do 100 comments. it's a lot. and i got over 1,000 comments on all sides of the issue. very revved up. i picked up my-year-old from school, and he's like, you know, dad, what's dry needling? and i said why do you ask that isaac? and he said well because my gym teacher gave me this letter to give to you. so just -- i used to say that it's not a safe place to be between the dry needlers and the acupuncturists. and at one point i proposed legislation in the state of maryland that would take these scope of practice disputes out of the medical boards and all the litigation give them to a -- give the ability for the legislature, just the ability for the legislature to appoint a committee to resolve it in the public interest. and the line out the door of all the lobbyists who were testifying against that bill was an image i will keep in my mind. nobody wanted that. they just wanted to battle it out. so i do -- i absolutely concur

that there are -- you cannot assume that just because the medical board or dental board or a different board has a particular policy it's going to be the right thing for the public interest. the flip side is they do provide very important public health protections. and particularly when people are sick they're not your economics 10 well-informed consumers. people who are sick are very vulnerable. there is an unbelievable record in the united states of people getting taken advantage of when they're most vulnerable, when they're sick, fraudulent cures things that hurt them. and it is very much the case that medical boards for example, protect the public for -- against physicians who are quite dangerous. as do the other boards. and i used to interview -- i interviewed all the medical board candidates and we set up a president for interviewing all the other candidates and i said i only have two questions. number one, will you put the

public interest first, even if it's about people -- if there are people out there who shouldn't be practicing, it is your job to get them out of circulation and to make sure you're protecting the public. and number two, be reasonable on scope of practice issues. because you know the fights that happened were just totally all-consuming when they happened. so how do you draw the balance when you have regulation like this? you know, if you're not going to be someone who just thinks all regulation is wrong and if you're not going to be someone who thinks all regulation is right and some things that make sense and some things that don't. how do you do it? how do you maximize the benefit and minimize the risk of a regulatory approach? and the answer is, you have to set up an approach a process, that has the public interest as the bottom line. and i don't think that the boards themselves can can really play an effective role in that. i think there are some state models that bring in external people to think those things

through. that those are good models, as you're thinking about global models figuring out what would -- where are the opportunities to do things that really are in the public interest to get the -- you know, it's not just, i think, what simon is putting on the table isn't just that they're u.s. health professionals treating people around the world, but people in the united states could log on and get a consultation somewhere else. well that may well make sense for certain things. and there could be a system set up that maximizes the benefits of that. but also minimizes the risks by having an assurance or partnership between different regulatory entities. i think that's the right conversation to have. i think that on the basis of evidence, on the basis of logic and best practice, you can pull people together and i've seen it. and i've even seen it on very controversial issues. we actually regulated abortion facilities in maryland and when we came out with our regulations, we had both the

right to life groups and the pro choice groups saying they thought we had done a fair job. and that was because we tried to strike a balance, and we were as transparent as we could about the thinking that went into that. here's where i think i really respect jeff's position on the first amendment, and how it relates and let me just react to that for a secretary. i think that in general, my view is that it should be the public interest interest that's the real, you know -- is the north pole that the compass is aligned to. it should not be an ideological view of the first amendment. as i listened, i think what he was saying it's whether the first amendment applies and whether there is an appropriate limiting it evident that's put on. i'm very familiar as a pediatrician in the state of florida asking about guns. and i do understand the fact that there are speech

considerations. i think that if there were a way to say that -- you know, what is the balancing test. so i think jeff may be focused on getting the first amendment to apply because that's a threshold issue for him. i'm more interested in what's the balancing test you apply. what is the balance between state regulatory agency and individuals in this regard and i think that the balance has got to be some assessment of the public interest, whether it makes sense. i would make the case, as a pediatrician, and along with my professional association, that it can be very important to ask about gun safety for the very reasons that jeff said. and that there could be -- the standard that would be applied is not just are they words coming out of someone's mouth, but does it make sense. on the other hand, on a therapy that has been totally discredited by the profession that it -- such as repairive therapy, which has essentially no support within organized and

evidence-based medicine that the public interest would -- would favor a regulation in that area. so for me, i could see that there is a yardstick that could be done that it's not so much whether the first amendment applies or not, but then how you would apply a appropriate test so you get regulation that maximizes the benefits to the public and minimizes the risks. and i think probably if we were all to sit down, even though we may come from different ideological parts of the spectrum, we probably could work out that it's totally reasonable for someone to be sending cat advice to someplace in the world to help cats, and something else might not be reasonable at all. and how do we draw that balance or what would be the process that could draw lines that would lead to better health lower costs and a interesting progress as technology evolves in health care. thank you. >> thank you, jeff. those are all great

