and inciting controversy and we are delighted to welcome dr.

sandeep jauhar. [applause] >> thank you so much for that generous introduction. i want to say what a pleasure it has been for me to be here this weekend. i brought my family. my children are actually now probably connoisseurs' of georgia book festival because we were at the decatur festival in august but they have given so that not a big thumbs-up as have i. and i also very quickly want to acknowledge the organizers specifically robyn goals and linda you are so helpful in bringing us here and our wonderful host beth logan, the

paragon of southern hospitality. when robyn invited me to come here, she gave me some parameters for this talk and she said talk mostly about yourself and what motivates you to get into writing and i fought as a writer of two memoirs how am i going to do that? how am i going to talk about myself? i will do the best i can. i was in the lobby of brice before coming here wonderful hotel and was chatting with one of the authors, what you going to talk about? i'm not sure. i will just go up there and be spontaneous. i will try to do that too. i don't know exactly where this is going to go but hopefully it will be enlightening. me start by telling you about myself.

i was born in india. our family was pretty itinerant when i was growing up. my father was a plant geneticist so we found ourselves moving around quite a bit because he ended up going to places that focused on crop science. we spent some time in wales and then we moved back to india in 2007 and i spent a year there and for those of you who know a little bit about modern indian history, it was 1976 the year of the emergency rule a tough time for academics and there were a lot of restrictions on free speech. my father decided we have to get out of here so we ended up

emigrating to the united states in 1977 and eventually ended up settling in setting california and that is where i grew up. like i said my father was a plant geneticist. my mother was of biochemist who worked part time but mostly was of homemaker and she spent time raising s and they wanted me to become a doctor. in that generation especially among immigrant indians there was nothing more noble and better that you could do. sort of coloring their vision was the fact that they had come with no money, financial insecurity and they thought this will -- going into medicine will confer stability on our children and allow them to do good for

the world's. i didn't buy into that when i was growing up. i have a lot of other interests besides science. i remember when i was growing up in india i would spend time with my grandfather a family practitioner in new delhi and i would watch him work and what he did was find. it was reasonably interesting but it didn't appeal to me deeply. might 10-year-old minds thought this is kind of cook book and i don't want to pursue medicine and i didn't see how medicine was going to allow me to develop my creative impulse and i was wrong about that actually but at the time -- so i was interested in a lot of different things so

my mother would sort of pushed me to become a doctor. one reason she would say, the, doctors of people will stand walk into the room. it didn't work out that way. in the end i ended up going to berkeley. i was very interested in the mysteries of the universe so i decided to become of physicists. in immigrant indian culture, rebellion is saying no to a career in medicine and going into physics. i was really the rebel. so i went to berkeley and

studied physics and graduated from undergrad and decided i was going to continue with physics. i wasn't sure what i wanted to do, but to go to graduate school and studied a very esoteric object called a quantum dots and i can talk to you about it afterwards. of very interesting entities that is sort of like an artificial adam. i became a writer. studying quantum dots, this was so far removed from what i am doing today, what ended up happening, there was a confluence of things. any of you who have done research especially graduate level research know that it is very slow and i found myself struggling with the equipment,

broken vacuum pumps. so the progress was incremental at best and right around that time someone who was very dear to made developed a severe case of lucas and in an effort to help her eyes ended up going to support group meetings and talking to doctors and gradually got more interested in medicine as a way to help her but also was fascinating to me how much was uncharted. how little was known about lupus or chronic disease in general and being a physicist, i had this idea that if i dug deeply enough i could figure things out for her and it became very clear is that medicine really is

a science of incredible uncertainty and is largely uncharted and that was appealing to the scientist in meade but the biggest appeal, i started to see medicine as away to help people. sounds naive, but it was -- the biggest motivating factor for me was at the time when i was sort of toward the end graduate school i desperately wanted out of the ivory tower. i wanted to be with people. i wanted to interact with my fellow human beings and i remember my brother, who is a doctor he is a cardiologist, in a residency at the time, he

visited me once and sort of walked around my lab. i showed him the laser and all the cool stuff i was doing and he looked at me and said this is such an ivory tower and i remember thinking, you know, it was -- the worst thing you could say to me at that moment because it really stimulated me to make a big change. i ended up finishing my ph.d. and applied to medical school. i firmly believe in serendipity. i have always been interested in writing, but had no opportunities to write and other than scientific writing. so after i applied to medical school and had gotten in i was walking in the physics department one day and i saw a

poster for a science journalism fellowship and sort of 5 when i was in high school, i like to writing and i should do something and i sort of had the summer off before i was going to go to medical school so i applied on a lark to the science fellowships and to my utter amazement ended up getting it and i went to time magazine for the summer before i went to medical school and time was an amazing experience for me because i have always been interested in politics and it was just -- it was -- it seemed so glamorous. i went there and first week i was there they sent me to the u.s. capitol to get up quote from bob dole about the working poor.

