Our Malady: Lessons in Liberty from a Hospital Diary

May 13, 2021

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May 12, 2021

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00:00Good evening and welcome to the program for
00:04biomedical Ethics Evening Seminar series.
00:06On behalf of our manager,
00:08Karen Kolbe on the associate
00:09director Jack Hughes and Serra Hall.
00:11My name is mark material.
00:13I'm the director of the program and about
00:16twice a month we host these evening ethics
00:18seminars which are open to all of you.
00:21You can find the schedule for the
00:23last couple of this year on our
00:25website biomedicalethics@yale.edu
00:26more glad you're here tonight.
00:28We have a special night
00:30tonight as you'll see.
00:31Amen, I want to let you know
00:33that I'm already we're already
00:34working hard planning next year.
00:36We're optimistically hoping
00:36that next year's sessions will
00:38be live at least most of them,
00:39but we'll be prepared to
00:40do them zoom if we have to,
00:42so we will let you know about
00:44that in plenty of time.
00:45We've got a couple more zoom seminars,
00:47at least before we finish
00:48up for this academic year.
00:52With the way the format for this talk
00:54goes is, Professor Snyder is going
00:55to give a talk for a little while,
00:57maybe half an hour or so,
00:59maybe a bit more, and afterwards
01:01we're going to have a Q&A session.
01:02Please send your questions to
01:04the Q&A portion on the zoom.
01:05I'll then read him to Professor
01:07Snyder and we'll get a chance
01:08to exchange some ideas that way.
01:10Not as good as if we were in person,
01:12but still it works out pretty well.
01:16I want to tell you that.
01:18I'm very very pleased that
01:20Tim is joining us tonight.
01:21You know,
01:22several years ago now I found myself
01:24of all places in the hospital
01:26with a sick member of my family
01:28and was reading and I had been
01:30given this book called Black Earth
01:31by Tim Snyder who I didn't know
01:34and it was an exceptional book.
01:35And so I actually reached out to
01:38professors night when I realized
01:39he was here at Yale.
01:41And you know,
01:41got to know him became a friend.
01:44Subsequently,
01:44heredoc up other books he's written
01:46and I am delighted to say that he
01:49agreed to come and speak to us tonight.
01:51Professor Snyder is the Richard C.
01:53Levin professor of History here at
01:55Yale University and a permanent
01:57fellow at the Institute for
01:58Human Sciences in Vienna.
01:59His work has appeared in
02:0140 languages and received,
02:02received a number of prizes including
02:04the Emerson Prize in the Humanities,
02:06the Literature Award of the American
02:08Academy of Arts and Letters,
02:09the Vaclav Havel Foundation Prize,
02:11and so many others.
02:13Professor Snyder was a Marshall
02:15Scholar at Oxford,
02:16has received the Carnegie
02:18and Guggenheim Fellowships.
02:19He's appeared in documentaries on network,
02:21television and in major films.
02:23His books have inspired poster campaigns,
02:25exhibitions, films, sculpture,
02:26a punk rock song, or rap song,
02:29a play, and an opera.
02:31His words are quoted in political
02:33demonstrations around the world,
02:35most recently in Hong Kong.
02:38Professor Snyder has a BA in
02:40European history and political
02:42science is from Brown and a Doctor
02:44of Philosophy in modern history.
02:45Along with the Marshall Scholarship
02:47from the University of Oxford and he's
02:50an Academy scholar at Harvard University.
02:52I'm quite an extraordinary CV
02:53and an extraordinary writer.
02:55Again,
02:55as you'll see,
02:56not too long ago in the past,
02:58Professor Snyder had a very serious
03:00illness and had exposure to the
03:02American health care system,
03:03including time spent here at Yale,
03:05New Haven Hospital,
03:06which left him troubled, to say the least,
03:08about our health care system and
03:10the things that he encountered.
03:11And he wrote a book as a result
03:13of that court normality.
03:15Hopefully many of you have read it.
03:17There's missed several medical
03:18students on the line who,
03:20I know,
03:21have read it.
03:22And we're going to be very grateful
03:25that doctor excuse me,
03:26Professor Snyder is going to speak
03:28about his book about things he
03:30encountered and then will open
03:31up the comma the conversation.
03:33So with that I will introduce
03:35you to Professor Tim
03:37Snyder. Thank you, Tim.
03:39Thank you Mark,
03:40and so thank you all for being here.
03:43Thank you Mark for your persistence Mark.
03:45Mark has been very friendly over the years
03:48and we've talked about a lot of things,
03:51but there there probably was never
03:53before a subject so awkward as this one,
03:56and I tried to keep distance for awhile.
03:59But Mark was persistent about wanting
04:01to talk about this book and wanted
04:04to talk about these experiences,
04:05so I yielded and I'll be looking
04:08forward to the discussion.
04:09With Mark and with the rest of you.
04:13So to begin where Mark left off and you
04:17know just to be very clear about all this.
04:21In case there was any doubt what
04:23I will chiefly be talking about,
04:26is an experience at Yale,
04:28New Haven Hospital in late
04:302019 and early 2020.
04:32This is this is not to
04:34pick on you in particular.
04:37I'm aware that most of the
04:39things that I'll be discussing.
04:42Are systemic problems or at
04:43least partly systemic problems?
04:45There are moments in the story where
04:47I think there is a Nexus of individual
04:50responsibility which could be defined named,
04:53but I'm less interested in,
04:54you know, in talking about New Haven,
04:57Yale, New Haven per say,
04:59and more interested in in what
05:01this experience might tell us,
05:03or what I might have learned about
05:05hospitals and healthcare and more broadly,
05:08about the way Americans think
05:09about rights and freedom.
05:11So what I what I did?
05:13As as Mark was kind of to say when when
05:16I left the hospital in in early 2020,
05:18my treatment,
05:19I left the hospital finally in February
05:21and my treatment ended in June of
05:23last year between February and June,
05:25I wrote this little I first,
05:27you know,
05:27because I'm historian gathered
05:28up all the sources and made a
05:31kind of chronological document.
05:32And there's a version of the
05:33book which is much more medical,
05:35which goes through kind of hour by hour.
05:38Actually, what happened to me?
05:39But I put all these together and
05:41wrote a little a little reflection
05:43called called our malady.
05:45What I'm going to be doing in in
05:47this talk to you is is focusing
05:49a bit more on what I take to
05:52be the medical ethical issues.
05:53And of course I am sure it will raise
05:56nothing which you haven't thought about
05:58or have haven't come into contact with.
06:00Perhaps though having the point
06:02of view of a patient and frankly
06:04the point of view of a patient
06:06who should have been dead,
06:07might add something.
06:08There might be some conceptual or
06:10at least rhetorical angle that I
06:12come up with it that might be fresh.
06:15And and and and useful now I'd like
06:17to be able to skip right to what I
06:20think the lessons are of my experience,
06:22but what I've what I've realized
06:24in in the few times that I've
06:26talked about this and when I,
06:28and when I've written about
06:30it outside the book,
06:31but I've realized, is that if I try
06:33to skip over what actually happened,
06:35then we spend the whole question
06:37answer period on trying to figure
06:39out what actually happened to me.
06:41So I'm going to do. I'm afraid
06:43this slightly tiresome thing first.
06:45Of talking about my experience
06:47from the patient POV, of course,
06:49and then I will move on from that
06:52experience to five or six lessons.
06:54Starting neroly with the medical and
06:56then working my way up towards the the
06:59more general political and the more and
07:02the kind of higher level ethical questions.
07:05So we'll see how far we can get.
07:09So I let's all just I'll just.
07:11I'll just dig in and you know,
07:14feel free to automatically,
07:15you know,
07:16spell check and correct my medical
07:18terminology as as we go through
07:20and of course as I narrate this,
07:22I'm not narrating what I knew at the time,
07:24right?
07:25I mean the story of what I knew at the
07:27time would be a much sadder story and it
07:30would sound much worse than this story.
07:33This story,
07:33by its nature,
07:34is a compound of what I felt at
07:37the time and what I understood.
07:39From doctors you know,
07:40with the kind of Doppler effect right
07:42of several days or several weeks,
07:44or what I understood frankly more
07:46often from piercing together the
07:48the medical record which I read
07:50in March in March and April.
07:52So this is this is a compound
07:54that's not what I experience,
07:55is not what the record says.
07:57It's the two of them brought together.
07:59So on the 3rd of December, 2019.
08:03I had appendicitis but I was
08:05in Munich in Germany.
08:07I went to the hospital,
08:09they didn't alter sound rather than MRI.
08:12I think at that point they misdiagnosed
08:15my appendicitis as a as a viral infection.
08:18If I were in Germany,
08:20I would now go off on a rant about
08:23how the German or the German speaking
08:26world's tendency to not prescribe
08:28antibiotics has has a kind of
08:31backward influence on to diagnosis.
08:33And it leads people not to diagnose things
08:35which might require antibiotic treatments.
08:38That's that's their problem, though.
08:39That's not.
08:40That's not that's not an American problem,
08:42however,
08:42that maybe I had appendicitis in Munich.
08:45I didn't get that diagnosis,
08:46and I continued off doing the work that
08:49I was meant to be doing in in Germany.
08:51I had a public lecture in Munich.
08:54I gave that public lecture my appendix burst
08:56the night after I gave the public lecture.
08:59Maybe during the lecture,
09:00I'm not sure,
09:01and the next the next few days I had,
09:04there was a fair amount of pain.
09:06Which I ignored and then I had a I had
09:09a I had a board meeting in Stuttgart,
09:12also in southern Germany,
09:14which I went to and did what
09:16I was supposed to do.
09:17At that point I had peritonitis.
09:19Of course I did that,
09:21got on the flight and declined medical care.
09:24Flew back home back in the United States.
09:26I didn't feel that well.
09:28Eventually I was persuaded to go
09:30to Yale Health. That would be the
09:3215th of December 2019 and from Yale.
09:34Health was sent on to Saint Rayfield's wear.
09:37The appendicitis, or you know,
09:39at that point, the burst and separated
09:41and so on appendix was observed.
09:44An correctly diagnosed at that point we
09:46run into a problem and the problem is
09:49the partial revelation of information.
09:51So I was told that I had appendicitis
09:54which was a bit of a surprise.
09:57You know I didn't.
09:58I didn't understand what was happening to me,
10:01although in retrospect it all
10:03seems very obvious.
10:04What I wasn't told was at the same MRI.
10:07Which revealed the appendicitis and also
10:09revealed a sizeable lesion on my liver,
10:11which is critically important
10:12information later in the story,
10:13but also at this point in the story,
10:15because at this point in the story,
10:17I'm asked whether I want a procedure
10:19to remove the appendix or whether
10:20I want antibiotics, and of course,
10:22if I'd known there was a lesion on my liver.
10:25My answer would have been both,
10:26but because I didn't know there
10:28was a lesion on my liver,
10:30my I think natural response was to say,
10:32oh, let's get the appendix out
10:33that will solve the problem,
10:35and the surgeon seemed to think that as well.
10:37So,
10:38so I had the I had the event I had the
10:42I had the long appendectomy complicated,
10:45but it's apparently successful and you know,
10:48in typical American fashion I was
10:50released immediately after the surgery
10:53with a very like with two and a half
10:56days worth of solid antibiotics.
10:58And again without any knowledge
11:00of the liver lesion,
11:02which of course was actually an
11:04Abscess and a growing Abscess.
11:06So this was noted.
11:07In the MRI it's in my record,
11:10but it wasn't in my release papers
11:12and it was never.
11:13It was never mentioned to me thinking
11:15that I was recovering and feeling better.
11:17I think because I was still on
11:19those 2 1/2 days of of any biotics.
11:22I asked the surgeon as well as my
11:24GP if it would be alright if I made
11:26a trip with my family to Florida,
11:29which in retrospect was a totally insane
11:31thing to do and I often have done it,
11:33but I felt better and I talked
11:35the doctors and the surgeon said
11:37she saw no reason why I shouldn't.
11:39Do that.
11:40If she didn't,
11:41then look at the record.
11:43I think if she looked at the record and
11:45notice that there had been a liver Abscess,
11:47she would have probably counseled me to
11:49stay at least until that thing got looked at.
11:51But she didn't look at the record,
11:53which is kind of a habit of hers.
11:55She never looked at the record
11:56multiple phone conversations,
11:57she just kind of got more and more
11:59narrow and defensive about what she done.
12:01So I went off to Florida in Florida on the
12:0323rd of December,
12:04which happened to be my mother's birthday.
12:06This was a long planned family trip.
12:07That's why I went to Florida,
12:09which is something I wouldn't ordinarily do.
12:11You know, regardless of circumstances,
12:13on the 23rd of December,
12:15early in the morning,
12:17about 5:00 in the morning,
12:19I experienced.
