To me as one of those who represent a Success Story of a great specialized care system, spinal cord injury and disease system of care. Before i get into exactly what the topic is, though, i want to ask a couple questions. What are some of the reasons why one becomes a clinician . Why did you choose to become a healer . Money . Raise your hand if its money. Bunch of millionaires in here, right . Social status. Everybody respects a doctor. Job security. Youre always going to have people focused on getting better, so you need people in those industries. And if youre a healer, youve got some job security if you do it well enough, and its probably a combination of all of those. But again, from the perspective of the patient, im willing to bet that somewhere on that list of what brought you into your respective discipline was a sense of compassion. What is compassion . Its a feeling of deep sympathy and sorrow for another who is stricken by misfortune. Who are we talking about . People who have become disabled, been diagnosed with a disease, but its accompanied by a strong desire to alleviate the suffering, so that puts you in the position of the healer. And as clinicians, thats what you do. You literally alleviate suffering. So, by show of hands, how many of you are va clinicians . Among you, who can undoubtedly say that you demonstrate compassion in your clinical work with each and every patient you touch . Each and every one of them. Its not a lot of hands. It should be more than that. You should all be raising your hands. Or you try. At least you aspire to show compassion. Show of hands if you aspire to show compassion with each and every patient. All right. So, tell me this, then why are we in this position where you enjoy the privilege of providing care for our nations bravest, our heroes . Is your system in a position now where it may go away . Why . Were not talking about the expansion of care. Dr. Yehia will talk about the excellent plan va has to make it successful. Im specifically talking about the spinal cord system and disease way of care thats enduring an earthquake and were testing its foundation. How did we get there . What happened . Now, given all thats happened, we can talk about phoenix, we can talk about toma, we can talk about all the other major things, but im talking about what i see when i go to your individual facilities and i talk to the nurses about morale, i talk to leadership about making Foundational Mission a priority, im talking about when access to care is denied. I know you all sincerely believe you show it, i believe that. And a question today, though, is it enough . I dont believe its enough, not with whats going on today. So lets take compassion a step further and separate the power to heal from another critical aspect of care that we consider important. Empathy. The psychological identification with or vicarious experiencing of the feelings, thoughts, or attitudes of another. And who are the another in this case . Veterans. Who suffered trauma, who suffered disease, combat trauma, sexual trauma, exposure. This is who were talking about. Now, how is empathy different from compassion . Unlike compassion, empathy is not about alleviating suffering, its about something rarely, if ever, found outside of the va, a military cultural competency that understands veterans. You wont see it outside the va in many cases. Its your Competitive Edge. When youre talking about competing with other systems, thats the edge you have, if you know what it really means. But the question is, do we know what it really means to be empathetic . And what role does it play in your role as healers . Thats the question were going to test this morning. So i want to do that by revisiting my journey, taking you on my journey. So i want you to bear with me. Close your eyes for a moment. And stretch. Close your eyes. I see you. Trust me, empathy. And i want you to stretch your imagination. [ explosion sound ] open your eyes. Thats how fast it happens. In a blink, no warning. That quickly. And at this point, stop moving. This side of the room, youre quadriplegics. Stop moving, please. On this side of the room, youre paraplegics. Youre lucky ones. Youre lucky. You get to move your arms and legs, but you cant move anything else, and you cant move. Bear with me. If your nose itches, you cant move. You cant. Youre paralyzed. You have to accept it. Over here, you can wave your arms, you can scratch, but dont stretch your legs, because you cant, and you just have to accept it. This is empathy. And i want you to take this journey with me for just a few minutes. While youre sitting there newly paralyzed, right now as you are, the next song you will hear after that accident you just suffered, its not a chainsaw or a lawnmower, its the jaws of life. [ drilling sound ] your car is cut open like a can. Things you remember are the smell of twisted, burnt metal, and its going to haunt you for the rest of your life every time you have that smell. Your body is extricated from the vehicle, and the last sound you will hear before going completely unconscious is this. [ sirens ] then it fades to black. And the first sound you will hear when you wake up is this. [ air and beeping sounds ] this is what it sounds like to be maintained by a machine, when you wake up to that sound. Thats what woke you up, in fact. And these are the next set of sounds that will haunt you for the next few nights as you try to figure out what the heck happened while staring in the dark. [ indiscernible voices ] hospital sounds, misery, cheerfulness, misery, a mix of everything. And youll be visited by a litany of people, people who are in your discipline, doctors, nurses, social workers, psychologists, nutritionists, as you face immobility, dependence, helplessness, sleeplessness, hunger, anxiety, depression, and nonstop pain. And meanwhile, your marriage, your kids, your bills, your classes, that thing you didnt get done, it all appears to freeze, but it doesnt. It simply moves on without you. And then all the preexisting conditions, all the choices you made that got you here, the diet, oral hygiene, the addictions, your