i had never interviewed anyone and i was a physicist. what did i know about it? so i applied my physics acumen, how am i going to -- all these reporters in the new york times, cnn they are trying to -- he was majority leader at the time, trying to get to him so how am i going to work my way in? i figured you know what? i will hang out by the bathroom because i knew he had a prostate condition and he was going to end up in the bathroom at some point. so the land the holds i was just hanging out by myself and he walked in. and i was so nervous i looked at him tall man and i said a bunch of gibberish i am sure it was gibberish and he sort of looked at me and kept walking, completely ignored me so after he came out, done with his

speeches and so on, i was talking to his press secretary and trying to get him to get me five minutes to get my quote so people at time magazine don't think i am a total loser and so the press secretary was in the process of blowing me off and bob dole walks up and i will never forget this. he said this is sandeep jauhar. he is an intern at time magazine and he wants to quote from the about america's working for. setup the five minute phone conversation. this is what he gleaned from what i was sure was a bunch of nervous gibberish because -- so really admire the man. and i end up speaking to him the next day and got my quote and so i got bitten by the writing bug that day that week.

so when i finished at that time magazine, it was the end of the summer and i was supposed to go to st. louis, to start medical school so i went and talked to the bureau chief of time magazine, a guy named dan goodgame. i really like writing and maybe i should become a writer, work at time and he is like go to medical school. you don't want to end up and being stained wretch like me. give me some names of people i can call in the future if i want to try to write about missing? he said sure. gave me the name of someone, half a trillion, miami herald, but what about the new york times? all right, sure. gave me the name of one of the

top editors so i went to st. louis. the first few weeks were tough going from time magazine to the anatomy lab and memorizing muscles and nerves. one day i decided to call up this guy at time magazine and i really believe that -- such an important role for serendipity in our lives. i ended up calling this fellow gerald a bullet, and he has since passed on, but he was the national political editor at the time and i didn't know it but he was -- i believe he was the panelist who asked michael dukakis what he would do if his wife were raped and murdered? so he had tremendous influence on the 1988 political presidential election. i didn't notice this at the

time. i called him up and was in the process of speaking to someone and suddenly he gets on the phone and i said -- look -- gerald boyd -- what do you want? i was sort of telling him i was a medical student and then it turned out he was from st. louis. not just that he was from st. louis but he actually had lived on the same streets i was currently living on, kings highway. so he started asking me where do you live? you are in medical school and at the end of the conversation he said next time you are in new york give me a call and we will have coffee. i said that is wonderful so i did what any aspiring writer would do up the phone, called american airlines and book the flight to new york. is then i called his assistant

and i said i am coming to new york and mr. boyd wants to meet with me. and who are you? so anyway i went to new york, they showed me into his office and i am looking around and there are pictures of him with george bush and the premier of china. at that point i was thinking all right, maybe you don't really know what you are doing. so he walks in and his tone had totally changed from the conversation lisa i have two minutes what do you want? so i started telling him that i wasn't in medical school but really wanted to be a writer and could i write for the new york times? and he said show me your stuff. i said i don't really have any stuff. i tried to explain how at time

magazine you don't get stuff. you just get quotes. he looked at me like i was totally crazy but he did do an amazing thing for me. he called in elizabeth rosenthal. she is a doctor and some of you must have read her pay until it hurts series for which i hope she gets the pulitzer but she came in and she said -- she went to harvard medical school. she was working as a journalist full time but doing a little medicine on the side. she said this isn't how you do things. go back to medical school and see if you can write for the local paper tried to get a portfolio and then send me your stuff. i went back and ended up going

