"What a Difference a Year Makes...or Does It?" - Reed Tuckson, M.D., President, Drew University of Medicine and Science

Welcoming Dr. Tuckson...

Dr. Tuckson is sufficiently spellbinding that I know he'll keep your
attention even as the lunch entrees come in.

Many of you know Dr. Tuckson.  He spoke here last year.  I have known
him for several years -- not very personally, but I have always
respected him for his energy, his insight and his ability to
articulate his insights so effectively.

He has been Commissioner of Health in the District of Columbia.  He
was  born in Washington, D.C., completed his M.D. at Georgetown
University and was a Robert Wood Johnson scholar at the University
of Pennsylvania.  He studied policy and health at the Wharton School
of Business.  Please welcome Dr. Tuckson.


* Dr. Reed Tuckson *

Thank you.  This is a daunting assignment: "What a Difference a Year
Makes... or Does It?"  You are a very intimidating audience.  You
all know more than anyone else knows -- certainly more than I know.
You're all very smart, so it's with some anxiety that I stand in
front of you.

Could it have been a year?  "What a Difference a Year Makes... or
Does It?"  The answer is "Yes and No."  I'd like to make 10 quick
points to answer whether or not this year made a difference.

1)  There is a constant in our work.  That constant is characterized
by the obligations and responsibilities inherent in the larger
purposes of your work.  Once you've made a choice to deal with human
survival -- once you've made a choice to prevent human suffering --
that enlists you in an army whose values -- larger purposes --
extend very deeply into time and the fabric of what a civilized
society is really about.  We are grounded in a set of traditions
that demand and require the creative use of every tool to
disseminate information to ameliorate human suffering.

This to me -- above all the points we can make -- seems the most
important.  We could always come together and talk about strategy,
technique, tactics -- but we have to put it into a context of what
it is that we are ultimately all about.  All this technology, that
we're having fun with....  We have to keep asking ourselves:  To what
end, all this busyness?  To what end all those toys?  To what end
does it all apply?

There are a variety of reasons and a plethora of motivations.  And
the Federal government is doing its part.  I commend the Department
of Health and Human Services for its leadership.  I commend the
Secretary's office that does this work.  I commend the CDC, the FDA
and the colleagues at NIH.  I see the activity over there as being
impressive and powerful and wonderful -- a little disjointed but....
What a difference a year makes.  Maybe so, and sometimes never.
They've always been disjointed, so no more this year than most.
But....

There is an opportunity to go forward.  With all that firepower can
you image what would happen if they put it all together and came up
with a  comprehensive strategic plan?  My God -- we could actually
do some work here!

2)  The paradigm shift in our field has, of course,
dramatically accelerated.  (We need a better word than paradigm.)
But there's a shift -- a change -- and it's fundamental to what
we're doing now.  There's a change now from a disease model to one
that is much more concerned with the individual.  A shift from a
subspecialty-dominated model to a more primary care model.  From
illness to prevention.  From fee-for-service to managed care.  We
are moving from individual preoccupation with illness to a
population preoccupation.  But more important than any of these
things is the increasing emphasis on demand management.  Health care
providers don't want to do some stuff that we used to do.  When a
patient used to come in, we'd check out everything, and we'd charge
for everything.  Generate your own demand!  And you've been very
comprehensive, so you feel wonderful about what you've done for the
patient--and your pocketbook gets very rich.

And now that we have your money, we don't want to give it back.  So
now we're interested in prevention.  So don't come--be well--
stay away.  We know we must make good, explicit, diagnostic judgments
and cost-effective therapeutic decisions, so we want lots of
information.  We want information about what's really going on out
there in the populations that we are caring for.

We want access to all this information so that we can be exquisite
in what we practice.  We want to be very careful about decreasing
demand.  So to do that, we accumulate data and we accumulate the
capacity for diagnosis and therapeutic decisions.  More important
for this discussion, we increase participation in the pre-disease
health decision-making stage--both by individuals and increasingly
by communities in association with professionals, both in the public
and private sector.  We are increasing participatory collaboration
between consumers--now called patients--and professionals in the
management of disease once it is expressed.  We now encourage those
collaborations once disease occurs.  This demand management with the
pre- and post-disease treatment are important.  And as we know now,
health and medicine are at the top of the popular stops on every
Internet system.

There will be increasing diligence applied to the appropriate uses
of resources.  This year has built on this paradigm shift and it is
inevitable that next year will as well.

3)  We've seen increasing competition occur over the past year, not
just around price and cost, but now--for the first time in any
real terms--we're seeing competition in quality.  We're seeing big
corporations that are being mean.  We'll demand to talk now about
quality--even though quality is still an underdeveloped science.
But the methodology--the science of evaluation--has increased
over the past year.  We'll see much more emphasis on
individual satisfaction and employer satisfaction with the quality
of their care.  They will be more difficult to satisfy.  With more
information, patients will increasingly demand satisfaction.
Patients will be making much better decisions.

4)  The global knowledge base has continued to grow
exponentially over the past year.  This affects everything we have
done.  There is empowerment of the individual and sometimes
communities; people now are very clear that they want to take part
in every part of their life and to participate in making the
decisions that affect their life.  The increased information enables
them to take greater control.  There is a greater democratization of
information, making knowledge elites rethink their relationship with
the citizenry.  We're now starting to see more and more articles
criticizing the cynical nature of the use of information by the
experts.  They are not talking to us about real information, they're
talking now about third degree abstraction of information.  It's a
game that only they know the rules to.  The President gives the
speech now, and you don't hear about the substance of the speech;
what you hear is whether he strategized himself to maximize his
political influence with 3% of the voters who all tie their shoes
with their left hand first.

