0:00:01.387,0:00:02.912
I am a palliative care physician

0:00:02.936,0:00:05.927
and I would like to talk to you[br]today about health care.

0:00:06.393,0:00:10.102
I'd like to talk to you[br]about the health and care

0:00:10.917,0:00:13.764
of the most vulnerable[br]population in our country --

0:00:13.788,0:00:19.039
those people dealing with the most[br]complex serious health issues.

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I'd like to talk to you[br]about economics as well.

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And the intersection of these two[br]should scare the hell out of you --

0:00:27.508,0:00:29.279
it scares the hell out of me.

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I'd also like to talk to you[br]about palliative medicine:

0:00:33.835,0:00:40.152
a paradigm of care for this population,[br]grounded in what they value.

0:00:40.544,0:00:43.741
Patient-centric care based on their values

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that helps this population[br]live better and longer.

0:00:48.458,0:00:50.808
It's a care model that tells the truth

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and engages one-on-one

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and meets people where they're at.

0:00:57.460,0:01:01.223
I'd like to start by telling the story[br]of my very first patient.

0:01:01.247,0:01:03.283
It was my first day as a physician,

0:01:03.307,0:01:04.798
with the long white coat ...

0:01:05.519,0:01:07.001
I stumbled into the hospital

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and right away there's a gentleman,[br]Harold, 68 years old,

0:01:09.849,0:01:11.450
came to the emergency department.

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He had had headaches for about six weeks

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that got worse and worse[br]and worse and worse.

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Evaluation revealed he had cancer[br]that had spread to his brain.

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The attending physician directed me[br]to go share with Harold and his family

0:01:27.791,0:01:31.113
the diagnosis, the prognosis[br]and options of care.

0:01:32.114,0:01:35.068
Five hours into my new career,

0:01:35.092,0:01:37.126
I did the only thing I knew how.

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I walked in,

0:01:39.790,0:01:41.134
sat down,

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took Harold's hand,

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took his wife's hand

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and just breathed.

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He said, "It's not good[br]news is it, sonny?"

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I said, "No."

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And so we talked[br]and we listened and we shared.

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And after a while I said,

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"Harold, what is it[br]that has meaning to you?

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What is it that you hold sacred?"

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And he said,

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"My family."

0:02:06.525,0:02:08.546
I said, "What do you want to do?"

0:02:08.570,0:02:11.737
He slapped me on the knee[br]and said, "I want to go fishing."

0:02:11.761,0:02:13.632
I said, "That, I know how to do."

0:02:14.646,0:02:16.600
Harold went fishing the next day.

0:02:17.760,0:02:19.392
He died a week later.

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As I've gone through[br]my training in my career,

0:02:23.098,0:02:24.585
I think back to Harold.

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And I think that this is a conversation

0:02:28.782,0:02:30.966
that happens far too infrequently.

0:02:31.737,0:02:35.502
And it's a conversation[br]that had led us to crisis,

0:02:36.173,0:02:38.837
to the biggest threat[br]to the American way of life today,

0:02:38.861,0:02:40.967
which is health care expenditures.

0:02:41.926,0:02:43.103
So what do we know?

0:02:43.127,0:02:46.056
We know that[br]this population, the most ill,

0:02:46.080,0:02:48.664
takes up 15 percent[br]of the gross domestic product --

0:02:48.688,0:02:51.482
nearly 2.3 trillion dollars.

0:02:52.307,0:02:55.867
So the sickest 15 percent[br]take up 15 percent of the GDP.

0:02:55.891,0:02:59.056
If we extrapolate this out[br]over the next two decades

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with the growth of baby boomers,

0:03:02.838,0:03:06.754
at this rate it is 60 percent of the GDP.

0:03:08.177,0:03:10.456
Sixty percent of the gross[br]domestic product

0:03:10.480,0:03:12.104
of the United States of America --

0:03:12.128,0:03:14.822
it has very little to do[br]with health care at that point.

0:03:15.148,0:03:16.962
It has to do with a gallon of milk,

0:03:17.540,0:03:19.064
with college tuition.

0:03:19.625,0:03:22.088
It has to do with[br]every thing that we value

0:03:22.112,0:03:25.237
and every thing that we know presently.

0:03:26.514,0:03:30.705
It has at stake the free-market[br]economy and capitalism

0:03:30.729,0:03:32.483
of the United States of America.

0:03:34.965,0:03:38.121
Let's forget all the statistics[br]for a minute, forget the numbers.

