When i was growing up. My father was a plant geneticist so we found ourselves moving around quite a bit because he ended up going to places that focused on crop science. We spent some time in wales and then we moved back to india in 2007 and i spent a year there and for those of you who know a little bit about modern indian history, it was 1976 the year of the emergency rule a tough time for academics and there were a lot of restrictions on free speech. My father decided we have to get out of here so we ended up emigrating to the United States in 1977 and eventually ended up settling in setting california and that is where i grew up. Like i said my father was a plant geneticist. My mother was of biochemist who worked part time but mostly was of homemaker and she spent time raising s and they wanted me to become a doctor. In that generation especially among immigrant indians there was nothing more noble and better that you could do. Sort of coloring their vision was the fact that they had come with no money, Financial Insecurity and they thought this will going into medicine will confer stability on our children and allow them to do good for the worlds. I didnt buy into that when i was growing up. I have a lot of other interests besides science. I remember when i was growing up in india i would spend time with my grandfather a family practitioner in new delhi and i would watch him work and what he did was find. It was reasonably interesting but it didnt appeal to me deeply. Might 10yearold minds thought this is kind of cook book and i dont want to pursue medicine and i didnt see how medicine was going to allow me to develop my creative impulse and i was wrong about that actually but at the time so i was interested in a lot of Different Things so my mother would sort of pushed me to become a doctor. One reason she would say, the, doctors of people will stand when you walk into the room. It didnt work out that way. In the end i ended up going to berkeley. I was very interested in the mysteries of the universe so i decided to become of physicists. In immigrant indian culture, rebellion is saying no to a career in medicine and going into physics. I was really the rebel. So i went to berkeley and studied physics and graduated from undergrad and decided i was going to continue with physics. I wasnt sure what i wanted to do, but to go to graduate school and studied a very esoteric object called a quantum dots and i can talk to you about it afterwards. Of very interesting entities that is sort of like an artificial adam. I became a writer. Studying quantum dots, this was so far removed from what i am doing today, what ended up happening, there was a confluence of things. Any of you who have done research especially graduate Level Research know that it is very slow and i found myself struggling with the equipment, broken vacuum pumps. So the progress was incremental at best and right around that time someone who was very dear to made developed a severe case of lucas and in an effort to help her eyes ended up going to support Group Meetings and talking to doctors and gradually got more interested in medicine as a way to help her but also was fascinating to me how much was uncharted. How little was known about lupus or chronic disease in general and being a physicist, i had this idea that if i dug deeply enough i could figure things out for her and it became very clear is that medicine really is a science of incredible uncertainty and is largely uncharted and that was appealing to the scientist in meade but the biggest appeal, i started to see medicine as away to help people. Sounds naive, but it was the biggest motivating factor for me was at the time when i was sort of toward the end graduate school i desperately wanted out of the ivory tower. I wanted to be with people. I wanted to interact with my fellow human beings and i remember my brother, who is a doctor he is a cardiologist, in a residency at the time, he visited me once and sort of walked around my lab. I showed him the laser and all the cool stuff i was doing and he looked at me and said this is such an ivory tower and i remember thinking, you know, it was the worst thing you could say to me at that moment because it really stimulated me to make a big change. I ended up finishing my ph. D. And applied to medical school. I firmly believe in serendipity. I have always been interested in writing, but had no opportunities to write and other than scientific writing. So after i applied to medical school and had gotten in i was walking in the Physics Department one day and i saw a poster for a science journalism fellowship and sort of 5 when i was in high school, i like to writing and i should do something and i sort of had the summer off before i was going to go to medical school so i applied on a lark to the science fellowships and to my utter amazement ended up getting it and i went to Time Magazine for the summer before i went to medical school and time was an amazing experience for me because i have always been interested in politics and it was just it was it seemed so glamorous. I went there and first week i was there they sent me to the u. S. Capitol to get up quote from bob dole about the working poor. I had never interviewed anyone and i was a physicist. What did i know about it . So i applied my physics acumen, how am i going to all these reporters in the New York Times, cnn they are trying to he was majority leader at the time, trying to get to him so how am i going to work my way in . I figured you know what . I will hang out by the bathroom because i knew he had a prostate condition and he was going to end up in the bathroom at some point. So the land the holds i was just