12:20Suddenly I woke up with rather
12:23severe peripheral neuropathy.
12:25Socks and mittens pattern
12:26along with fever and sweating.
12:28So I went down to the nearest hospital
12:31in Florida which was basically a
12:34hospital with next to no doctors.
12:36The concern in Florida was naturally
12:39full about neurological conditions
12:41like like Yo Mahe go back.
12:43I was the thing that we people
12:45were upset about partly that was
12:47because in Florida they were free
12:50of the context of the appendectomy.
12:53They knew that it had happened Ectomy.
12:56But they didn't know about the
12:57liver lesion and they didn't know
12:59what the liver lesion because I
13:01didn't know about the liver lesion,
13:03so I couldn't tell them about it
13:05and I didn't know it because my
13:07physicians hadn't told me about it,
13:09so the there were actually liver markers
13:12which turned up in Florida ACL for example,
13:14but those liver markers weren't in context.
13:16They wanted to send anybody's
13:18attention because they because
13:19they were looking at neurological
13:21symptoms and therefore they were.
13:22They were doing a neurological
13:24work up and not noticing, right?
13:26Not noticing the signs of infection.
13:28In general,
13:28and of liver infection in particular,
13:30so they went for a Spinal Tap.
13:32The Spinal Tap produced nothing.
13:33The next it was.
13:35It was my mother's birthday.
13:36Nothing was really happening.
13:37There were no doctors actually around
13:40except for the one who did the Spinal
13:42Tap that was the closest contact I
13:43had with a doctor or not counting
13:455 minutes with the hospital list.
13:47The neurologist talk to me over Skype.
13:49You know which of course,
13:50even in my weakened condition,
13:52talking terminologist over Skype
13:53seemed kind of absurd to me,
13:55so I went back to my family.
13:57I wanted to be with my family.
13:59Over Christmas.
13:59I want to happy birthday amount to my mother.
14:02All that kinda.
14:04The symptoms and return a couple of
14:05days later on Christmas Day I felt weak.
14:08I had a headache.
14:09I thought this was resulted in Spinal Tap.
14:11There's so many things coming into the
14:13picture now. Bright that it's hard.
14:15It's hard to reason and separate them out.
14:17But then in the 2620 seventh new
14:19symptoms emerged, I began to tremble.
14:20I began to shiver, right,
14:22uncontrolled bouts of shivering.
14:23And at this point the decision was
14:25should I go back to the hospital
14:27in Florida or should I go on?
14:29Should I go home to New England?
14:31And you know, here comes a sentimental part.
14:33I went back to New Haven,
14:35which was again probably a crazy thing to do.
14:37I mean,
14:37I've already I've flown across
14:38the Atlantic with peritonitis and
14:40now I was flying unknowingly,
14:41but I was flying from Florida
14:42to Hartford with with
14:43sepsis, but my thinking if you can call
14:45it thinking was that I just didn't
14:47want anything to happen in Florida.
14:49If something terrible is going to happen,
14:50I wanted to happen in New Haven,
14:52you know, or at least I felt at home
14:54and where I would be with people
14:56who I would more or less trust.
14:59On the way, we called the surgeon.
15:02At Yale, New Haven,
15:03who denied the logical even the
15:05logical possibility that there could
15:07be a connection between my current
15:09condition and the surgery she had
15:11performed 12 days late 13 days earlier,
15:13which of course turned out to be
15:15completely wrong, and she declined to
15:17contact the emergency room at Yale,
15:19New Haven to prepare for my arrival.
15:22So I flew with Subsys, arrived at Hartford,
15:24then friends drove me straight from Hartford.
15:27I was with children.
15:28It was complicated.
15:29A friend met me at the airport in Hartford.
15:32Drove me straight to Yale, New Haven.
15:34This was so I arrived early
15:35morning on 29 December.
15:36As many of you will know that Saturday,
15:38as many of you know,
15:40Saturday, Saturday night,
15:40Friday night Saturday night is terrible.
15:42Time to be an emergency room at Yale?
15:44New Haven.
15:44It wasn't my first time.
15:46It was the first time though with you know,
15:48in such a condition what was striking
15:50was how hard it was to get admitted.
15:52I mean,
15:52there were there were a lot of people in
15:54that emergency room who are sicker than me.
15:57There were a lot of people who
15:58are a lot less sick than me.
16:00I had a I had a hard time
16:02getting myself admitted.
16:04And here I have to point to something
16:06I mean rather directly part of
16:07the trouble I had in any admitted
16:10in part of the trouble I had in
16:12getting getting taken seriously
16:13was that I wasn't that articulate.
16:15At this point, you know,
16:16in general, like I tend to be very,
16:18I mean,
16:19as my records are always describing
16:21me as like very pleasant and
16:22at one point even lovely,
16:24which I think just means that I was
16:26too polite. Basically the entire time.
16:28But the person,
16:29the person who is accompanying
16:30me at that time,
16:31who very kindly met me at the hospital,
16:34'cause my wife was with our children.
16:36Was was black and this clearly
16:38made a difference,
16:39and that's not just something that I,
16:41you know sense with some kind of
16:43antenna I can more or less pin down
16:46how it made a difference because the
16:48person who was with me was not only black,
16:51she was also a physician and the
16:53nurse who greeted us refused to
16:55believe that she was a physician.
16:57How do I know this?
16:59I know this because once I was
17:01admitted and was behind a curtain,
17:03I over heard the same nurse
17:05talking to another nurse.
17:06And laughing at the claim that this black
17:08female could possibly be a physician
17:10of the kind she described herself
17:12as being which, of course she was.
17:14And then once I was in the emergency room,
17:17there was a there was a similar kind
17:20of confrontation where it my American
17:22radar for racial things at least told
17:24me that my friend was being taken much
17:26less seriously by the doctor with whom
17:28she was speaking by the resident,
17:30with whom she was speaking,
17:32because she was an African American.
17:34Or perhaps because she was
17:35an African American.
17:36Email, but there was a level of
17:38controversy there which didn't seem
17:40to be appropriate in this situation,
17:42and the direction of the controversy
17:45was my friend saying that something
17:47serious had happened and the resident
17:49denying it and and being on the side of
17:52perhaps he has flu or is dehydrated, right?
17:55You know, in fact, I was.
17:57I was, I was pretty sick.
17:59Then we had we had a
18:01medley of further mistakes.
18:02So I was in.
18:04I was in the emergency room for 17 hours.
18:07Before I was released 12 hours
18:09before there was a diagnosis,
18:10and then the and the reason why the
18:12diagnosis was reached rather easily.
18:14When my right when they looked at my
18:16record from the appendectomy surgery,
18:18which which revealed that I had
18:20this Abscess in my liver.
18:21And then they looked at my
18:23liver and lo and behold,
18:24it turns out that's what it was, obviously.
18:27But before we get to those before we
18:29get to that, that's 12 hours later.
18:31So I mean, there's a point worth noting.
18:33No one actually looked at the record
18:35of my of my surgery in New Haven,
18:38which was 12 days before.
18:39No one looked at it for 12 hours, right?
18:42And that's not because I didn't ask them to,
18:44and it's not because I didn't point
18:46out the kind of intuitive you know
18:47possibility that if you have one,
18:49if you have a procedure in your abdomen
18:51and then you have another problem,
18:53maybe the problem is also in the abdomen,
18:55but they didn't not.
18:56My admin was the only part of
18:57which wasn't scanned.
18:58My neck was scanned, my head was scanned.
19:00Everything about with scan and every
19:02possible blood test and and the the
19:04move which was made was to suggest that.
19:06Well, since we can't think of what
19:08it can be and it can't possibly be.
19:10Us right there there not the problem.
19:12It can't possibly be us.
19:13It must have been those doctors in Florida.
19:15They must have infected you with
19:17during the during the Spinal Tap.
19:19That must be meningitis.
19:20So I got I got a second Spinal Tap
19:22and the spinal daimin.
19:24I don't.
19:24I hate I don't want to go on the Spinal Tap,
19:28but the second Spinal Tap which
19:29should never have happened,
19:30was performed in the following way.
19:32The attending told the resident
19:34that she should do it.
19:35Whatever she do she should she should.
19:37She should avoid the previous puncture site.
19:39So then she.
19:40Put the needle into the previous puncture
19:42site so she had the needle in and then
19:44she had to pull the needle back out.
19:46Put it in one vertebra higher OK,
19:48so she's getting the needle in one
19:49vertebra higher, and then her cell
19:51phone rings and you know it's it's.
19:53It's funny what happens when
19:54you have a needle up someone's
19:55spine and your cell phone rings.
19:57Your hand quivers like this, right?
19:58So I had that nice sensation of the
20:00of the needle between my two vertebras
20:02has her hand involuntarily quivers
20:03because of course we're conditioned to
20:05respond to our cell phones like animals,
20:07and that's what that's what we do.
20:09So, so that was pleasant,
20:11and but I shouldn't talk only about the
20:14resident because in the five minutes,
20:16but it's at the Spinal Tap took the self,
20:19the attending cell phone also
20:21also Rang twice,
20:22so that was negative of course.
20:24And then after 12 hours you know
20:26someone finally checked my record
20:28and said haha there was a liver
20:30infection after the appendectomy,
20:31which was never followed
20:33up on their diagnosis.
20:34Sure enough,
20:3517 hours after admission to emergency room,
20:37my liver was drained so.
20:39The the morning after that,
20:41which would be the morning
20:42of 30 December 2019.
20:43A couple of things,
20:44a couple of revealing things happen, I guess.
20:473.
20:47The first is that a Member,
20:49a young member of the surgical team
20:51appears and wakes me up and she wakes
20:53me up to say I'm a member of this.
20:56I was in the surgical team.
20:57I just wanted to check in and see if
21:00everything was OK and at that point,
21:02like I didn't really understand a lot,
21:04but I understood enough to
21:05say that everything was OK.
21:07As I said something like,
21:08no, everything's not OK.
21:09It turns out that your team
21:11didn't tell me that I had a liver
21:13condition after the appendectomy,
21:14and that's caused a lot of trouble.
21:16And at the at the moment when I said no,
21:19everything is not OK.
21:20Her eyes, just her eyes widened like this,
21:22as if that was something I wasn't
21:25allowed to say and she turned her
21:27back to me and ran from the room
21:29and then ran down the Hall and
21:31I could hear the squeak of her
21:32sneakers as she ran down the Hall,
21:34and I'm sure she had a lot of other things
21:37to do, but that's, you know, that's not.
21:40How you should be interacting with patients.
21:42Second thing which happened the
21:43next morning was that the taboo word,
21:45sepsis was finally mentioned.
21:46So I had sepsis.
21:48Obviously right?
21:48I mean this was clear to the physician,
21:51friends and relatives who
21:52were thousands of miles away.
21:53You know could remotely diagnose this
21:55as sepsis is the only place it wasn't
21:58clear was in the emergency room somehow.
22:00But I say somehow, but there was there
22:03was there were a number of reasons,
22:05but one of them is this my you know.
22:08I mean, I understand that sepsis is is is.
22:12Basically it's it's not something for
22:13which there is a clear test that pro
22:16calcitonin is an indicator micro.
22:18Calcitonin reading was 35 times
22:20higher than normal, it was.
22:22It was clearly suggestive of sepsis.
22:24But the attending misread the
22:25procalcitonin reading by two orders
22:27of magnitude because she misread it
22:29by two orders of magnitude and miss
22:32recorded by two orders of magnitude.
22:34My record initially was negative
22:35for sepsis and so it took a long
22:38time to figure out that sepsis
22:39might actually be the problem,
22:41and as a result I think of them
22:43of the mistake that was made.
22:45No one wanted to use the word sepsis.
22:48It became taboo to say sepsis even
22:49though so no one actually said the
22:51word sepsis until deep into day
22:53two when the infectious diseases
22:55doctor finally turned up and she
22:57was very straightforward about
22:58that and about everything else.
23:00The third thing which happened
23:01on that day is that after.
23:04After my liver after my liver was drained,
23:06a tube was inserted right?
23:07So so the idea is that you know you
23:09drain a little bit by by penetration,
23:12but you drain a lot more
23:13afterwards with the bag and it was.
23:15It was made clear to me over and over
23:17again that the important thing is the bag.
23:20I'm going to drain this food into the bag.
23:22I've got a lot of fluids going to bag.
23:25That's how I'm going to get better.
23:26But nothing was raining to the bag and
23:28so I tried to draw attention of people
23:30to this that nothing was actually draining.
23:33I talked to nurses,
23:34doctor, doctors.
23:34But no one seemed to actually understand
23:37how the bag was supposed to work,
23:39and so I sat in Yale,
23:41New Haven from December
23:4330th until January 5th,
23:44with nothing drained into the bag
23:46with my repeatedly mentioned it.