presentations and give us a lot to think about. i want to open up to questions now. let me take an opportunity to ask a first one so start getting yours ready. i think this question and i don't mean to put you on the spot rene, and others feel free to answer, too. i think this question may be most for you rene. i don't know what extent you've thought about this. i think both josh and jeff alluded to, there are international aspects about this and that's what i wrote about as well. and i'm just wondering, as we all know, the united states is not the only country in the world. other countries are aware of this too and doing things too. rene do you know, you know, are there other examples of what the european union is doing what china is doing? what are other countries doing with this? it seems to me eventually someone is going to be trading these services internationally. if the u.s. is going to put up barriers we're going to be the only ones. do you have a sense of what the rest of the world is doing with this right now? >> yeah a little bit. i think we're all sort of in the same boat. a lot of this is new. or we're wrestling with a lot of clinical, political and other

issues as well. i will say, for example in the eu, license you're follows where the physician is located which makes sense and which facilitates the greater access to care, obviously. because physicians don't have to worry about being licensed where the patient is located. but a lot of other areas have not yet had the sort of fully developed regulatory approach the united states has. now, one thing i will say is that sometimes i tell my clients, have you thought about starting this somewhere else outside the united states where you have fewer regulations to worry about where you have fewer political considerations. i mean we heard about the board, and i think dr. sharp sharfstein, you alluded to this. there is some protectionist bent for these boards as well. so i think we're generally all in the same boat, but i would say that given the way our laws are -- the way our laws are

enacted, the way egg regulations are promulgated, the federal and state level. all the various boards that you have to deal with if you have a regional and national network you have in mind and want to develop. it's hard to do in the united states. >> let me open it up to questions now. so a couple instructions. please wait to be called on. raise your hand if you have a question, wait to be called on, wait for the microphone so everyone in the room and audience can watch your question. and announce your affiliation. with that, any -- any questions? >> my name is lee young. my question now is how are you going to do -- or what should be done in the medical sector or in

the public citizens. one is like hacking or manipulation of equipment or internet or some kind of obstruction, basically. okay. and then you have a regulation, but currently there is also a trend -- as i say maybe more related to the fraud operation. and they are now promoting occupation without examination. what they call it now is a competency which is very strongly worded and maybe very subjective. and then if the people complain to the government agencies and they ignore the complaint, really, and what they say is they are not in the best

interests of the public. so how are you going to regulate government agencies rather than professional health care? >> go ahead, josh. >> so i -- to your first point about security i think that's extremely important. and i think that is a potential role for regulatory standard because even if you could work it all out that there is a great dermatologist in germany who is perfect for your kind of rash, and everybody believes it's appropriate to do over -- but suddenly, you know, you're -- you know www.simonsrash.com shows up on the internet and there's all your pictures because that's been stolen that's not a good outcome at all. so i do think one of the things that is important is to have strong security standards and enforcement of the standards so everybody is participating is at least able to have some level of competence about privacy. i think that's a really good point. the issue about medical board

jobs are very hard. and boards in general, jobs are very hard. because some of the things are very easy. there is something that has been horribly done horribly wrong and needs to be clear discipline or even someone losing their license. but a lot of them are in a gray area. and it's very important for boards to be as prompt as possible be able to at least, you know as -- at a certain level, be transparent about its approach to different issues. and then usually there's recourse to the courts if boards don't do -- for both the provider and for the patient and in the case of a totally egregious decision occasionally the courts will pick that up. but there is enormous authority. and i have seen very unhappy practitioners who felt they were being treated unfairly by the board, and very unhappy patients who felt like they were mistreated and the board didn't really listen to them. and you know, as the health secretary, i couldn't get involved in every case. and you have to appoint very

good people. you have to try to orient them as well as possible. it's sort of like you know, a judge has to make a tough decision sometimes, and then there is an appeal. and in this case you have to think about the board being run well as well as there being some opportunity in certain circumstances for appeals. >> do you know anything about the security issues rene? >> no, i think -- i mean the security issues are very important, but i think we have other laws and requirements. the eu has an incredibly sophisticated privacy and security regime. so i -- while security is an important issue, i think they're addressing a myriad of privacy and security laws that most developed countries have. >> a question in the back. start with the way back and then a couple in front nearby. >> thank you. my name is kyle gibson. i'm a former intern working with simon. i think i see bill in the

audience. happy and pleased to see this issue has been brought to life through simon's work. when i was doing research on this a lot of the -- the biggest challenge seemed to be licensing within states to practice medicine. my question is open to the panel. if the day comes in which, you know licensing is eliminated per states to practice across state laws do you see this phenomenon spilling over to other industries? so what i'm thinking is the practicing of law. right now i'm doing research on mobile banking in africa. and there are similar regulations prohibiting i guess the flow of commerce between countries, and even between banks. so i wanted to get your thoughts on that. thanks. >> so does this set a precedent for other industries. >> so yes. if the first amendment applies to occupational speech which it should, then it will be a

precedent that applies outside the context of medicine. but as josh was suggesting, how it applies will be different. and you know the particular test that we would use in the first amendment likely, although i don't know -- it would be something like the test for commercial speech, which recognizes there is a substantial it interest, constitutional interest that should be protected but maybe not as big a constitutional interest as in other context -- for example, pure political speech. so what would this mean? in the context of medicine you would expect there to be reasonably robust protections because appendicitis in florida is the same as in alaska. but florida and alaska have different laws and might have different banking laws that are peculiar or different real estate laws for whatever reason. and so the kind of tele occupational regulation that will exist, even in a context in which the first amendment applies, will allow for the kind of flexibility that josh is describing, i think. but it should apply to just about everything.

