Dr. Virginia Latham
Internist and President, The Massachusetts Medical Society
Age: 63
Interviewed January 25, 2001
Concord Oral History Program
Interviewed by Renee Garrelick
Dr. Virginia Latham describes the challenges of practicing medicine as a new century begins.
The business of medicine as driver for the practice of medicine.
Concord internist, practicing with Dr. Elmer Purcell as independent physicians
Emerson Hospital invitation as first physician in formation of Emerson Practice
Associates to develop a salaried primary care group that worked for the hospital.
Reasons for dissolution and failure of Emerson Practice Associates
Balancing patient care with cost of staying in practice
Problems of managed care
Role of the Massachusetts Medical Society founded in 1781
Tort reform and litigation
Living Wills.
The practice of medicine these days is being driven by the business of medicine. The drivers came into play, I think, when it became clear that the costs of all medical services were taking up a very substantial portion of the national budget. People started looking at how you could make medical practice more efficient and less costly. That led to the divergent stream, one side being the for-profit companies stepping in and thinking if there is really a way to make this more reasonable we can play the role of middlemen and organize the doctors and there are still enough ways to profit, or whatever you want to call it, in the system for us to take part of it out as a business profit. The other pathway was how can we pare costs down in order to achieve savings particularly in terms of the ways the government looked at it. Either one of those drivers end up being a business driver which has very much changed the way in which medicine is perceived by the public.
There is a hostility and a suspicion about why people are getting tests or not getting tests, there is concern about whether or not services are warranted or not warranted, and it's put physicians, patients, hospitals, nursing homes all in the more adversarial approach than a healthful approach. Let's face it, at least 99% or more of the people who went into medicine, went into it in order to try to help other people. To be caught in the dilemma between trying to help someone with any regard to where the pain is coming from and being driven out of business, being driven into bankruptcy, being driven out of state because you can't make ends meet, is a real dilemma. And it is a moral and ethical dilemma that I think is very inappropriate in medicine. It's not clear how we're going to get away from these problems. I started practicing medicine late in my own life. I was 44 years old. After going to Harvard Medical School in my late 30s and doing an internship in Boston, I came to Concord to practice in 1984 with Dr. Elmer Purcell, who was an absolutely delightful man practicing internal medicine. He had a very devoted patient following. He and I had a good relationship and really thoroughly enjoyed taking care of the wide variety of patients from this area.
The two of us were independent physicians and the bottom line was that the economics of the times were such that the harder we worked, the more difficult it was to pay our overhead expenses. We both had waiting lists of patients and really more business than we could handle, but the economic drivers were by then already turning out to be very difficult to deal with. I left in 1989 to run the Harvard teaching program in the outpatient services at the West Roxbury Veterans Administration in Boston. Since Elmer was closer to retirement age than I, he left and started to work part time in Lowell at the VA there.
One of the things that was being advocated for nationally in the late '80s was that hospitals would salary primary care physicians thereby assuring a steady stream of patients who had an affiliation to the hospital and would provide patients who when they became sick would come into the hospital and would be using the lab, the X-ray services and the specialists at the hospital. As part of that effort, Emerson Hospital in Concord decided to develop a primary care group that worked for the hospital. They came to me and asked me, for several reasons, to come be the first person in that group. I was already known in the community, I lived here, and they also had their every three-year inspection by the Joint Commission of Hospitals coming up. That was something I had become fairly expert at where I was at the VA, so they asked me to come to work half-time as a salaried internist and half-time running the quality assurance activities at the hospital and preparing for the national accreditation review. That primary care group eventually became the Emerson Practice Associates giving it the ironic name, EPA.
From the point of view of the number of patients, my practice was full in about three months. Then multiple other people were hired to come on. About the time I physically arrived at Emerson, another physician had also been hired so we arrived somewhat simultaneously. He had been practicing in Ayer and was set up in an office in Westford, and I was set up in an office at the John Cuming building at the hospital. We were the first two physicians.