education level, sexual trauma, exposure to combat, all that now unforeseeably matters and has an impact, but now it matters. And then your own mind begins to play tricks on you. You shake your head, even though youre paralyzed. Have you ever heard about the running dream that your patients have . This is the dream where typically at about 3 00 or 4 00 in the morning, just as the suns coming up, youre in the middle of a dream sequence where youre in a wheelchair. You now understand what happened to you, and your body starts to force you to think about what it was like before it happened to you. Youre in the chair, youre rolling along, and suddenly, you take the first step, you stand up, you take the first step, step, step, step, step, trot, trot, and youre running as fast as you can, and then you wake up. And no matter how hard you try, you cant go back to sleep to get back into that body that knew what it felt like to run. This is your mind doing this to you. Now i want to talk a little bit about my first family medical conference and the way it went. My uncle bill was a vietnam veteran, gunnery sergeant. When i became paralyzed, he was the one that came and sat in on the conference, and he had a lot of pride in his nephew, chief warrant officer, marine corps, drill instructor, and he didnt want to see me this way. And he said, doctor, is my nephew ever going to walk again . Doctor. No my thoughts are, what . Thats it . Its that simple . What about the 3 that walk again . Statistics. I might be one of that 3 . Youre a doctor. Youre not god. How do you know . How are you so certain that you can basically define my life in two letters, one word, no . And speaking of god, why me . Why . What did i do . Does anybody care . Now ive completed rehab, ive tried to move on with my life, my new life, and now im a veteran whos homeless. Now im an angry veteran. Now im noncompliant, im overweight, im making poor dietary choices, im a burden to you. Im a veteran being denied access. Im a veteran being denied the drug i need. Im a veteran who needs my wheelchair fixed right now. Im a veteran who fears retaliation if i complain. Im an undesirable. Im a human being and i need your help. Please dont make me wait. Please dont make me wait a second longer. Does anyone care . I wonder if thats the last question paul chism asked before he died, alone. Hes not an abstraction to me. This is a person that i talked to, touched, got to know. And i dont need to tell you what happened to him, because its right there. Heres the thing, though he became disillusioned with the relationship that he had with his providers and the va. Some of it was because he had a traumatic brain injury. He was an opioid abuser. There were reasons. An undesirable. And he said, you know what, im not doing this. Ill pay for my care in the private sector, ill cobble it together from different sources. Ill get an attendant here, have home care nursing here, ill have room care here. And over the course of his life that was cut all too short by his choices, he found out the hard way, the best care is in the va, is in the spinal cord system of care, for him, and he wanted to come back. The problem is, he was now a victim of his choices, and he became a victim of his choices, and he died wondering whether anybody cared about him. Now, because i care about you, im going to give you a gift that you cant give to me or to any of the paralyzed veterans in this room or to the 60,000 men and women who served their country and now live with paralysis. Please, move your legs. Move them around. Move your arms, quadriplegics. Move them, come on. Youre doing it for me. Move your legs. Stretch. Feels good, doesnt it . Now tell me how anybody whos a healer would ever deny access to care, ever slow down an admission, ever put something aside and make someone wait, who would never had that gift ive just given you, or leave a veteran in isolation or put policy and process and rules before compassion. I know youre all people, you have to make a living, you have to follow rules to keep your job, and youre professionals. Guess what, were not professional patients. You dont give us our purpose. We give you your purpose. Were why you exist, and im thankful that you exist. And so, in closing, we talked about this yesterday, there are forces out there that want to eliminate this specialized system of care. Again, were not talking about expanding to the community and all the things that have to happen to give greater access. Were talking about this specific system of care. And theyll move a step closer to being successful with every Paul Chisholm that we end up finding out about, every one of those Paul Chisholms is going to be the reason. Your Competitive Edge in these times is your ability to provide care with compassion, but more importantly, your ability to empathize. I want to thank you this morning for empathizing with me. Thank you. [ applause ] if your nose itches, you cant [ applause ] move. You cant. Youre paralyzed. I want to say to sherman, im one of those 3 . Im actually a pva member whos fortunate enough to be able to move my legs. But it rings very true listening to what sherman had to say, because what you do matters to me as an actual user of the Va Health Care system and the sci system of of care. So i thank you all for being here. You all make a huge difference for people like me, and i really dont know what we would do without folks like you. So, this morning, im stalling a little bit because were miking up our keynote speaker. Were fortunate to be joined this morning by our keynote, dr. Baligh yehia. He is currently the deputy undersecretary for health for Community Care. It probably goes without saying that he maybe has the toughest riddle to crack in washington, d. C. , right now, how to deliver on access that is continuing to grow. While in expanding that access into the community, which is a complicated proposition, all the while hes surrounded by a political minefield trying to solve this problem. I certainly dont envy what dr. Yehia has to deal with, even though we kind of cross paths because i deal with the political environment