like financial services should be huge. the practice of law frankly is something that is big. psychology and maybe life coaching and diet and nutrition. those are the kinds of things people can actually do from a distance and they could do much more cheaply, much more conveniently, if it were possible to do across state lines. >> let me just clarify that i do support medical licensure by state. and the reason is, there is a strong history of medical licensure by state. in maryland we did a lot to improve the function of the medical board. there are some terrific doctors serving and did a great job clearing a backlog, and taking much more rapid action while they were expanding procedural safeguards for doctors. it's a really hard thing. it goes to my previous question. and i think that it has credibility in part because it's relatively local. we have experts from the university of maryland who is on the chair of the board, johns hopkins, and so if you're taking someone's license away, you're doing something like that, it

helps for there to be an internal credibility within the community about the fact that it's the medical profession doing it. it's not some, you know external, national global board of doctors. it's actually a local board. so i think that getting the boards right is correct. what the relationship between boards are and the kind of compacts that rene talked about and the expansion of those i think that would be the right area to pursue. i would say that as you think about how you approach policy judgments, i would afford a lot of importance in the need for the people to be licensed for where they are taking care of patients. and i see this different a little bit than in the case of the veterinarian, because in the case of thenarian it's about sort of the definition of how to practice. you know, you should have to do a visit before you do something. i mean those sorts of things i think, are like, you know

trying to regulate the practice within a place that you're doing it. whether or not i think there's an appropriate role for the first amendment or other things to say actually you don't need to get licensed in this other state anyway i would have much more of a concern about that, because i think there is a huge public health value to having well-run medical boards in -- at the state level. but i see that as a little different than the case of what is under the jurisdiction of the board and how the board may be going about its work within a state. >> that's true. although just as a quick response as a constitutional lawyer, the mere fact that free speech rights are inconvenient to the government is not a justification for ignoring them. the constitution is the foundational document and our free speech rights are foundational. and even if they create what might be a sub optimal regulatory state, that may be what a free country total rates. >> and i appreciate that. as a pediatrician, i would say -- i gave a speech at one

point in law school where i said, i'm familiar with the argument that the -- you know, the bill of rights is not a suicide pact when it comes to terrorism. i would say the first amendment is not a suicide pact what it comes to public health. >> fair enough. >> did you want to weigh in? >> the only sort of -- talking about the boards, aren't most boards complaint-driven doctor? number one. a lot of boards are underfunded number two. so the question i always have is, are the boards the best way to regulate the practice of medicine, given those two things i've just mentioned. >> you know, i -- i think that the question is certainly, there are boards that are underfunded. and i think you could look at a lot of front page stories to say they're not doing as good a job. a number of them. as they could do. it's complicated to think of how you would do better, other than to improve boards like we were

able to do, i feel like in maryland and in other places. because of the local nature of medicine and the history that's there. i mean, i guess in this respect, maybe i'm the more conservative person on the panel, and that like i would be careful about throwing out, you know, more than a century of regulation at the state level. unless you really had a sense of what you would do. do people really want one group you know hearing all these cases within you know -- and it is true, though. there are local standards of care for certain things. and so -- >> but aren't those -- not to interrupt you, but aren't those disappearing over time? >> that's probably a debatable proposition. i think there are people who would like to see some of the differences disappear. but it may be that, you know, if you have a board that has -- you know, there are a group of experts in a particular field

from one part of the country they don't realize that there's a unique different kind of disease or history or treatment or wariness or something that's going on somewhere else. and, you know i think that it's -- i -- i have written about the flaws of medical boards. so i'm not in any way trying to defend them. on the other hand, it's not that easy to think of a national medical board that would be able to do that much better, i think. >> let's open up to other questions. i see a couple in the back there. maybe the guy closest to you. and then the one in front of him and then the one over to the right. >> hi. steve chisolm with the chisolm group. cato institute, great work. i enjoy the panel. my question may not be particularly jermaine. i was thinking about the v.a. health care system, the veteran affairs system. they're trying to talk about telemedicine and things at the federal level, but obviously it would affect the first amendment. i'll admit to being an attorney.

