johns hopkins university school of medicine, the ceo of children's national health system, and the head the memorial sloan-kettering cancer center. they discussed hospital capacity, the opioid crisis and obesity in the u.s. david rubenstein is a cofounder of the carlyle group and the current president of the economic club. he moderated the hour-long discussion. [inaudible conversations] >> can have your attention, please. can everybody you meet your attention, please. thank you. thank you. everybody, please continue eating eat very, very quietly. this is being televised on c-span and so we do want any extraneous noise, so thank you very much. two announcement i should abate earlier. one of our event sponsors the

united banks rick, thank you very much. [applause] and our new member breakfast is next tuesday april the tenth at the intercontinental hotel, and please, members were interest in attending, you're welcome. let me introduce our distinguished panel. to my immediate left, paul rothman. paul is the ceo of johns hopkins medicine. is also the dean of the johns hopkins medical school, a native of queens. he went to undergraduate at mit where he was not only a star student but also captain of the crew team. yes, then went to yale medical school where he also coached the team at yale and when he got his crew were to be hiding he was committed to medicine and he subsequently did his work at columbia university college of physicians and surgeons, and use

rheumatologist by training and he was there for many years in the later was recruited to be the head of internal medicine at the university of iowa carver school of medicine and subsequently became the dean of that medical school before he became that of johns hopkins medical school in 2012. his wife is a doctor as well and she is a specialist in gastroenterology. right? okay. very impressive. craig thompson -- i should disclose i'm on the johns hopkins board and i should disclose them also on the sloan kettering board. i'm not the good of a member but i'm a member of the board. drake is a native of many different places, grew up in boston, alaska, other places. his father was in the coast guard but he did his undergraduate work at dartmouth where he was an olympic level kayaker turkey competed for the olympics and u.s. olympic kayaks

in 1972 but did not make it. but medicine did pretty well as result of that, not being in kayaking. he did his undergraduate work at dartmouth and his medical degrees from university of pennsylvania. he subsequently trained at harvard medical school and subsequently did work at university of washington's hutchison cancer center come work at the university coddle medical school, worked at university of pennsylvania medical school and he later became ahead of the cancer center there and then he became the head of sloan kettering in 2010 and he holds that position today. he somebody who are started three different biotech companies and holds 30 pounds in immunotherapy. his wife is also in the family business and she is an md, phd and a cancer researcher. okay. very distinguished. and kurt newman, card has the

distinction of also being a member of our club. kurt was an athlete as well, not at the college level but as a baseball player in high school. [laughing] he made a mistake in college. he went to the universe of north carolina but he's going to duke university medical school. from there he trade at children's hospital in boston. and then later harvard medical school and subsequently came in 1984 to children's hospital which next year will celebrate its 150th 100 50th anniversary. it's hard to believe. [applause] at children's hospital he has been surgeon in chief of the joseph robert surgical center,

also involved with the center there for pediatric innovation and he has been the ceo of children's health system since 2011. his wife is also in the family business she is a neonatal nurse practitioner. okay, wow, very impressive backgrounds. let me ask you the first question. all of you when you go to a cocktail party, do people say to you, i have this hurt here? i have this painter? what do you think? do think i need see a doctor you think it is cancer? the people ask after this all e time? >> occasionally. >> mostly by me i guess. >> no, not at all. you always want to help people so i think it's something you try to do for folks that you meet, but it's difficult when you're acting in the role of being either their physician for this transit pentatonic.

i try to tell them goes here on physician because i'm not going to diagnose you at a cocktail party. >> craig, do you ever get this? >> i think this is, think fitting time you're at a cocktail party, particularly in new york washington or any major city you get asked, because some of pointed this out to me about a month ago, really health is a new wealth in america. as america's got a wealthy enough to go to put a roof over our heads and be able to feed our families, maintaining health and wellness throughout life is really key. people look to the physician community, because all three of us run healthcare systems they want to give get that wisdom ao get the understanding. at every level the ask you from the ache in my shoulder, should take, georgia what should i do for my health? one of the recent were said to be part of a panel like this is it a chance to join a bigger cocktail party and get some of the information out. [laughing] >> do you ever get people asking about your children?