23:48But nobody having any response to it
23:49until finally by accident and nurse whose
23:52responsibility was entirely different,
23:54told me that the bag was the bag was
23:57incorrectly set up and fixed it,
23:59at which .6 days out I started,
24:01I started to drain.
24:02So I mean, I'm not going to.
24:04I'm not going to clean this
24:06area causal relationship here,
24:07but during those six days,
24:09the infection in my liver grew
24:10substantially and I had to have two
24:12more procedures to drain the liver.
24:14After that,
24:14Anne was on food antibiotics to February,
24:16so lame ducks through June,
24:18at which point I went off to Europe.
24:20OK,
24:20I'm sorry that I'm sorry to go
24:22into so much to so much detail
24:24to tell to tell the story.
24:25I just,
24:26it turns out that if I don't give
24:28the detail then I always have to go.
24:30Always have to go back to it.
24:32What I'd like to do now is is is.
24:35Make a few hopefully constructive
24:37suggestions about where this might
24:38go ethically or practically,
24:40and this is probably the place where
24:42I acknowledge you know the various
24:45kinds of privileges which allow me to
24:48be able to make this sort of venture
24:50the most important privilege,
24:51I think, was luck. I've just I was.
24:54I was very. I was lucky.
24:56This the second is that I had friends who
24:59tried to look after me summer positions
25:01and then the third is that afterwards,
25:04unlike a lot of people,
25:05I got time off from work and was able
25:07and you know it was able to have the
25:10time therefore to try to put some of
25:12this stuff together and to think about it.
25:14So as I promised,
25:16I'm going to try to.
25:17I'm going to start at a very low level here.
25:20Neroly with you know some issues of
25:22practice that I noticed and then move up
25:24towards medical ethics and then maybe
25:26end up with some with some higher level.
25:28Political ethics before we get
25:29before we get done,
25:30I'm going to be right back.
25:35Just need my glasses to check the time.
25:38Alright so the at the lowest level there's a
25:41point which I've I've already basically made,
25:44which I'm sorry have to make that
25:46I'm going to make it and that
25:49is that is local eragon's.
25:51So I brought my medical record from Florida.
25:53I mean I was as a patient.
25:56I was probably not insistent enough or
25:58not loud enough, but I wasn't organized.
26:01I mean even like half dead I was organized.
26:04I had my files like I was a
26:07historian like down to the end I had.
26:09I had beautifully organized
26:10my files from Florida.
26:11My record from Florida.
26:13I had it on disk.
26:14I had it on paper.
26:15I had an annotated in my
26:17own handwriting and so on,
26:19including the liver findings being circled
26:21in my hand with question marks next to it,
26:23saying liver issue.
26:24Question mark.
26:25Question mark, right?
26:27But when I arrived in the
26:29emergency room in Young Haven,
26:30no one wanted to look at that record,
26:33and the resident at that point said,
26:35and I quote, we do things our own way.
26:39So you can just interpret that the second
26:41example of the local arrogance for me
26:43would be the second Spinal Tap, right?
26:45The second Spinal Tap shouldn't
26:47have happened.
26:48Before Yale personnel looked
26:49at their own record right?
26:51I mean, if you,
26:52if you had looked at their
26:54own record and said OK,
26:56there's nothing here,
26:57then meningitis certainly is a possibility.
26:59Go for it.
27:00But the idea that it's more likely
27:02that it's so unlikely that we made
27:04a mistake that we're not even
27:06going to look at our own record.
27:08It's more likely that there's meningitis,
27:10you know, from from a doctor in Florida,
27:13that anything that we could
27:14have done during our surgery,
27:16and therefore a second Spinal Tap
27:18before leaving. Looking at the record.
27:20That that strikes me is, you know,
27:22is being unreasonable and demanding a
27:24kind of explanation that goes beyond reason.
27:27But the second,
27:28the second point,
27:30which again I've already made would
27:31be would be the racism, right?
27:34And of course I'm in a poor position in
27:36general to be complaining about this.
27:39I'm just I'm just noting it right.
27:41I'm just noting it.
27:43I had the tiniest,
27:44tiniest,
27:44tiniest brush with it,
27:46but it was a pretty unmistakable
27:48brush and I'm I'm aware that this
27:50is a larger systemic problem,
27:52and that was driven in by the context
27:55that night of 29 to 30 December,
27:57when I was behind the curtain.
27:59And heard a lot of things.
28:01One of the things I heard was
28:03a conversation of the police
28:04officers outside my curtain because
28:05it was a weekend night.
28:07There was a lot for police officers to do,
28:09or at least people for them to watch.
28:11But they were.
28:12They were watching or doing anything.
28:14So they talk back and forth and
28:15the way they talked in some of
28:17the terms they use reminded me
28:19of the systemic character
28:20of racism in this country.
28:22A third, a third issue or third level
28:25would be the language of profit.
28:27So when I you know,
28:28by the time I got my wits back and more
28:31or less put together what had happened
28:34and Anne had my final let's call it
28:36exit interview with with the surgeon,
28:39the surgeon had moved to the position
28:41that yes indeed you know there was a
28:43there was a liver infection and we're
28:46very sorry and we should have told
28:48you and so on that was our mistake.
28:51But but she defended.
28:52She defended the appendectomy protocol.
28:55Which I just don't want to hear.
28:57I mean the appendectomy protocol
28:58in this country is sick,
29:00it's just it puts people at needless risk
29:02for them to leave the hospital so quickly.
29:05It doesn't.
29:05It's not supported.
29:06I mean, I took the time to read
29:08the literature on this.
29:10It's not supported by the literature,
29:11it's it's not supported by
29:13what peer countries do.
29:14It's not supported by what anybody does,
29:16as far as I can tell.
29:18I mean, recently friends from Bulgaria
29:19to India have also had appendectomy's,
29:21and they all they all stay in
29:24the hospital and they all get.
29:25They all get fluid.
29:26They'll get filled in biotics,
29:28and I mean that seems to be medically sound.
29:30Just for now,
29:31productively in my own condition,
29:32it would have prevented the the
29:34liver problem as well, right?
29:35And just the fact if I just stayed
29:37in the hospital for half a day,
29:39not even the three to five days of the week.
29:42If I just stayed in the hospital
29:44for half a day after,
29:45instead of leaving immediately
29:46after the surgery,
29:47somebody would have noticed the liver
29:49thing somebody would have said it right.
29:50The longer I mean somebody flipping
29:52through that would have said,
29:53hey, by the way,
29:54did you notice there was a liver thing but?
29:57You know, but instead I was out and I
29:59was gone and I guess my question is,
30:02I mean, as a rhetorical question,
30:03but you know,
30:04feel free to take it as
30:06not a rhetorical question.
30:07Does anyone really believe that
30:09this is possibly justified, right?
30:10OK, the third, the third level is.
30:14The diminution of doctors,
30:15I mean,
30:16the kind of humbling of doctors
30:18in this system.
30:19I I was really struck by this.
30:21I was really struck by the lack of by the.
30:25By how little authority physicians
30:27have in the system compared to
30:29how much authority non physicians
30:30think they have in the system?
30:33I'll just give,
30:34I'll give us a trivial example
30:35here as an outpatient trying
30:37to trying to track down these
30:39neurological systems which persisted
30:41and persist after this this,
30:43this this interval I saw a
30:45neurologist and yell New Haven.
30:47He was very helpful and who ruled
30:50some things out and and then I
30:52thought was very sound in every way.
30:55But as I was waiting for him as I was
30:56waiting for my appointment with him,
30:58I had, I sat in the waiting room
30:59and I had to watch a video of him,
31:01you know, and how great he was.
31:03And that's not it's not that much
31:05like the eye mind that I just think
31:08that that's humiliating of him.
31:09I think that's humiliating of you.
31:11I don't think you should be
31:13putting advertising posters.
31:14I don't think you should be the front
31:16men or front women for anything.
31:18I think the moment that you're put in
31:21advertising posters for a hospital,
31:22you're like the label on a product and
31:25and you're being used. And I don't.
31:27I think that's the wrong relationship,
31:29but I don't think that's what that's
31:31what patients should be seen.
31:32I think it's fundamentally unacceptable.
31:35I'm and, but it's not just that
31:36it's a symptom of a larger problem,
31:38which is that you don't have
31:40enough power in the system.
31:41I'm talking to positions.
31:42Then the next level of problem
31:45that I noticed is what I would
31:47call the limitation of contact
31:49and here that this this functions
31:51at several different sublevels,
31:52one which is really striking and I think
31:55comparing the past is that I couldn't.
31:57There was no doctor responsible
31:59like when you're sick,
32:00especially over the course of weeks,
32:02but you want there to be one person
32:05who's your doctor and I have an intern.
32:08I have a GP in the system and I like him.
32:12He's been very good.
32:13But he was not present right.
32:15He wasn't.
32:15He simply wasn't present,
32:16and I've been given to understand
32:18that this is now typical,
32:20and it strikes me as strange.
32:21You know that there's no one person
32:23who's overseeing this process,
32:24which spins out over over days and weeks.
32:26And that means that as the patient,
32:28you have to kind of become your own
32:30PR person where you're constantly
32:32retelling the story,
32:33and you become responsible
32:34for remembering details.
32:35Because of course the records are hard,
32:37you know.
32:37Well,
32:38I don't have to tell you how hard
32:40the records are to deal with.
32:42But, uh,
32:43the second level of this would
32:44be the way nurses are rotated.
32:46So if you're in yell, New Haven,
32:48you know,
32:48at least on the floor that I was on for days,
32:51then your nurses are rotated
32:52in and out in and out,
32:54in and out on these on these
32:56I think it's 12 hour shifts,
32:57maybe 8 hours shifts and you have
32:59no sense of continuity, right?
33:01So I was I was.
33:02I was there,
33:03for I was there for about 7 days
33:05and I happen to get the same nurse
33:07a couple of times and it was
33:09always such a relief when I had
33:11the same nurse because I thought.
33:12All of this generation out not to be true.
33:15I thought she might remember
33:16something about me, right,
33:17but but you know, she didn't really,
33:19but it was you.
33:20You kind of want to have a
33:22nurse just like
33:23you kind of want to have a doctor and but
33:26somehow it doesn't seem to work out that way.
33:29Third, third subproblem here would be just.
33:31Dramatic dramatic failures of body language
33:35on the part of both doctors and and nurses.
33:40It's a mistake that not all of you,
33:43but many of you make is that when you
33:45ask questions of patience, you nod.
33:47If you want to, yes and you shake
33:50your head when you want to know.
33:52And of course, when you do that,
33:54or when you're expecting a yes or
33:56when you're expecting, you know.
33:57And of course, if you do that,
33:59you're completely invalidating the entire
34:01procedure of asking questions because
34:03you're asking from position of authority.
34:04And when you nod your head,
34:06you're suggesting the correct answer
34:08and you're ruling out the thing that.
34:10The patient might actually need to tell you,
34:12and like so many of you do that,
34:15and I mean I just I,
34:16I just I started making like
34:18lines and like checking them off,
34:20you know,
34:21counting off every five times and
34:22not a doctor or nurse would do the
34:25non thing or this shake their head
34:27thing but the most dramatic failure
34:29of body language is the failure
34:31of eye contact which is dramatic.
34:32Some of the more experienced doctors
34:34do still start by walking into
34:36the room and making eye contact.
34:38But frankly most of you don't and.
34:40None of the nurses to do,
34:42I'm sorry to say that that's
34:44that's a dramatic mean.
34:45That's the way that the the
34:47moment of contact with the patient
34:48begins has to be through the eyes.
34:51And if you miss that,
34:52if you miss the first eye, contact.
34:54If the patient notices,
34:55you're not making eye contact 'cause
34:57the patient is looking for eye contact,
34:59they have nothing else to look for,
35:01but your eyes.
35:02If the patient notices that,
35:04then the whole encounter takes
35:05a different term.
35:06And the reason why nurses never make eye
35:08contact is because in the hospital at least,
35:11the nurses are behind.
35:12I don't know what those machines
35:14on wheels are called.
35:15I mean,
35:15I thought of them as the control stations
35:17in the sense of controlling the nurses,
35:19but their eyes are always behind the screen,
35:21so the nurse always walks in and the
35:23physicality of this is really important.
35:25The nurse always walks in
35:26pushing this thing right,
35:27and her eyes are always 100%
35:29of the time on the screen.
35:30So the patient's first
35:32reaction to the nurses.
35:33OK,
35:33there was a nurse.
35:34And then there's something really important
35:36she's looking at who knows what that is.
35:37But the most important thing in this
35:40conversation is not is not going to be me.
35:42Which leads me to the next thing
35:44which I was really struck by,
35:46which is the narrowness of attention span.