it will also be done at the local level, particularly with rural veterans. it's a major issue in the country right now. i wonder if the panel mayo pine about that. >> anyone know anything about that issue? >> i think that it -- you know there are parts of the country that are in desperate need of access to care. veterans are of particularly in need of mental health care and other types of services that aren't available in all places. and one of the things that comes up, for example, in the military medicine and veterans administration is whether it makes sense to -- you know what -- you have both huge gaps in access to care and quality problems at certain places. and can you -- is there a strategy that involves more telemedicine that could address both of those at once. and i think that all those are very fair policy questions. and in the end, the question is are people healthier and can you design something to really serve the needs of veterans. that should be the -- you know,

litmus test. not some arbitrary measure of speech, but are veterans getting healthier. >> and i think this brings up another issue. sometimes we take a one-size-fits-all approach. it's just telemedicine. but i think we can all agree for example in tele mental health care, you don't really need to lay hands on patients to be effective. it's really about communication. i would think that for subspecialties like that, telemedicine is a great fit. and ought we not to treat that differently than tele cardiology or something else. so maybe we ought to start thinking about this in a more sophisticated way as opposed to just one-size-fits-all and everything fits under this umbrella telemedicine. >> it's certainly true that doctors can say things to patients short of an actual diagnosis and implementation of treatments. ron hines, for example people would write to him and say i have been to two different veterinarians, they have given two different diagnosis and could you just look at the files and give me your opinion.

help me make a decision. because i have to make a decision. and ron is the kind of person who has got a great deal of experience and i can help out. and you know, with respect to people who are in rural areas one of the things that ron got in trouble for is that there was a -- there was an impoverish impoverished double amputee in maine living by himself and the only thing he had was his beloved dog, and his dog was sick and dying. and ron was talking this guy through certain things to help alleviate his dog's suffering. and eventually ron found a veterinarian in maine who would treat the dog for free, for this amputee. and another veterinarian heard about that that ron hines in texas had been providing some initial help to this over the phone and reported ron hines for doing that. and that is pure economic protectionism. there is -- no rational person would say that this -- this imabovished double amputee who is not going to a veterinarian who is getting free help from a guy in texas that that should be stopped.

it's ludicrous. that's one of the things that happens and one of the reasons why we need to have a rational telemedicine regime. >> another question right there. >> hi. pat mike else from kato. this probably goes to the dr. sharfstein but maybe to the panel in general. it has to do with the complexity of the ultimate regulatory regime we're going to have. i can see, to maybe differ with you on the remote cardio, if you put a halter monitor -- heart monitor on a person, some remote physician can read that and make a reasonable diagnosis and proper prescription without seeing the person. however, if you show up with some kind of -- maybe substantial skeletal pain syndrome, to an orthopedic person, you're going to have to be examined, because you can't remotely do the manipulations that are required in order to

come to a reasonable perspective diagnosis. where this question is leading is, it seems to me, given these differential regulatory possibilities, that we may wind up with a group of folks having to go through the entire diagnostic code manual to decide which one requires a personal visit, and which one does not. and that will entail all kinds of special interests getting in on this. how do we prevent this from becoming 10,000 pages of regulations that nobody understands? >> sounds like you've seen those regulations on some other issues, i'm guessing. >> i'm thinking of a person -- famous person from m.i.t. >> so i think that you're asking a very, very good question which is -- and this is partly about the approach to regulation. how do you strike a balance that's not such a kind of

jerry-rigged balance that it's impossible to actually apply. and it just makes things frustrating for literally everyone. and that can happen as part of regulation. i think, you know, there are organizations that their expertise is in trying to cut through very complicated issues and come up with very clear guidelines. examples would be compensation programs that get set up for, you know military, former military members who have been exposed to certain things. what are their -- you could go through -- come up with the most complicated flowchart in the world or come up with basic criteria that are fair and reasonable and able to be applied. the institute of medicine of which i'm a member does this a lot. they take very thorny questions and they say, we need to come up with a regime for doing this that is implementable and reasonable. they will bring together people across an issue that -- and then they'll say this is an approach that would be in the public interest, and nothing is perfect. but this is the best we think we

can do. and so you have to charge -- in my opinion it's not -- i used to think a lot at the state about stakeholder groups versus expert groups. and oh we're going to get a stakeholder group together and it's going to have 25 people on it, and each one of them is going to go back and check with their own group. right. that would be -- people would say to me when i would hear about this, like, your next career is not as professional poker player, josh. because i would make a face just like you. i would be like oh no, how are we going ever going to get to a reasonable outcome, even one that people could live with if everyone feels beholden to their individual group. on the other hand, if you set up an expert group which can have a lot of public input and public participation in but people aren't representing their group and they're given a very clear charge and you've got a great person leading it, you can really get reasonable things. and people just have to -- you know, you're striking a balance. you have to set that up. so i think it can be done.

