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Colfax Avenue here in Denver, Colorado
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was once called the longest,
wickedest street in America.
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My office is there in the same place,
it's a medical desert.
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There are government clinics
and hospitals nearby,
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but they're not enough to handle
the poor who live in the area.
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By poor, I mean those who are on Medicaid.
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Not just for the homeless;
20 percent of this country is on Medicaid.
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If your neighbors have a family of four
and make less than 33,000 a year,
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then they can get Medicaid.
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But they can't find a doctor to see them.
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A study by Merritt Hawkins
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found that only 20 percent
of the family doctors in Denver
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take any Medicaid patients.
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And of those 20 percent, some have caps,
like five Medicaid patients a month.
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Others make Medicaid patients
wait months to be seen,
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but will see you today,
if you have Blue Cross.
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This form of class discrimination is legal
and is not just a problem in Denver.
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Almost half the family
doctors in the country
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refuse to see Medicaid patients.
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Why?
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Well, because Medicaid pays less
than private insurance
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and because Medicaid patients
are seen as more challenging.
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Some show up late for appointments,
some don't speak English
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and some have trouble
following instructions.
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I thought about this
while in medical school.
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If I could design a practice
that caters to low-income folks
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instead of avoiding them,
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then I would have guaranteed customers
and very little competition.
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(Laughter)
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So after residency, I opened up shop
doing underserved medicine.
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Not as a non-profit,
but as a private practice.
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A small business,
seeing only resettled refugees.
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That was six years ago,
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and since then we've served
50,000 refugee medical visits.
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(Applause)
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Ninety percent of our
patients have Medicaid,
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and most of the rest we see for free.
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Most doctors say you can't
make money on Medicaid,
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but we're doing it just fine.
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How?
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Well, if this were real capitalism,
then I wouldn't tell you,
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because you'd become my competition.
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(Laughter)
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But I call this
"bleeding heart" capitalism.
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And we need more people doing this,
not less, so here's how.
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We break down the walls
of our medical maze
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by taking the challenges
of Medicaid patients,
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turning them into opportunities,
and pocketing the difference.
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The nuts and bolts may seem
simple, but they add up.
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For example, we have no appointments.
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We're walk-in only.
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Of course, that's how it works
at the emergency room,
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at urgent cares and at Taco Bell.
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(Laughter)
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But not usually
at family doctor's offices.
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Why do we do it?
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Because Nasra can't call
for an appointment.
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She has a phone, but she
doesn't have phone minutes.
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She can't speak English
and she can't navigate a phone tree.
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And she can't show up on time
for an appointment,
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because she doesn't have a car,
she takes the bus,
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and she takes care of three kids
plus her disabled father.
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So we have no appointments;
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she shows up when she wants.
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But usually waits less
than 15 minutes to be seen.
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She then spends as much
time with us as she needs.
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Sometimes that's 40 minutes,
usually it's less than five.
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She loves this flexibility.
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It's how she saw doctors in Somalia.
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And I love it, because I don't pay
staff to do scheduling,
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and we have a zero no-show rate
and a zero late-show rate.
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(Laughter)
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(Applause)
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It makes business sense.
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Another difference is our office layout.
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Our exam rooms open
right to the waiting room,
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our medical providers
room their own patients,
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and our providers stay in one room
instead of alternating between rooms.
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Cutting steps cuts costs
and increases customer satisfaction.
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We also hand out free medicines,
right from our exam room,
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over-the-counter ones
and some prescription ones, too.
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If Nasra's baby is sick,
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we put a bottle of children's Tylenol
or amoxicillin right in her hand,
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she can take that baby straight back home
instead of stopping at the pharmacy.
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I don't know about you, but I get sick
just looking at all those choices.
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Nasra doesn't stand a chance in there.
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We also text patients.
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We're open evenings and weekends.
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We do home visits.
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We've jumped dead car batteries.
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(Laughter)
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With customer satisfaction so high,
we've never had to advertise.