What turned out nationally, and it was certainly true at Emerson, was that when hospitals endeavored to set up these primary care practices, they did not have the expertise, with all the goodwill in the world, in what really goes on in an office. The practice of office medicine is extremely difficult for somebody whose expertise is in running a hospital. Everything about it is different. And we had a series of people who were put in charge of running the Emerson Practice Associates from the business of the hospital point of view who simply weren't experienced in what goes on. They were not office managers. We had someone who had been an expert in designing and decorating physicians' offices. Well, that doesn't teach you anything about billing or what are the things you physically need at the front desk and what have you. Then we had a series of other people with expertise in marketing, expertise in a variety of things, but none of them were expert in how to run an outpatient office. Because we constantly have our patients to take care of, they kept hiring new physicians to come in which was logically thought, oh, boy, you have all these patients, we need to hire more physicians to come in. But the reality is that expenses are very high in Massachusetts and salaries are comparatively low. In order to get young people who were just graduating from school with an astronomical debt to be willing to come to practice, they had to increase the salaries. It reached the point where toward the end the new people they were hiring who had no patient base and no experience were being paid considerably better than the people who were working sixty hours a week, which was a very unpleasant dynamic for people. The real thing was that in looking at the numbers and seeing what it costs to keep primary care offices open, Emerson as other hospitals decided that that was an expense they could not longer afford.
That created two things neither of which I feel are valid. One of them is that all of the physicians would continue to take care of the patients and Emerson, or whichever hospital was doing this divestiture, would continue to have the same flow of patients because the patients would stay because the doctors would stay. The reality is that just as the hospital couldn't break even on these practices, individual physicians and physicians in small groups can't break even on them either. The groups that aren't working for hospitals tend to do somewhat better simply because they have control over the expenses where physicians working for hospitals have no control over expenses. I, even as the leader of my little group, had absolutely no control over how much I paid for rent. They sublet space and they charge back whatever they wanted as rent against us. We had no say over where they bought the uniforms or whether it was better to use this kind of paper or that kind of paper so we were not in a position to cost save. All we could do was bring in more revenue but unfortunately in this state, Medicaid, Medicare and some of the HMOs pay less per unit time than it cost to keep the office open. So it's like making widgets and selling them below what it cost you to make the widget. No matter how many you sell, you never get ahead. So the revenue stream was the only thing the doctors had control over. Short of spending less time than I personally feel is appropriate to do a good job of taking care of patients, it's impossible to see enough patients to make much of a positive margin.
So it ended. We had approximately three months notice. The impact was that many of the physicians left which I think somehow surprised the people at Emerson Practice Associates who had continued to say, well, there's no reason why you can't go into private practice and do well but that had a certain logic deficit from my point of view. If we paid them a fee, they would help us do well. That had a certain logic gap which was that if they couldn't make the practice break even when it was coming out of their pocket, why would it be logical for me to pay them to tell me how to run the practice? The other part was the assumption that the patients' loyalty is primarily to the hospital. That's true for people who have been in the hospital or people who have some other connections. For example, many, many of my patients were doctors and their families or nurses and their families from Emerson Hospital and obviously that's where their loyalty is. But for many other patients who've never been hospitalized, their loyalty is to the physician. They were driving from as far away as North Shore and Cape Cod and west of Worcester, so when they left our practices, they left to go back to doctors associated to hospitals closer to their homes. In any case, as of right this minute, I'm not sure how many of the primary care people at Emerson Practice Associates are still in practice but the last numbers I saw it was about half. I know in our practice which was five doctors at the time that things fell apart, one of the doctors moved to Seattle, one of the doctors who was an endocrinologist doing primary care two-thirds or three-quarters of the time decided to do just endocrinology. One of them went to another group that was affiliated with Emerson but is not part of the Emerson physician organization. They did their own labs and X-rays and so forth so that takes that business out of Emerson. And one of them was to join a group in Lincoln to try to make a go of it there.
The average patient load for a full practice for a primary care physician is quoted at 1800 to 2200 patients. I typically had about 1200 patients working half time. So it's a lot of human beings to feel a sense of responsibility for because any one of them can have a problem at any time. It's one of the reasons that single doctors doing primary care have almost vanished. They are a vanishing species because in order to provide 24-hour, 7-days a week, 365-days a year care for people, you have to break that up among individuals. People remember fondly back in the '30s dear old doctor so-and-so in our little town, and he was always available. But in those days there was not either the technical expertise, the wide range of facilities and equipment, nor the expectation on the part of the patients that everything had potential for being cured. Much of what those people did was soothe the dying wonderfully. I'm not knocking it at all. That was the ideal that drove me to medical school was of that being the kindly local physician holding people's hands. But the reality nowadays is that medicine is far more complex and complicated.