you have to think of organizations that can do it. and then you give them the challenge. >> you know another possibility is that maybe we don't need a multitude of complex rules. maybe there is actually a simple rule. and the simple rule is the doctor has to exercise professional judgment. and so for example, in ron hines' case, if -- let's say he examines an animal. he is legally authorized to euthanize the animal, amputate a limb, perform surgery, provide powerful drugs based on his exercise of professional judgment. that's what being a texas licensed veterinarian means. and there are plenty of instances in which he would talk to somebody, via the internet and say, you know what, you're presenting questions and i can't actually give you good advice, because it seems to me the nature of your problem isn't amenable to a telemedicine solution. and so you have to go see a vet. so rather than think, well we have to enumerate every conceivable per mutation of the doctor-patient relationship in

order to regulate it, what we should say is when you have passed the threshold requirement of actually being a doctor and we have invested in you the authority, then engaging in responsible telemedicine is an extension of that authority. and that seems to make sense. i said this to the court repeatedly, if dr. hines can do all these things to an animal in person, why do you think his capacity to exercise judgment utterly disappears merely because he's having a conversation over the internet? it doesn't make any sense. there is no rational conception of a doctor and patient in which that makes sense. >> the issue, though, is where the regulation is going to happen. so let's say that the animals were in another state. he's taking -- he's charging for the advice he's giving, just -- but the other state -- the -- has basically no ability inside that state to challenge any problem if there were a serious problem.

so there's at least a -- i think a clear risk to consumer protection, if you were to say, you're a doctor in maryland it's up to you your judgment whatever advice you want to give, medical advice prescriptions, anything, on any topic, because you know my license is -- i can take care of big people as we call adults in pediatrics. and then it's all back on the maryland medical board where they can't very easily go out to somewhere else to evaluate the care or see what's actually going on. that strikes me as a framework that could be quite risky to consumers. >> although you might have -- there is this general concept of law that if you enter someone's jurisdiction and do things that are tortious you could be held responsible in that jurisdiction. if we had these compactses where we recognized interjurisdictional practice and say i'm a doctor in texas and talking to somebody in maryland by virtue of this compact or operation of general principles of jurisdiction if i say

something or do something that results in harm to the patient there, i've just subjected myself to the jurisdiction of that board. and i can be disciplined or do whatever. you know i don't know how to work -- you're the expert in that area. but i just mean that the thing that struck me about the vet licensing case and the general approach to telemedicine is that we trust physicians to exercise reasonable judgment in the in-person context. and i don't know why we're terrified of them being able to exercise similar reasonable judgment in the telemedicine context. they're still grown adults, they still have medical licenses. although i understand the complexities it presents. >> i don't want to go too far, but i think two things you have to tease apart. there's, you know -- if it were all within the same state you know, i would be very much -- much much much closer to your position. it's when you split the jurisdiction, make it harder for people who could be harmed to you know for -- i think you wind up with a potential for a policy failure. >> i think there are other

questions, the middle back. >> yeah, wes cooper smith from generation opportunity. a lot of the telemedicine regulation we're talking about could be construed over interstate commerce. rights one -- talking to a physician from another state. should physicians be allowed to regulate that type of commerce. >> the constitutional lawyer and the tenth amendment and all those issues. >> yeah, i mean, so the question is, whether or not when a state is attempting to regulate the movement of medical advice, for example, or some kind of occupational advice across state lines, what does the dormant commerce doctrine which says states can't create unreasonable barriers to interstate commerce what does that have to say. it's actually not a very popular

doctrine among the supreme court. it hasn't been clearly litigated. there is actually some -- there was a -- there was federal appellate law that says that what the dormant commerce clause is really worried about is the movement of goods. and if it's just cash or advice that may not -- now, may not actually be something moving in interstate commerce. it's probably not tenable and there would be disagreements about it. as i understand it the telemedicine problem hasn't been considered primarily as an interstate commerce problem, although it strikes me that that kind of thing will ultimately be litigated. i'm sorry, i can't give you the right answer in constitutional law is always maybe. so i can't give you a definitive answer. >> a couple more questions. i saw the guy in the fourth row there, i think. right over there. the podium was blocking me. we'll get to her next. >> victor, institute for justice. this is principally aimed at dr.

sharfstein, but please do weigh in as you see fit. is it remotely realistic to expect any sort of regulation of telemedicine to be -- to be en harrsable? i mean, i see a host of problems in, you know if we set up this vast regulatory framework assuming there will ever be a consensus on it in which you know, you would have -- you would have to record, for instance, skype conversations with your doctor, or you know i see like nightmare scenarios where state and medical boards are partnering with the nsa to, you know, get -- get data and be able to regulate that way. so i -- i just wonder how exactly could -- how exactly could any regulatory framework around telemedicine really ever be enforced? >> sure. i could see your nightmare scenario and raise you another

nightmare scenario. i won't do that. you have a lot of discussions where you're trading nightmare scenarios. i think rene laid out a framework -- i would be interested in his view whether it could work if it were picked up. so you have compacts where people can see patients across states. if that were something that were to be facilitated, then people could see patients across states and the enforcement would come that if somebody stepped across the line did something wrong, there was a complaint, the medical board would then be able to take action. you know wouldn't -- i don't think that there is any necessity there be some kind of crazy amount of surveillance or anything else. most things are done by -- you know, people -- doctors have an obligation to take medical records, just like they do in the in-person requirement -- in-person medical practice. and if -- you know i was the patient, you were the doctor in another state in one of these compacts and i felt that there was a problem i would explain

