Light. Afterwards airs every saturday at 10 00 p. M. And sunday at 9 00 p. M. Eastern. You can watch all previous afterwards programs on our website at booktv. Org. As 2015 comes to a close many publications offer their recommendations for the best books of the year. Here is a look at some of the book the wall street journal suggests to its readers. Jonathan bordens american war lords looks at Franklin Roosevelts relationship with generals who helped win world war ii. In the fall of the ottomans, examines the middle east during the first world war. A manual jarrett, recalled the 1960 murder of the Prime Minister of the newly formed republic of the call and go. Although it was a cold war, the threat of military conflict throughout its existence, it was the non war, the single non war, the third world war which could have obliterated human and animal life on the entire planet. That is a look at some of the books the wall street journal recommends from over the past year. Booktv covered many of these authors. You can watch the full programs on our web site booktv. Org. Up next on booktv, sandeep jauhar, director of the Heart Failure program that Jewish Medical Center weighs in on the current state of health care in the united states. His talks from last weekends of than a book festival just over an hour. [applause] host thank you for that generous introduction. I just want to say what a pleasure it is for me to be here this weekend. My children are congo sewers of georgia book festivals. The jeter festival in august. A big firms up a. The organizers specifically robin gold and linda who are so helpful and bringing us here and our wonderful host, beth logan, the paragon of southern hospitality. When robin invited me to come here. Parameters for this talk, talk mostly about yourself, and getting to writing. As a writer of two memoirs, however i going to do this, talk about myself, do the best i can, i was in the lobby before coming here. And chatting with one of the authors, what you going to talk about, going to be very spontaneous and try to do that too. I dont know where this is going to go but hopefully it will be and lightning. Let me start by telling you about myself. I was born in india. Our family was pretty itinerant when i was growing up. My father was a plant geneticist. We found ourselves moving around quite a bit. And focused on crop science. We spent some time in wales, i spent the year there and for those who know a little bit about modern indian history, it was 1976, the year in drug gandhi issued her emergency rule. My father decided we have to get out of here. We settled in Southern California where i grew up. Like i said my father was a plant geneticist. My mother was the biochemist who worked parttime but mostly was a homemaker and she spent time raising us and they both wanted me to become a doctor. In that generation especially among immigrant indians there was nothing more global and better that you could do. Coloring their vision was the fact they had come with no money, a lot of Financial Insecurity and they fought this going into medicine will confer stability on our children and allow them to do good for the world. I didnt buy into that when i was growing up. I had a lot of other interests besides science and i remember when i was growing up in india i would spend time with my grandfather who was a family practitioner in new delhi and i was watching him work and what he did was fine. Reasonably interesting but just didnt appeal to me deeply. My 10yearold mind fought this is kind of cook book and i dont want to pursue medicine and guidance see how medicine was going to allow me to develop my creative impulse and i was wrong about that but at the time, i was interested in different things. So my mother would push me to become a doctor. One reason she said i want you to become a doctor so people will stand when you walk into a room. It didnt work out that way. In this end i end ed up going to berkeley and i was very interested in the mysteries of the universe so i decided i was going to become a physicist. Immigrating indian culture, rebellion is saying no to a career in medicine and going to physics. I was really the rebel. I went to berkeley and studied physics and graduated from undergrad and decided to continue with physics. Not sure what i wanted to do. And go to graduate school and studied very esoteric, very interesting infinity, unlike artificial adams. You can see where this is going. I became a writer. I was this was so far removed from what i am doing today. There was a confluence of things. Any of you who have done research, graduate level research, know that it is very slow and i found myself struggling with the equipment, and broken vacuum pumps. The progress was incremental at best. Right around that time someone very dear to me developed a severe case of lupus. And talking to doctors. And more interested in western, also was fascinating to me was how much was uncharted in medicine, how little was known about lupus, chronic diseases in general and being a physicist, i had this idea that if i dug deeply enough i would figure things out for her. But it became very clear that medicine is a science of incredible uncertainty and is largely uncharted. That was appealing to the scientists in me but the biggest appeal was i started to see medicine as a way to help people. I know it sounds naive, but it was really, the biggest motivating factor at the time, when i was toward the end graduate school, i desperately wanted to get out of the ivory tower, wanted to be with people, to