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Let's talk about the value we get[br]for all these dollars we spend.

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Well, the Dartmouth Atlas,[br]about six years ago,

0:03:45.439,0:03:48.192
looked at every dollar[br]spent by Medicare --

0:03:48.216,0:03:49.827
generally this population.

0:03:49.851,0:03:53.787
We found that those patients who have[br]the highest per capita expenditures

0:03:56.050,0:03:59.425
had the highest suffering,[br]pain, depression.

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And, more often than not, they die sooner.

0:04:03.824,0:04:05.349
How can this be?

0:04:05.789,0:04:07.193
We live in the United States,

0:04:07.217,0:04:09.707
it has the greatest health care[br]system on the planet.

0:04:09.731,0:04:12.236
We spend 10 times more on these patients

0:04:12.260,0:04:14.446
than the second-leading[br]country in the world.

0:04:15.196,0:04:16.649
That doesn't make sense.

0:04:17.764,0:04:19.123
But what we know is,

0:04:19.147,0:04:22.318
out of the top 50 countries on the planet

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with organized health care systems,

0:04:25.949,0:04:28.047
we rank 37th.

0:04:30.017,0:04:34.303
Former Eastern Bloc countries[br]and sub-Saharan African countries

0:04:34.327,0:04:37.863
rank higher than us[br]as far as quality and value.

0:04:40.485,0:04:43.023
Something I experience[br]every day in my practice,

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

0:04:47.927,0:04:50.807
more is not more.

0:04:52.196,0:04:54.185
Those individuals who had more tests,

0:04:54.209,0:04:55.479
more bells, more whistles,

0:04:55.503,0:04:57.931
more chemotherapy,[br]more surgery, more whatever --

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the more that we do to someone,

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it decreases the quality of their life.

0:05:05.422,0:05:07.693
And it shortens it, most often.

0:05:09.896,0:05:11.721
So what are we going to do about this?

0:05:11.745,0:05:13.148
What are we doing about this?

0:05:13.461,0:05:15.073
And why is this so?

0:05:15.097,0:05:17.001
The grim reality, ladies and gentlemen,

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is that we, the health care industry --[br]long white-coat physicians --

0:05:20.447,0:05:21.857
are stealing from you.

0:05:22.877,0:05:25.068
Stealing from you the opportunity

0:05:25.974,0:05:28.334
to choose how you want to live your lives

0:05:28.358,0:05:30.839
in the context of whatever disease it is.

0:05:30.863,0:05:33.632
We focus on disease[br]and pathology and surgery

0:05:33.656,0:05:35.037
and pharmacology.

0:05:37.319,0:05:39.395
We miss the human being.

0:05:41.434,0:05:42.961
How can we treat this

0:05:42.985,0:05:44.778
without understanding this?

0:05:47.029,0:05:48.968
We do things to this;

0:05:50.948,0:05:54.425
we need to do things for this.

0:05:56.161,0:05:57.941
The triple aim of healthcare:

0:05:57.965,0:06:01.057
one, improve patient experience.

0:06:01.081,0:06:04.275
Two, improve the population health.

0:06:05.467,0:06:10.250
Three, decrease per capita expenditure[br]across a continuum.

0:06:11.591,0:06:13.334
Our group, palliative care,

0:06:13.358,0:06:17.375
in 2012, working with[br]the sickest of the sick --

0:06:19.000,0:06:20.151
cancer,

0:06:20.175,0:06:21.520
heart disease, lung disease,

0:06:22.017,0:06:23.168
renal disease,

0:06:23.192,0:06:24.389
dementia --

0:06:25.681,0:06:27.839
how did we improve patient experience?

0:06:29.010,0:06:30.609
"I want to be at home, Doc."

0:06:30.633,0:06:32.844
"OK, we'll bring the care to you."

0:06:32.868,0:06:34.680
Quality of life, enhanced.

0:06:35.732,0:06:37.090
Think about the human being.

0:06:37.114,0:06:39.045
Two: population health.

0:06:39.069,0:06:41.920
How did we look[br]at this population differently,

0:06:41.944,0:06:44.792
and engage with them[br]at a different level, a deeper level,

0:06:44.816,0:06:48.017
and connect to a broader sense[br]of the human condition than my own?

0:06:49.091,0:06:51.675
How do we manage this group,

0:06:52.584,0:06:54.353
so that of our outpatient population,

0:06:54.377,0:06:59.275
94 percent, in 2012,[br]never had to go to the hospital?