it, and then people would look at your records just like they do in any me board case and have to make a decision. it might be a hard one to make but then you would have a framework because then you would be licensed both in your own state and in my state and the process would play itself out. i don't know. >> well the thing with compacts everybody has to remember, you're only as strong as how many states are actually part of the compact. so what you find, there is licensure compact a simple process, you're licensed in one compact state, you're deemed to be licensed in the other compact states, some exceptions apply. the problem there is, if you look at the map of who is part of the compact, a lot of your biggest states are not. so you're left with this situation where a lot of your least populist states are members of the compact and biggest states are not. and if you look at the folks who have the states that have decided to be part of the physician licensure compact it's states like -- i think it's

west virginia one of the dakotas, idaho. california is not going to do it any time soon. texas is not going to do it any time soon for all kinds of reasons. so compacts solve part of the problem. but again, they're only as good as how many states are actually part of the compact. >> i think if this were an easy problem to solve simon wouldn't be spending his time on it. there is the question of how easy it is to get it done and then the question of whether it would work if you could get it done. so it's not going to be that easy to get rid of state medical boards either. but while you're in the system of state medical boards, the fact that there are some efforts moving forward it could be that that is the most likely even though they're all somewhat less likely way to overcome the professional problems that we're talking about. >> and i don't -- and i don't get a sense that there is a -- there's heavy support for a national licensure system, a federal licensure system on the hill. in fact, it's a nonstarter for a lot of folks.

>> i think i had been missing a question over on the left. let's get to that question. >> all right. my name is nicole ross, a reporter with wmal radio i apologize, i cannot stand up. i'm kind of swimming in equipment over here. i have two questions. the first i'll direct to dr. sharfstein and whoever else would like to chime in on the panel. if we talk about the impact on health care jobs that telemedicine will ultimately have, you can talk about how on one hand there's a shortage of physicians. on the other hand, telemedicine is clearly moving toward remote monitoring. who will be monitoring all that data, and it's not necessarily a full time physician. so i'll start with that question. >> it's a great question. but i don't think my professional training gives me a great answer to it. because i'm not an economist. i do think there are obviously going to be implications. i guess what i would say is you

can look at the country and see a mismatch between need and resources for medical services. and the goal would be with a good telemedicine program would be to address that mismatch, so you could get more services to people who need it and in the end get better health. that would probably would allow more flexibility for where people could live. but in terms of what that would do to physician work force in different places, i don't know the answer to that. >> yeah, i don't. >> yeah i think it's fair to say it would be pretty disruptive, and i think maybe your view of it depends on what you think about disruptions and many of us including me love to have the economy disrupted and have consumers benefit from that. but i do understand that other people who are -- maybe more concerned about disruptions to people's work lives. you had a second question? >> yes. the second question. this will be towards the first speaker. but again if anyone else wants to chime in that would be fine. the federation of state medical boards changed their definition

of telemedicine in april to include video teleconferencing, but not audio-only phone conversation. i'm wondering how much weight does that hold? if that matters. and the degree to which people can can -- again, degree on a definition and how that might impact patient care. >> the definition of -- you're absolutely right. the model policy they redefined tele medicine and left audio-only out. a lot of states have their own definitions of telemedicine. and a lot of them don't include audio-only. so i think the fsmb definition was not a surprise at all. the definition is only important in that the fsmb model policy addresses telemedicine. so anything that falls outside of that the rest of the model policy does not apply. i think if you talked to a lot of folks a lot of folks will tell you that patients -- a lot of patient prefer phone. it's more convenient it's much

more accessible to them. you don't need broadband. and a lot of employers will tell you that when they give the choice to their employees as to whether or not they want to receive services by phone or by audio/video, a lot of them choose phone because of the convenience factor. having said that i think even the -- some of my clients who are in the business will tell you, you can't do everything by phone. and there are certain things that physicians will not do by phone, will refer you back to your primary care physician. and so the phone can't solve everything. but i think the people i speak to the people i represent the employers i talk to, would like a more expanded definition of telemedicine including audio-only. that doesn't mean the physician doesn't have access to the patient's medical record, a questionnaire. so in other words, it's not just a cold phone call without any other information. >> i think maybe we have time

for one more question. i see somebody. i've been ignoring this side. >> thank you. jeff pearlman just a lawyer off the street. doctor you indicated that you supported mr.rowes' position on consumer affairs, i guess so long as it was limited to one state. i think that's what i understood you to say. so is it true that if i live on western avenue, which is the border line between maryland and d.c. anything that happens anywhere in the district, if i want to call -- if i'm the veterinarian and i get a call from the amputee that it's okay for me to answer. yet if my friend of 40 years who is also an amputee lives across the street in maryland and i cross the street to answer his question about his dog, that the suggestion by mr. rowes that that could result in a -- that