>> portrait of the asked about themselves i can say well, i don't take care of adults, but i actually enjoy getting those calls about children and having the opportunity to find the right doctor or hospital for them. >> your running big healthcare systems. do you think someone does not run a big healthcare system would all of a sudden be in charge of a big healthcare system and do a good job? [laughing] >> kurt, what do you think? [laughing] >> well, you know, if i look at myself, i mean, i was chief of surgery and a surgeon at children's for almost 30 years when i became ceo. it was a big jump to go to being ceo of the hospital from being chief of surgery. if i were somebody's personal doctor, i'm not sure -- well -- better stop there.

>> so i guess one level any physician today in modern healthcare is a small business owner. they are running a team of people. they're trying to live up for product, understands why never seen i imagine they delude themselves into thinking they can do this kind of stuff. in fact, it's a much more complex task that just going from running, take care of a patient's health care to actually understand what it takes to run whole health system. all of us have been a chairmanship for number of years and to increase in jobs in our careers and i think like any other industry you need experience at all levels before you can really run the health system in this modern era. >> i think they'd set it off. >> what you regard as the most serious healthcare problem facing the united states right now? paul?

>> expenditures, spending 80% of our gdp on healthcare. it's unavoidable now if you look at the baby boomers aging, it's just going to get worse. we would have to do with the cost involved in healthcare and at the same time ensure that we actually improve the quality of their healthcare we deliver. i actually think the cost of healthcare is a largest issue. >> what a work in the white house in the late they did 7%. now it's about 18%. what you think is the biggest healthcare problem? >> i will expand on what paul said. i think since many people in the room are focusing on businesses and how do you maintain your business, healthcare is a single rising costs because of that right now to buy wellness for your key employees. this getting to 18% of gdp, this cost is a real burden on american business and industry. on the other side of it though we are one of america's

businesses industries and we are the leaders of innovation in the biomedical space for the entire world. we pioneered all the new drugs, all the new devices come all the new techniques and we employ almost 20% of americans in the healthcare industry. but it's too industries. it's providing quality care at a reasonable cost across the spectrum at one level of the divide and its maintaining america's innovation edge. i had the privilege of representing the oldest cantus in the country and in the world, throughout the world, and all the time i going to different hospitals, given healthcare systems around the world and everyone wants to introduce me started with the or from where everyone from the nurses trained in years to get their experience, where the devices that are going to be used, what equipment, where the supplies all are based on companies and yes or technique still in u.s. and where it might for that and we export the industry at the will get one spectrum that are

biggest farm in healthcare is to maintain america's innovation edge as leading industry and at the same time not drag down the american economy. we can't get above 18% of gdp and yet when you deliver wellness to our population. >> what do you think the biggest healthcare problem is? >> cost is obvious a big part of it but i look at it in the sense that a don't think we're doing enough for children. obviously i'm a little biased over not investing in children when we ought to be investing. so we're not getting the outcomes that we want, not doing the prevention, the access, mental health is a big issue. we have this tremendous very constant health system but we're not in many ways attacking taking care of the fundamentals. >> today we are almost finished after obamacare became law. would you say for hospitals that obamacare, your hospital, has it been a plus or a minus?

>> so it ends up because of, marilyn has a different payment system and every other institution so for us it didn't have a huge effect one way or another. we look around the country, the affordable care act did increase access by about 20 million people have access to health care they didn't have before. i think that's a great part of obamacare. and so for me from that it had huge effect. there are other things we could talk in terms of some of the downside of obamacare but i think if you look at what really the big positive effect obamacare said on health care in america is access to care for 20 million out of about 48 million people who did not have access before he went into effect. >> what would you say? >> what policy it is right, that expansion of access so that people felt that they could go to a doctor because they had insurance is the big positive we got out of obamacare. the american cancer society, i was just with the gary a couple

weeks ago giving back-to-back talks, is able to show that for breast cancer, lung cancer and for colon cancer, people can now, this is enough years since the start of obamacare, to go for screening more effectively when they have insurance. so it has driven down the death rate in all three of those cancers because people got identified and diagnosed earlier because they went because they thought that insurance, they didn't insurance, they could go to the doctor as a right and do that. but there are many complicated things as paul said. it's not all a net positive and there still room for improvement in u.s. health care. >> i think for children and families that was a big plus and it is a big plus when you think about we used to have all the controversies around pre-existing conditions. we don't hear that anymore. that's largely because of the rules they came in with the affordable care act. kids can stay on their parents insurance until their 26.