interact with my fellow human beings. My brother who is a doctor, a cardiologist in residency at the time. And the cool stuff i was doing and looked at me, such an ivory tower. The worst thing he could say to me, it stimulated me to make a big change, finishing my ph. D. Applied to medical school. I was very interested in writing, but had no opportunities to write. And after i applied to medical school, a poster for a science journalism scholarship, on a lark, when i was in High School Like writing, going to medical school, and applied for the fellowship. And and it was an amazing experience, interested in politics, and seemed so glamorous. I went there, and the quote from bob dole about the working poor. And what did i know about, and all these reporters. And trying to get to him, and hang out by the bathroom because i knew he had a prostate condition. He was so nervous, tall man, set a bunch of did bridge, i am sure it was gibberish and he looked at me and kept walking, completely ignored me. After being done with speeches and went on, i was talking to his press secretary and trying to get in to get the five minutes to get my quotes, people of Time Magazine dont think i am a total loser so the press secretary was in a process of blowing me off and i will never forget this, he said this is in deep shock, he is an intern at Time Magazine and you wants to quote from me about americas working for. This is what he gleaned from what was a bunch of nervous gibberish. Really admire the man and end of speaking to him the next day and got my quote. I got bitten by a low writing bug. When i finished up at Time Magazine, it was the end of the summer, supposed to go to st. Louis, and i when and i said dan, i really like writing and maybe i should just become a writer and work at time, go to medical school and dont end up and exchange wretch like me. I remember those words very well. Can you give me some names to call don in the future to try to write about medicine and he said sure, gave me the name of someone in the tampa tribune, miami heralds, what about the New York Times . Sure, he gave me the name of one of the top editors, went to st. Louis and the first few weeks were tough. From Time Magazine to the anatomy of wapner and memorizing muscles and nerves, i decided to call this guy at Time Magazine, there is an Important Role for serendipity in our lives, this fellow, his name was gerald boyd he was the National Political editor at the time. I believe he was the panelist who asked Michael Dukakis what he would do if his wife were raped and murdered. So he had a tremendous influence on the 1988 political president ial election but i didnt notice any of this at the time. I was in the process of speaking to someone and suddenly he gets on the phone and gerald boyle, what do you want . Telling him i was a medical student and then it turned out that he was from st. Louis. And the same street on kings highway. At the end of the conversation, next time you were in new york give me a call. I did what any aspiring writer would do, Call American Airlines and book the price of new york. I called his assistant, coming to new york and mr. Boyd wents to meet with me. Who are you . They showed me into his office and i am looking around and there are pictures of him with borgia bush and the premier of china and at that point i was thinking all right, maybe you dont know what you are doing. His tone had totally changed from the conversation. He said i have two minutes, what do you want . I started telling him i was in medical school but want to be a writer and write for the New York Times. And he said show me your stuff, we dont have any stuff. Tried to explain how at Time Magazine you dont get stuff, you get quotes. He looked at me like he was totally crazy but he did do an amazing thing for me, he called Elizabeth Rosenthal who is a doctor. Some of you must have and she said she went to Harvard Medical School and she was working as a journalist full time, doing a Little Medicine on the side. This is and how you do things. Go back to medical school and see if you can write for the local paper, try to get a portfolio and send me your stuff so i end ed up going to the st. Louis postdispatch and i met a fellow there, very good guy, an editor named john curley who had grown up in manhattan and he took a liking to me and admired my gumption asking for an internship and in the end offered me an internship, and faced with this decision how do i do an internship at the st. Louis postdispatch when i am in medical school. I had this opportunity and dont want to do it and they are going to keep track. I cant be away from mid school for a large amount of time and he said there are many hours in the day. I just remember that and i thought i am going to just go with this. I went to the scene was postdispatch and they started giving me stories. I would drive out there after morning classes, skid the afternoon and read the transcription. And show up at 1 00 and the editor would say we want you to write, we hear a lot of people like getting stung by wasps. We want you to write about people being stung by losses in forest park, you have until 5 00 and it would just be and it was trial by fire. And diabetes, did a profile on surgeon and i would send stuff to the New York Times and she would read it and sometimes respond and sometimes she wouldnt blue jihad i had the little portfolio and the excerpt was when i finished mid school i got an internship in new york at new york hospital. And so i called libby and the science section of the New York Times