I'm currently president of the state medical society that takes three days a week. I was only working half time the entire time I was working for EPA because I was always doing something administrative. And I'm doing consulting in Providence on best practices which means looking at what's the best way to treat various kinds of illnesses. Wearing my hat as Massachusetts Medical Society President I have to make certain that I am not in any conflict of interest with anything that goes on in Massachusetts. In the spring I'm not certain what I'm going to do when I finish being president of the medical society.
The Massachusetts Medical Society, which has been in existence since 1781 and still sticks by its original charter, is an organization of currently approximately 18,000 members, to do all things good to assure that the people of the Commonwealth receive good medical care and provide education and training for physicians. But what we do do primarily is patient advocacy work through the legislature and through the regulators such as sponsoring bills such as a HMO managed care bill that was passed last summer. That bill seeks to try to assure patients optimal care and tries to remove any kind of conflicting business interests from interfering with people getting optimal care. We do a great deal of education as a sponsoring body for continuing medical education credits for the state. Every physician in the state in order to be licensed has to have 100 hours of classroom training within every two-year period. We run many of those programs and supervise when other organizations like hospitals run them. We also do a lot of educational programs on other things like how to set up your office computer, how to deal with difficult employees, or other things that are more business oriented but oriented to help physicians cope with what they have to do in the course of a day. In addition we run something called The Physicians Health Services. It is a service for physicians who get into trouble with drugs or alcohol or behavioral difficulties to be treated and monitored in a private way in coordination with the Board of Registration and Medicine to rehabilitate them, and if they continue to have problems, make sure they are not practicing.
The New England Journal of Medicine is our publishing arm. Over the last few years they've taken a lot of hits over some unhappiness of a previous editor, but currently we have a new editor that we brought on board last year. It was a very exciting experience as I actually co-ran the search committee to get the new editor in. I co-ran it with a doctor who teaches at Harvard and is head of our publications committee. We had on the search committee people like the head of the National Institute of Medicine, the Robert Wood Johnson Foundation, head of the department at Stanford, so there were many people involved in the search. In fact the majority of the people involved in the search were people that had nothing to do with the Massachusetts Medical Society or the New England Journal of Medicine and were some of the brightest medical minds in the country. So it was very exciting to work with people of that caliber and that kind intellect. We ended up with a superb person, Jeffrey Grayson, who I feel badly that he's having to deal with some of the leftover angst from people who were dissatisfied with the previous editor. Jeff by training is a pulmonologist and head of the pulmonary critical care department at the Brigham & Women's Hospital.
At the Medical Society we ran a program last June entitled "The State of the State of Healthcare." It was incredible as we had the head of the Massachusetts Nursing Association, Massachusetts Nursing Homes Association, Massachusetts Hospice Association, Massachusetts Hospital Association, and so forth. Each person was allotted ten or fifteen minutes to give a slide presentation on what was going on in their portion of healthcare. You could almost have used any random slides for anyone else's speech because everyone was saying the same thing. The bottom line is the total amount of money flowing into healthcare from all its multiple sources is less than the cost of the living care, and people are wondering why.
There are several drivers right now that have really made things take off in a big way. Population is aging and older people by definition get sicker more often and take more medication. Secondly, the pharmaceutical industry is still a very, very profitable business. It is one of the most profitable businesses in this country. We have this bizarre situation where you could go to any other country in the world and buy pharmaceutical products made in the United States for less than it costs you to buy in the United States. Those costs are taking a much larger bite out of the healthcare dollars than they used to. The amount of money that the pharmaceutical companies are currently spending on advertising, including and especially the direct to the patient advertising is astronomical. If it were put back in, you could probably inoculate every child in this country against every illness they might ever get. The profits are huge. So that piece of the healthcare dollar has to be reigned in. My concern wearing the hat as head of a physician organization in the state is what's happening in physicians' practices. What we are seeing is bankruptcy, not just people being bested by hospitals like the Emerson Practice Associates experience, it is all kinds of physicians everywhere - one or two people out in the Berkshires, a large group on the North Shore. It cuts across all different kinds of practices. Anesthesiologists can't attract people to come into the state to work and it's difficult to find radiologists trained to read mammograms. It's everywhere. It's goes to all parts of the state, all kinds of practices, all ages and types of practices, and nothing is currently being done to address that.