0:06:59.919,0:07:01.552
Not because they couldn't.

0:07:03.213,0:07:04.998
But they didn't have to.

0:07:05.022,0:07:06.751
We brought the care to them.

0:07:07.356,0:07:11.385
We maintained their value, their quality.

0:07:13.220,0:07:16.227
Number three: per capita expenditures.

0:07:16.746,0:07:18.144
For this population,

0:07:18.168,0:07:23.221
that today is 2.3 trillion dollars[br]and in 20 years is 60 percent of the GDP,

0:07:23.245,0:07:27.979
we reduced health care expenditures[br]by nearly 70 percent.

0:07:28.873,0:07:32.322
They got more of what they wanted[br]based on their values,

0:07:32.346,0:07:34.405
lived better and are living longer,

0:07:35.464,0:07:37.233
for two-thirds less money.

0:07:42.880,0:07:44.915
While Harold's time was limited,

0:07:45.663,0:07:47.564
palliative care's is not.

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Palliative care is a paradigm[br]from diagnosis through the end of life.

0:07:54.677,0:07:55.854
The hours,

0:07:56.361,0:07:58.753
weeks, months, years,

0:07:59.916,0:08:01.074
across a continuum --

0:08:01.098,0:08:02.982
with treatment, without treatment.

0:08:03.006,0:08:04.362
Meet Christine.

0:08:05.196,0:08:07.127
Stage III cervical cancer,

0:08:07.151,0:08:10.172
so, metastatic cancer[br]that started in her cervix,

0:08:10.196,0:08:11.679
spread throughout her body.

0:08:12.719,0:08:15.362
She's in her 50s and she is living.

0:08:16.743,0:08:18.336
This is not about end of life,

0:08:18.360,0:08:19.875
this is about life.

0:08:21.180,0:08:23.070
This is not just about the elderly,

0:08:23.094,0:08:24.756
this is about people.

0:08:25.929,0:08:27.141
This is Richard.

0:08:27.706,0:08:29.347
End-stage lung disease.

0:08:30.427,0:08:32.853
"Richard, what is it[br]that you hold sacred?"

0:08:33.581,0:08:36.596
"My kids, my wife and my Harley."

0:08:37.094,0:08:38.105
(Laughter)

0:08:38.129,0:08:39.279
"Alright!

0:08:40.544,0:08:43.782
I can't drive you around on it[br]because I can barely pedal a bicycle,

0:08:43.806,0:08:45.297
but let's see what we can do."

0:08:46.385,0:08:48.922
Richard came to me,

0:08:48.946,0:08:51.843
and he was in rough shape.

0:08:52.444,0:08:54.225
He had this little voice telling him

0:08:54.249,0:08:56.650
that maybe his time was weeks to months.

0:08:57.488,0:08:58.754
And then we just talked.

0:08:58.778,0:09:02.867
And I listened and tried to hear --

0:09:02.891,0:09:04.178
big difference.

0:09:04.202,0:09:06.371
Use these in proportion to this.

0:09:08.479,0:09:11.004
I said, "Alright, let's take it[br]one day at a time,"

0:09:11.028,0:09:13.555
like we do in every[br]other chapter of our life.

0:09:14.573,0:09:18.982
And we have met Richard[br]where Richard's at day-to-day.

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

0:09:23.059,0:09:27.222
but he's thriving in the context[br]of end-stage lung disease.

0:09:31.040,0:09:33.533
Now, palliative medicine is not[br]just for the elderly,

0:09:33.557,0:09:36.161
it is not just for the middle-aged.

0:09:37.535,0:09:39.066
It is for everyone.

0:09:39.090,0:09:40.629
Meet my friend Jonathan.

0:09:41.903,0:09:43.383
We have the honor and pleasure

0:09:43.407,0:09:45.727
of Jonathan and his father[br]joining us here today.

0:09:45.751,0:09:48.583
Jonathan is in his 20s,[br]and I met him several years ago.

0:09:48.607,0:09:51.929
He was dealing with[br]metastatic testicular cancer,

0:09:52.700,0:09:53.952
spread to his brain.

0:09:54.465,0:09:55.647
He had a stroke,

0:09:56.375,0:09:57.923
he had brain surgery,

0:09:57.947,0:09:59.959
radiation, chemotherapy.

0:10:01.579,0:10:03.375
Upon meeting him and his family,

0:10:03.399,0:10:06.230
he was a couple of weeks away[br]from a bone marrow transplant,

0:10:06.254,0:10:08.515
and in listening and engaging,

0:10:08.539,0:10:13.585
they said, "Help us[br]understand -- what is cancer?"

