future I feel we need to design a better approach to supporting people through a very complex medical system. Do you think we'll see a swing of the pendulum towards a more holistic way of providing care which would include mental health and perhaps more inclusion of alternative medicine practices, or do you think we're going to become even more cartesian in our approach?

(Hunnel) Well I think for us to succeed both as a society and as a profession, it's going to have to be a more holistic approach. We went through a fast and dramatic shift toward depersonalization with the computerization of medical records and as I stated before that the demand to do best practices and somebody constantly looking over your shoulder, no one individual can maintain not only mental sobriety but professional society under those constants presses. So you were learning how to delegate and how to allow alternate care pass to intersect with what we do, its kind of the endpoint if you, of a specialty. We here at the Shipley Center have instituted and are ramping up our nurse navigator system which we believe is going to make a big difference in our patients. We hope that all of our consoles that we see for a complex problem are introduced very quickly to our nurse navigator. A nurse navigator that will actually follow them through their pre-op testing, their hospitalization and then make sure that they are recovering appropriately and then we will transfer that to somebody else in the LeeHealth system that will take ownership of that patient for a period of time to ensure that complete recovery has happened. I think those sorts of things and those efforts are going to pay great dividends to us as professionals to the patients and their families. It is getting back to that personal touch the Dr. Nygaard alluded to. Then, secondarily we just have to look at all alternatives, you know for a long time meditation was thought to be voodoo but it's statistically and scientifically there's tremendous benefits to meditation. So I think we have to have an open mind to things that we don't necessarily truly understand and look at it with again I hope with rigorous intellectual honesty but where there is benefit to some of these things we ought to incorporate it into our care and I see that coming. Particularly perhaps in the younger professionals as they come out, I'm a kind of twilight of my career, but I hope that the younger professionals are being exposed to some of these things in their training and if they're not it's a shame because ultimately that's what's going to happen to be part of their care package if you will.

(host) I'm curious, what do you both think the leading cause of death is going to be in the next 10-15 years?and why?