to the st. louis post-dispatch and i met a fellow there a very good guy an editor named john curley who had grown up in manhattan and he had taken a liking to me and admired my gumption in coming and asking for an internship and in the end offered me an internship and then faced with this decision, how to i do an internship at the st. louis post-dispatch while i am in medical school? i called my brother and said i have an opportunity, i kind of want to do it but they are going to keep track. i can't be away from medical school for large amounts of time and he said you know what? there are many hours in the day. remembered that and i thought i am going to go with this. i went to the st. louis post-dispatch and they started giving me stories. i would drive out there after morning classes, skip the

afternoon and read the transcription and show up at 1:00, my editor there would say you know what? we want you to write -- there are a lot of people getting stung by wasps. we want you to write a piece about people getting stung by wasps and you have until 5:00. it would just be like okay, and it was trial by fire and i did a few featured pieces as well, one on diabetes and i did a profile of a surgeon and i would send my stuff to the new york times to libya and she would read it and sometimes she would respond and sometimes she wouldn't and i had a little portfolio and the next step in serendipity was when i finished mid school i ended up getting an internship in new

york and at new york hospital so i called libby and the science section of the new york times had a new editor. a woman named cornelius been. when new people come in they want to mix things up and bring in their own people. so i was one of her people. she took a liking to me and i pitched an article about a leprosy hospital in carville, louisiana. she said sure. we will send a photographer down. go down and do the story so i went to cargill and stayed two or three days and wrote this piece and it came out about three days after i started my internship and two days before i met my wife, sonya. it was an eventful week.

and corey dean would say why don't you write about your internship? i said okay. it turned out to be a great indication, because in an internship everything is new. as you go on in medicine you get jaded. you see things and you start questioning but when you are and in turn everything is new is rubles a year end up with i don't give a hoot what i write. i am going to write about what i see and the things that interest me and the things i am going to question. i remember one of my early pieces as an intern, there was a fellow in hospital and who was having difficulty swallowing and

when he would swallow food would go into his lungs. everyone was getting ready to put in the feeding tube into his stomach. the thing was he kept saying i don't want the feeding tube but no one was listening to him. i was on the team and whenever i would bring it up people would say what i you saying? what is the alternative? the alternative to me was listen to what he is saying, let him eat edit he dies of desperation pneumonia, that is the way he wants to live. but because it was such an egregiously crazy choice, who wants to die, people declared without capacity. you can't make your decision. they are getting ready to put in the feeding tube. it was so bothersome to meet at

i remember one morning i went to his room and i said they are going to go for your feeding tube today and he said i don't want it. i said you know what? and i went to the refrigerator and brought out some thin liquids. i said here. drink this. he hadn't drunk anything in over a week, maybe two, and so he drank it and maybe he coughed a little bit, he drank it and i said -- i documented his charge, did my own swallowing study and he can swallow. he doesn't need to a feeding tube. i called the surgeon and just called it off. those are the things you need to experience when you are naive because now today, honestly if i

were walking through the ward and i saw a guy like that who couldn't swallow and was getting ready to get a feeding tube i would probably just let him get it because i wouldn't be invested. when you are an interim you are investing your patients in a way that you aren't, you don't know them as well as you move on. and that is unfortunate but it is the reality. those are the things i started to write about, things that interested me. things that seemed ethically or dubious and so by the time i was done with my residency i had 15 or 20 pieces in the new york times. by then believe it or not i had a book agent who said you should write a book. i said oh sure. i just wanted to have an agent. i thought was cool to have an agent. at the end of my residency i

said look why don't we just take my pieces and staple them together and call it a book? we pitched that idea which didn't go over very well. the editor, of my publisher said we don't really like your idea but we have an idea. why don't you write about your residency, a memoir of development, novel of education? that is what i ended up doing and got turned into my first book which is called in turn. end there are a lot of pieces i published as the president but a lot of stuff i didn't publish. one thing corry told me was the diary and write down the stuff

that is interesting to you. so i did and i thought it was so important. when young doctors and aspiring writers asked me how do you get started? i say you have to record your reflections. .. i had been in school for 19 years. 19 years after graduating from

high school. i had that quantum dot detour. so i was just ready to be done, and reap some rewards for all that all those sleepless nights and what i found was that doctors were very unhappy, and when you're in training, the focus is on the physiology and learning about the heart. it's not really about the culture of practice. so i was largely blinded to that. and then i took on my first role and i'm talking to doctors and i find they're very unhappy with medical practice today. and it wasn't just about the