had gotten a new editor. New people come in, they want to mix things up and bring in their own people. So i was one of the people, she ended up taking a liking to me and i pitched an article about of leprosy hospital in carville, louisiana. And she said sure, we will send a photographer down, go down and do the story so i went to cargill and that they are two or a few days, broke this piece up and it came up three days after i started my internship. Two days before i met my wife, sonya. Still it was an eventful week. And corey dean would say why dont you write about your internship . I said okay. Looked like it was a great invitation because during internship everything is new. As you go on in medicine you get jaded, you see things and start questioning but when you i and in turn, at the same time it is physically brutal so you sort of end up with i dont give a hoot what i write. I am going to write about what i see and things that interest me and things i am going to question. One of my early pieces as an intern, there was a fellow in hospital who was having difficulty swallowing. When he would swallow food it would go into his lungs. Everyone was getting ready to put in a feeding tube into his stomach. The thing was he kept saying i dont want a feeding tube but no one was listening to him. I was on the team and every time i would bring it up people would say what are you seeing . What is the alternative . I didnt say it but the alternative to me was listen to what hes saying, in meat and if he dies so be it. That is the way he wants to live. People had because he had such an egregiously crazy choice, people declared him without capacity. You cant make your decision. They were ready to put in a feeding tube and it was bothersome to me that i remember one morning i ran into his room and said you go to your feeding tube today and i dont want it. And i went to the refrigerator and brought out some liquids and i sit here, drink this and he hadnt drunk anything in over 0 weeks, maybe two weeks. So he drank it and maybe it cost a little bit, and i documented the charge, did my own swallowing study and he can swallow, doesnt need a feeding tube and i called the surgeon and called it off. Those are the things you need to experience when you are naive because if i were walking through the war and saw a guy like that who couldnt swallow, i would lead him get it. I wouldnt be invested. When you are entering you are investing your patients and away that you arent when you are attending. You dont know the man as well as you move on. That is unfortunate that that is the reality. Those of the things i started to write about, things that interested me, things that seemed ethically dubious so by time i was done with my residency i had 15 or 20 pieces in the New York Times. And by then i had an agent who said you should write a book. I said sure. I just wanted to have an agent. I thought it was cool to have an agent so at the end of my residency, why dont we just staple them together and call it a book . So the editor my publisher said we dont like your idea. Why dont you write about your residency, but building a memoir of development, novel of education so that is what i end up doing. My first was called in term. A lot of pieces by published there was a lot of stuff i didnt publish and one thing quarried told me islam keep a diary and right now on what is interesting to you so i did and i thought it was so important, young doctors and aspiring writers as me how do you get started . Have to record your reflections, keep a journal and that is what i did and i am glad i did. So i wrote in turn and let me talk briefly about my second book, i say a few things and take questions, when i took my current job at long island jewish, in july of 2004, i had been in school, for 19 years, 19 years after graduating from high school. And ready to be done reaping the reward of sleepless nights and what i found was doctors were very unhappy when you are in training on the physiology and learning the hard, it was the culture of practice, largely blinded to that, took on my first role. Wasnt just about the stresses we already know. It was not just about the paperwork and malpractice fears and so on. The deeper problem. It was an existential process. Without being able to practice the way they were trained to practice the way they aspired to practice. Sort of watch this and learned a little bit, but i was really happy. It was academic practice and working with trainees and specifically show academic practice because i wanted to be around, wanted to hold on to, shortly i found myself with a significant amount of debt and feeling i had to moonlight to the ends meet, it started a new family and most folks would be surprise a lot of academic physicians do that, in the moonlight on the side and one of the reasons we choose academia is a we want to be around academics, we want to be around young physicians, we want to teach, but the Salary Structure is different and in american medicine today we are rewarded for doing as much as possible, the feeforservice model, do more and more and more. One reason i chose that is i did not want to be in the position that i had to do more and more and more but then i found i had to start moonlighting and i found practice in queens with a cardiology fringe of my brother who offered me this big doing stress tests and supervising stress tests on the weekend and this is where i really learned about how medicine is practiced in some parts of this country. Most doctors are good but no question there is a subset in my