35:48So at least in my my story was
35:50not that long of a story.
35:52My story was only two weeks old.
35:54You just you only need to know things
35:57that went back to the past two weeks,
35:59but nevertheless,
35:59at least in the emergency room,
36:01the stuff which happened 2 weeks
36:03ago in New Haven and even the stuff
36:05that happened 5 days previously
36:06in Florida wasn't important.
36:08That was, that could have been
36:10before the beginning of the universe.
36:11You know what?
36:12What matters is just the records that
36:14we've got, just that just the readouts.
36:16Just the test that we're doing right now,
36:19and that's what matters.
36:20The right now matters.
36:22And you know, there's a story,
36:23and this and the story sometimes
36:25takes a moment to tell,
36:26but the story can actually,
36:27you know, be the answer.
36:29I I know, all of you know that,
36:31but I I was really.
36:32I was really struck by this because
36:34I had a pretty simple story to tell,
36:36which was that my gut was operated
36:38on and maybe the problems in my gut.
36:40But that story required me to
36:41go back two weeks in time,
36:43and somehow that seemed like it was too much.
36:46Then you know that then with this
36:49attention with the and with and with
36:51and with and with the narrow and
36:53with the limitation of eye contact
36:55there's a related point which is the
36:57subordination to machines and the
36:59reason why it's related to attention
37:01is that the machines are really
37:03good at getting your attention.
37:04I mean,
37:05they're really getting everybody's attention,
37:07but I'm afraid,
37:08like in the hospital from
37:09patients point of view,
37:11the watching the heads of
37:12the doctors and nurses,
37:14it's a little bit too much
37:15like you're in some kind of.
37:17Arcade game arena.
37:18You know from the 1980s it's a
37:20little bit too much like the machines
37:22are getting all the attention,
37:23like when you watch the heads
37:24in the eyes move.
37:25Where are the heads in the eyes
37:27moving and things are moving from one
37:29screen to the next screen to the next screen,
37:31right?
37:32And that's because that's machines
37:33with machines are designed to do.
37:34They're designed to get attention and
37:36patients are not designed to get attention.
37:38We're not that good at it.
37:39You know we're doing it for the first time.
37:41The machine is doing it for the
37:43five billionth time, right?
37:44The machine has been programmed,
37:45and there's like they've been
37:47running through algorithms,
37:47and it's been tested.
37:48It's very good getting your attention,
37:50but we're not.
37:51We're not going to get your attention.
37:54And so you know one like one thing,
37:56which I'm terribly depressing during
37:58those days when when I was on the
38:00floor of young New Haven was that I
38:02would see doctors doing teaching rounds.
38:04You know,
38:04senior a senior doc is like leading
38:06the junior docs in the junior docs are
38:08like being very attentive or pretending to.
38:10And the senior doc.
38:11Is this guy in particular right?
38:14I'm picking up one person,
38:15I know,
38:16but this guy in particular had his phone
38:18like his notes were on his phone I guess,
38:20or something and he.
38:22So while these all these young
38:23people are trying to look at him
38:25and make eye contact with him,
38:27he's looking at his phone, right?
38:29And maybe his notes are there. I don't.
38:31It doesn't matter, it's still.
38:32It's a pedagogical disaster because what
38:34he's doing is he's inadvertently teaching
38:36all of these people that it's not important.
38:38I contact, right?
38:39It's not important to actually
38:40be with the people you're with.
38:42Right, but so how can that be a model
38:44for how you're reaching patients?
38:46I mean, as a teacher I would just say
38:48you might as well stay home like that.
38:50Teaching round might as well not happen.
38:52It would probably be better just
38:54to stay home,
38:55then did then to do that sort of thing.
38:57OK, now onto onto the broader lessons
38:59and these then sort of come from.
39:01And then I'll wrap it up 'cause I realize
39:03we're getting towards 45 minutes here.
39:05Some of the broader lessons come
39:07from where I hit the system.
39:10So is Mark knows Mark suggested
39:12like I've basically been a healthy
39:13person aside from migraine,
39:15the couple of other you know
39:16not so serious things.
39:18Migraine means that I've had.
39:20I've been in migraine means that I've
39:22been in dozens of hospitals and have had
39:25some ethnographic experience and lots
39:26of different countries with hospitals.
39:28But aside from that,
39:29I basically been a healthy person
39:31and so I had kind of the advantage
39:34of naivete coming into this,
39:35and one of the things I was
39:37naive about was privileged.
39:39My own privilege.
39:40Not that I didn't think I had privilege.
39:42Not that kind of day.
39:44It was more that I didn't realize
39:46that privilege in our medical system
39:48means having relatively less bad care.
39:51So I realize I have had relatively
39:53less bad care than other people
39:55are relatively less bad health
39:57insurance and other people and and
39:59what I realized in the system was
40:01that that's like we're supposed to
40:03feel comfortable because we have
40:05less bad care than other people.
40:07If and this is, you know,
40:09the logic comes down to a kind of logic,
40:12exclusion of exclusion,
40:13or really ****** because it's like
40:15what you're supposed to be satisfied
40:17with is relatively better care,
40:19you know, then you're put into.
40:21You're put into this state of
40:22competition with everyone else,
40:23and as a patient you can't help.
40:25Although people of course not
40:26going to cop to this,
40:27you can't help but look around and think,
40:29OK,
40:29like am I going to go before
40:31that person or that person go for
40:32me and what's going to happen?
40:34And if but if we had universal care
40:35then you know that that feeling
40:37would go away and I don't say that
40:39just out of nowhere.
40:39I say that you know talking to you
40:41from a system where there is universal care.
40:43Having had a lot of experience
40:44in systems where there's
40:45universal care, the moral
40:46atmosphere is totally different.
40:48The second thing which comes out of
40:50my experience and where I'm going to
40:53wrap this up is a larger thought,
40:55but it related thought about about
40:57the nature of freedom, so you know,
40:59in in the US when we talk about freedom,
41:03we're always talking about freedom from
41:05and we're talking about being left alone.
41:07We've been talking,
41:08we're talking about not being restrained,
41:10right? That's that's all.
41:11That's all freedom was, but in the hospital,
41:14you know, I felt that like,
41:16I felt that sense of like.
41:18I have to resist.
41:19I felt that when I was very sick
41:22but I also felt something else,
41:24something very different,
41:24which was a sense of solidarity.
41:26You know that that people were helping me.
41:29You know people in the hospital
41:30were helping me.
41:31People outside the hospital were helping
41:33me and that that to be a free person.
41:36It isn't enough to just kind
41:37of rage and being individual.
41:39You all there also has to be kind of.
41:42There has to be a system,
41:43a set of structures which you
41:45can't possibly build yourself
41:46right that there's a kind of.
41:48So therefore there's a kind
41:50of paradox to freedom.
41:51It's partly about being
41:52this raising individual.
41:53That's fine,
41:53but it's also partly about the solidarity
41:55which builds up the structures which
41:57allows you to become an individual,
41:59and I think that's true in health care,
42:01but I think it's also it's a
42:03broader point that Americans,
42:04I think miss all the time and the experience
42:07in the hospital helped me to see that,
42:09and it leads me.
42:10I mean, not just that thought,
42:12but a lot of the things I've said before
42:14led me to the broader conclusion,
42:16which I imagine some of you share For
42:18these reasons or for different reasons.
42:20Which is that health care?
42:21Has to be human, right?
42:24And you can.
42:25You can get to this from.
42:27You can get to this from,
42:29you know the body like one of
42:31the other things that American
42:32discussions of freedom avoid is the
42:34body we talk about their freedom in
42:36terms of abstractions like speech,
42:38right?
42:38There's something very problematic
42:39about talking about free speech,
42:41because speech is an abstraction.
42:43There's freedom of speech for free people,
42:45right?
42:45But it's the person that's free ultimately
42:47and not the speech we give our freedom
42:49to abstractions that don't exist,
42:51like a free market.
42:52There's no such thing as a free market.
42:55But nevertheless we talk about it a lot,
42:57but we don't talk about very much
42:59or very well is our is our bodies,
43:01and of course it means it's
43:02a dumb thing to say,
43:04and it's something you guys see all the time.
43:06But if you can't move,
43:07if you're really sick,
43:08you're not free.
43:09If you don't have a sense of the
43:11future because you feel you're very
43:13sick and you might die, you're not.
43:15You're not free, right?
43:16So you can't have a serious
43:17discussion of freedom
43:18without the body,
43:19and we try to do that in the US,
43:21and where this where this becomes
43:23a discussion about rights is
43:24where this meets the market.
43:26Because you know the problem in a
43:27commercial medical system medical system
43:29which is oriented towards profit,
43:30is that it's ultimately going to be
43:32about people being the right kind of
43:35sick for the right amount of time.
43:37That's what it's going to be about,
43:38and the way to get around that
43:40conceptually and ethically is to
43:42get the body out of that kind
43:43of efficiency calculation.
43:44And the only way to do that is to say,
43:47I think is to name healthcare
43:48as a human right,
43:50because that's what a right means.
43:51A right means that something has
43:53a dignity around it such that you
43:55can't talk about it just in terms
43:57of how quickly we can get this
43:58thing you know out of out of the
44:00hospital how quickly we can get
44:02this thing in the right place,
44:04it removes that logic.
44:05If you talk about you talk about rights.
44:07So that's that's where I ended up.
44:09I've left a lot of things out of the book,
44:11but I've given you a lot of detail.
44:13I probably talked about a lot of things
44:14you've already thought through yourselves.
44:16Thank you very much for your
44:17patience and I'll look forward
44:18to hearing your questions.
44:23Here we go, sit up straight on.
44:25You were going there we go OK?
44:29Oh man, thank you so much Tim for telling
44:33your story and for being Frank with us.
44:38How point out a couple things before we
44:40get to the question and answer portion.
44:42I see there's a number of questions
44:43or comments were already stacking up
44:45and I'll get to them as best we can.
44:47First, a simple thing,
44:48which is to apologize to the people
44:50whose questions I don't get too.
44:51We will have a hard stop at 6:30,
44:53but this teams left us plenty
44:55of time to speak.
44:56The second point I want to make
44:58which which Professor Snyder
44:59two alluded to just briefly,
45:00is that what did not happen here
45:02is he came to me and said I had
45:04a bad experience and I want to
45:06come and speak to your group.
45:07Speak to the physicians at the hospital.
45:09Thank you folks and tell you
45:11what for what happened.
45:12Here was I read the book and I
45:14sought him out and said we need
45:16to talk about this and we need to
45:18hear it and we have an audience
45:20filled with two important Brooks.
45:21Three important groups.
45:22Really. One is the people.
45:23Many people who deliver care at Yale,
45:25New Haven Hospital and who are part
45:27of the American health care system.
45:29This is how we make our lives.
45:31The second is we have folks here
45:33who are leaders in healthcare and I
45:35wanted us to hear it an I wanted us to
45:37get a chance to engage him in some dialogue.
45:40And the third importantly is we have
45:42people here who are future physicians,
45:44future nurses and future
45:46leaders in healthcare.
45:48You know when we have a problem,
45:50we have a serious problem that
45:51there's a big lesson here.
45:53Which was it's?
45:53It's easier and more common
45:55to look the other way,
45:56but that's not an option here.
45:58So if there's one lesson the
45:59students get out of this,
46:01and I think there's many lessons
46:02I'd like you to get out of this,
46:04but this one is that you know things
46:06didn't go well and we could make excuses.
46:09We could give rational, rationalize it,
46:10or we can look at, look at it squarely,
46:12make that eye contact with our problems,
46:14and see how we want to address it.
46:17So, again, this was not Tim saying.
46:18I'm coming to complain to you guys.
46:20This was missing come and speak to us
46:22and so with that I want to give you
46:24I'm going to be reading your questions
46:25if you have questions or comments,
46:27please put him through the Q&A and I'm
46:29going to share these with with Tim now.
46:33And and to get to some of these.
46:36Some of these are simply,
46:38you know, no question,
46:39just shame so many missed opportunities
46:42to provide basic level of health care.
46:44Very disturbing.
46:45You could easily have died.
46:47Hubris, carelessness, system failure.
46:48Question is a specific questions surgical
46:50teams usually having morbidity and mortality
46:52conference to learn from bad outcomes.
46:55This count.
46:55This seminar is a form of
46:57morbidity and mortality conference,
46:59but more specifically,
47:00the surgeons meet when things don't go well.
47:03And talk about it to try and prevent
47:04it from happening.
47:05Next time.
47:06Do you know Tim?
47:06If that happened in your case?
47:10So first I want to say
47:12something about system failure,
47:13'cause I I just I like that term when
47:16I was when I was going through this.
47:18So you have to remember like I mean thank
47:21you Mark for pointing out that I'm not
47:23like I didn't actually want to do this.