could be resolved by a cause of action and tort law, that wouldn't be adequate. that's not -- >> i understand the question. i appreciate it. i think, you know, first of all, my main point i think that it's a different issue within the state versus between states. and i think my -- i think that to the extent to what jeff is saying, there is a first amendment issue in a doctor-patient relationship, and it needs to be balanced in different ways. i think we're pretty close on that. as you get across the -- across jurisdictions, then it has a lot to do with enforcement the. and, of course the keys you're talking about is probably -- we're also talking about charging, i would imagine. that you're not just walking across the street because you're doing it somebody is actually getting paid for something. i don't think it's -- in all the balancing, it's that much of an imposition for someone to get licensed in more than one place. and i think that the value of that is they get judged

according to the system that we have had in this country for a long time for regulating professionals. and in a certain area. i see value in that. and just sort of -- i don't think that the fact that there are always going to be cases that are across the street, whenever you're talking about any law. is it fair that you can do one thing in one state and another thing you can't do right across the street? well, that's just the way the law works. it's the same thing here that if you believe there is value to allowing local regulation of medical practice, which i do believe, then you have to live with the borders that are reflected in that. and i think that if it were just a crazy, insurmountable hurdle, i would have chest pain with that, it isn't, and if you're literally living on the line, you should be licensed in both places. >> i think i should point out, last i heard -- i think only 6% of physicians are licensed in three or more states. so while we're talking about this sort of new innovative

movement that seems under way, most practice is still local. and i guess the question then becomes, as we become more -- as we're in an increasingly mobile society, are the numbers so low because of the administrative burdens, applying for a license it's costly, or is it because, again, it reflects the reality of medicine on the ground, that it's mostly local? >> with that i apologize. i think we have to wrap things up. we're going to adjourn for lunch on the second floor. maybe the hammists can join us see if you can accost them. let me thank the panelists, let's give a round of applause. that was an excellent panel. i enjoyed it very much. i hope you did too. the senate approved the nsa surveillance bill this afternoon, breaking the impasse on government surveillance and restoring key authorities of the patriot act. politico writes that the 67-32

vote in favor of the usa freedom act was a stinging rebuke of majority leader mitch mcconnell and his leadership team to failed to persuade senators to make what they argued were critical changes to the bill. the measure, which passed the house last month now goes to president obama for his signature. this weekend the c-span cities tour is partnered with time warner cable to learn about the history and literary life of lincoln, nebraska. >> one of the most important american writers of the 20th century, given almost every literary award possible in her lifetime before she died. except for the nobel prize. she was known for some of her masterpieces like "my antnia," "death comes for the archbishop" and many others. in 1943, she made a will which

had a few restrictions. one was she did not want her letters to be published or quoted in whole or in part. left behind at least 3,000 letters we know about now. fortunate the biggest collections are here in nebraska. and furthermore, in her will she left one other important thing. she said she left it to the soul executors to decide. and they believe as educational organizations that it belongs to our shared heritage and we ought to know more about her. >> an important historical figure in nebraska's history was solomon d. butcher. >> solomon butcher was a pioneering photographer out in koster county in western nebraska. he took photos from about 1887 1886, until the early 1890s, of homesteaders and houses and was able to tell the story of this

important development in american history. okay. well, i am going to show you one of my favorite images of the solomon butcher collection. it's actually a photograph of the christman sisters. it is four sisters who each took a homestead claim in koster county. this shows women homesteaders. it was the first time that women could own land on their own. it didn't belong to their husband's. it didn't belong to their fathers. single women could own their own land. and that was a really big deal with the homestead act. so each sister, each of the -- each of the christman sisters took a homestead near their father's ranch. they each built a small house on the -- on the homestead which was part of the homestead act. and they would take turns staying in each other's house and working each other's farm.

so the sisters really pulled together and made it in nebraska. >> watch all of our events from lincoln, saturday evening all of our events for lincoln saturday evening at 6:00 on c-span 2's book tv and sunday at 2:00 on american history tv on c-span 3. >> now a discussion of the world economy and market volatility with some of the world's top financial investors and wealth managers. they cover what's ahead for the economy, including the possibility of higher interest rates in the u.s. this is part of the milken institute global conference. you can see all of our coverage of the conference at c-span.org. >> i want to introduce our moderator of the panel. gillian chet is columnist manager. she's served as assistant editor for market coverage and a

reporter in tokyo london, russia and brussels. she's a best selling author and her next book on the global economy and financial system is going to be published later this year. please join me in welcoming our host gillian. >> well, good morning, everybody. thank you for that very kind welcome. and welcome to the first session of this year's milken. the sub content could be yikes, what on earth is going to happen next. by any measure the world has been through an extraordinary decade. first we had a gigantic credit bubble. then we had an even more shocking financial market collapse, if not turbulence. and then we had a truly

staggering policy response which has in many ways tipped the global financial markets into the equivalent of alison in wonderland. they reckon that about eight to ten trillion dollars worth of aid was provided by central banks in forms of quantative easing. and we also lived a day in the world of extraordinarily low bond deals and the sovereign debt market right now has negative yields. you have a number of companies such as nestle at negative yields. so it's an extraordinary time. in spite of all of that aid, we still have a global economy that is at best sputtering. i was noticing in this morning's financial times, which i hope you all read american companies