The hospitals are finally being heard. They are in critical trouble and they're finally being heard and have started to turn things around. The nursing situation is terrible because young women and men are no longer going into nursing. It is a wonderful profession. They are a mainstay in the entire healthcare system to people who are sick. It is very hard to find people who go to nursing school. What the head of the Nursing Association said was why would a young person go to nursing school when they know if they went to engineering school or they learned computer software, the year they graduate they'd earn the same amount as they would as a graduate nurse? Twenty years later as a graduate nurse they would barely be earning any more than they were those twenty years before and the engineer or the software expert would have multiplied their salary three or four times. Furthermore, the nurse particularly a hospital-based nurse has to make the commitment to work 12 midnight to 7 a.m. shift, work Christmas day, work all kinds of odd hours, and that's the same problem although to a lesser degree that we're seeing with physicians. Why would a young person who graduates from medical school with an average of $100,000 debt go into a job where it's going to take them twenty years to pay the money back, and they're going to be working nights and weekends and odd hours and never see their families? It's compounded in Massachusetts because physicians' salaries in Massachusetts by national statistics are 49th out of the 50 states, and we have one of the highest cost of living in the country. So the combination is now for the first time making it difficult not just to get the practicing physicians to stay, but our premier hospitals like Mass General, Brigham & Women's that are ranked 1 and 2 by studies for all over the country are having trouble getting people to come chair departments and so forth. The prestige and the big name appeal coming to those places loses a great deal when the salary they offer is considerably less than the same person would get at maybe Johns Hopkins, Duke or Northwestern, and the cost of living is much higher. So we have a particular problem in Massachusetts.
When I said Massachusetts was 49th, California is 50. California and Massachusetts probably bought into the concept of managed care to a greater degree than any other part of the country. A lot of people were very concerned about how do we do the most for the most people. And I think basically all doctors and certainly the medical society push that quality of care, access of care, and affordable care are the most important things that we can make an effort to achieve. Ten or fifteen years ago when the gurus and the think tanks thought that managed care was the way to go and that was going to solve those three problems, California and Massachusetts really bought into that. We pared out costs down, we decreased the number of available hospital beds, and we tried to also pare down what went on in the offices to be as efficient as possible. Therefore, in 1997 when Congress passed the Balanced Budget Act which took a great deal of money out of Medicare, our state had already gotten rid of all of the waste in the system, or the vast majority of waste, so since we were already running at a pared down minimum, we no longer got enough to pay the cost of doing business. There has recently been an attempt nationally to try to make up for some of that. They actually cut more than they realized they were cutting in Congress, and some money has flowed back to hospitals but it's still not enough to make up the difference in Massachusetts.
Why does that matter when you're thinking about HMOs and things? There are three main sources of payment for medical care in Massachusetts, Medicare, Medicaid, and the HMOs. We have the highest penetration of HMOs in the United States both for the population under 65 and for the population over 65. In addition, we have the highest penetration of HMOs taking care of Medicaid patients in the United States. For the patient base in the state somewhere between 85 and 90%, and it may be slightly over 90%, are paid for by one of those three mechanisms. In the past Medicare paid well enough so a physician or a hospital seeing Medicare patients and some Medicaid patients even if the Medicaid patients didn't pay the cost of doing business, the Medicare did, it came out in the wash. But none of those sources of payment have increased their reimbursement over the past ten years. Medicaid has not increased reimbursements in Massachusetts since 1993 and this is 2001. During those years the cost of doing business in the average office has risen at a rate of about 3.7% a year, and there hasn't been any increase in reimbursement. Medicaid is a state project and the state has had it's surplus in the budget. These have been boom times, now we're facing a probable major decrease in the economic health around here and in non-boom times the chances of increasing the Medicaid payments seem slim. The HMOs have gotten in financial trouble themselves. At least two of the HMOs in our State ate into their reserves to try to expand into New Hampshire, Rhode Island, Maine and other states where they didn't make a go of it, and having eaten into their reserves so badly that at least one of them went into receivership and another one is teetering on the brink. They have not increased their payments for a unit of service either. Medicare has in many cases decreased payments. So the cost of doing business has risen while the reimbursements have fallen.
We're now looking at what we can do. On the short term what we're trying to do is try to get Medicaid payments brought up to a reasonable level. We have a bill in the legislature right now and we're supporting a bill that someone else put into the legislature. As to Medicare, the people in Massachusetts were involved in the AMA and working with them to try to put some of the funding that's coming back into the Balanced Budget Act Reform Act into physician practices. Currently all the money that is going back to organizations is going to the hospitals, nursing homes, and managed care organizations, but it's not flowing to the physicians. Thirdly, in terms of the payment streams from the HMOs, we are asking businesses and the legislature to support our efforts to make certain that some of the increase in premiums that the HMOs are now asking of industry flow to the providers of care. Currently, that's not the case. The HMOs in the State have increased their premiums dramatically this year, and some of it is going to hospitals but most of it is going into rebuilding their reserves. They need to rebuild their reserves to stay alive, but none of it is going down to the people who provide the care.