that's huge when you think about the college age, all the things that go on, mental health issues and so forth. and then the lifetime caps, a child with a serious medical illness can run through $1 million $1 million-dollar cap in no time which was very prevalent before obamacare. so in those three ways and made a big difference for children and families. >> my experience showed he could be on their parents health care system after 26 as well. [laughing] >> we will be happy to take care of your kids. let me ask you today, if summary shows up at hopkins and they say i'm sick, i'm an emergency room, i need treatment, i don't have any health care insurance, nothing. do you turn them away? who pays for them? >> if anyone comes to emergency rooms they will take of them. that's when the the great things about american health care is i don't think certainly by law at one level but in terms of no hospital terms with anyone who needs care.

i think it's essential because it's health care providers to our role is to prove the health of our communities and i think physicians have that responsibility to our community and i think people do that and i think it every hospital. >> how much -- >> at our system, , it's about $100 million a year. >> you have the same problem i assume? >> not as great a problem, but again we provide, as paul said, we provide support for anyone who comes to our commission up to five times the poverty limit will forget any debt or co-pays or any of those issues. the biggest point where the makes a difference is, is in our pediatric population for oncology. we take care of the largest number of kids in the country, 750-800 new kids with a diagnosis of cancer in newark area we take it. that's devastating for the family for all the reasons kurt

said. cancer does a respect any socioeconomic barrier and so we provide that care. >> how much a year? >> i would say with the kids alone probably 20 or $30 million. >> you have a lot of people who don't have insurance, or not? >> that's true. even the ones that insurance, its prickly medicaid. over half the children we take care of, and this represents what's happening in children just in general are on medicaid, 55%. we are trying to provide access where these kids live, not just wait into to come to the hospital. we want to be in ward seven and eight. we want to be in prince george's county were a lot of these kids don't have coverage. >> what happens come when people seems to meet you to go in the hospital stay there for couple days, maybe a a week or whatever. i do try to rush seems. i do nothing but his notice that what you try to get people out

quickly? at what point do you lose money if they stay for five, six days is childbirth going to bed outpatient thing soon? [laughing] >> i think there is definitely a push to get people out of the hospital. the driver, it's not economic. the driver is actually because we think people, if they can, will do better at home than they do in hospital because it safe and on the road to recovery. the real driver for decreasing the link of state hospital is not economic right now. it's really because we can do more and more. when asked all my surgical chairs, i said what percentage of surgery you do will be in an outpatient setting in ten years? it is basically 80%. 80% of surgery surgery done in our hospital will be as an outpatient within a decade. hip replacement joint replacement. so there's a lot of care we think because of technological advances we are not able to do in a different setting.

hospitals, if you are -- if you can't get illness, hospital is we have to be but if you don't, if you don't have comorbid diseases that increase your risk, if you do well, a simple procedure you will do better the less time you in the hospital. >> i think would try to get people out of the hospital. >> how many beds to have john's hopkins? >> are whole health care says as 2000 beds. the main ship has 1100. we have about 2000 beds. we admit probably 100 160,000 e a year between all those. but the biggest thing, when hundred 60,000 inpatients. we take care of 2.8 million visits as outpatients. so compare that even today, over tenfold more. >> but you don't look at it like that. hotels they try to fill up the rinse every night and hospital you have 1100 beds to fill up every night. >> we could get edwin out faster

than we can and we still what the hospital. we are bursting at the seams. we went 85-90% capacity which is the most you want to run. and even at times you at 100% capacity and that's probably true of most of her hospitals. we are running as fast as we can. >> so how many? >> comparative numbers, we are a small organization. we have-14 that hospital. we run as paul said at about 92%. to us, cancer care has moved into much more effective therapies that you see about all the time. in the news the new precision medicines from the new immuno oncology devices but it is more protracted. the treatment time to get cancer under control takes longer. we are seeing cancer move from an inpatient to seek to an outpatient disease. we made the decision five years ago to build an outpatient surgery center for complex cancer care. we do complex breast cancer

procedures we do the full spectrum of cancer care now in a facility five blocks or remain hospital. you cannot stay more than 23 hours at. we propose to pioneer this out, we thought maybe in a a decadee be able to convince 7000 people. that was our business plan, to build and pay for this facility. we did 7000 in the first year, and what we've done about that is that patients recover more effectively in their own home. they have lower infections, and the cost is driven down and they have better satisfactions. if you do the education right, you can actually gain access to the complex care we have at the hospital but not have to burden down the hospital with the care mission of taking people day in and day out. >> how many beds to get? >> we have 313 beds, and obviously that sounds small compared to these. >> are the field every night?