hanging out by myself and he walked in. And i was so nervous i looked at him tall man and i said a bunch of gibberish i am sure it was gibberish and he sort of looked at me and kept walking, completely ignored me so after he came out, done with his speeches and so on, i was talking to his press secretary and trying to get him to get me five minutes to get my quote so people at Time Magazine dont think i am a total loser and so the press secretary was in the process of blowing me off and bob dole walks up and i will never forget this. He said this is sandeep jauhar. He is an intern at Time Magazine and he wants to quote from the about americas working for. Setup the five minute phone conversation. This is what he gleaned from what i was sure was a bunch of nervous gibberish because so really admire the man. And i end up speaking to him the next day and got my quote and so i got bitten by the writing bug that day that week. So when i finished at that Time Magazine, it was the end of the summer and i was supposed to go to st. Louis, to Start Medical School so i went and talked to the bureau chief of Time Magazine, a guy named dan goodgame. I really like writing and maybe i should become a writer, work at time and he is like go to medical school. You dont want to end up and being stained wretch like me. Give me some names of people i can call in the future if i want to try to write about missing . He said sure. Gave me the name of someone, half a trillion, miami herald, but what about the New York Times . All right, sure. Gave me the name of one of the top editors so i went to st. Louis. The first few weeks were tough going from Time Magazine to the anatomy lab and memorizing muscles and nerves. One day i decided to call up this guy at Time Magazine and i really believe that such an Important Role for serendipity in our lives. I ended up calling this fellow gerald a bullet, and he has since passed on, but he was the National Political editor at the time and i didnt know it but he was i believe he was the panelist who asked Michael Dukakis what he would do if his wife were raped and murdered . So he had tremendous influence on the 1988 political president ial election. I didnt notice this at the time. I called him up and was in the process of speaking to someone and suddenly he gets on the phone and i said look gerald boyd what do you want . I was sort of telling him i was a medical student and then it turned out he was from st. Louis. Not just that he was from st. Louis but he actually had lived on the same streets i was currently living on, kings highway. So he started asking me where do you live . You are in medical school and at the end of the conversation he said next time you are in new york give me a call and we will have coffee. I said that is wonderful so i did what any aspiring writer would do up the phone, called American Airlines and book the flight to new york. Is then i called his assistant and i said i am coming to new york and mr. Boyd wants to meet with me. And who are you . So anyway i went to new york, they showed me into his office and i am looking around and there are pictures of him with george bush and the premier of china. At that point i was thinking all right, maybe you dont really know what you are doing. So he walks in and his tone had totally changed from the conversation lisa i have two minutes what do you want . So i started telling him that i wasnt in medical school but really wanted to be a writer and could i write for the New York Times . And he said show me your stuff. I said i dont really have any stuff. I tried to explain how at Time Magazine you dont get stuff. You just get quotes. He looked at me like i was totally crazy but he did do an amazing thing for me. He called in elizabeth rosenthal. She is a doctor and some of you must have read her pay until it hurts series for which i hope she gets the pulitzer but she came in and she said she went to harvard medical school. She was working as a journalist full time but doing a Little Medicine on the side. She said this isnt how you do things. Go back to medical school and see if you can write for the local paper tried to get a portfolio and then send me your stuff. I went back and ended up going to the st. Louis postdispatch and i met a fellow there a very good guy an editor named john curley who had grown up in manhattan and he had taken a liking to me and admired my gumption in coming and asking for an internship and in the end offered me an internship and then faced with this decision, how to i do an internship at the st. Louis postdispatch while i am in medical school . I called my brother and said i have an opportunity, i kind of want to do it but they are going to keep track. I cant be away from medical school for large amounts of time and he said you know what . There are many hours in the day. Remembered that and i thought i am going to go with this. I went to the st. Louis postdispatch and they started giving me stories. I would drive out there after morning classes, skip the afternoon and read the transcription and show up at 1 00, my editor there would say you know what . We want you to write there are a lot of people getting stung by wasps. We want you to write a piece about people getting stung by wasps and you have until 5 00. It would just be like okay, and it was trial by fire and i did a few featured pieces as well, one on diabetes and i did a profile of a surgeon and i would send my stuff to the New York Times to libya and she would read it and sometimes she would respond and sometimes she wouldnt and i had a little portfolio and the next step in serendipity was when i finished mid school i ended up getting an internship in new