stresses we all know. it upabout the paperwork and the malpractice fears and so on. it was a deeper problem. there was a -- what i started to think of as an existential crisis. it was more that doctors felt they weren't being able to practice medicine the way they were trained to practice the way they aspired to practice and that cass deeply troubling to them. and so i sort of watched this and learned a little bit. i was fairly happy. i was an academic practice. and working with trainees and i specifically chose an academic practice because i wanted to teach -- i wanted to be around young people and -- rather than -- and people who had that naivete that i had, that i

wanted to hold on to, and -- but shortly after i started in my practice i found myself with a significant amount of debt and feeling i had to moonlight so make ends meet. started a new family. and most folks will be surprise it that a lot of academic physician does that. they moonlight on the side. one reason we choose academia is we want to be around academics we want to be around young physicians, we want to teach, but the salary structure is very different, and in then medicine today you're rewarded for doing as much as possible. the fee for service model, do more more, more. and one of the reasons why i chose academic met sin, diwant to be in that position where i had to do more and more and more.

but then i found i had to start moonlighting and i found a practice in queens, with a cardiology friend of my brother, who offered me this gig going -- doing stress tests and supervising stress tests on the weekends. and this is where i really learned about how medicine is practiced in some parts of this country. now, most doctors are good. but there's no question that there is a subset in my profession that has taken advantage of the fee for service system and it's not -- you can call it whatever you want. some doctors will get upset by the implication there's fraud going on.

let's not call it fraud. let's say the system creates moral hazards that encourages doctors to respond to financial incentives and this is happening, okay? when i was a resident when i learned about health care economics there was an example of an orthopedic group that under the fee for service system was doing 200 to 300 total hip replacements for a year. when they went to a bundled model, that number dropped from 200 to 300 -- i don't remember the exact number -- to one. one total hip replacement. you can't tell me doctors don't respond to financial instance senttives. we do. doctors are just us a human as anyone. and so i'm working in this practice and it was a mill. there were literally this line

of unsuspecting patients getting ready to have stress tests, many of which were honestly unnecessary. and the more i worked there the dirtier i felt. i felt really dirty that i had to do this. but i felt like i had no options at that point with the financial situation i was in, and so that precipitated a real crisis in me. it was a -- maybe it was a mid-life crisis. i don't know. but it took a toll on me, took a toll on my relationship with my family and the book is about what i call the mid-life crisis

of american met din, and also about my own personal crisis, and how i worked my way out of it. and eventually i did. but -- i was able to re-ininvestigate rate my personal relationships and i'm in a much better place today than i was about six seven years ago. howhowever, american medicine is still in a crisis. what are re going to do about american medicine? there's no simple solution unfortunately. i think that the fee for service system does create a lot of problems that eventually, i believe, will need to be addressed and the system will need to be supplanted by something else. i don't know exactly what that system will look like.

but it's going to happen. it's happening. anytime you have a huge system that is responsible for one out of every six dollars we spend, and it's so dysfunctional then it's going to get to a tipping point, and i believe it's at that point because you can't have a system that is so gargantuan that affects all of our lives and have no one be happy with it. i mean doctors are unhappy but most importantly, patients are unhappy. you ask any patient. patients are mart. they know when they're getting the short shrift. they know when they're doctor isn't listening to them. they often times suspect they're being asked to undergo unnecessary tests. they know what's going on. they know they can't find a primary care physician today, or if they do they have to wait

three months to get an appointment in some parts of the country. so there's a lot of dysfunctionallity in the system. it will change. now, for doctors i think that we have to reclaim what is important to us. the system is in a state where insurance companies, the government, are in many ways telling us how to practice and a lot of doctors feel almost like pawns in this system, and when i graduated from medical school the graduation speaker had some wise words. he said know what is important to you. the ideals you hold near and

dear and stick to them. so i think those words apply just as much to me now as a mid-life practitioner, as they did when i was an intern. we have to identify what is important, and for me, in the end, it's about the human interactions and if you talk to doctors who are unhappy, even the unhappiest doctors will say the best part of their jobs is enter acting with people, talking to people. and that is something that no entity can take away. so, for me, it's always about the human moments and what i like to call the gentle surprises. i want to give you one story about the gentle surprises of medicine. i remember when i was a third

