suggested in terms of our knowledge base, what Dr. Detmer has suggested in terms of what truly could be expert systems and, quite frankly, discoveries that have not even been thought of today.

DR. RUBIN: Bob Rubin. I would like to ask Dr. O'Neil, in light of his Kierkegaard quote, whether we have gone past the paradigm of the primary care physician or the primary case manager? Indeed, if 10 percent of the people account for 70 percent of the health care costs, isn't what we really need—particularly given recent articles in the New England Journal of Medicine and JAMA that show that perhaps primary care physicians are not the best managers of chronic disease like heart disease, cancer, and so on—a specialty-dominated system that uses some of the multiskilled allied health professionals that you talked about? Isn't that what we are looking for in 2020 rather than sort of this transitional mode of primary care physicians?

DR. O'NEIL: We certainly had specialty domination in the past that has not seemed to produce the kinds of health outcomes or the kind of health system that you spoke of. Yet I do believe that there is terrific promise for not divorcing specialization and specialized knowledge from the system but creating different ways to get it incorporated, as opposed to the individual practice of specialty physicians. Having primary care physicians and also having those primary care physicians relate to a specialty information base very differently than they relate to them today is as much a viable option for the future to produce the same type of outcome.

PARTICIPANT: What I would like the audience to contemplate also is, as we talk about downsizing the health care industry, academic health centers, and training programs, think about the economic impact that that will have on local communities. We should try to not look like the steel industry. There should be enough intellectual power here to think about what it means when in the Chicago or New York City begin to downsize that whole industry—downsize it appropriately and efficiently. Yet then what should people be training for as an alternative? How can we prepare for that?

DR. LARSON: Dr. Larson, from Georgetown University School of Nursing. I agree, Dr. O'Neil, with your comment on the need to downsize nursing as well as medicine, particularly the diploma and associate degree programs. However, like several other things we have talked about today, public policy does not match the direction in which we need to go. About 95 percent of Medicare funding for nursing education goes to hospitals with diploma programs, and those programs are totally antiquated.



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