0:10:15.764,0:10:17.417
How did we get this far

0:10:18.513,0:10:20.814
without understanding[br]what we're dealing with?

0:10:21.276,0:10:23.690
How did we get this far[br]without empowering somebody

0:10:23.714,0:10:25.626
to know what it is they're dealing with,

0:10:25.650,0:10:29.258
and then taking the next step and engaging[br]in who they are as human beings

0:10:29.282,0:10:31.378
to know if that is what we should do?

0:10:31.402,0:10:34.481
Lord knows we can do[br]any kind of thing to you.

0:10:37.133,0:10:38.338
But should we?

0:10:41.870,0:10:43.554
And don't take my word for it.

0:10:43.578,0:10:48.030
All the evidence that is related[br]to palliative care these days

0:10:48.054,0:10:52.175
demonstrates with absolute certainty[br]people live better and live longer.

0:10:52.199,0:10:55.543
There was a seminal article[br]out of the New England Journal of Medicine

0:10:55.567,0:10:56.717
in 2010.

0:10:57.621,0:11:00.285
A study done at Harvard[br]by friends of mine, colleagues.

0:11:00.309,0:11:01.690
End-stage lung cancer:

0:11:01.714,0:11:03.832
one group with palliative care,

0:11:04.695,0:11:06.377
a similar group without.

0:11:07.782,0:11:11.134
The group with palliative care[br]reported less pain,

0:11:11.901,0:11:13.118
less depression.

0:11:13.556,0:11:16.463
They needed fewer hospitalizations.

0:11:16.487,0:11:17.894
And, ladies and gentlemen,

0:11:18.639,0:11:22.282
they lived three to six months longer.

0:11:23.805,0:11:27.246
If palliative care were a cancer drug,

0:11:27.867,0:11:31.284
every cancer doctor on the planet[br]would write a prescription for it.

0:11:32.845,0:11:34.059
Why don't they?

0:11:35.570,0:11:38.914
Again, because we goofy,[br]long white-coat physicians

0:11:38.938,0:11:42.984
are trained and of the mantra[br]of dealing with this,

0:11:44.401,0:11:45.635
not with this.

0:11:50.697,0:11:54.441
This is a space that we will[br]all come to at some point.

0:11:55.709,0:11:58.433
But this conversation today[br]is not about dying,

0:11:58.457,0:11:59.830
it is about living.

0:12:00.289,0:12:01.613
Living based on our values,

0:12:01.637,0:12:03.056
what we find sacred

0:12:03.080,0:12:05.497
and how we want to write[br]the chapters of our lives,

0:12:05.521,0:12:07.355
whether it's the last

0:12:07.379,0:12:08.776
or the last five.

0:12:10.258,0:12:11.672
What we know,

0:12:12.277,0:12:13.664
what we have proven,

0:12:14.475,0:12:17.012
is that this conversation[br]needs to happen today --

0:12:17.946,0:12:20.005
not next week, not next year.

0:12:20.029,0:12:22.859
What is at stake is our lives today

0:12:22.883,0:12:24.683
and the lives of us as we get older

0:12:24.707,0:12:27.247
and the lives of our children[br]and our grandchildren.

0:12:28.310,0:12:30.183
Not just in that hospital room

0:12:30.207,0:12:32.117
or on the couch at home,

0:12:32.141,0:12:34.529
but everywhere we go[br]and everything we see.

0:12:36.326,0:12:41.546
Palliative medicine is the answer[br]to engage with human beings,

0:12:41.570,0:12:45.024
to change the journey[br]that we will all face,

0:12:46.304,0:12:47.804
and change it for the better.

0:12:50.148,0:12:51.555
To my colleagues,

0:12:52.823,0:12:54.087
to my patients,

0:12:54.702,0:12:55.876
to my government,

0:12:56.303,0:12:58.362
to all human beings,

0:12:58.386,0:13:01.756
I ask that we stand and we[br]shout and we demand

0:13:02.641,0:13:04.232
the best care possible,

0:13:05.352,0:13:07.582
so that we can live better today

0:13:07.606,0:13:09.287
and ensure a better life tomorrow.

0:13:09.311,0:13:11.278
We need to shift today

0:13:12.452,0:13:15.333
so that we can live tomorrow.

0:13:16.838,0:13:17.989
Thank you very much.

0:13:18.013,0:13:19.301
(Applause)