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Yet are growing at 25 percent a year.
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And we've become real good
at working with Medicaid,
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since it's pretty much the only
insurance company we deal with.
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Other doctor's offices chase
10 insurance companies
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just to make ends meet.
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That's just draining.
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A single payer system is like monogamy:
it just works better.
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(Laughter)
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(Applause)
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Of course, Medicaid is funded
by tax payers like you,
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so you might be wondering
how much does this cost the system.
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Well, we're cheaper than the alternatives.
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Some of our patients
might go to the emergency room,
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which can cost thousands,
just for a simple cold.
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Some may stay home
and let their problems get worse,
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but most would try to make an appointment
at a clinic that's part of the system
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called the Federally
Qualified Health Centers.
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This is a nation-wide network
of safety-net clinics
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that receive twice as much
government funding per visit,
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than private doctors like me.
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Not only they get more money,
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but by law, there can
only be one in each area.
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That means they have a monopoly
on special funding for the poor.
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And like any monopoly,
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there's a tendency for cost to go up,
and quality to go down.
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I'm not a government entity,
I'm not a non-profit.
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I'm a private practice.
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I have a capitalist drive to innovate.
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I have to be fast and friendly.
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I have to be cost-effective
and culturally sensitive.
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I have to be tall, dark and handsome.
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(Laughter)
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And if I'm not, I'm going out of business.
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I can innovate faster than a non-profit,
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because I don't need a meeting
to move a stapler.
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(Applause)
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Really, none of our innovations
are new or unique,
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we just put them together in a unique way
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to help low-income folks
while making money.
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And then instead of taking
that money home,
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I put it back into the refugee community
as a business expense.
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This is Mango House.
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My version of a medical home.
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In it, we have programs
to feed and clothe the poor.
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An after-school program, English classes,
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churches, dentist, legal help,
mental health, and the scout groups.
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These programs are run
by tenant organizations
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and amazing staff,
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but all receive some amount of funding
form profits from my clinic.
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Some call this social entrepreneurship.
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I call it social service arbitrage.
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Exploiting inefficiencies in our
health care system to serve the poor.
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We're serving 15,000 refugees a year
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at less cost than where else
they would be going.
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Of course, there's downsides
to doing this as a private business,
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rather than as a non-profit
or a government entity.
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There's taxes and legal exposures.
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There's changing Medicaid rates
and specialists who don't take Medicaid.
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And there's bomb threats.
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Notice there's no apostrophes, it's like,
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"We were going to blow up
all you refugees!"
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(Laughter)
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"We were going to blow up
all you refugees,
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but then we went
to your English class, instead."
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(Laughter)
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(Applause)
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Now, you might be thinking
"This guy's a bit different."
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(Laughter)
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Uncommon.
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(Laughter)
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A communal narcissist.
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(Laughter)
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A unicorn maybe,
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because if this was so easy,
then other doctors would be doing it.
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Well, based on Medicaid rates,
you can do this in most of the country.
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You can be your own boss,
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help the poor and make
good money doing it.
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Medical folks,
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you wrote on your school
application essays
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that you wanted to help
those less fortunate.
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But then you had your idealism
beaten out of you in training.
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Your creativity bred out of you.
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It doesn't have to be that way.
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You can choose underserved medicine
as a life style specialty.
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Or you can be a specialist
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who cuts cost in order to see
low-income folks.
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And for the rest of you,
who don't work in health care,
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what did you write on your applications?
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Most of us wanted to save the world,
to make a difference.
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Maybe you've been
successful in your career,
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but are now looking for that meaning?
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How can you get there?
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I don't just mean giving
a few dollars or a few hours,
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I mean how can you use your expertise
to innovate new ways of serving others.
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It might be easier than you think.
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The only way we're going to bridge
the underserved medicine gap
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is by seeing it as a business opportunity.
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The only way we're going to bridge
the inequality gap
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is by recognizing our privileges
and using them to help others.
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(Applause)