eitherf us who have worked with physicians know there is a definite hierarchy and those hierarchies get in the way. but i fly aplace lot these days. people ask me where i live and i say seat 11c. on ae never gotten on plane and thought if i got one of the top 10 pilots in the country. of the top 10 doctors and the reason is teamwork. you can build a system that delivers consistent high quality if you can build teams. i think we can learn a lot in the medical profession. the last two ideas are both about variation. we have heard over and over how we as a country have failed when we compared to our peers in terms of overall achievement for the amount of money we spend on that's true. it's not uniform. as this graph shows, if you live in fairfax, virginia or marin, california, uf as high a life expectancy is anywhere in the world. whereas, if you live in tunica, mississippi, you are worse off than if you were in algeria or bangladesh. why is that? why do we tolerate that? we've got to figure that out. there is not easy answers to that and it's been a problem for decades. we have mechanisms