are on track according to my company, for about a trillion dollars of buy backs this year. we also have world where people are warning about potentially creating all kinds of con todayacontagen risks, but ukraine, china, and many others as well. are we heading for significant volatility, and if so, will that be good or bad? because of course the dirty secret about volatility is that we journalists love volatility it helps us sell papers. it helps create news. but many of you in the room also love volatility because it creates enormous opportunities for arbitrage and for all kinds of financial profits. so we have a terrific panel of people to talk about where it will world is going. i think many of them are very, very well known to you. on my far right is alex friedman. next to me immediately next to

me is josh friedman, cofounder of cannon. on my left, your right a man very well known to you who has been a veteran of these conferences, who is josh harris who is cofounder of apollo. on his left, your right is allen howard cofonder of brannan-howard. so we have a number of asset managers and one lonely banker who will tell us what's going on in the world. i would like to start perhaps with alex and ask you, when you look at the year ahead, are you worried about an explosion in volatility? >> you know, i spoke on this panel last year, and what i hope sd nobody would remember what i said a year ago, because i'm sure a big chunk of it is wrong.

so to that question i expect some time over the next four to six months we'll see real volatileity and the market will pullback. that will be a good time. we have about two years left in this run. when you think about the drivers, and i'm not smart enough to get beyond the big drivers. i try to stick with them. we have pretty much everybody easing. yes, the united states is heading in the the other direction, but slowly, so you have a lot of easing. you have cheap energy, and you have falling currencies and some of the more worrisome areas particularly in europe. all of those support risk on. but more importantly t quote from abraham lincoln life a choice among alternatives. there really is no alternative right now other than risk assets, i would argue, given what you just referenced which is negative yields in the traditional sovereign world. so volatility yes.

buying opportunities, still a couple of years of this rising tide environment. but shifting more to fundamentals. >> so a world where everyone is grabbing for risk. i mean history suggests that very rarely ends well. every five to eight years we have a big market reset. in 2001 and 2008. so what would be the not end well story. in the near term a lot of political risk. which not fully priced into the market. longer term we have huge structural issues around liquidity, which i know we're going to talk about. and the thing that worries me the most is as investors are forced out, you're seeing pension funds reallocating. as they reallocate the the implications to the elderly are not factored in. they have huge implications. you have indebted nations all the the sudden are going to be bailing out their elderly.

>> certainly history suggests it's usually the dumbest money that jumps on the trend at the last minute. allen, do you think we're heading for another crisis? you think every five to eight years there's a big round of market turbulence? >> i think the market is extremely unstable in the structure we have today, as it's been since the financial crisis. and that's partly due to the effects that happen in changing the way likdty banks offer. and so clearly as we know we've had small events such as october 15th and much larger in terms of the nsb, but both of these are examples means whenever we get events the volatility that they produce is of a magnitude where we haven't seen before. so the real issue is do any of the small events ever lead to something bigger?

and we'll have to see if we get something more fundamental based in the future. >> right. right. josh, what do you make of the current climate? is are you concerned about the potential for nasty shock in the next year or so? we managed to have two joshes and two friedmans. >> so i can pass on any question i want. >> exactly. you can fight for which question you answer. i'm surrounded by joshes. >> i think sometimes it's easier to prepare than predict. when you have natural interference with financial markets, you get build up in balances and they build up and build up. and it's a little bit like the last little grain you put on the sand pile and then all the sudden top of it collapses. last year we actually had quite a lot of volatile events take place. there were some significant out of the ordinary major adjustments in certain areas. obviously what happened with the swiss frank.

and i think that caught most macro players by surprise. what happened in oil prices was extreme. really extreme. i think it's generally something not predicted by the general public. you now had the fed so intent on not surprising people on interest rate that they warn people to the point where nay do raise rates it will be a shock. so i think sometimes the best thing to do is just know that eventually all the unnatural buildups will produce an adjustment, but rather than to spend too much time predicting when they'll happen maybe it's better to just prepare. >> right just to prepare. josh, the other josh. you can be josh two. >> i've never been described as a veteran of conferences. so i maybe have to stop speaking or something.

there's been a change in structure of the markets. so the people that used to make the markets are the banks. banks are driven out of doing that. who has replaced them? really the people on the stage. more than a third of it now is daily liquidity vehicles. so what happens when retail decides to move out of -- so daily liquidity vehicles are buying assets that probably don't have daily liquidity in the event of a shock. so when something bad happens you're going to see an amplification of a trend out. because the people that have to step in and buy are going to have, you know, much higher they're going to set the price of risk in a much more agretsz aaggressive way. there's a lot of capital on the sidelines. we ourselves have $30 billion in unspent capital. so there's definitely people that will ultimately step in. but there will be a volatility within a range. i don't think it's actually bad for the