profession that has taken advantage of feeforService System and is not call it whatever you want, some doctors will get upset by the implication there is fraud going on. Lets not call it fraud, say the system creates a moral hazard that encourages financial incentives and this is happening. When i was a president and learned about Health Care Economics it was an example of Orthopedic Group that under the feeforService System was doing 200 to 300 replacements the year. When they went to a bundled model it went to one total hip replacement. You can say doctors dont respond to financial incentive. We do. Doctors are as human as anyone. I am working in this practice end it was there were literally this line of unsuspecting patients ready to have stress tests many of which were honestly and necessary 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 but the financial situation i was in. That precipitated a crisis in me. Maybe it was a midlife crisis but it took a toll on me, took a toll on my relationship with th what i in, and also about my own personal crisis, and how i worked my way out of it. And eventually i did. But i was able to reininvestigate rate my personal relationships and im in a much better place today than i was about six, seven years ago. Howhowever, american medicine is still in a crisis. What are re going to do about american medicine . Theres no simple solution unfortunately. I think that the fee for Service System does create a lot of problems that did. I was able the fee for Service System creates problems that i believe need to be addressed and the system will need to be supplanted by something else. I dont know what the system will look like. But it is happening. Anytime you have a huge system that is responsible for 1 out of every 6 we spend and is so dysfunctional, it is going to get to a Tipping Point and i believe it is at that point because you cant have a system that is so gargantuan that affect all of our lives and have no one be happy with it. Doctors are unhappy but most importantly patients are unhappy. U. S. Kenny patient, patients are smart, they know when they are getting short shrift. They know when their doctor is listening to them. They often times suspect they will be asked to undergo unnecessary tests. They know what is going on, they cant find a primarycare physician today or when they do they have to wait three months to get an appointment in some parts of the country. So with a lot of this functionality in the system it will change. For doctors, we have to reclaim what is important to us. The system is a state where insurance companies, the government are in many ways telling us how to practice. Of lot of doctors feel like pawns in the system. When i graduated from medical school, the graduation speaker had some wise words. He said know what is important to you. The ideals that hold near and dear stick to them. Those words apply to me as much as a midlife practitioner as it did when i was an intern. We have to identify what is important. For me in this end it is about the acumen interactions a few talk to doctors who are unhappy even the unhappy as doctors will say the best part of their jobs is interacting with people, that is something that no entity can take away so for me it is about human moments and the gentle surprises, i will tell you one story about the gentle surprises of medicine. I went to the emergency room in the south bronx and had two week stint there and 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 what we call cited fluid. It is a brute force procedure. Hook it up to a tube or bucket, and i am here to drain the fluid out of your belly and she said okay, sure, go ahead and she still had alcohol on her breath. So i cleaned her belly with iodine soap, and put in the catheter and put the tube into a bucket and started feeling of a bucket and i said look, i am not putting it back in if it comes out. She said okay, sure. I am watching this fluid drained and a nurse comes in and he said you just got paged. She was carrying my beeper and i said ok, can you keep an eye on her . I answered my page, she said sure. If you move, wont put it back in. Another ten patients to see, okay. I answered my age and three minutes later i walked into the room and the catheter is how to, the buckets are all upturned and their is fluid all over the floor. Oh my gosh, a look at her accusingly and said i thought i told you not to move. She said dr. I did. A man came in and had a seizure on the bucket. I was like oh god. 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 a man walked in and had a seizure on the bucket. This is what doctors experience. These are special moments. Note Insurance Company can take that away from me. Okay . We doctors have to become more conscious about what kind of physician we want to be. I right in the book about sort of three professional architects, nights, and names and ponds. My parents year and the grandfathers year, doctors were nights. They were admired like no other professional group, right up there with astronauts and for good reason. American medicine improved patientss longevity from 65 right before 1world war 11, to 71 a generation later. Improvements of 6 or 7 years of life and that was because of polio vaccinations and antibiotics and coronary bypass surgery and pacemakers. Doctors really delivered. And doctors went through a phase when they became thought of as knaves and the culture shifted. When doctors were nights, that was the era of general hospital. Early on when doctors doctor killed thdair but then there wa change in culture, that year of mash and haweye. Then there was er, painted doctors as human, as flawed. I talk about knights, and names and ponce. Doctors are all three. But we all have a touch of least three professional archetypes in us and we have to try to bring out the best. 