We have a reasonably good working relationship with the American Medial Association, (AMA). We don't agree on everything that they do, and they certainly used to have a reputation for being on the far right, feet in the mud. However over the past ten years there has been sort of a dramatic shift and we find that the AMA is one of the strongest advocates for figuring out how every patient should get access to healthcare. We're looking at how to help people pay for prescription drugs and how we're going to deal with the costs of those drugs and it really has changed. It's like the ad that one of the car companies is running now, this is not your father's car, this is not your father's or grandfather's AMA either.
Much of my time is spent interacting with political legislators. Just yesterday I was speaking to the Associated Industries of Massachusetts and I went down to the Cape to talk to the Chamber of Commerce, but in-between times we have a very good working relationship with Attorney General Tom Riley who's been very interested in what's happening in healthcare. We've worked with the federal officials in the pursuit of fraud and abuse and we're very anxious to try to clean up any fraud and abuse in any part of the medical care system. In addition we have very good working relationship with the previous head of the Senate Committee on Health Issues. Currently, no one has been appointed to fill his shoes for this session so we will be meeting with that person as soon as they're appointed. We meet regularly with Tom Birmingham who's the head of the State Senate and Finneran who's the head of the State House of Representatives, and we have meet with Lt. Governor Jane Swift. I have not personally met with Governor Celluci but other people within the medical society have, and we also have a good working relationship with regulators such as the Department of Insurance Regulators. Sometimes they turn to us.
For example when one of the HMOs was in bankruptcy last year we asked the Insurance Regulator and the Attorney General to try to help see how to help the HMO survive and get out of debt. People might wonder why when the doctors are so beset and besieged by the HMOs we would be interested whether one of them survived. The answer to that is if only one HMO survives, which actually is something of a risk at the moment, it leaves every physician and every patient in the state totally vulnerable because they have a complete monopoly. No one has any bargaining power at all. Physicians have very little bargaining power as it is. It's against anti-trust regulations for us to speak to each other about what any insurance company pays us in an era when huge, national multi-billion dollar companies can merge and that's not considered anti-trust. Dr. Jones and Dr. Smith working on the same floor in an office building can't talk to each other about the contract the local HMO has offered them because that is anti-trust. That seems very bizarre and we're working at a national level to try to change the laws. But at the moment doctors have very little room to negotiate. The hospital can negotiate when they are having troubles with payments. The hospitals have the option to try to raise funds from fundraising activities of volunteers, the hospitals have substantial reserves and some of them enormous reserves to ride out the hard times. Individual physicians can't go out and hold fundraising activities. They have little or no reserve to start with and they can't negotiate from a power of strength. Even an organization like the Massachusetts Medical Society can't negotiate or talk to anybody about anything that involves any kind of payment. We can say to the HMOs it's important that part of your increase in your premiums that you're charging industry flow to the providers of healthcare. We can't discuss what that might be or how it would be, that's anti-trust. The only physicians who can talk to each other about any deals that anybody is offering them in these various contracts that we get are people who are in what is called a risk group which means that a HMO pays a group of doctors a lump sum to take care of a given number of patients.
Harvard Pilgrim Healthcare was the only HMO that got into a position of bankruptcy and then went into receivership. They actually are turning things around. We do meet with people like expert economists and experts in the financial health of the HMOs. I meet with the other leaders in the medical society and with the directors of the HMOs one at a time on a very regular basis. We try to keep our finger on whether or not things are going well.