47:26You know more Mark asked
47:27me a number of times and.
47:30But once I did it,
47:31I gotta do it the way I do it,
47:33'cause this is the only
47:34honest way I can do it,
47:35but I like the I like to like system
47:37failure 'cause when I was a patient.
47:39It felt like bad luck like
47:41again and again bad luck.
47:43Bad luck here. Bad luck there.
47:44Bad luck there. Bad luck there.
47:46Bad luck there. Bad luck there.
47:48But then after a while you realize.
47:50It's not actually bad luck like that.
47:52After awhile your analytic
47:53brain kicks in and says no.
47:55Wait a minute.
47:56There are patterns here.
47:57This isn't just an individual
47:58thing happening to you,
48:00this is,
48:00there are things you can actually analyze
48:02which I tried to do a little bit as far
48:04as the morbidity and Mortality conference.
48:07I I don't.
48:08I don't know.
48:08I have not.
48:09Although I have,
48:10I have their people were
48:11very close to me at Yale,
48:13New Haven.
48:14You know who I love and cherish that
48:16I have not maintained contact with
48:17anyone who was taking care of me
48:20during this particular moment, so.
48:21I don't, I don't know.
48:23Not that
48:23I know of. Thanks, Jim.
48:25So I would make it take a second here
48:27to make a small point which is of all
48:30the things that went wrong there has.
48:32I think it came into place
48:34since your time in the hospital.
48:35Tim, a law national law that
48:37says that everybody has access to
48:39their medical records very easily,
48:40much more easily than in the past.
48:42Now there are certain exceptions to that,
48:45but for the most part,
48:46any patient in the hospital
48:47can quickly access their MRI.
48:49The Progress note the physician wrote today,
48:51etc so.
48:51Perhaps there was a small improvement
48:53in that you Tim could have been
48:55reading your own MRI results and said,
48:57well, what the hell is this?
48:59However,
48:59amount would point out that that
49:01may help move us somewhere in a
49:03small way in the right direction.
49:05But of course that assumes that the
49:07person reading it is healthy enough
49:08to focus on it is educated enough to
49:10understand it and is fluent in English,
49:12or else has friends or relatives who
49:14are very sophisticated medically.
49:15It's kind of a savviness requirement
49:17that we've talked about in the past.
49:19And by the way, when you're sick as hell.
49:22Trying to make sense out of the
49:24MRI report is not something we
49:25should expect of our patients,
49:27but that is one small thing and we'll
49:28talk about this another session.
49:30But actually that law has its own
49:32problems in Pediatrics and I don't
49:33want to go down that road right now,
49:35except to say that that it is
49:37frustrating that the information
49:38was there that could have led to
49:40a very different course and you
49:42weren't told that it was there.
49:44Another question,
49:45please order comment from my friend France.
49:47I learned this more than 20
49:49years ago and nodding.
49:50If you want yes or not.
49:51So basic communication
49:52skill leading the patient,
49:53you know we all learned this in
49:55medical school or should have
49:57whether or not we incorporated.
49:58Which is, you know we say things like,
50:01well, you've never had a venereal disease,
50:03right?
50:03That's not actually the way we're
50:05supposed to ask the question so,
50:06but it's an excellent point to
50:08be reinforced to all of us,
50:10not just the students lack of eye
50:13contact is again commented on.
50:15Here's a question that one of
50:17the physicians writes God.
50:18I'm so sorry you went through that
50:20horrific chain of experiences at
50:22any hospital, and especially here.
50:24It's enormously helpful to hear
50:26this feedback.
50:26I fully agree with you about
50:28the problem of racism.
50:30The overly quick discharge,
50:31the lack of a single team captain,
50:33the excessive attention to machines,
50:35and the lack of attention to patients.
50:38It strikes me that another significant
50:40problem was the repeated failure
50:42to correctly obtain critical
50:43information from the medical chart.
50:45The liver Abscess the procalcitonin level.
50:48How do you think we can liberate
50:50doctors from machines,
50:51electronic records while
50:52simultaneously improving transmission
50:53of critical care test
50:54results from the electronic
50:55medical record to physicians?
50:56And so it's a very insightful question.
50:58Then we have two problems.
51:00One is we spend too much time
51:02looking at the machines,
51:03and the other is actually that
51:05someone didn't pay close enough
51:06attention from the machine.
51:07Is there?
51:08Is there a way we can get away from
51:10the machines and still improve
51:12the transmission of those critical
51:13results that you can think of?
51:15Tim,
51:16I mean, as someone who's you know takes
51:18someone who's totally outside of this?
51:20I would say your problems are deeper than
51:23that because you physicians also just
51:25spend way too much time entering records.
51:28And you don't like the way you
51:30enter records and your level of the
51:33frustration of that comes from your
51:35spending time with the machines,
51:37then feeds back negatively on the care.
51:39I think so. I think it's I think you have to.
51:42I would scrap what you got and start.
51:45I mean I think makes no sense to have
51:47a monopolist monopoly monopolistic.
51:49Who's designed one system which
51:51everybody has to use,
51:52which is fundamentally correct.
51:54Me, if I'm wrong about about
51:55fees rather than about diagnosis,
51:57an about planning.
51:58I think that should be scrapped and
52:00and that and the system that should
52:02be the system that should be used by
52:05doctors should be designed by doctors.
52:07I think that would have to be the rule
52:09and 'cause I have not met a physician.
52:12You know, in the hospital or in
52:14private life or anyone who says well,
52:16let's record keeping system we
52:18have going now.
52:19Is this really good?
52:20That's really the thing we should have.
52:22So I it's it's.
52:23It's the technique of having
52:24every system connected.
52:26Shouldn't that shouldn't be difficult.
52:27I think it's just.
52:28I think the what strikes
52:30me as being you again,
52:31you guys can correct me,
52:32but she's being very weird.
52:34Is the way that you're constantly
52:35like using these drop down menus and
52:37you know being forced down various
52:39pathways which are basically about
52:40billing rather than having like
52:42rather than just like getting the
52:44clear line of reasoning across.
52:45And then when I read all the other thing
52:47which happens I mean is is you guys?
52:50I mean sorry to say this but you guys
52:52write things that aren't true on the record.
52:54Sometimes in order like in
52:56order to make things go faster.
52:57And it just seems like that
52:59shouldn't have to happen.
53:00But I don't have any.
53:02I mean my my my silver bullet would
53:03be you have to start from scratch and
53:05have the doctors actually design it.
53:06Like have the doctors say what they
53:08would actually like to be dealing with,
53:10because I don't think any of
53:11you like to be dealing with the
53:12thing that you're dealing
53:13with now. I think that's a fair statement.
53:15Have not? I've not met a physician who says,
53:17man, this is so much better.
53:19There are aspects of it that are better
53:20in an what's somewhat sad for those
53:22of us who are a bit grayer is that
53:24there are more and more physicians
53:25who don't know any other way.
53:28This is how they were raised and when
53:30we say you know what just put the thing
53:33aside from it and look at the look
53:35at the patients where my case look
53:37at the kids mother and talk to her.
53:39Yeah, connect to separate that 'cause
53:41there's so many responsibilities
53:42with the keyboard and with and with
53:44the computer, yeah?
53:46Can I can I jump in their
53:48markets like this that I this?
53:50Was this thing about physicality?
53:52I mean I just learned that
53:53this was taught in Med school.
53:55That's what I was wondering the whole time.
53:58Like is this actually taught in Med school?
54:00Because it seems like so many
54:02of the physicians and the
54:03nurses are getting this wrong.
54:05The physicality getting the physicality wrong
54:07because from the patients point of view,
54:09subconsciously we're being demoted, right?
54:10We're being demoted all the time that
54:13you know the the stupid robot that the
54:15nurses are pushing in front of them.
54:17Is always more important than us.
54:19It's always getting more attention
54:20than we are.
54:21Is getting more of her eyes more
54:23of her arms more for everything.
54:24More of his everything.
54:25And and with doctors is not
54:27quite so dramatic.
54:28But it's also true.
54:29We were being demoted all the time because,
54:31you know, your cousin,
54:32'cause doctors are not
54:33better than anyone else.
54:34Like when you look at a screen
54:36you forget you have a body,
54:37but the person who's watching
54:39you doesn't forget your body.
54:40The person who's watching you
54:41sees the body slanted away and
54:43the headless land away in the
54:45Iceland away and sees the eyeballs.
54:46You know, going back and forth.
54:48Like in that for us as a demotion.
54:50And worse,
54:51I mean other thing which happens
54:52is that the presence of the
54:54machine distracts the patient,
54:55not just the doctor.
54:57So if you're a patient,
54:58even if you're like a smart together patient,
55:00very often you're sitting there
55:02waiting 'cause you got like.
55:03One thing you want to ask the doctor you,
55:06and you're trying hard to
55:07remember that one thing,
55:09and then the doctor comes in.
55:10You got your 5 seconds with the doctor,
55:13and the doctor looks at the phone
55:15and you forget what it wants.
55:16You get distracted by the his
55:18distraction or her distraction.
55:20So I think like that you know,
55:22I just can't test over.
55:23I can't just I can't exaggerate too much.
55:25You know, like this can't be exaggerated.
55:27The physicality of the doctor,
55:29patient connection from the patients
55:30point of view is really, really important.
55:32Because we're in this,
55:33it's very hard for us to communicate
55:35and like any barrier that stood
55:37in the way of our communication.
55:38Any demotion write anything.
55:39And what when,
55:40what you do first matter so
55:42much like when you walk into in
55:44some of you are great at this,
55:46but when you walk into the room you
55:48gotta hit the eye contact you gotta
55:50hit like the eyes and then the body.
55:53We know like even if you happen to be
55:55like spacing out and you're not even
55:57doing a good job at looking at us,
55:59we at least feel like you are right
56:01and that makes a huge difference.
56:02OK, that was my little rant about that.
56:04Appreciate that you
56:05know we're under.
56:06We're under a great deal of pressure,
56:07so I wear two hats here as I think you
56:10know Tim and some of you folks know
56:12say I'm the chief of neonatology as
56:13well as the head of the ethics program.
56:15And so I also oversee a lot of physicians
56:17who run newborn intensive care units,
56:19and one of the things that that
56:21we got a great deal of pressure
56:23was you need to include.
56:24For example, the parents and
56:25everything you talk about.
56:26And of course, much of what we talk
56:28about necessarily involves the computer.
56:30And there are those who argue that.
56:32Let's do all the computer stuff over here
56:34and then let's get up without the computers,
56:36walk into the patient's room and
56:38say good morning and tell them
56:39what we think is going on.
56:41Ask them what they think is going on,
56:43and then talk about the plan for the day.
56:46And and I think that's really helpful to
56:48hear about the separation with the machines,
56:51and that's something that I don't think
56:52any of us feel we're doing well Tim.
56:55And so this is.
56:56This is helpful to hear from you.
56:58You know, we we sometimes hear
56:59from patients just today,
57:01and I I hear a patient complaints
57:03about physicians or about the N ICU.
57:04But but it's unusual.
57:05This is for us.
57:07This is an opportunity.
57:08I'm hoping that the folks on this
57:09conference realized we often get people
57:11who say have something they want to say.
57:13It's not that often that we get an
57:16accomplished observer and author.
57:17An Reporter to spend in detail time
57:19explain to us what went wrong so
57:20you know it behooves us to listen.
57:22The other point that I made that I
57:24really want to emphasize in this.
57:26This is key,
57:27and this is something that we do in
57:28our unit and that I've also been
57:30frustrated in the hospital with
57:32relatives and others in friends
57:33in the hospital is that there's
57:35gotta be one person in charge,
57:36and that person has to be iaccessible.
57:38I'm fascinated with for years doing
57:40at this console here in another
57:41other hospitals might say, well,
57:43who's actually in charge of this case?
57:44And no one can answer the
57:46question that fascinates me.
57:47In our unit,
57:48I think everybody knows it's
57:49written on the board in every room.
57:51Who is the attending physician?
57:52Now, mind you,
57:53it changes from week to week sometimes,
57:55but there's one person who's ultimately
57:56in charge of what's going on,
57:58and that, I think is is so important.
58:00Once we have a diffusion of responsibility,
58:02among other things to communicate,
58:03then it just doesn't happen
58:04the way it should.
58:06So let me see if I can see,
58:08so we have hardly any questions except
58:09for the 41 that are lined up your temp.
58:12So let me get to some more of these.
58:16Unfortunately, the US the decision
58:18was made during the managed Care
58:20era of the 90s that primary care
58:22physicians were not to have authority
58:24for the patients overall care.
58:25Just gets to the point that we
58:27just both made patients subjected
58:29to it during times of conflict.