>> i'm sorry? >> all the field every night? >> yes. we have a look that different, because we, kids and families frequently need to be in the hospital more than, say, been able to be an adult and be able to be at home. so we are full. we're thinking about expansion. with a big plan around an expansion with the research and innovation center out at walter reed that will free up more beds to have at the hospital. >> what's the definition of a child for the purposes of -- how old can you be and not get admitted? are you to anyone and not eligible? >> is this your kid? [laughing] >> no. they are over 21. what age can you say you're not a child anymore. >> i think generally it's in the 18, 19, 20 range but we've had so much success with certain diseases that used to, that children didn't survive with, if you think about it, cystic

fibrosis or congenital heart disease, certain cancers. and those kids and families get used to be care of at the childress hospital. they love the environment, the doctors, nurses, the art, , the music, clowns, et cetera. they keep coming back. it's not uncommon to see sometimes a 40, 50, 60 year old for that specific condition. >> so you have medical school, one of the best run medical schools in the world. you accept roughly 3%. >> that's probably about right. i had security hundred applicants for 120 spots. >> half female come half male? >> what's amazing, , the average gpa, average is 3.91. >> what are these people doing in college? did that nothing else -- >> here's the interesting thing. we can fill our class threefold over with people without gpa.

in fact, if you just a really well in school, that's not sufficient. we would look for people who, i mean, institutions like ours, all three of us i think, institutions have the unique ability to change the world and to make an impact. we are looking for people not just to do well in school but have demonstrated they can make an impact i want to make an impact on society and on the world. we are looking for people who are beyond just having high gpas. we want someone who has done something that demonstrates to us that they're going to utilize the resources. >> what percentage get in? did all graduate? >> yes. less than 1%. it's interesting, we just saw hopkins -- not to brag but hopkins school meds has the highest of any med school, 37% of all graduates are on faculty at another medical school. we are trying to train the leaders. people go and change the world. >> we had so few medical

schools. schools. why don't they expand? why bunch of a bigger medical school? your classes what one in five people? >> 120. it ends up, so med schools have increased in size by about 30% over the last six or seven years. the limiting factor now is not the medical school class but the residency slots. remember, after you train school you have to do a residency in whatever special you want to do and those slots have been capped by the federal government. they are paid for by medicaid. if not increased and so it were producing more students but there are not places for them to train, we're doing a disservice to the students because they would have a place to change. they have had been squeezing ot foreign medical students who took a lot of the slots. every year increasingly american medical students cannot get into residency programs because the caps have been -- >> what type of debt doesn't average medical student have by the time he or she graduate? >> nationally, the debt is about

$190,000. and that's nationally. at a place like hopkins because we have a lot of philanthropy, our average debt is about $110,000 so quite a bit lower. national $190,000. >> if you want to take that debt back quickest, you going to plastic surgery? [laughing] >> well -- >> the question is does that large that influence the special agent of students? [laughing] >> it does. >> in fact, it's interesting, if they do surveys of their graduate students and asks that exact question, the number is lower that i anticipate is the reality. so if you ask them very few come less than 20% of the students say that especially decision was influenced by their debt. but in reality i don't think that's, i think a lot of them

are influenced by -- >> perth scores but can a tighter shoelaces, do you ever meet these people before you admit them? >> so medical school now, sort at hopkins and most med schools have was called a holistic approach. as is that i can fill my class with perfect scores if that's at the point. when looking for people who actually can interact with people. we do testing while they're in our new process to make sure they can interact well with people. we look for more than just hiring. tying shoes is a big part but -- [laughing] not the only part because there's velcro, a lot of ways to get around that time your shoes. we're looking for people who have empathy, who want to go out and serve mankind. so the interview process is called this holistic in a process where we really try to dissect out. >> to be serious about it, when i was growing up doctors,

lawyers made a high income. it's down in recent years. it's hard to attract people at the are attractive because you want to serve people. it's not because income would be that great relatively speaking, is that right? >> people worry about gen x, whatever we will call millennials and worry about the work ethic and all that, come to my first year medical school class and interview those folks. they are the most amazing, dedicated people you'll ever meet. they are really here for every reason you want some to go into medicine to serve mankind. the money is not why, as you said, salaries are relatively flat. it's not the driving force. ..