year resident. i was -- i went to the emergency room in the south bronx, and i had a two-week stint there, and late one night i was asked to drain the fluid out of the belly of a woman with alcoholic cirrhosis. her belly was full of fluid, and it's a very brute force procedure. you put a needle in, hook it up to a tour, put the tube in a bucket and drain the fluid. so i went ins' and introduced myself and said, i'm here to drain the fluid out of your belly. and she said okay, sure, go ahead. and she still had alcohol on her breath. so, i said, okay. i cleaned up her belly with iodine soap and i put in the catheter the needle to the catheter, and put the tube into a bucket, and i started filling

the bucket and i said, look, if you move and this comes out i'm not putting it back in. and she says oh, okay sure. so i'm just there watching the fluid drain and a nurse comes in and says doctor you just got paged. she was carrying my beeper. i said, oh, okay. well, can you keep an eye on her while i go out and answer my page. she said sure. and i remind my patient, you move and the catheter comes out i'm not going to put it back in because i have another ten patients to see. she said okay. so i go out and answer my pain. three minutes later i walk back into the room and the catheter is out the buckets are all upturned and there's like fluid all over the floor. and i was like oh my gosh. so i look at her accusingly and i said, i thought i told you

not to move. and she said doctor i didn't. a man came in here and had a seizure on the buckets. i was like, oh, god. and then the nurse walks in and i said i thought i told you to keep an eye on her. and she said i did. but then man walked in here and had a grand mal seizure on the bucket. this is what doctors experience. and these are special moments. no insurance company can take that away from you. okay. we doctors have to become more conscious about what kind of physician we want to be. and i write in the book about

sort of three professional archetypes. knights, naves, and pawns. and in my parents' era and my grandfather's era, doctors were knights. they were admired like no other professional group. right up there with astronauts. and for good reason. american medicine improved patients' longevity from 65, right before world war ii to 71, less than a generation later. improvement of six or seven years of life and that was because of polio vaccinations and antibiotics and coronary bypass surgery and pacemakers. doctors really delivered. they were knights. and then doctors went through a phase where they became thought

of as naves, and the whole culture shifted. when doctors were knights, that was the era of "general hospital." early on when doctors -- when dr. kildare, and then during this navish period, it was the era of m.a.s.h. and hawkeye but hawkeye was a great doctor but he was flawed. and there was "e.r." that painted doctors as human, as flawed. so i talk about knights, naves, and pawns and the reality is that doctors are all three. we all have a touch of these three professional archetypes in us and we have to try to bring

out the best, okay? and we have to do it in a culture that doesn't really understand what we're going through. and i'll tell you one last story and then i'll take questions. so when i was a resident, we used to round in the intensive care unit. so there was a -- one night when i had been on call, and i -- the following morning we were rounding on our patients, and anyone has been in expensive care unit knows the horrible tragedies that happen in icus and our intensive care unit was no different. there's a guy who had been misdiagnosed with a slip eddies can and had actually severed his

spinal cord and was now completely paralyzed and there were patients who had multiple my loma on ventilators and it was a horrible unit, and so our teamed stayed up all night and we were rounding with an attending neighborhood abe sanders, and he was a great attending. he was a jocular fellow, and so we were going through and we found ourselves in a room of a patient who was on a ventilator, and we were presenting the case and sanders sort of like looked off, looking through the window and any of you who have been at new york hospital know that there's a greenburg pavilion built over the fdr drives and looks out on to the east river. so sanders said, come over here.

look out the window. and it was brilliantly sunny day, and there were boats on the river, and we looked down there and there was a boat and there were a few people on the boat, and they looked like they were having a great time. sipping bloody marys and they all looked beautiful, you know, and we were like sweaty and disgusting and had been on call all night and there was a fellow on board who was looking up at the hospital and he was -- turned out he was looking right at the window that we happened to be standing at. and sanders said, see that guy down there? and i looked at him and he was about sanders' age but is fit, tan, and he was with all these beautiful people and he was looking up and he said that guy down there, do you know know what he is thinking?