58:31Specialists objected to it,
58:33limited access to them,
58:34and insurance companies acquiesced
58:35choosing also to relatively
58:37undervalued primary care services,
58:38thereby steering young providers
58:40away from the field. In many ways,
58:42the American public has what they ask for.
58:45They are in charge.
58:47I hope this provides some context.
58:49Uhm? I don't know if you want to
58:51comment on that observation, Tim.
58:54I I mean. You know nobody
58:59ever gets what they deserve.
59:01Or what they ask for, really,
59:02I think I mean, I think Americans are.
59:05Americans would like to be able
59:07to have more primary care doctors.
59:09I mean that this is there's not enough
59:11people doing geriatrics or not.
59:12People doing Pediatrics or not
59:14enough primary care physicians
59:15and a lot of the country.
59:16You guys know all of this and it
59:18seems to me that given where we are,
59:20we should be incentivizing people to do that.
59:22I mean, that's not going to help,
59:24but I think when people say my doctor,
59:26you know that's what they mean,
59:28they mean they mean their GP and people
59:30find it hard to have someone who they
59:32can call my doctor and I'm not going
59:34to pull this trick too many times.
59:36So I'm going to pull it now.
59:38One of the things which is really nice
59:40about being in Vienna is that I have
59:42my doctor and like if I need to see her.
59:44I just walked down the street and
59:46walked through her door and I wait 20
59:47minutes and I see her and that makes
59:49her my doctor in a way that like it's
59:51very hard to have my doctor in the US.
59:55It's it's certainly as though I know
59:57some people like that who practice here
59:59in New Haven and who might iaccessible
01:00:01there are people who are doing it right,
01:00:04but the system itself doesn't
01:00:06make it easy for them.
01:00:07Yeah, of course it doesn't.
01:00:09Another comment as a nurse
01:00:10for over four decades,
01:00:11your story makes me sad on so many levels.
01:00:14I'm especially struck by your descriptions
01:00:16of the obvious miscommunication,
01:00:17opportunities to connect the
01:00:19dots of your story to understand
01:00:21your concerns and fears.
01:00:22But what was happening and
01:00:24really listen with every sense.
01:00:26The only comment I would add to that
01:00:28is that part of it I would suggest
01:00:30is that the system is set up to
01:00:33make it more difficult to listen,
01:00:35including the obligations we have to
01:00:37spend hours every day at the keyboard.
01:00:41And in addition on a more fundamental level,
01:00:43there is less and less time to listen.
01:00:45That time is so much,
01:00:47I think a factor in where we
01:00:49go wrong with these things.
01:00:50When people feel someone asks you is
01:00:52everything OK and they have set aside
01:00:5430 seconds for that exchange and you say no,
01:00:57well, no, that's my 30 seconds are up.
01:00:59I mean maybe it's fear of the conversation.
01:01:01Or maybe it's fear of I can't afford to
01:01:03lose 10 minutes finding out what's wrong.
01:01:06It could be some of
01:01:07both. I mean, would it be impossible
01:01:09Mark to have rotations where like?
01:01:11Some some doctor, every some doctor on
01:01:13every shift doesn't have to do with
01:01:14machines like just to have a free
01:01:16floater who like that's your shift
01:01:18where you're just going to be like.
01:01:19I don't know your hospitalist that
01:01:21day and you're not going to touch any
01:01:23machines are not allowed to all you're
01:01:25allowed to do is talk to the patients
01:01:27you're not allowed to touch a machine.
01:01:28Couldn't I mean,
01:01:29couldn't there be such a shift?
01:01:30And when people like taking that shift?
01:01:32And wouldn't patients love those people?
01:01:34Oh my God. Well,
01:01:35that sounds like the dream.
01:01:37The counter argument will be
01:01:38from some as well as how many.
01:01:40How many RV use that person produces.
01:01:42Which is to say how much
01:01:43collections that person produces.
01:01:44I think it's a beautiful idea.
01:01:46In my ideal world, by the way,
01:01:48that person doesn't have to spend some,
01:01:49and there was a time long ago
01:01:51as an attending physician.
01:01:52You spend very little time on documentation.
01:01:54Your notes were very brief.
01:01:55The residents wrote long notes.
01:01:57You were briefly, but you had more time
01:01:59to actually spend talking to people.
01:02:00So I would love it in some, in some.
01:02:03In some world where we did have
01:02:04someone like that and I would
01:02:06love the attending specifically.
01:02:07To have the time to go from room
01:02:09to room and just chat with people
01:02:11and see what's really going on.
01:02:12The time pressure pushes against that.
01:02:14There's something else I would I would
01:02:15comments you Tim, that's important.
01:02:16Observation to share is that
01:02:18you mentioned that.
01:02:18Are we teaching people
01:02:19about the body language?
01:02:20I mean,
01:02:21one of the doctors commented she learn
01:02:2220 years ago about when we leave the
01:02:24question we shake our head yes or no.
01:02:26As you alluded to,
01:02:28which you observed as a patient.
01:02:30And I would say that that those of
01:02:31us who teach medical students and
01:02:33teach residents are painfully aware
01:02:34that there's two aspects of this.
01:02:36There is what we teach him.
01:02:37What we say like tonight,
01:02:38and then there's what we show him.
01:02:40OK, so if I sit here tonight and say,
01:02:42listen,
01:02:42what you need to do is really
01:02:44focus on the patient.
01:02:45Or in my case, the parent.
01:02:46I take care of newborns,
01:02:47focus on them when they're talking to you,
01:02:49and I tell him that six times,
01:02:51and then they follow me around for a day
01:02:53and they see me just stare at the computer.
01:02:55You know,
01:02:55what do you think they learn?
01:02:57They learn that this is
01:02:58how you really do it so.
01:03:00This, in this fault,
01:03:01lies in ourselves ourselves,
01:03:02being the faculty terms of how
01:03:05we do it and how we model it.
01:03:09Here's a question,
01:03:10and you can talk to me about
01:03:11this afterwards if you like,
01:03:13but this is from one of
01:03:15our educational leaders.
01:03:15Would you be willing to allow this
01:03:17recording to be shown to medical students,
01:03:19residents, nurses,
01:03:20and attendings and professors?
01:03:21We all need to be reminded of
01:03:23the perspective of the patient
01:03:24and how we can do so much harm
01:03:26so casually and carelessly.
01:03:28No,
01:03:28you're very you're very welcome to use it.
01:03:30I mean, there's nothing in this
01:03:32which isn't in the book, so I mean,
01:03:34it's it's already out there.
01:03:36So if someone thinks that this
01:03:37is a valuable teaching tool, I.
01:03:39I'm very happy with, you know,
01:03:41so long as it's credited
01:03:43to this forum and so on.
01:03:45Before I'd be delighted if
01:03:46it were used. Thank you, thank you.
01:03:49So will we. Will talk about that.
01:03:51My friend who's asked this question.
01:03:53We will talk about that offline.
01:03:55Other comments.
01:03:55Spot on fantastic Amen. Thank you.
01:03:58I also read the book great.
01:04:00Thank you for illuminating
01:04:01something that many of us who
01:04:03trained outside the US experience.
01:04:05And why many are retiring from the system?
01:04:09The CEO of Yale, New Haven Hospital
01:04:11should be in your audience,
01:04:12and I don't actually know if
01:04:14the CEO is the CEO is not.
01:04:17Is not tone deaf,
01:04:18so I do hope that we that we
01:04:19have some leadership listening
01:04:20and if not that they are made
01:04:22aware of some of these concerns.
01:04:26Have you communicated your experience to
01:04:28administration at Jan Haven Hospital?
01:04:30If not, would you be willing to?
01:04:34That would be a sort of.
01:04:36I mean there when the book was published,
01:04:38a formal procedure began to look
01:04:40into the case, and I said I'd be.
01:04:43I said I'd be willing to talk to
01:04:45the two doctors who were doing it,
01:04:47but that hasn't actually happened.
01:04:49It might have been that I was busy.
01:04:51You know, it might have been that they
01:04:54had a limited amount of time to do it,
01:04:57but the answer is yes, I I I am.
01:05:00I mean, I hesitated to do the thing
01:05:02which Mark was asking me to do,
01:05:04which is kind of like.
01:05:06Lay this all out to you,
01:05:07but I would of course be very happy to
01:05:10take part in the conversation like that.
01:05:13Thank you. How much of an effort
01:05:15did you make while at Yale,
01:05:17New Haven Hospital to see the
01:05:18records the staff had available
01:05:19to them while caring for you?
01:05:21And if you did try what
01:05:22occurred when you tried,
01:05:23did you try and see your
01:05:24electronic medical record him?
01:05:27ACBL. I mean, as I said as I said,
01:05:32the main problem I had was at the
01:05:34beginning when I actually was carrying
01:05:36my record around and I had and I think
01:05:38I even knew had a sense of what the
01:05:40relevant stuff in the record was and
01:05:41I couldn't get that across it. No.
01:05:43But while I was at Yale, New Haven,
01:05:45I didn't try to look at my record.
01:05:47I asked my record after I after I
01:05:49left a couple of weeks after I left.
01:05:52I mean, I did.
01:05:52I had a problem in Florida where
01:05:54they did the Spinal Tap and like
01:05:55you know I was concerned about
01:05:57about Guillain Barre because that's
01:05:59what everyone's concerned about.
01:06:00My father just had a friend who
01:06:02would who had died of it and
01:06:03it was very much on our minds,
01:06:05but I couldn't get there like they they
01:06:07took the Spinal Tap at like 2 in the
01:06:09afternoon and I couldn't get there.
01:06:10I couldn't get the results.
01:06:11You know, for like 14 hours after that.
01:06:13But that wasn't that wasn't at Yale,
01:06:15New Haven and I only ever got them.
01:06:17Was like I persuaded the nurse to
01:06:19write them down on a piece of paper.
01:06:21And I promise that I wouldn't tell anybody.
01:06:23Like that's how I figured out I
01:06:25didn't have to go and buy was by,
01:06:27you know,
01:06:27but this nurse writing this thing
01:06:29out in pencil and like my looking at
01:06:31it like this, well that that's
01:06:32certainly been improved since then.
01:06:33However, once again,
01:06:34that's for the patients who are savvy enough
01:06:36with their cell phones with their computers,
01:06:38and to know how to interpret the information.
01:06:40Or at least they know what to look for.
01:06:42So it's a partial solution at at best.
01:06:44Yeah, Professor Snyder.
01:06:45Thank you for sharing your insights with us.
01:06:47It's a priceless opportunity.
01:06:48That's, by the way, I'm not thank you.
01:06:50This is someone who wrote question your team.
01:06:53It's a priceless opportunity for us
01:06:54to hear your unique perspectives.
01:06:56To what extent do you think your
01:06:58experiences were unique and to what
01:07:00extent do you believe they can be
01:07:02extrapolated to other health systems,
01:07:04both in the US and internationally?
01:07:07So
01:07:08I think the only thing which is different.
01:07:12About my experience is that I have the
01:07:15toolkit to talk about it, so that's it.
01:07:18I'm a historian, I can talk,
01:07:20I can write, I think that's the only
01:07:23that's the only difference. Uh, I mean,
01:07:26I say that partly because of my of my,
01:07:30you know, my my acquaintances or
01:07:32friends who are doctors who tell
01:07:34me that my experience was typical.
01:07:36So I mean, those are people that
01:07:39yell and and and elsewhere right?
01:07:41So when I'm told by not the people who
01:07:44treated me but the people who are taking
01:07:47those shifts that this is normal, right?
01:07:50That I shouldn't be.
01:07:52That's a product that's sad,
01:07:53of course, but this is.
01:07:55Typical, right when I'm told by
01:07:57ER doctors at Yale that if like
01:07:59if any of their family members are
01:08:01in an ER anywhere in the country,
01:08:04they're going to fly to that
01:08:05hospital right away because they
01:08:07know it could be a disaster.
01:08:09Well, that makes me think that what
01:08:11happened to me was unfortunately
01:08:12pretty typical of American ERS and and,
01:08:14you know, in a way, like I was,
01:08:17you know I had a lot going for me,
01:08:20of course,
01:08:20but but it was a kind of brush
01:08:22with normality, you know,
01:08:24like nobody knew who I was.
01:08:26Like in my view,
01:08:27like in one way that was kind of blindsided
01:08:28was like thought of like I thought of you.
01:08:30New Haven is yell and like it isn't,
01:08:32you know,
01:08:33kind of is but like nobody knew I was like
01:08:35I was it was a Saturday morning there are,
01:08:37you know it was Saturday morning.
01:08:38There are a bunch of drunks there like
01:08:40there was a lot of stuff going on.
01:08:41I was just like one more guy and like
01:08:43and that's like for awhile so that's
01:08:45a kind of advantage like I was just
01:08:47one more guy like I was just kind of there.