People are getting very unhappy with the abstraction of information.
There is more of a demand for conversational learning.  Now, you see
the patient saying "Direct me to the resources," versus "Give me the
conclusion."  Now you look at the bulletin boards, and you see the
patient posting something like: "I saw on Prime Time Live, a
discussion about ... and I need more information."  Prime Time Live
didn't give me the information; the person is saying it didn't meet
my needs.  Where can I turn for my conversation?  I can't talk to
you on television; you don't even know what questions are stimulated
for me.  So now they go online to get the information.

We have an enormous deluge of information in the last year, and an
expansion in the complexity of information, which is making it
difficult for people to make sense of it all.

5)  Since last year, we're seeing the uneven access in the
distribution of information persisting.  This threatens the very
nature and character of what a modern democracy is all about.  Those
who are being locked out as the train leaves pose frightening
consequences for pluralistic American democracy.  We're seeing the
elites gobbling up more and more and more.  There are a whole lot
more on the bottom then there were before.  We see divisions along
fault lines that pose very difficult questions.  And it's perverse
that those that most need the information are the ones that aren't
given the chance.  I'm really excited about movements that are
trying to make that happen.  Libraries used to be "temples of
pluralism" -- and I know for me, the library was the gymnasium of
the mind.  It evened things up.  And new technology has similar
possibilities.  But library budgets are the ones being cut the most.
With the uneven distribution of knowledge, we no longer have that
temple of pluralism.

The increase in the democratization of information has not affected
the public policy discourse or debate in any way that improves the
democracy.  How is it that the discussion is so immediately personal
and so self-involved?  I'm concerned that there's no connecting
outside of the narrow interest of common sufferers.  This virtual
cyberspace is still vacuous.  Is it a virtual place or a real place?
There's no real community forming.  The people that are connected
probably will have a better chance to develop a shared vision of how
things should be.  The question is how that spills over to have an
impact on the pluralistic democratic society.  This is the
conversation we're having -- where the technology starts to
transcend into some larger purpose.  But the schools don't have
phone lines -- 80% of computers in schools aren't connected to
anything.  Everybody's all connected up,  but the kids aren't
connected to anything, so they're just as dumb as they were last
year.  The teachers are overwhelmed; they don't know how to use this
stuff.  We need a new type of literacy among our educators.  We want
computers in the church.  There are opportunities to establish real
communities even while building virtual connections.

6)  It seems to me that information is so plentiful that knowledge
is still sorely missed.  I have had to turn off my computer and pick
up a book.  I knew lots of stuff but it didn't mean anything.  The
nature of the information transfers into knowledge.  How do you take
knowledge and information and turn it into change.  We need to keep
on, keep on, keep on, every year about how people use information to
give them a chance for help.  What is the effect of the combination
of the words with the pictures and the sounds?  These are new ways
of learning.  We have to celebrate an increase in nonlinear, random
learning more than we've ever had to before -- particularly those
situated in more real-world applications.  How do people learn to
process?  How to we learn to layer information?  How do we build
learning organizations that respond to learning environments?  Next
year we need to address these questions.

And we still have illiteracy.  The American people are still
unprepared to sit still long enough to actually comprehend what they
see.  How do we deal with that?  I'd like to issue a note of
caution:  enabling services are good, but if there ain't any
enabling services, there's no way any of this will work.  Everyone
likes new toys and glitz -- but the real work is how to touch
people.

7)  There's an increasing emphasis on self-therapy.  We've seen over
the last year a real love affair with homeopathic and holistic
healing.  All sorts of information becomes equalized on the Net.
There is this love for the natural stuff.  The question is whether
we can get over the oppressive paternalism of the expert.  Are we
prepared to listen to the patient on their own terms?  We think that
we know what people are concerned about, but we really don't know.
We're going to get a lot smarter as we get humbler.

8)  We can't possibly know all the answers.  And the patient that
does come to see us is going to scare us.  We can't possibly know
everything they know about their disease.  They'll have already
gotten 14 second opinions and have talked to people with the same
disease.  They will walk into the therapeutic arena and say, "Hey
doc -- what about the Joe Schmoe theory from the Mayo clinic."  And
the doctor will say, "No, I hadn't heard about that yet."  And the
patient will say, "I want your email number."  With all this
controversy over RN's... well I'm waiting for the OLNP -- the online
nurse practitioner.

9)  Tools to evaluate effectiveness are in great transition.
Surveys are showing a decrease in necessary hospital visits,
increased competence, increased ability to cope and live with
chronic diseases.  I think in the end more information is better
than less information.

10)  Finally, something I did not see answered over the past year--
the influence this technology and interaction will have on
malpractice claims.  One thought on the matter is that as people are
more involved on their care--they're co-conspirators in a sense
--they would be less likely to sue.  But the more they know--the
wider range of second opinions--the more expectations there will
be and the uglier and meaner it will get out there.  What's going to
happen when people are weighing what second opinions might mean?

In conclusion, I urge you to always think about the large purposes
and the transcendent values of this work.  We need to, in all, think
and recommit ourselves to life and to health.

I offer this quote from Stanley Crouch:  "Keep the larger
values in mind."

Thank you very much.  It's been a great year.