Tort reform was a very, very major effort of the medical society over the years but it kind of quieted down over the last five to ten years because in fact insurance premiums had been fairly steady instead of on the astronomical rise they were on in the '70s and '80s. In the '90s they were fairly steady for a number of reasons including the fact that fewer cases were found against the physicians. The physicians have been much more careful about documentation. Even though enormous sums are being given by juries to people who they feel were victims of malpractice, the number of individual doctors having successful suits against them have flattened out. Currently, we're facing in this year a big jump in insurance premiums again. So it will again come to the forefront of people's minds. One of the enormous inequities in this State is we have something called joint and several liability. For example, if someone sues a nursing home and a physician and they say the nursing home is 95% responsible and the physician is 5% responsible for the bad outcome and the award is $4 million, if the nursing home can't pay it's share, the doctor has to pay the whole 100% because it's joint liability regardless of the fact that he was judged only 5% guilt for whatever it was that happened. That's sort of a unique quirk in the Massachusetts law. Somebody slipped on your sidewalk if they walked by and they sued and it was said well the city was supposed to take care of that sidewalk and they didn't and they were 95% guilty but you were 5% guilty because you might have noticed they hadn't cleaned the sidewalk and go out and clean it yourself. But if for some reason the city didn't pay, you the homeowner with your minor amount of guilt would be responsible for the whole amount. That just doesn't make sense. So I think tort reform efforts are coming back in again.
Tort reform really is something that goes beyond medical care. I personally think it's absolutely ridiculous if you fall off the ladder, you can sue the ladder company. You get these products with the most ridiculous labels, you know this Frisbee is not for eating, because everyone is worried about runaway liability in this country.
A bad outcome doesn't equal somebody having done the wrong thing. People can do the wrong thing and maybe the outcome isn't bad and nobody gets upset. But the reality is that people die, people get injured, bad things happen that no one has any real control over. It is a scary thing. It leaves doctors to worry a great deal about double and triple documenting beyond any logical necessity to do so just in case something comes down the pike. It puts yet another barrier between the patient/physician relationship if the physician is sitting wondering if I operate on this person, is he going to sue me if his back is not comfortable for the rest of his life? It puts a very unpleasant shadow between the physician and the patient.
Doing tests certainly has been one of the factors that has played into the cost of medical care. There are a number of other things. Currently, due to this fear of a physician that they might need to do a CAT scan even if they would bet their bottom dollars that the person doesn't have any kind of a major brain injury from that fall against the desk last night. There is nothing clinically that suggests they did, and if they were the one who fell against the desk or their wife or husband had done it, it wouldn't even have occurred to them to pursue it because the person doesn't have any signs of serious disease, they will order a MRI or CAT scan which costs hundreds of thousands of dollars just as a protection against the remote possibility that there could be something more serious going on. Now the new addition to that dynamic is that patients read on the Web or in magazines about every possible test that can be done. So you have people walking in the door saying I want a MRI. Here's this scan I read about that I can have and I read that there is only one hospital in Wisconsin that does it and I want to be sent there. If the person really has an illness or an ailment that the test would be useful for, that's one thing. But in reading about it, people may get ideas that it is the panacea for all problems when it has nothing to do with anything that might be wrong with them. So that has been added to the physician's inherent concern in the back of his mind, should I be testing for the one in ten thousandth chance? There's also this dynamic now of the patient demanding or wanting something and to say to the patient, that doesn't make sense, number one makes the patient think the doctor is not on his team, and number two it puts the doctor at another level of risk.
A particular pet project of mine is the issue of living wills. I was actually the first medical director of our local hospice at Emerson and that was one of the only two hospital-based hospices in the state at the time. At the medical society we are actively advocating, and this sounds a little macabre, that the day after Thanksgiving be called living will advance preparation day. In the last two years we have gone around the state and gotten mayors and the governor to sign on to this concept as well as encouraging patients and working with hospitals to make certain that patients are asked the question of what they want in advance to getting into dire straights. Its amazing to me having known many, many families in the process of practicing medicine and having talked to many, many people who have different ethnic and educational and cultural backgrounds to have very varied opinions about this sort of thing. What's interesting is that often the family perception of what the patient wants and my perception sometimes too is way off of what the patient wants. The very elderly man in his 90s who has had multiple surgeries and seems to have a poor quality of life tells you of course, I want to be on the machine much to your surprise. Then the other person who seems to be in wonderful health and has everything to live for says the opposite. I am delighted to be able to say that it is an issue that more and more doctors are taking up as something that needs to be discussed at the medical school level now and people are being given the option to think about what they want in various circumstances. Unfortunately, every state has sort of different rules and if you look at the forms that are considered legally acceptable in New Hampshire, they're different in Massachusetts, they're different in Connecticut, we need a little more consistency. But the most important key thing is this patient's close friend or family member and doctor have the same piece of information. The one thing that everybody has in common is that any of us could be in the emergency room tonight with somebody having to make those decisions. It is important that we think about them ahead of time.