the firewall between me and admissions is getting larger and taller! i have no role in admissions at all. >> is the incidence of cancer in the united states increasing? >> importantly, david, it is increasing. but it is increasing for an important reason to recognize. 100 years ago cancer rates were significantly lower than it is now but we live 20 years last now. the major drive in the increasing incidence is our ability to live longer and healthier lives. of course i cancer is a disease of aging. the incidence of cancer doubles with every decade of life. as americans are living into their 80s, with great success we are seeing a higher incidence of cancer on that basis. our ability to prevent cancer is also getting better. so the actual ability to deal with complicated cancer, the

improvement in survival is one percent a year. it has been that one percent every year since 1990. so mortality has gone down almost 25 years. >> if you are to get cancer in stage one, let's suppose this breast cancer. it is 99 percent now recovery rate. is that something like -- >> certainly, the common cancers caught early, survival rate is well over 95 percent. the problem is getting it diagnosed early enough. skin cancer is more and more, look into those kinds of numbers. colon cancer, people that is quite appropriately we are getting to those kinds of numbers. women are doing a great job with breast exams, mammography, we're starting to get to that kind of number. but it reaches a plateau with all of the cancers. if i can just talk about breast cancer, where learning is not

one disease. for the most common form of breast cancer, yes, caught early in stage one survival is in the 95 percent plus. but there are rare forms of breast cancer we are just learning about periods where unfortunately, we do not have effective therapies. and for those women we need new and innovative approaches. that is printers row lit fest with prostate cancer. many men will get prostate cancer and it will not cause diseases. and for a long time without smoking was the only issue with lung cancer. it is not any longer. but we have a very effective therapies now. some wait too long with lung cancer to go to the doctor. >> cancers which have the lowest survival rates, glass, and pancreatic cancer. >> there are a number of cancers in the 200 well-recognized symptom types of cancers that we not diagnose by pathology. two that are in a relatively

common, almost no effective therapies are pancreatic cancer. patients do not present symptoms, they come after the tumor is widely disseminated. in most instances. because it is an area you do not feel a lot. and brain cancer, oddly, it chats with social economic status in a positive way. so the better your socioeconomic, the more likely you are to get brain cancer today. the adult forms of brain cancer as opposed to childhood forms, so i'm no effective therapies. >> why would that be? >> no one is any real idea. they've identified this and it correlates with lots of things. as we heard 10 years ago that might have to do with cell phone use. remember it was a good tracker in the 90s and early 2000.

with a cell phone facing and more economic status. but it is an association. we don't really understand why there is an increase in brain cancer in particular this fatal form of cancer. we need more research and that particular cancer, -- >> today using a cell phone will not cause brain cancer. >> there is really no, anything reliable to suggest other than the association that brain cancer is of an increase with people of higher socioeconomic status. the idea that your cell phone is the cause is just not possible. we have seen it go away because everyone in america has a self appear. >> the higher socioeconomic class and you get away your money, would your chance go down? [laughter] correlation is not the same as causation! [laughter] what is the most common thing that people come to the

children's hospital with a common complaint?>> probably the most common thing are different types of injuries. whether it is concussion, fractures, -- situations like that. those are not the most serious but the most common. >> let me ask you this. how much time do you spend fundraising? because even with government reimbursement and people paying and so forth, i assume you still need more money. what percentage of your time to spend looking for donors? >> i advocate for johns hopkins medicine all the time. and if it be with donors, it could be in congress, it can be with regulators. i am always advocating for the hopkins medicine whether it is potential donors or people who,

remember, most of us, most of the monies from the federal government. $8 billion, over 4 billion from the government. relationships of people on the hill are important. >> patients often thought to be people that might give money. i heard a story once. someone was very happy at hopkins. they said in my will, i will give a lot more money. if that person came in for an operation, you are sure the doctors would do the best job, right? [laughter] >> i was a one of the major donors for johns hopkins, is a very well-known donor.he lives in new york. he said, dr. rothman, you only get money while i am alive. [laughter] that was actually i think a really good approach to