york and at New York Hospital so i called libby and the science section of the New York Times had a new editor. A woman named cornelius been. When new people come in they want to mix things up and bring in their own people. So i was one of her people. She took a liking to me and i pitched an article about a leprosy hospital in carville, louisiana. She said sure. We will send a photographer down. Go down and do the story so i went to cargill and stayed two or three days and wrote this piece and it came out about three days after i started my internship and two days before i met my wife, sonya. It was an eventful week. And corey dean would say why dont you write about your internship . I said okay. It turned out to be a great indication, because in an internship everything is new. As you go on in medicine you get jaded. You see things and you start questioning but when you are and in turn everything is new is rubles a year end up with i dont give a hoot what i write. I am going to write about what i see and the things that interest me and the things i am going to question. I remember one of my early pieces as an intern, there was a fellow in hospital and who was having difficulty swallowing and when he would swallow food would go into his lungs. Everyone was getting ready to put in the feeding tube into his stomach. The thing was he kept saying i dont want the feeding tube but no one was listening to him. I was on the team and whenever i would bring it up people would say what i you saying . What is the alternative . The alternative to me was listen to what he is saying, let him eat edit he dies of desperation pneumonia, that is the way he wants to live. But because it was such an egregiously crazy choice, who wants to die, people declared without capacity. You cant make your decision. They are getting ready to put in the feeding tube. It was so bothersome to meet at i remember one morning i went to his room and i said they are going to go for your feeding tube today and he said i dont want it. I said you know what . And i went to the refrigerator and brought out some thin liquids. I said here. Drink this. He hadnt drunk anything in over a week, maybe two, and so he drank it and maybe he coughed a little bit, he drank it and i said i documented his charge, did my own swallowing study and he can swallow. He doesnt need to a feeding tube. I called the surgeon and just called it off. Those are the things you need to experience when you are naive because now today, honestly if i were walking through the ward and i saw a guy like that who couldnt swallow and was getting ready to get a feeding tube i would probably just let him get it because i wouldnt be invested. When you are an interim you are investing your patients in a way that you arent, you dont know them as well as you move on. And that is unfortunate but it is the reality. Those are the things i started to write about, things that interested me. Things that seemed ethically or dubious and so by the time i was done with my residency i had 15 or 20 pieces in the New York Times. By then believe it or not i had a book agent who said you should write a book. I said oh sure. I just wanted to have an agent. I thought was cool to have an agent. At the end of my residency i said look why dont we just take my pieces and staple them together and call it a book . We pitched that idea which didnt go over very well. The editor, of my publisher said we dont really like your idea but we have an idea. Why dont you write about your residency, a memoir of development, novel of education . That is what i ended up doing and got turned into my first book which is called in turn. End there are a lot of pieces i published as the president but a lot of stuff i didnt publish. One thing corry told me was the diary and write down the stuff that is interesting to you. So i did and i thought it was so important. When young doctors and aspiring writers asked me how do you get started . I say you have to record your reflections. Ill say a few things and then well take questions. So when i took my job, my current job at long island jewish, it was in the july of 2004 one month before my son mohan was byrne. And i was born. And i had been in school for 19 years. Nineteen years after graduating from high school. Remember, i had that quantum detour. [laughter] so i was just ready to be done and, you know reap some rewards for all that, all those sleepless nights x. What i found and what i found was that doctors were very unhappy. And, you know, when youre in training, the focus is on the physiology and learning about the heart. Its not really about the culture of practice. So i was largely blinded to that. And then i took on my first role and im talking to doctors, and i find that theyre very unhappy with medical practice today. And it wasnt just about the stresses that we all know right . It wasnt just about the paperwork and the malpractice fears and so on. There was a deeper problem. There was what i started to think of as an existential crisis. It was more that doctors felt that they werent being able to Practice Medicine the way they were trained to practice the way that they aspired to practice. And that was deeply troubling to them. And so i sort of watched this and learned a little bit, but i was fairly happy. I was in academic practice and working with trainees, and i specifically chose an academic practice because with i wanted to teach, i wanted to be around young people and residents and people who had that naivete that i had. I wanted to hold on to. But shortly after i started in my practice i found myself with a significant amount of debt and feeling that i had to moonlight to make ends meet. Started