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 i the following morning we were rounding on our patients, and anyone has been in expensive care unit, knows the horrible tragedies that happen in icus, and our intensive care unit was no different. Theres a guy who had been misdiagnosed with a slip eddies can and had actually severed his spinal cord and was now completely paralyzed and there were patients who had multiple my loma on vor i there were patients with multiple myeloma the run from the letters and it was just a horrible unit. And so our team had stayed up all night and we were rounding and we were rounding with an attending named abe sanders. It was a great a candy. It was a jocular fellow, and so we were going through and with ourselves in a room occupation was on a ventilator and we were presenting the case. N. Sanders sort of looked like, looked often just looking through the window. Anyone whos been at near cost of no theres a pavilion built over the fdr and it looks out on to the east river. Sanders said come over here. Look out the window. It was brilliantly sunny day, and they were both on the river. 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 sweaty and disgusting and had been on call all night. There was a fellow on board was looking up at the hospital. It turned out he was looking up right at the window the we happen to be standing at. Sanders said see that guy down there . There . And i looked at him, he was about sanders age that he was fit into an antiwas with these beautiful people. He was looking up and he said see that guy down there . Do you know what hes thinking . And we all like looked, are we going to go to this . We just want to get out of the hospital. Lets finish rounds. Do you know what hes thinking . None of us ventured a guess. N. Sanders looks look at us and said that guy is thinking i should have been a doctor. [laughter] and this is what we struggle with as positions because people still love you our profession in simple terms. But today ive a more nuanced view of medicine, and doctors are not perfect and our profession isnt perfect but i do feel that doctors do want to be nice. And i think that theres a lot that we have to go through in the next 10, 15, 20 years. We need to get with you 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 would go to bed with 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 we will find some solutions to the mess we are in so that medicine can really reclaim its american medicine can reclaim its place as unquestionably the best in the world. So i will into their, and take some questions, but thank you so much for coming. [applause] if you have a question please line up. Im writing about my mothers life. This is were i find [inaudible] every time weve gone to the hospital with her, which we are no longer doing, the doctors talk to her and asked her questions and she cant speak. This goes on and on and on and you tell the doctors over and over again, she has no capacity to answer your questions. We are advocate. This has gone on and on. Physicians, they dont pay attention. Shes obviously gone and yet they continue to ask her how do you feel . What do you want . Its extremely frustrating. When i finally found a doctor would listen to me and said no more hospitals, hospice, cocktail, palliative care. I wept. I literally wept. I sat and cried. I said i cant believe youre listening. Thats profound, yes. Unfortunately your experiencexperienc e is not unique. Endoflife care is probably the single weakest link in the american medical system. And youre absolutely right. Unfortunately, your intuition is probably correct. The doctors didnt listen to you, and i see this every day, that we go into a patients room and we say do you want this, this or this bikes and we present the information in ways that they dont understand. Sometimes they cant process it because they are sick and they are anxious. And we do it all in the name of patient autonomy, right likes patient made this decision. We giving the patient the decision. Patients dont always want the decision. They want to be guided in many cases. I remember one case ill tell you very briefly of the children who came to the hospital and had apparently told all of doctors who were taking care of him that he never wanted to be incubated. He was in a situation where he was bleeding into his longs his longs. I get a phone call saying that we did all, we put in the stent and whatever antisplenic is longs so were just going to let them a young guy and the choice was just let him drown, bleeding, let them die, or do something about it. And i have witnessed so much of what you described of doctors sort of quickly presenting options, probably ive done it myself, and then not really thinking about whether the patient understood the option. So in this particular case i knew that the interns and residents have not done a good job explaining to this fellow. They probably ask them, if you work in which i want to be on a breathing machine clicks and you probably said no, i dont want to be. But he didnt know exactly what you sign up for so theyre going to actually let him die. I said do you know what, i am sure you didnt have the conversation you need to have with this bill. Im going to put the breathing tube in. We