financial -- >> can you have a lot of money that you have to raise i assume? >> where mission-based organization. we have been cancer dedicated hospital since 1884. and so, we are all about the mission that ties us to the millennias and in important ways because there more and more a generation that wants to see improvement. and a purpose. 10 percent of my time is true fundraising but i'm always out there talking about the importance of our mission and what it means to people. the hope that it gives to patients. we benefit from that in a number of ways. i will give you just two of them. we just completed, i spoke to several family members with part of the efforts four cycles for survival. it is a spin event in a spin studio. a cycle event where teens come together to raise money for rare cancers be the kind of cancers that do not normally get light shed on it.

assessment, we were in 16 different cities there we had two -- 250,000 people donate for the cause of rare cancel. we raised $39 million. you can do this and it raises extra research that we need. but beyond that, because of what memorial has meant for the understanding of cancer, we are privileged to have 10 and a half million living donors. we have not taken care of anywhere near that number of people. but they believe in the mission of what we are doing to decrease human suffering from a disease that no one deserves to have. >> president nixon said there was a war on cancer. this is in his first term. will cancer be eliminated in our lifetime? >> so, there is a sort of three different ways to think about what causes cancer.

cancer, in the end, has its root in the fact that we regenerate our body all the time. make all of our blood cells over every hundred days. make all of our skin over every two weeks. we make all of our hair over about every 100 days as well. and the process when you break your arm and you regenerate it, and means that the cells have to proliferate through and prepare that tissue. every time a cell divides there's a chance of it making a mistake and copy information that makes you up that you inherited from mom and dad in your dna. cancer arises out of those. it is a natural rate of mutation that occurs just in repair for us as organisms. unfortunately, that natural rate probably does say that there will be some incidents in cancer as all of our tissues grow older. forever, no matter what we do. we know 85 percent of cancer today is really preventable, because of things that we have done to ourselves.

environmental items like tobacco, exposure to the sun, the biggest preventable identifiable risk of cancer is obesity. we do not really know why. but it has passed tobacco as a leading cause of preventable cancer. that is something that we can affect. it is something we can make a difference within public health measures and others. finally, there is a genetic predisposition that about five percent of cancer comes from people that unfortunately inherited a gene that is involved in our regeneration process. that is not working properly. that is brca one and two. >> people have cancer treatment, chemo, let's say. they lose their hair. why do they lose their hair? >> how her hair in her head is growing every day of our lives.

-- even for those guys that maybe hair challenged, we actually have hair follicles. here is growing every day. unfortunately, when you get chemo therapy, part of the side effects of chemotherapy is to tell every hair follicle to stop the growth and start over again. so what really happens is 100 percent of your hair falls out in about one week. then it all starts to grow about. and that they had had a friend through that, that is what happens. it is a complication that is constantly reminding a patient of what they are going through. and that is why it is so upsetting to everyone. >> how much time you have to spend fundraising and what about the children's national health system? why is it a system? >> that was when i became ceo, i was little frustrated by people that knew about the hospital but they did not know about all the other things we were doing.

whether it was in the community with our clinics, mental health or mobile health. whether it was research that we are doing and like these great hospitals. i wanted to find a way to signal that we were bigger than a hospital. so what came up with was this idea the children's national health system. to be honest i'm not sure it is perfect. we are taking another look at it because for 150 years, there is the identity that we were the hospital for the children of this region. it is a health system. it just doesn't resonate. so we are looking at that. on the question of philanthropy, it is a big part of my job. i have to really be out there and telling our story. there are many people in this room, whether it is ourselves or companies, they have

supported us because they believe in our mission of taking care of all children. no matter who they are. also being at the top of our game. being one of the top hospitals in the country. when you are taking care of so many kids, we have some problems here in washington d.c. with some of the health disparities. infant mortality, asthma. these are not where they need to be and so, our hospital takes on that mission and it is a big thing. we are trying to do it best we can. we cannot do it without philanthropy. there is a direct correlation with all of the great things we can do and i have got to just say that your honored guests has been a big supporter. what we are trying to do. >> you are a surgeon by