we all looked and oh, are we going through this? we just want to get out of the hospital. you know what he is thinking? i looked down and none of us ventured a guess. and sanders says, that guy is thinking, i should have been a doctor. [laughter] >> and this is what we struggle with as physicians. people still view our profession in simple terms but today, i have a more nuanced view of medicine, and doctors are not perfect, and our profession isn't perfect but i do feel that doctors still want to be knights, and i think that there's a lot that we have to go

through in the next ten 15, 20 years; we need to figure out a way to reclaim our professionalism, we need to figure out how we want to practice. we need to improve access to medical care. we need to control costs otherwise we're going to bankrupt our economy. so there's a lot that we have to do but american medicine is technologically the best in the world, and i fervently hope that we'll find some solutions to the mess we're in so that medicine can really reclaim its american medicine can reclaim its place as unquestionably the best in the world. so, i will end there and take some questions. but thank you so much for coming. [applause]

>> i'm writing about my mother's end of life issues. this is where i find -- [inaudible] -- my mother has alzheimer's it was clear in her chart and every time we went to the hospital with her, the doctors talked to her and asked her questions she can't speak and this goes on and on and on, and you tell a doctors over and over again, she has no capacity to answer your questions. we're her advocates. but this is gone on and on. with physicians. they don't pay attention.

she is obviously gone. and yet they continue to ask her, how do you feel? what do you want? and extremely frustrating. when i finally found a doctor who would listen to me and said no more hospitals, no more interventions, hospice, cocktail palliative care, i literally wept. i couldn't believe he was listening to me. >> that's profound. i think unfortunately your experience is not unique. end of life care is probably the single weakest link in the american medical system and you're absolutely right. unfortunately, your intuition is probably correct the doctors didn't listen to you, and i see this every day. that we go into a patient's room

and say, do you want this, this or this? and we present the information in ways they don't understand, sometimes they can't process it because they're sick, and they're anxious, and we do it all in the name of patient autonomy. right? the patient made this decision. we're giving the patient the decision. but patients don't always want the decision. they want to be guided. in many, many cases. and i remember one case -- i'll tell you briefly of a gentleman who came to the hospital and had apparently told all the doctors who were taking care of him that he never wanted to be intubated, and so he was in a situation where he was bleeding into his lungs, and i get a phone call saying that we did all -- question put in the stint and he

is bleeding into his lungses and doesn't want to be intubated. and he is a young guy. and the choice was just let him drown, bleeding into his lungs, let him die, or do something about it. and i have witnessed so much of what you described of doctors sort of quickly presenting options, probably i've done it myself and then not really thinking about whether the patients understood the options. so, in this particular case, i knew that the interns and residents hadn't done a good job explaining to this fellow -- they probably asked him, if you were -- would you ever want to be on a breathing machine? and he probably said, no i don't want to -- but he didn't know exactly what he was signing up for. so they were going to actually let him die. ' and i said, i'm sure you didn't have the kind of

conversation you needed to have with this fellow. i'm going to put the breathing tube in. so we put the breathing tube in, and even though he had written in the chart do not rhesus rhesus---h -- resuscitate, and we had a tough course and we eventually got the tube out, and i went off service. i came back on service, and i went to his room, and i said i was the doctor who decided to put in the breathing tube, and i know it was written in the chart you didn't want it but you would have died if you didn't get it. and he said, i've been through a lot. but thank you. and so we have to improve the communication because we can't just throw it all on the patient without guiding them. so, thank you for your comment. >> i'd like to say congratulations for making your life an adventure, rather than a goal-oriented, allowing things

to bring you greater -- the research and the opportunities you have taken advantage of. i applaud you for that. >> thank you. >> number two the question is, what kind of oppositions or hurtles have you had to -- hurdles have you had to overcome or deal with in doing your research writing your books? i'm sure that everybody isn't patting you on the back. >> no. >> i'm curious. >> i've been pleasantly surprised that a lot of physicians have supported me in my writing. especially my colleagues. because doctors and patients aren't stupid. they see the system the way it is. they know there's a lot of stuff going on. some of it moral hazard nefarious, whatever you whatnot to call it. it's funny that there was a group of doctors, i would say that is shocked.

maybe they're shocked i wrote about it or shocked this stuff is really going on. i'm not sure. and they've been fairly negative and vocal in their opposition to the book and then there's this group of doctors many of whom come up to me in the hospital and say doctor i heard you wrote this book and it was in "new york times" best seller. and you write about -- [inaudible] -- everyone knows this is going on. and so it's been a mixed response but i've been pleasantly surprised that a lot of people have been supportive. thank you. >> after seeing your wonderful review of -- i'd like to hear

more -- particular live you being a cardiologist and physicist, how you feel technology will change the interaction between patient and the physician. >> i think it's already changed interaction. how many of you go in and good-do see you doctor and he or she doesn't look up from the computer screen. and this happens every day. with electronic medical records. and i think the technology may help us work our way out of that mess with better voice recognition software so that -- he writes about that, where we'll have software that will transcribe exactly what the doctors and patients are saying that you can edit later, but topol writes about virtual visits and telemedicine. i don't know how it's all going to pan out. i'm not sure if the quality will be there.