a new family and most folks will be surprised that a lot of academic physicians do that. They moonlight on the side. And one of the reasons we choose academia is that we want to be around, you know academics, we want to be around young physicians, we want to teach. But, you know, the Salary Structure is very different. And in american medicine today, youre rewarded for doing as much as possible right . Its the feeforservice model. Do more, more, more. And one of the reasons why i chose academic medicine is i didnt want to be in that position where i had to do more and more and more. But then i found that i had to start moonlighting. And i found a practice in queens with a cardiology friend of my brother who offered me this gig going, doing stress tests and supervising stress tests on the weekends. And this is where i really learned about how medicine is practiced in some parts of this country. Now, most doctors are good. But theres no question that there is a subset in my profession that has taken advantage of the feeforService System. And its not, you know, you can call it whatever you want with. You know, some doctors will will get upset by the implication that theres fraud going on. Lets not call it fraud. Lets say the system creates a moral hazard that encourages doctors to respond to financial incentives. And this is happening. Okay . When i was a resident, when i learned about health care economics, there have an example of there was an example of a Orthopedic Group that under the feeforService System was doing 300400 total hip replacements for a year. When they went to a bundled model, that number dropped from 200 to 300. I dont remember the exact number, with two one. One total hip replacement. So you cant tell me doctors dont respond to financial incentives. We do. Doctors are just as human as anyone. And so im working in this practice and it was a mill. There were literally this line of unsuspecting patients getting ready to have stress tests, many of which were honestly unnecessary. And the more i worked there the dirtier i felt. I felt really dirty that i had to do this, but i felt like i had no options at that point with the financial situation i was in. And so that precipitated to a crisis in me. It was a, maybe it was a midlife crisis. I dont know what it was but it took a toll. It took a toll on me, it took a toll on my relationship with my family. And the book is what i talk about as the midlife crisis of american medicine but its also about my personal midlife crisis and how i worked my way out of it. And eventually i did. And i was able to reinvigorate my personal relationships, and im in a much better place today than i was about six seven years ago. However, american medicine, i believe, is still in a crisis. Okay . So what are we going to do about american medicine . Theres no simple solution, unfortunately. I think that the feeforService System does create a lot of problems that eventually i believe will need to be addressed, and the system will need to be supplanted by Something Else. And i dont know exactly what that system will look like. But its going to happen. Its happening. Anytime you have a huge system that is responsible for one out of every six dollars that we spend and its so dysfunctional, then its going to get to a tipping point. And i believe its at that point. Because you cant have a system thats so gargantuan that affects all of our lives and have no one be happy with it. Right . I i mean, doctors are unhappy, but most importantly patients are unhappy. You ask any patient, okay, patients are smart. They know when theyre getting the short shrift okay . They know when their doctor isnt listening to them. They oftentimes suspect that theyre being asked to undergo unnecessary tests. They know whats going on. They know that they cant find a primary care physician today. Or if they do, they have to wait three months to get an appointment in some part of this country. So theres a lot of disfunctionalty in the system. It dysfunctionalty in the system. It will change. Now, for doctors i think that we have to reclaim whats important to us, okay . The system is in a state where Insurance Companies the government are in many ways telling us how to practice. And a lot of doctors feel almost like pawns in this system. And, you know, when i graduated from medical school the graduation speaker had some wise words. He said, he said the things that you hold near and dear and stick to them. So and i think those words apply just as much to me now as a midlife practitioner as they did when i was an intern. We have to identify whats important. And for me in the end its about the human interactions. And if you talk to doctors who are unhappy, okay, even the unhappiest doctors will say the best part of their jobs is interacting with people, talking to people. And that is something that no entity can take away. So for me its always about the human moments and or what i like to call the gentle surprises. So im going to try to give you one story about the gentle surprises of medicine. So i remember when i was a third year resident i was i went to the emergency room in the south bronx, ask i had a two and i had a two week stint there. Late one night i was asked to drain the fluid out of the belly of a woman with alcoholic cirrhosis. So her belly was full of fluid. And its a very brute force procedure. You put a needle in hook it up to a tube put the tube into a bucket and just drain the fluid. So i went in, i introduced myself, and i said im here to drain the fluid out of your belly. And she said okay sure, go ahead. And she still had alcohol on her breath okay . So i said okay. I cleaned her belly with iodine