background, right? why do they want to do things at 7:00 a.m. when they might be groggy? my not in the afternoon when they might be more awake? why so early? >> what you don't know they probably have been up for a couple of hours already making rounds and they are really at the top of their game. they are up early and you want patients when they are at the top of their game also. >> should take an aspirin every day? [laughter] >> the big question is should everyone take aspirin? and -- if there was no side effects i would say yes. but in fact there are essential side effects of taking aspirin. i think what most people believe it is for the right person than they should take it. the right person someone that has a high risk of getting heart disease. and that risk can be measured by several ways. one of which, if everyone wants to know that you can go online and look at some of these

calculators. you can do it online. it has to do with smoking, drinking, your weight, blood pressure, parents.with a calculator and they can give you the risk of having heart disease within 10 years. if your risk is 10 percent or greater of having heart disease within 10 years, you should take an aspirin. now, sometimes tests, it is obvious he not a very sophisticated way to measure your heart risk. so there are tests that you can do there's something called a coronary artery scale. the cost is between 75 and $100. you can get at the hospital or physician. it has a much better predictive value than the online scorecard. again, if your risk is greater than 10 percent of having heart disease in 10 years -- >> do you take an aspirin every day? >> i do. >> i realize that you on the board of merck but leaving that

aside. >> i would say statins, they are in the cardiovascular space. something that certainly, clinical trials that have been done today suggested that there is no lower limit. you decrease if you do not have side effects from drugs you do not get the muscle aches and pains. that in fact the lower the cholesterol the better off you will be. is it a complete panacea? no. we are all hoping would also lower incidence of alzheimer's and other diseases. it doesn't seem to have an impact or maybe about that. i do not have everyone should take a statin. i think we should, again, got your individual risk profile. it is about cholesterol in this case. that is what statins affect. i will just put in a plug for something much, much cheaper. that is aspirin, again. there is fairly compelling

evidence that if you can safely take aspirin without the side effects, like g.i. bleeding. it has an ability from the esophagus to stomach and intestines, it does dramatically lower -- >> do you take it? >> i do take it. >> should people get an annual physical? some say it is a waste of money. do you recommend it? >> i definitely recommend that. especially with children. you want to catch these early. make sure children, if there is an issue, it can be something simple or complicated as mental health issues. i think doctors are and nurse practitioners are in, being able to see people over time is important. >> mammograms. there was a discussion of mammograms should not be done as frequently as they previously thought. they think they should be done how frequently? >> i think the, we are still seeing different

recommendations for different age groups and different risk profiles. on average, i think you really have to go to your physician. or her physician to do this regular mammography. it is certainly beneficial. but the frequency is really as paul said, matched with your profile. you need to have with what your family history is, your own personal history is, your age. >> how often should get prostate? >> prostate has become a very complicated problem because most prostate cancer in men is not going to lead to significant morbidity or shorten their lives. most men will live without it impairing their lifespan. and so, but there is still a percentage that progress. the problem is we can identify those prostate cancers that a pathologist has to call prostate cancer but we can't

discriminate if it was when you will live with for the rest of your life. most men have diagnosable prostate cancer when dying of other causes in their 80s. they never knew it and do not need to be treated for it and are unlikely to ever have the disease. the tests right now are all focused on what discriminates someone with prostate cancer advances. the programs are being offered are called watchful waiting. people using multiple blood tests to try and make the decision. but right now there is not one universal except in one that we can do. it is an area of intense research request with prostate cancer another is a very famous researcher at hopkins. someone once asked me if i would recommend and my assistant came in and said he really think that enabling men to maintain their ability to make love after a prostate surgery is something that

deserves a presidential medal of freedom? [laughter] some people said i can see why others may but maybe that is the most important thing. and i said it is not a medal of honor thing but a peace prize thing. [laughter] right now, the opioid crisis. how serious is this? you see that hopkins all the time? >> the upgrade crisis is actually one of the great tragedies in america. because, the tragedy goes back to the fact that opioid deaths and overdoses in the epidemic, is interesting. it has been present in the country for a while and it wasn't until it started to hit suburban america and middle-class america at the level it is now that it has risen to the height and has intrinsic public view. >> doctors oversubscribed --