put a breathing tube in and even though it written in the chart do not resuscitate, and he had a tough course but 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 is written in the chart you didnt like 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 typing them. So thank you for your comment. Number one, i would like to say congratulations for making your life allowing you to things to bring you where youre at and the research and the opportunities that you taken advantage of. I applaud you for that. Thank you. Question, what kind of propositions or hurdles have had to overcome or deal with in doing the research, writing their books . Im sure everybody isnt patting on the back. No. Definitely not. Ive been pleasantly surprised that a lot of physicians have supported me in my writing, especially my colleagues. Because doctors and patients are stupid. They see the system the way it is. They know that theres a lot of stuff going on so the moral hazard, nefarious, whatever you want to call it. Its funny that there was a group of doctors i would say that is shocked, maybe their shock i wrote about or they are shocked that this stuff is really going on. Im not sure. And they have been, you know, fairly negative and a vocal into oppositiooppositio n to the book. Then theres this group of doctors, many of whom come up to me in hospital and say thank you, i heard you wrote this book, it was a New York Times bestseller about overdosing all this stuff. They said, why is it a bestseller . Everybody knows this is going on. [laughter] and so its been a mixed response but ive been pleasantly surprised a lot of people have been specific. Thank you. After seeing your wonderful review of erics new book in the New York Times i would like to more, particularly of being a cardiologist and a physicist how you feel technology will change the interaction between patients and physicians . I think its already changing. How many of you go in and go see your doctor and he or she doesnt look up from the computer screen, you know . This happens everyday. With Electronic Medical records. I think the Technology May help us work our way out of the mess with a better Voice Recognition software so that its written about, well of software that will transcode exactly what the doctors and patients are saying that you can edit later. But he also writes about virtual visits and telemedicine. I dont know how its all going to pan out. Im not sure the quality will be better, the diagnosis at a distance. I personally feel i need to see the patient can 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 are going to go see and they have a million issues, problems that you read on the paper and then you walk in and they are 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 machinist ever going to be able to confer a healing touch. Theres something that just touching your patient that is beneficial. So i think technology will play a role in changing and hopefully improving assets but its never going to replace a doctor or a nurse. I would like to ask them you talked about what your fellow physicians think about your writing, but i thought your brutally honest about your mother, your father, your fatherinlaw, your wife. So why did they have to say . Well, you know, so i wife is also a physician and she has been on the journey with me. She knows sort of the crisis that i went through. I think she knows whats in the book. [laughter] and shes read excerpts of it but i think she sort of has a policy of benign neglect, like she doesnt want to Read Everything because she knows it all already. My brother, you know, hes a pretty hearty fellow, thick skinned, tough skinned. We said okay, look, you do whatever you want. But overall my family has been very supportive i think especially sonia who lets me do these things in sort of keeps everything going and is a fantastic position in her own right. So ive been lucky. But theres always that dubious spot when youre writing a memoir and your writing about your life. Because on the one hand when your life is so intertwined with other peoples lives your story is also partly their story. So how do you disentangle it . You cant say how to write, and i sort of, what 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. Fortunately my family was supportive. You say that the system has to change to reduce the cost of health care it can be said you did know exactly how but im sure youve had some thoughts. Ive been fall since 1960, 1970 we said it was out of control. So its still out of control. At one time we thought maybe corporations would be happy to pay the bill would be the catalyst but obviously corporations just moved overseas another stopping the health care even. What you see as the catalyst thats going to create a change . When youre talking in early 1970, that was in the nixon era, and nixon, you know, to his credit solve the problem and actually instituted price controls on a number of Industries Including health care. And then lifted him on a number of industries that kept them on health care. And he was a republican. So price controls were republican, you know threenode system was careening out of control. I think the percentage of the gdp of health care in that era was Something Like 9 . Entity is closer to 18, 19 . So its a huge problem. I think that the force service 54 Service System has to be replaced on the windows read stephens new book but i havent read the book but it did read the piece in the new yorker and i think he identifies the kaiser model as being the way out of the mess, where