soap, and i put in the catheter, the needle to the catheter and put the tube into a bucket, and i started filling buckets. And i said, look, if you move and this comes out, im not putting it back in. And she said okay, sure. You know . So im just there watching this fluid drain, and a nurse comes in and says dr. Jauhar, you just got paged. Because she was carrying my beeper. And i said, oh, okay. Well can you keep an eye on her while i go out and answer my page . She said, sure. And i reminded my patient if you move and this catheter comes out, im not going to put it back in because i have another ten patients to see. She said, okay. I go out answer my page. Three minutes i walk back into the room, and the catheters out, the buckets are all upturned, and theres, like, fluid all over the floor. And i was like oh, my gosh. So i, i look at her accusingly and i said, i thought i told you not to move. And shes, like doctor, i didnt. A man came in here and had a seizure on the buckets. I was like, oh god. [laughter] and then the nurse walks in, and i said i thought i told you to keep an eye on her . She said i did, but then the man walked in here and had a grand mal seizure on the buckets. [laughter] this is what doctors experience. [laughter] and these are special moments. No Insurance Company can take that away from me. [laughter] okay . We doctors have to become more conscious about what kind of physician we want to be and i write in the book about sort of three professional archetypes; knights, knaves and pawns. And in my parents era, in my grandfathers era doctors were knights. They were, they were admired like no other professional group. Right up there with astronauts. And for good reason. American medicine improved patients longevity from 65 to right before world war ii to 71 less than a generation later. Talking about an improvement of six or seven years of life. And that was because of pole e owe vaccinations and antibiotics polio vaccinations and coronary bypass surgery and pacemakers. Doctor cans really delivered. They were knights. And then doctors went through a phase where they became thought of as knaves, and the whole culture shifted. Okay, when doctors were knights that was the era of general hospital, you know . Early on when doctors were just, you know, dr. Kildare. But then during this knavish period you saw a change in the culture. It was the era of m. A. S. H. , you know, and hawkeye. Hawk item eye was a hawkeye was a great doctor, but he was flawed. Then there was e. R. That painted doctors as human, as flawed. So i talk about knights knaves and pawns. And the reality is that doctors are all three. We all have a touch of these three professional archetypes in us. And we have to try to bring out the best okay . And we have to do it in a culture that doesnt really understand what were going through. And ill tell you one last story, and then ill take questions. So when i was a resident we used to round in the intensive care unit. So there was a one night when i had been on call and the following morning we were rounding on our patients, and anyone whos been in an intensive care unit or worked in an intensive care unit knows the horrible tragedies that happen in icus. And our intensive care unit was no different. There was a guy who had been misdiagnosed with a slipped disc and had actually severed his spinal cord and was now completely paralyzed. And there were, you know patients who had multiple myeloma who were on ventilators, and it was just, you know, it was a horrible unit. And so, and so our team had stayed up all night, and we were rounding. And we were rounding with an attending named abe sanders. And abe was a great attending. He was a jocular fellow. And so we were going through, and we found ourselves in the room of a patient who was on a ventilator and we were parenning the case presenting the case. And sanders sort of like looked off, and he was looking through the window. Any of you who have been at New York Hospital know that theres a greenberg pavilion that looks out onto the east river. So sanders said come over here. Look out the one doe. And it was window. And it was a brilliantly sunny day, and there were boats on the river. And we looked down and there was a boat, and there were a few people on the boat. And they looked like they were having a great time, you know . Sipping bloody marys, and they all looked beautiful, you know . And we were like, you know sweaty and disgusting and, you know, had been on call all night. And there was a fellow onboard who was lacking up at the hospital looking up at the hospital, and it turned out he was looking up right at the window that we happened to be standing at. And sanders said, um, you see that guy down there . And i looked at him and, you know, he was about sanders age but he was fit tan, and he was with, you know all these Beautiful People and he was looking up, and he said see that guy down there . Do you know what hes thinking . And we all like looked and it was like, oh, are we going to go through this . We just want to get out of the hospital. Lets just finish rounds. Do you know what hes thinking . I looked down, and none of us ventured a guess. And sanders looks at us and says, that guy is thinking i should have been a doctor. [laughter] and this is what we struggle with as physicians, because people still view our profession in simple terms. But today i have a more nuanced view of medicine. And doctors are not perfect and our profession isnt perfect. But i do feel that doctor cans still want to be doctors still want to be knights. And i think that theres a lot that we have to go through in the next 10, 15, 20 years. We need to figure out a way to