>> there is a huge complexity to others as clearly -- i hate to say it, so, one of the issues is physicians prescribing opiates but that is driven by the idea that pain is the fifth vital sign. the fact that if you do not care for someone's pain you might get dinged by regulators. so there is a drive the regulatory bodies to try and decrease everyone's pain level. let's this idea that pain is a vital sign and lead to people saying that is what i am being measured not let's make sure i can get rid of everyone's pain and let's i think it's one reason i don't think anyone can tell you why it ends up the prices went down.

and is made higher so it's also another factor. >> imagine obesity earlier. for the first time in a long time, white males and maybe others, their life expectancy in our country is going down in part because of obesity. it is because were exercising less, food is not as good? was the reason. do we have more sugar and the food? it is an equally complex problem partly the world and being obese. this is not a good one. we look at simple instruments as an average meal. that we, people want to see what a mcdonald's hamburger looks like. we have increased our mail size. in the end it is more calories in and out. there's about a very important research being done. one sort of interesting and good for a lunch meal and what we just did, the average

american eats a meal. lunch or dinner in nine minutes. okay? you didn't have to believe me. go around to whatever your favorite lunch or dinner shop is. we have learned a lot about the physiology of eating and how it is our body knows we have got nutrition and not to move on. the hormones that signal between your stomach and determine whether you ate something, if it was a diet soft drink it doesn't have any caloric intake. you will not tell the brain that you had caloric intake but if you're being a role you will get caloric intake. the synthesis of that hormone, there is a series of them. but it takes 20 minutes. so you can't, the stomach has to have food content in it for 20 minutes before it can make the hormone to signal back up to the brain that we ate and it is good. let's move on and hunt for whatever we are going to do.

the average french family eats a meal and 38 minutes. and so, everyone talks about what is the mediterranean diet? it really could boil down, this is a sufficient explanation. just the time that it takes socially that they eat a meal to actually get the satiety, not to over eat. and this is over a chronic time. so you gain weight over five years. over 10 years. not over next month. we really as a society, to not understand the rules of good nutrition.learn about cardiovascular health but not like with diabetes and other things. we will see a bunch of new -- we now know that fat is not the problem. it is simple carbohydrates, calories that make it much

worse for the obesity epidemic. we take way too much simple sugars in our diets. you can see all of the dice around that. finally, exercise really does make a difference. exercise allows our body to cleanse itself in a way that was just discovered, the nobel prize was won last year or year and and a half ago for the discovery of a process called -- we clear ourselves and rejuvenate cells and we do not know how much of that factors in versus just, when you are obese you do not exercise as much. is it a compounded problem in that case? >> walking past jim equipment is not enough. you actually have to use it. >> you actually have to use the gym equipment. i do think of you just think about how our lives have changed, you do not walk the distances that used to. you get to a gym and you are doing physical things. >> teenagers that come to your

hospital, is alcohol a big problem or drugs? >> i was alcohol is a much bigger problem. but getting back to the opioid thing. one of the really saddest parts of that crisis is to see babies that are born addicted. we have numbers of these where the mothers have become addicted and like dr. rothman, there are also several reasons for this. but i think the answer may be in research and trying to determine objectively what pain is and how much we need to treat it. not just provide prescriptions were lots of drugs. >> if you can do it again would you go to private equity or medicine? [laughter] you have to think about it, okay! >> medicine without a doubt. it is the greatest thing anyone

can have. but i love private equity though. [applause] >> private equity or investment banking or medicine? >> i'm incredibly lucky to have found medicine as a profession. it is a good thing i was not very good athletes i had to find something i could really do. i have to tell you, even now in my career, it is exciting to wake up every morning. and have the opportunity to help people. some of the most difficult times. it is great. [applause] >> what would you do? investment banking, private equity, hedge funds or medicine?>> loving a surgeon and care children and families. being a ceo is a little different. but there are times where maybe budget time, being an investment banker might be a good idea. but i just love what i'm doing and having impact for kids and families in washington. [applause] >> incorporated you all for the great job you are doing. thank you all for an interesting conversation. i know all of you and you've done a great job in the institution.

thank you for giving us your time and your thoughts. [applause] >> the aspen institute hosting a series of discussions on the future of college sports. today a conversation about what might happen if student athletes were compensated. some of the speakers today will include former college basketball coaches and players. ncaa officials and experts on sports law. this should be starting shortly. your watching live coverage on c-span2.

up this. [inaudible conversations] >> hello everyone. i'm the executive director of the aspen institute. sports society program. welcome to our new