the diagnosis at a distance. i personally feel that i need to see the patient listen to the patient, before i can make a good treatment plan, because every doctor has been through this. you read up on the patient you're going to go see, and they have a million issues, problems you read on the paper and then you walk in and they're reading "the new york times," and then you think that really totally changes how you see them. so i think that the direct face-to-face interaction is critical and not to mention that a machine is never going to be able to confer a healing touch. there's something about just touching your patient that is beneficial. so i think technology will play a role in changing and hopefully improving alaska certification but it's never going to replace a doctor. or nurse. >> i would like to ask -- you talked about what your fellow

physicians think about your writing, but i thought you were brutally hospital about your mother, about your father about your father-in-law, and even about your wife. so what did they have to say? >> well, my wife is also a physician, and she has been on the journey with me, and she knows the crisis i went through. so i think she knows what is in the book. and she has read excerpts of it. i think she sort of has adopted a policy of benign neglect, like she doesn't want to read everything because she knows it all already. my brother, he is pretty hearty

fellow thick skin, tough skin. he said, you do whatever you want and -- but overall my family has been very supportive, i think, and especially sonya who lets me do these things in and sort of keeps everything going and is a fantastic physician in her own right. so i've been lucky. but it's always that dubious spot when you're writing a memoir and writing about your life because on one hand when your life is into intertwined with other people's lives your story is partly their story so how do you disentangle the two. you can't. so i sort of -- when i was going through what was a tough crisis for me, i sort of adopted the policy of, i'm just going to write what i think, and so be

it. and fortunately my family was supportive. >> you say that the system has to change to reduce the cost of health care. and you said you didn't know exactly how. i'm sure you have had some thoughts. i've been involved since 1960 and in 1970 we said it was out of control. and so it's still out of control. one time we thought maybe corporations having to pay the bill would be the catalyst. but obviously corporations just moved overseas and now they've stopped paying for health care. what's the catalyst that will cheat a change? >> when you talked early 1970s, that was in the nixon era, and nixon to his credit, saw the problem and actually instituted price controls on a number of industries, including health care, and then lifted them on a number of industries but kept them on health care.

and then he was a republican. so price controls for a republican, you know he knew that the system was careening out of control. i think the percentage of gdp of health care in that era was something like nine percent, and today it's closer to 18-19%. so it's a huge problem. i think the fee for service system had to be supplanted by -- replaced by something else and i don't know how many of you read steven brills' knew new book. i think that he identifies the kaiser model as being the way out of the mess, where physicians and healthcare systems issue their own insurance product. they collect the premiums and they have the natural innocenttive to limit costs.

of course you have to put in various protections into place so they don't unnecessarily limit spending, but i think the kaiser model is a very reasonable one. i grew up in southern california, in the '70s and '80s and we went to kaiser and we got perfectly good health care. some people advocate a single payer system. i don't see that happening in this country. what works in -- abroad doesn't -- won't work in the united states. i don't think. i remember one of my professors, who is teaching healthcare economics, was talking about the national health service in england and then someone asked him, why don't we just do that here. he is like, america is too different. in england they live in a rainy climate, they drink warm beer,

they learn to tougher it out at a young age. that's not going to work in the united states. and he's probably right. so we have to tweak the system we have. if wore going build the system from scratch, i think the single payer system is the best system. >> enjoyed your books and i think your second book is a wonderful book because it describes the realities of the practice of medicine today. i think a lot of people don't understand the reality of practice of medicine today. i'm also a physician and i can relate to your book, particularly because i also met my wife as an intern at the new york hospital. she is here. the question i have is not a medical question. it's more of a literary question. how does a writer doctor find an agent and deal with an agent which is something you don't learn in medical school. >> i was fortunate because i was writing for "the new york times" so the agent actually found me and reached out to me. but let's talk afterwards. are you a writer?

[inaudible] >> well, find me afterwards and we'll talk about it. thank you again. [applause]