reclaim our professionalism. We need to figure out how we want to practice. We need to improve access to medical care. We need to control costs otherwise were going to bankrupt our economy. So theres a lot that we have to do. But american medicine is technologically the best in the world, and i fervently hope that well find some solutions to the mess that were in so that medicine can really reclaim american medicine can reclaim its place as unquestionably the best in the world. So i will end there and take some questions. But thank you so much for coming. [applause] im writing abouty mr im writing about my mothers end of life [inaudible] this is where i find that doctors dont listen anymore. [inaudible] clear in her chart and yet every time weve gone to the hospital with her which were no longer doing the doctors talk to her and ask her questions, and she cant speak. And this goes on and on and on, and you tell the doctors over and over again she has no capacity to answer her questions. We are her advocates. Thank god she has advocates. But, i mean, this has gone on and on, you know with physicians that dont pay attention. Shes, obviously gone. Uhhuh. And yet they continue to ask her, how do you feel . What do you want . And its extremely frustrating. When i finally found a doctor who would listen to me and said no more hospitals, no more interventions, hospice, cocktail s, i wept. Yeah. I literally wept. I sat and cried. I said i cant believe youre actually listening to me. Yeah. So, i mean thats profound. I think, you know, unfortunately, your experience is not unique. Endoflife care is probably the single weakest link in the american medical system. And youre with absolutely right. Unfortunately, your intuition is probably correct, the doctors didnt listen to you. And i see this, i see this every day, you know . We go into a patients room and we say do you want this, this or this, and we present the information in ways that they dont understand. Sometimes they cant process it because theyre sick, theyre anxious. And we do it all in the name of patient autonomy, right . The patient made this decision. Were giving the patient the decision. But patients dont always want the decision. They want to be guided in many cases. And, you know, i remember one case ill tell you very briefly of a gentleman who came to the hospital and had apparently told all the doctors who had taken care of him that he never wanted to be ip due baited. And intubated. And so he was in a situation where he was bleeding into his lungs, and i get a phone call saying that we did all, you know, we put in the stent, whatever and hes bleeding into his lungs, and he doesnt want to be intubated. And he was a young guy. And the choice was just let him drown, bleeding into his lungs just let him die or do manager about it. And or do something about it t options, probably ive done it myself and then not really thinking about whether the patients understood the options. So, in this particular case, i knew that the interns and residents hadnt done a good job explaining to this fellow they probably asked him, if you were would you ever want to be on a breathing machine . And he probably said, no i dont want to but he didnt know exactly what he was signing up for. So they were going to actually let him die. and i said, im sure you didnt have the kind of conversation you needed to have with this fellow. Im going to put the breathing tube in. So we put the breathing tube in, and even though he had written in the chart do not rhesus rhesush resuscitate, and we had a tough course and we eventually got the tube out, and i went off service. I came back on service, and i went to his room, and i said i was the doctor who decided to put in the breathing tube, and i know it was written in the chart you didnt want it but you would have died if you didnt get it. And he said, ive been through a lot. But thank you. And so we have to improve the communication because we cant just throw it all on the patient without guiding them. So, thank you for your comment. Id like to say congratulations for making your life an adventure, rather than a goaloriented, allowing things to bring you greater the research and the opportunities you have taken advantage of. I applaud you for that. Thank you. Number two the question is, what kind of oppositions or hurtles have you had to hurdles have you had to overcome or deal with in doing your Research Writing your books . Im sure that everybody isnt patting you on the back. No. Im curious. Ive been pleasantly surprised that a lot of physicians have supported me in my writing. Especially my colleagues. Because doctors and patients arent stupid. They see the system the way it is. They know theres a lot of stuff going on. Some of it moral hazard nefarious, whatever you whatnot to call it. Its funny that there was a group of doctors, i would say that is shocked. Maybe theyre shocked i wrote about it or shocked this stuff is really going on. Im not sure. And theyve been fairly negative and vocal in their opposition to the book and then theres this group of doctors many of whom come up to me in the hospital and say doctor i heard you wrote this book and it was in New York Times best seller. And you write about [inaudible] everyone knows this is going on. And so its been a mixed response but ive been pleasantly surprised that a lot of people have been supportive. Thank you. After seeing your wonderful review of id like to hear more particular live you being a cardiologist and physicist, how you feel technology will change the interaction between patient and the physician. I think its already changed interaction. How many of you go in and gooddo see you doctor and