entirely. So, its certainly a complicated proposition. I asked him, i said, whats the one thing you want these folks and this audience to know most, and he said they need to know that im a practicing va physician. Youll note that when we were sitting up front, he raised his hand when sherman asked that question, so he has a vested interest in the system that were here talking about today. I think you probably have his bio. I couldnt do justice to the number of awards that hes received, his background. He received his md from the university of florida, did his residency at johns hopkins, and hes been at university of pennsylvania medical system for some time now. Hes also a professor there while also practicing in the va and while navigating the political minefield that is Community Care policy with va at the national level. So, please show a nice, warm welcome for our keynote speaker this morning, dr. Baligh yehia. [ applause ] thank you. Thank you all. Can you hear me okay . All right. Well, thank you for having me today. And sherman and i have done a couple conversations together and sat on different panels, and im always inspired by what he has to say and i think its important for clinicians to be moved by talks like that, because i think it shows that youre not callused, youre open, and youre there to do the right thing for patients. So, thank you. What i wanted to talk about today is really how we move towards high [ inaudible ] i can use the podium mike. Can you guys hear me okay . Okay, lets start again. Today well talk about moving towards a High Performance network. Theyve already limited me okay, lets start again. Today well talk about moving towards a High Performance network. Theyve already limited me because i like to use my hands and move around, so im going to do my best to stay in front of this microphone. I think we should start where Many Health Care organizations across the country are starting, which is how do you maximize value for our patients. And for us, its really our commitment to that. Many of you have seen a slide similar to this, which is really the triple aim of health care, which is how can we get better health, better care and experiences, and then better value for our patients. And this is really a little bit of what many Health Care Systems and plans and organizations across the country are striving to do in this environment, which is really maximizing the good experiences and care and positive outcomes that we want for our patients while at the same time being as efficient as possible in using our resources. When we think about how to maximize that Value Proposition for our veterans, i think we really need to start with them, and we need to think a little bit about where they are. We have veterans that live in every corner of the United States, literally in smallest of cities or smallest of towns to the largest of cities. And this is very unlike other Health Care Systems or health plans, where they actually get to choose which market they enter into, and then they compete for patients. Were very different. We need to provide health care to a population that can live anywhere. And so, that fundamentally makes what we do different than entering into a market organically and saying, hey, we think this is a good market to be in, were going to try to attract patients to us. We have to go where the patients are, not the other way around. And its important to note that we cant have a physical infrastructure in every single one of those locations, and so we really start to think about, well, how do you create a network of providers across the country to take care of our veterans that live everywhere. We also need to be thinking about this in the context of increasing demand for care. As many of you know we have an aging population and other issues and you can see in this graph that the thub of appointments both inside and outside the v. A. Has been growing in recent years so not only are we trying to make changes to develop a high performing network, were doing it in the context of more individuals coming to us to receive their health care. We also need to think about the location. Im like many of you, every one of your patients is different and theres unique nuances about who they are as an individual and what their medical condition is. We have the same thing in different geographies and i just put up three different locations for you as an example. When we think about alaska or maybe some more of the frontier states like montana, youll see a large proportion of the care is actually being delivered by partnerships and alaska happens to be great partnerships with our dod facility and Tribal Health partners in that state so more care is delivered outside of our walls then inside of our walls. Very different when you think about new york city where we have a lot of different clinics and Access Points and so more likely that veterans in that location will be treated by a v. A. Provider than a Community Provider. Its important to think about that as we think about moving towards this high performing network. It cannot be the same in every location. It has to vary by that geography and the population density of veterans. I think very important for this group here as well as it varies by specialty. Theres certain things we have been partnering for, freestanding dialysis clinic, we we buy a lot of dental care. Most or all Maternity Care is done outside the v. A. s walls, Community Nursing homes and home health. Theres certain things that are predominantly provided within a v. A. Facility such as Mental Health care service, jerry at tricks, spinal cord injuries and prosthetics. We need to think about the Different Services not only do they vary by geography, they also vary by what type of care is purchased. So, thats important, because when we think about how do we design the right system, and its definitely the topic of discussion these days here in d. C. , is whats this right proportion of v. A. And Community Care and how can they work together. You need to think about all those different nuances. And i really am a person that doesnt think of this as all