01:08:49But the only difference only is
01:08:50that like I the only difference is
01:08:51that I was taking notes the whole
01:08:53time when I could and that I would.
01:08:55You know that I could.
01:08:56Write about it.
01:08:57As far as other systems,
01:08:58I think other systems are different.
01:08:59I mean,
01:09:00I read about this a little bit in the book,
01:09:02but we had we had one of our kids
01:09:04in here in Austria had another
01:09:06one in the United States and it's
01:09:08it's a very different experience
01:09:09and it has to do with time.
01:09:11I mean the word time.
01:09:12Maybe the single most long with attention.
01:09:14The single most important
01:09:15word that's been pronounced.
01:09:16If you have a kid and the the doctors,
01:09:18I mean,
01:09:19you know I don't want to push
01:09:20you too **** ** this month,
01:09:22but if you have a kid in the system
01:09:24where the doctors are under no
01:09:26financial constraints whatsoever.
01:09:27There going to be a lot fewer caesareans
01:09:29my first child would have been necessary,
01:09:31and in the US 100%, but it was,
01:09:33but he wasn't because we are in a system
01:09:36where there was zero pressure and they
01:09:37had their second kid in United States
01:09:40and there was pressure to do a B&C.
01:09:42Didn't happen, but you know,
01:09:43if we did have been the other way around,
01:09:46our first business there in US and the
01:09:482nd is ring because the first one was
01:09:50necessary and it makes a huge difference.
01:09:52If you know like in Vienna you have a
01:09:54minimum of four days after childbirth,
01:09:56you have to stay in the hospital.
01:09:59And the reason is so that the parents learn
01:10:01how to bathe a kid and how to breastfeed,
01:10:03which is not, you know, as you know,
01:10:04it's not obvious how to do those things.
01:10:06If you have a kid in the US,
01:10:08you know you get a piece of paper
01:10:10which has some breasts on it
01:10:11and you get a phone number,
01:10:13maybe of a lactation consultant.
01:10:14But you're just not going to
01:10:15be there as long you know.
01:10:17And that difference in time really matters.
01:10:18And I'm just.
01:10:19I'm using birth because we've
01:10:20been talking about death,
01:10:21but it's like it's the same principle.
01:10:23So I think there.
01:10:24I think there are, you know,
01:10:25I think there are better systems.
01:10:26I mean one thing which I
01:10:28find kind of depressing.
01:10:29I see a lot of doctors
01:10:31because of the migraines.
01:10:32You know,
01:10:32it's like and and that's and I end up
01:10:34chatting with migraines like a subject
01:10:36that doctors kind of like to talk
01:10:38about because they're so complicated.
01:10:39So I kind of get a lot of doctors
01:10:41and and the GPS here will say things
01:10:43like you really should take care of
01:10:45your problems taken care of here in
01:10:47Austria before you go back to America.
01:10:49And like that,
01:10:50I find that so depressing,
01:10:51right?
01:10:51Like my patriotic self finds that finds that
01:10:53so sad and I wish it weren't true like I wish
01:10:56it weren't true but there are differences.
01:10:58You know there's there's in
01:10:59the main differences feel.
01:11:00Like so much of what we've talked
01:11:02about has to do with patient anxiety,
01:11:04and then in some of the replies,
01:11:06very,
01:11:06very politely and cautiously.
01:11:08You know you and your you and
01:11:09your colleagues mentioned how
01:11:11you're under time pressure too.
01:11:12And I know you are.
01:11:13I get that so much the difference
01:11:15over here is that that like,
01:11:17I don't feel like the doctors
01:11:19are under so much time pressure.
01:11:20I just I don't feel that like
01:11:22when I when this is all over.
01:11:24In June I flew with my family to Austria.
01:11:27In July I went to see a GP here and
01:11:29she like she dropped everything.
01:11:31At like 2 hours on my case because it was so,
01:11:34you know she wanted like she didn't
01:11:35like she didn't take a G like every she
01:11:38went through everything all over and
01:11:39I didn't have an appointment with her.
01:11:41I didn't have an appointment, but like
01:11:42she thought that was the important thing,
01:11:44and so that's what she was going to
01:11:46do and that feeling that like OK like
01:11:48somebody might actually have time for you.
01:11:50And from her point of view that she
01:11:52somehow I don't know how it works exactly,
01:11:54but clearly she's not being, you know,
01:11:56clocked on 20 minutes segments right,
01:11:58but from her point of view that she feels
01:12:00like, oh, I could actually do this, right?
01:12:02OK, there's this new patient.
01:12:03Something's going on this clip confusing.
01:12:05I'm going to spend like my afternoon
01:12:06on this that like that.
01:12:08It happens, is nice,
01:12:09but also just the feeling that
01:12:10it could happen.
01:12:11Is so calming tickets so it's like this.
01:12:13It's so liberating.
01:12:14The sense that like, OK,
01:12:15the system is a system is going to work on
01:12:17the other in the other differences money
01:12:19which we didn't talk that much about,
01:12:21but you know it.
01:12:22So for so many people in America that
01:12:24that's that's a source of tremendous
01:12:26anxiety or just a reason why they don't
01:12:28even go into care or they don't care.
01:12:29They worry like I'm not going to get
01:12:31worse treatment than somebody else.
01:12:33'cause I've got the wrong card.
01:12:34I don't have a card at all and
01:12:36you can lift that anxiety.
01:12:37People just feel so people just feel better.
01:12:39So yeah, I mean I, I don't, I think.
01:12:42I think my experience was was representative.
01:12:45Man,
01:12:45I do think other systems do
01:12:47certain things better.
01:12:49Of course, you've had the
01:12:50opportunity to observe it as of
01:12:52as a patient in various systems.
01:12:53So often I hear folks who have only
01:12:56been exposed to 1 system say, well,
01:12:58this system is clearly the best be cause,
01:13:00but I have to tell you that, for example,
01:13:03I have colleagues in Canada who talk
01:13:05about their assistant versus ours.
01:13:06There's advantages and disadvantages.
01:13:07I've actually never heard one say.
01:13:09I sure hope someday we can.
01:13:11We can switch to the US system.
01:13:13I've never heard somebody
01:13:14ever come close to that.
01:13:16They all are are quite clear
01:13:18that they as physicians.
01:13:19That they prefer working in
01:13:20that system to this system.
01:13:22Those who are familiar with both and
01:13:23there may be exceptions to that.
01:13:25Maybe I'll hear from one in the queue.
01:13:27Wait, let me go to another comment please.
01:13:29Thank you so much for sharing your
01:13:31experiences and your insights to
01:13:33say we need to do better would
01:13:34be a gross understatement.
01:13:36Can you talk more about what you
01:13:37perceive is diminished authority
01:13:38of physicians within the system?
01:13:40As you noted in your interaction
01:13:42with the neurologist and how this
01:13:43related to your larger experience
01:13:45with the medical system?
01:13:46What do you think are some concrete
01:13:47steps that we could take beyond
01:13:49ensuring universal access to care?
01:13:51And which is clearly important
01:13:52so specifically about the
01:13:53diminished authority of physicians.
01:13:54What do you think we could do to change that?
01:13:58Yeah, that really I'm.
01:14:00I'm glad that questions here towards the end
01:14:03because my experience is such a such a mix.
01:14:06You know, like I did meet some folks
01:14:09who I do not think should be practicing
01:14:12medicine under any circumstances,
01:14:14I think they should be doing something else.
01:14:17But in general my interactions
01:14:19with physicians taught me that
01:14:21these are people who should have
01:14:23more rather than less authority.
01:14:26And I don't know that there's
01:14:28an easy answer for this.
01:14:29I mean, it's it's it's nice that
01:14:32you know so many of the reactions
01:14:34are we have to do better.
01:14:36I mean, that's that's kind, you know.
01:14:38And that's appropriate.
01:14:39But I tend to think that what's
01:14:42holding you back is a system.
01:14:44Which none of you individually can change,
01:14:46and this is part of my reason for like mixed
01:14:49feelings of talking to Yale, New Haven.
01:14:52I mean, you yell New Haven.
01:14:54Young Haven is a regional monopoly in
01:14:57a commercial medical system and either
01:14:59there are things that are not going
01:15:01to change until we don't function
01:15:03so much as a commercial medical
01:15:05system with regional monopolies.
01:15:06I think when those things change,
01:15:08I think doctors will have more authority.
01:15:11How to give doctors more authority
01:15:13in the present system, I don't know.
01:15:15I mean the things that I see
01:15:18oppressing you are one.
01:15:19You're being turned into
01:15:21advertisements for hospitals,
01:15:22which I think is degrading and immoral too.
01:15:25You you are forced your language has
01:15:27been forced into into a fundamentally
01:15:29financial language by by the by the
01:15:32record keeping system and three.
01:15:34You don't seem to control your
01:15:36time very well.
01:15:37It seems that someone else is telling you
01:15:39how to spend your time and and and and then.
01:15:43Of course for all the people who are,
01:15:46you know,
01:15:46the the kind of lack of clarity which
01:15:49comes with the word provider of who
01:15:51is actually a physician in the room,
01:15:54which is sometimes unclear for patients.
01:15:56And I don't know.
01:15:57I don't want, you know,
01:15:59but but so that's what I see.
01:16:01I don't know how to solve all of it.
01:16:03I mean, I I had this.
01:16:05I mean, I was thinking yesterday.
01:16:07Like maybe you guys need a labor union.
01:16:09You know,
01:16:10maybe maybe you should be a
01:16:12union because you don't have.
01:16:13I mean, it's like do I was.
01:16:15Also I mean,
01:16:16oh,
01:16:16another thing is of course these because
01:16:18you're working for not all of you
01:16:20but likes working for staffing firms.
01:16:22And you sign these contracts which
01:16:24basically have gag clauses to them, right?
01:16:26I mean,
01:16:26that's another way that you're held back.
01:16:29Many of you, and in the you know the result.
01:16:32Like if you look back at the pandemic at
01:16:34which I hope you can look back at now.
01:16:37He was really striking how low
01:16:39the voice of doctors was,
01:16:40you know,
01:16:41like how I mean in various ways like that.
01:16:43People don't respect doctors enough,
01:16:45but also how doctors had trouble
01:16:47speaking out.
01:16:47I think partly because of these
01:16:49clauses in their in their contracts
01:16:51and how like you know the doctors.
01:16:53I mean, I don't think I don't think
01:16:55the AMA has the I don't think it
01:16:58has the push that it wants to.
01:17:00I don't think it's. Even close.
01:17:03So you know, I don't know exactly
01:17:05how to solve that problem,
01:17:06but I part of it though is like a validation
01:17:09of professional authority. I mean,
01:17:11I think I think physicians should have.
01:17:14We should think of physicians as people
01:17:16who have authority as opposed to people who
01:17:19are just one part of a money making system.
01:17:21Sorry to put it that way and
01:17:23patients are slowly learning.
01:17:25You know, we're not.
01:17:26We're slow on the uptake.
01:17:28You know? Like that, it's for you.
01:17:30It's an iteration for us.
01:17:32It's like once or twice or three
01:17:34times in a lifetime or whatever.
01:17:36But patients are slowly learning
01:17:38that that's the way that it is there.
01:17:40Slowly learning that doctors are
01:17:41not what they think they are,
01:17:42and that's bad for everybody, right?
01:17:44Because then patients don't patients trust
01:17:46will trust doctors even less than they do,
01:17:48and and doctors will have a harder
01:17:49and harder time getting patients
01:17:51to do things like vaccinations,
01:17:52which they really they really
01:17:53should be doing.
01:17:54So I think we're in kind of a
01:17:56vicious circle with vicious cycle
01:17:57with the commercialization and
01:17:59I think the answer has to start.
01:18:01I mean, This is why I ended up with rights,
01:18:03because if you think of health
01:18:05care as a human right,
01:18:06you're also dignifying the doctor.
01:18:08Because the doctor is the person who directly
01:18:10is not just any provider of a service,
01:18:12but the doctor is the
01:18:14caretaker of a right right.
01:18:15The doctor then has a has an
01:18:17inherently more dignified position.
01:18:18If we're talking about something
01:18:20which is a right, I think I mean,
01:18:22I think that's one.
01:18:23That's one of the reasons for me.
01:18:25Anyway,
01:18:26I like that language.
01:18:28I
01:18:28appreciate that. I mean, it's it's a.
01:18:30It's a point that I've.
01:18:31That I've made to the medical students
01:18:33that I'm sure I'm not the only one who's
01:18:35made it over the years is that you know,
01:18:37in the big system there are lots
01:18:39of people looking out for the,
01:18:40you know, the federal budget.