he or she doesnt look up from the computer screen. And this happens every day. With Electronic Medical records. And i think the Technology May help us work our way out of that mess with better Voice Recognition software so that he writes about that, where well have software that will transcribe exactly what the doctors and patients are saying that you can edit later, but topol writes about virtual visits and telemedicine. I dont know how its all going to pan out. Im not sure if the quality will be there. The diagnosis at a distance. I personally feel that i need to see the patient listen to the patient, before i can make a good treatment plan, because every doctor has been through this. You read up on the patient youre going to go see, and they have a million issues, problems you read on the paper and then you walk in and theyre reading the New York Times, and then you think that really totally changes how you see them. So i think that the direct facetoface interaction is critical and not to mention that a machine is never going to be able to confer a healing touch. Theres something about just touching your patient that is beneficial. So i think technology will play a role in changing and hopefully improving alaska certification but its never going to replace a doctor. Or nurse. I would like to ask you talked about what your fellow physicians think about your writing, but i thought you were brutally hospital about your mother, about your father about your fatherinlaw, and even about your wife. So what did they have to say . Well, my wife is also a physician, and she has been on the journey with me, and she knows the crisis i went through. So i think she knows what is in the book. And she has read excerpts of it. I think she sort of has adopted a policy of benign neglect, like she doesnt want to Read Everything because she knows it all already. My brother, he is pretty hearty fellow thick skin, tough skin. He said, you do whatever you want and but overall my family has been very supportive, i think, and especially sonya who lets me do these things in and sort of keeps everything going and is a fantastic physician in her own right. So ive been lucky. But its always that dubious spot when youre writing a memoir and writing about your life because on one hand when your life is into intertwined with other peoples lives your story is partly their story so how do you disentangle the two. You cant. So i sort of when i was going through what was a tough crisis for me, i sort of adopted the policy of, im just going to write what i think, and so be it. And fortunately my family was supportive. You say that the system has to change to reduce the cost of health care. And you said you didnt know exactly how. Im sure you have had some thoughts. Ive been involved since 1960 and in 1970 we said it was out of control. And so its still out of control. One time we thought maybe corporations having to pay the bill would be the catalyst. But obviously corporations just moved overseas and now theyve stopped paying for health care. Whats the catalyst that will cheat a change . When you talked early 1970s, that was in the nixon era, and nixon to his credit, saw the problem and actually instituted price controls on a number of industries, including health care, and then lifted them on a number of industries but kept them on health care. And then he was a republican. So price controls for a republican, you know he knew that the system was careening out of control. I think the percentage of gdp of health care in that era was Something Like nine percent, and today its closer to 1819 . So its a huge problem. I think the fee for Service System had to be supplanted by replaced by Something Else and i dont know how many of you read Steven Brills knew new book. I think that he identifies the kaiser model as being the way out of the mess, where physicians and Healthcare Systems issue their own insurance product. They collect the premiums and they have the natural innocenttive to limit costs. Of course you have to put in various protections into place so they dont unnecessarily limit spending, but i think the kaiser model is a very reasonable one. I grew up in southern california, in the 70s and 80s and we went to kaiser and we got perfectly good health care. Some people advocate a single payer system. I dont see that happening in this country. What works in abroad doesnt wont work in the United States. I dont think. I remember one of my professors, who is teaching healthcare economics, was talking about the National Health service in england and then someone asked him, why dont we just do that here. He is like, america is too different. In england they live in a rainy climate, they drink warm beer, they learn to tougher it out at a young age. Thats not going to work in the United States. And hes probably right. So we have to tweak the system we have. If wore going build the system from scratch, i think the single payer system is the best system. Enjoyed your books and i think your second book is a wonderful book because it describes the realities of the practice of medicine today. I think a lot of people dont understand the reality of practice of medicine today. Im also a physician and i can relate to your book, particularly because i also met my wife as an intern at the New York Hospital. She is here. The question i have is not a medical question. Its more of a literary question. How does a writer doctor find an agent and deal with an agent which is something you dont learn in medical school. I was fortunate because i was writing for the New York Times so the agent actually found me and reached out to me. But lets talk arwar. Writer . [inaudible] well, find me