01:18:41There are lots of people looking out
01:18:43for the hospitals financial well being,
01:18:44but sometimes with the patient
01:18:46in front of you,
01:18:46you can't assume anybody else is
01:18:48actually looking out for him.
01:18:49And so that's gotta be you.
01:18:50And that's got to be.
01:18:52The physicians have to internalize it.
01:18:53The nurses to that that we can
01:18:55assume what someone else is
01:18:56actually watching out for this guy,
01:18:57we have to assume it's us.
01:18:59I don't know to what extent
01:19:00members of the faculty here,
01:19:01the people in the medical staff
01:19:03actually feel gagged and I.
01:19:04I won't speak to that,
01:19:05I hope not so much,
01:19:07but your point is well taken
01:19:09about about the position we hold,
01:19:10and indeed about about what may
01:19:12ultimately come from the public trust
01:19:14about things like vaccines that will
01:19:16tell you I heard this is totally anecdotal,
01:19:18of course,
01:19:19by the heard recently from about secondhand
01:19:21about a very intelligent person who
01:19:22had chosen not to take the vaccine.
01:19:24Relatively young person who said
01:19:26religious don't really trust that
01:19:27this wasn't brought forth so quickly
01:19:29for financial reasons, and I thought,
01:19:31really don't trust 25 she.
01:19:32Wow everybody should charge 25 but.
01:19:34Other people think,
01:19:35well,
01:19:35maybe we can't trust the doctors
01:19:37as well as we could,
01:19:38which is one reason why a lot of people,
01:19:40pediatricians in particular I think,
01:19:41think that you know we're trying
01:19:43to now get kids vaccinated and
01:19:44where people are more likely to
01:19:46trust is not that if we've lined
01:19:48up at the CVS with 1000 strangers.
01:19:49But if we go to our pediatrician
01:19:51and get that I think were more
01:19:53likely to trust that,
01:19:53and the more trust we earn,
01:19:55the more likely it is will be able to
01:19:57get kids vaccinated the way we want them to,
01:19:59and so many other things.
01:20:03Thank you another comment please.
01:20:04Thank you for sharing your story.
01:20:06My question as a historian,
01:20:08do you think the ingredients are present
01:20:11for us to be able to fix these problems?
01:20:14Clearly the challenges are
01:20:15formidable managerial, economic,
01:20:17educational, cultural, psychological.
01:20:18Oh my goodness, this is a huge question here,
01:20:20but the question is how would you
01:20:22prioritize the right approach?
01:20:23You've touched on a lot of this Tim,
01:20:25but I'll let you handle this
01:20:26question as as you feel best.
01:20:28So all those problems,
01:20:29how would you prioritize the right approach?
01:20:32Well, I mean, I think the main
01:20:34the main problem is the the way
01:20:37the economy has been shaped.
01:20:39I mean to put it slightly globally,
01:20:41there are a few things in the American
01:20:44Medical system that couldn't be.
01:20:46Couldn't be solved with less money.
01:20:48No. It's not, it's just.
01:20:52It's not right that it's a.
01:20:53It's a fifth of the GDP.
01:20:55It shouldn't be 1/5 of the GDP.
01:20:58That's just too much.
01:20:59There's just too much money there.
01:21:01There's there's too much money is being
01:21:03made in the wrong parts of the system,
01:21:05you know,
01:21:06and without picking on too many people,
01:21:08I'll just say implants.
01:21:09But there, there's,
01:21:10and so when you ask yourself like
01:21:12how you know how in Germany you
01:21:14get better outcomes with 1/3 as
01:21:16much money being spent right,
01:21:18or in Austria with like half as
01:21:20much per capita being spent,
01:21:22how do you get?
01:21:23How to get better outcomes and
01:21:25I think like the the answer.
01:21:26So that's from justifying the problem.
01:21:28The problem is that if it's a fifth of
01:21:30the economy than the lobbying power you know,
01:21:33and the easier the money and the less the
01:21:36money has to do with actual medical care,
01:21:38the more it's going to be
01:21:40efficient and lobbying.
01:21:41But the closer you get
01:21:42to actual medical care,
01:21:43the worst the lobbying is going to be,
01:21:45the easier the money is,
01:21:47the more focused the lobby is going to be.
01:21:51So for example,
01:21:52you know private equity companies
01:21:53getting their own hospitals like the
01:21:55private equity companies are going to
01:21:56be very good at lobbying for that,
01:21:57even though it's, I think,
01:21:59been a disaster for hospitals.
01:22:01But so in order to beat that,
01:22:03you have to have a big idea.
01:22:05It can't be an incremental idea,
01:22:06it has to be a big idea.
01:22:08Then it has to be idea like this is and
01:22:10this is where I'm going with it anyway.
01:22:12Like you,
01:22:13it has to be,
01:22:14freedom has to be some big American idea.
01:22:16It can't be like we've got the
01:22:18Affordable Care Act and now
01:22:19we're going to like Jigger and
01:22:20Jugger or we got Medicaid.
01:22:22We're going to push it down five years.
01:22:24I think the only way to beat that kind
01:22:25of power is to have like an inspirational
01:22:28story of how things can be much,
01:22:29much, much better than they
01:22:31are than they are right now.
01:22:33That's that's the best.
01:22:34That's the best I can do on that one.
01:22:37Some of it, I appreciate
01:22:39that him and and you know,
01:22:40in the book you touch on freedom
01:22:42and how the system actually
01:22:43infringes on our freedom limits.
01:22:45Our freedom an. I mean,
01:22:47I think some of this may also touch
01:22:49back to your point about arrogance.
01:22:51You spoke about local arrogance,
01:22:52but I would say there's also something
01:22:54I guess if you tell me if you tell
01:22:57me that the Germans spends so much
01:22:59less money per capita than us and
01:23:01yet they get better health outcomes.
01:23:03The arrogant response that I could give is,
01:23:05well, then the problem is either differences,
01:23:07either the healthcare system,
01:23:08the way it's delivered.
01:23:10Or it's the people so one could argue,
01:23:12well, it's the people people in
01:23:13America just don't lead healthy
01:23:15lifestyles and they and you know
01:23:17they have too many guns and they they
01:23:19eat the wrong food at and they don't
01:23:21exercise and so on and so forth.
01:23:22And I think it's it's.
01:23:24It's a temptation for those of us who
01:23:26work in the healthcare system and say,
01:23:28well the reason we have to spend so
01:23:30much more money and still get worse
01:23:32outcomes because our population is
01:23:33just so much sicker. And you know what?
01:23:35I don't dismiss the possibility
01:23:37that that's some of it,
01:23:38but that's certainly doesn't
01:23:39explain the tremendous difference.
01:23:40You're absolutely right.
01:23:41And Jack choose who teaches the
01:23:43first year medical students in the
01:23:45Professional Responsibility Course
01:23:46has talked about that dramatic
01:23:47difference in the percent GDP
01:23:49here versus other countries,
01:23:49and that per capita expense
01:23:51here versus other countries for
01:23:52outcomes that aren't as good.
01:23:54And even if we say that for various
01:23:56reasons our population is sicker,
01:23:57it doesn't come close to explaining
01:23:59that gap in performance and that gap
01:24:01and expense between here and there.
01:24:03So I think that part of our arrogance
01:24:05is not turning back on ourselves
01:24:07and saying some of this is how
01:24:09we are delivering the service.
01:24:11It's also it's how the service is defined.
01:24:14I mean, as I mean it, it makes you
01:24:16know there's no point telling you this,
01:24:18but the the earlier you're investing,
01:24:20healthcare resources,
01:24:21the more they matter more they matter
01:24:23over the course of a life, right?
01:24:25So in our system,
01:24:26but our system is not about health, right?
01:24:29I mean, that's one of the differences,
01:24:31like when the the Austrian,
01:24:32the German system is much
01:24:34more about public health.
01:24:35But I mean when you say public health
01:24:38in America, you think of someone who's
01:24:40been trained to run a hospital, right?
01:24:42But?
01:24:42Public health means you're trying
01:24:44to rate help people grow up in
01:24:46such a way that they're not going
01:24:48to be sick later on, right?
01:24:49And that it's part of what you're describing
01:24:52is part of the American problem is that we,
01:24:54you know,
01:24:55we see we see disease is something
01:24:57you kind of wait for.
01:24:58You know, you wait for it,
01:25:00and then you hit it out of the
01:25:02park as opposed to prevent it
01:25:04from happening in the 1st place.
01:25:06So you know the obesity in the
01:25:08addiction and all that stuff.
01:25:09You could say, well,
01:25:10that's that is part of our arrogance
01:25:12that we've defined medicine as a.
01:25:14You know, I'm now sorry to be
01:25:16so like you know Buddhist,
01:25:17but we define medicine in terms
01:25:18of solving problems as opposed to
01:25:20preventing things from happening.
01:25:21And then we fix that.
01:25:23We,
01:25:23we fixate on the on the problems
01:25:24that we can solve as opposed to
01:25:26like trying to lay things out
01:25:28for young people in general,
01:25:29so that they have healthier lives
01:25:31and it's dumb little things like,
01:25:32you know, public education.
01:25:33Having six hours of gym class every week,
01:25:35you know,
01:25:36like they just little things like that,
01:25:38which are which have to do
01:25:39with public health.
01:25:40But then you get,
01:25:41you know you get less obese kids,
01:25:43but nobody's making money out of that.
01:25:45Right,
01:25:45nobody's making money out of
01:25:46preventing kids from being obese.
01:25:48You can't make any money out of that.
01:25:50And yet you know the health
01:25:51gains as such would be huge.
01:25:53So I mean, if you make if you,
01:25:55if you think of health as a right,
01:25:57then you could say, well,
01:25:58my kid has a right to gym class.
01:26:01Or you know,
01:26:01if you have that language then
01:26:03you can go somewhere with
01:26:04it. It is. It's not worthy to me that
01:26:07you have especially explained that that
01:26:09pediatricians are the third most important
01:26:10people in the health care system.
01:26:11I would say that the apps Attritions
01:26:13are more important and then the public
01:26:14health that people who do research in
01:26:16public health or maybe even more important
01:26:17still that you have getting ahead.
01:26:18I mean, we've talked about this
01:26:20in class too with the students.
01:26:21Is that that you know it's we spend a lot
01:26:23of time pulling drawing people out of
01:26:24the River and eventually one guy says,
01:26:26you know, I think I'm going to go
01:26:28stream and see what's wrong with
01:26:30the bridge that so many people keep
01:26:32falling into the River.
01:26:33And and getting a hammer and nails
01:26:35and fixing the bridge isn't nearly as
01:26:37**** and it doesn't really pay as much
01:26:39as pulling people out of the room.
01:26:41And that that's certainly part of
01:26:42the problem, but you know the time
01:26:44is going by so quickly here.
01:26:46For this is sessions him.
01:26:47We've got a minute if you'd like
01:26:49for the last comment you made,
01:26:51I thought was was beautifully articulated,
01:26:52but if we have a minute,
01:26:54if you have a final message you'd
01:26:56like to share with this group.
01:26:59No, I just I. The only thing
01:27:01I want to say is I want it.
01:27:03I want to thank you.
01:27:04I want to thank you for coming.
01:27:06I want to thank you for for listening.
01:27:07This isn't this isn't the ordinary
01:27:09kind of talk where you know I
01:27:10talk about something and you
01:27:11listed in the thing we're talking
01:27:13about is somewhere over here.
01:27:14You know, we're talking about something
01:27:16that we that we both see in which in
01:27:18some sense belongs to both of us.
01:27:19And so that means it's a it's it's.
01:27:21It's more of us it's it's more of
01:27:23a reach for me and it's more of
01:27:24a reach for you and I appreciate
01:27:26your reaching out as well.
01:27:27That's all I wanted to say.
01:27:29Thank you Tim and thank you so much for
01:27:32taking the time and for spending the
01:27:34time and turning your very difficult
01:27:36very bad experience into something
01:27:37that maybe some folk can benefit from
01:27:40down the down the line by virtue of
01:27:42the time you spent writing the book.
01:27:44And I know you've spoken in various
01:27:47places and certainly the time you
01:27:49spent with us is very much appreciated.
01:27:52Thank you so much.
01:27:53Professor Snyder.
01:27:54We've got a couple more sessions
01:27:56to see here folks.
01:27:57You can check the website
01:27:58biomedical ethics at Yale.
01:28:00We're going to speak about
01:28:01the ethics and the politics of
01:28:03disabilities during the pandemic
01:28:04and otherwise in a couple of weeks.
01:28:06But in the mean time,
01:28:08this has been a very interesting night
01:28:10and I would say to my colleagues
01:28:12and students if this is unsettling,
01:28:14then it shows you're paying attention.
01:28:16Should be unsettling.
01:28:17Thanks a lot, Tim.
01:28:18Appreciate it goodnight folks.