survivors is continuing in the latvian capital riga after a roof collapsed on thursday evening in a busy street with dozens of people are being confirmed dead including some of the rescue black is not clear how many people may still be trapped underneath the rubble. it is to find them online. with more people believed to be under the debris. rescue workers in riga are continuing their search e crews are risking their own lines to search to the supermarket wreckage earlier three firefighters died in ten others were injured when another part of the building collapsed as the war. meanwhile people have been waiting for news of missing loved ones. my wife she's in there. i have no information yet and she's not among the dead or injured to where ever i called i never get an answer. the reason for that collapsed deal is it known that speculation his center around plans to build a roof top garden. media reports said the group was undergoing reconstruction authorities suspect that building codes may have been violated. even though it's quite clear that we have to take necessary steps to prevent tragedies like this one from happening again it's the reason why we're going to take more severe control measures in construction sites and this crying. witnesses said they heard the term for the roof police are examining whether supermarket employees failed to react to warning sirens the supermarket opened in twenty eleven. he was even nominated for an architectural lines at the time. the lys to read and corresponding get into the guild this joint is online. first off can you tell us all our rescue teams confident that they can make it in time to those still trapped in the rubble. oh dear due to a crawling on the live earth and google them to continue their work cool well that night the paper make up only people who have been sighted in the building but in the defeat of the faith that they are looking to find any to buy that. the death toll has been only when you think you're a bit of a word and excel fifty people. i fear that the number of potential conflict between grief the rhythm that we'll all get to know there are more people are going to be in the building but there's no official confirmation that the information. the arabian like it if it didn't go into a tree full of looking for love or to go to break the tragedy unfolded shortly before six pm to be living the moment we get two people are expected to lose to the store tomorrow to his conviction. we've all been on in the big thing to walk for the roof of the building to collapse and what the pope will scenarios did that and the political dogma. for the club brought in. the idea that some sixty people dead the latest count this is a staggering loss of life was in the nation's response to the touch well actually improving really deeply doctor but i then turned to the goal. the word for giving the kid in nineteen ninety one when the country with gained independence vote open for vocation of the spread of condolences to the victims' families. meanwhile the us the top donate the money to the victim's family to go change it. also there are queues of people are totally different to the to donate blood and i consider to be but we have not been directed to cocoa to the top but the tragedy. there were recovered and are now three days of national mourning that there's going to be a moment that i was so well that comes with monday morning in memory of the picture. also many appear to show up to the about helping and told him at the orchid weekend in pictures will look for that and to respond to steal this from the designs are very much. get. the actual marriage courses were rushed to release the greenpeace ship arctic sunrise and its crew of three point six million euro battle and allow the detainees the country russia says the hamburg based court has no authority exclusively in russia itself seventeen the greenpeace activists including the arctic sunrise discount and peter willcox be released onto the front panel of judges. that means that twenty nine of the things he has now been granted bail they will face charges mexicans and ten oftentimes import gas from oil platforms in the auntie coach. lisa calling it the west's incidents of modern day slavery and ron cummings in the uk. three women being free from a house in central london where they were allegedly held against them will fit. simply saying that the youngest of the women never had any contact with the outside world. a man and woman have been arrested since been released on bell residents of lamb and woke up on friday morning to find their district making international headlines. many people are shocked to learn of the case of modern slavery in their london district. is it better the antics of may it is difficult to understand how people could be imprisoned admit that it makes it that it's all there is more less shocked by the news. but sadly i'm not surprised she's actually just looking around thinking about our own. how easily i think that could happen. in central london. after watching a tv program about forced marriage one of the women called the helpline of a charity featured in the program. it basically tells us that sent their being accounts and they need its support to come out to take difficult situation he reached we take it because they seriously the twenty oh seven held promise a constant state. i made some lame. very sensible playstation three was the assistant dean of the state. the man and woman both sixty seven were arrested in connection with the case and have been freed on bail. police say they are not british nationals few other details are known so far. offense is taking place in us to commemorate president john f kennedy was assassinated on this day fifty is doubtless texts thousands gathered in dallas for a ceremony to honor the thirty fifth president was assassinated three years into his term. jfk minds among the nation's most popular products is remembered for his youthful energy and bold initiatives some timely deaths brought to an abrupt the boy here in germany in another sign of progress towards a new government for the country chatham eccles conservatives and the spd have agreed on health care plan as well the cheese icing and they want to make insurance premiums more dependent on us no income. and they want to freeze employers' contributions. wilson agreed to increase the stone previously not seen the show if there is light at the end of the tunnel quote for greek debt. that's the sentiment from both the german council on the greek prime minister here in berlin. greece has unveiled a budget that it says shows the nation's deep economic crisis is coming but august is from the imf ecb and the eu for time to increase when i was agreeing that austerity measures and gone far enough. in the head of the eurozone finance ministers group says that some colleagues are using patients with that. still today's meeting in the german capital was upbeat. some announced brought results to berlin. after years of economic crisis. greek prime minister can finally point to signs of progress. and once those gains to be acknowledged. but almost. we are getting into a pace of economic revival up to seven bang on tues the recession will be hooked up to korea he faces. some might call the country's eight hundred twelve million euro surplus this year a sign of hope. he said green st also was held to service three hundred billion euros of debt is stabilizing and would not ask for new loans or seek changes in aid programs keeping its holdings. america will shed our teens at first when bearing fruit with this guy thinking. we held talks in a spirit of greece will follow through on pledges to his mate. i'm stressing that we are seeing light at the end of the tunnel. it's not an easy path. and if it's going it's zenith of its kind and the hubby. medical acknowledged creatures efforts but refuses to use our posterity. she also looked ahead in january americans take over the rotating eu presidency she said every effort would be made to assure those six months our success for all of you out. bree are political correspondent john barrett for some perspective here john we have two very different views of green finances. athens saying it's on track with its debt and the troika though saying that more disparity is needed was right. but i think by the riot act to be paradoxically i expanded this way. the finance minister in athens in the us today the presented these very promising figures as you mentioned annual report. in two to twenty thirteen. an athens man is to show the prime recent pics. this new system is slowing down and most economists think not just increase itself but european economists think that in fact you can be modest growth next year in greece which gives the lives of the people who said yet that the austerity package would mean that a new push to increase deeper into recession. on the other hand as if the finance minister also said that next year. he is the government would have a deficit of priming deficit of about five hundred million euro it's not that is wiring for the toy cat because it seems that the funds that are being made all the sudden away. secondly they also think having looked at the figures themselves that it may not be five hundred million but it may be one in the hof billion. and that's a bit worried about that greece will not stay on the course that it has speed and has agreed to go on and which is peering into percent free yeah those numbers are causing concern job but what about your real and what's a sentiment to politicians here sink. greece's of the woods i didn't anyone think the creases out of the woods but as the times when nothing was saying and as the figures themselves there is an astonishing progress that has been made when we think of what the situation was even a year and it seems extraordinary that the increase is expected to weigh in on any come out of recession the show modest growth next year. don burke is ever john thanks for the when tending to the gem economy now and business confidence rebounded more strongly than expected in november often dipping in october. munich based economic institute says that its multiple of seven thousand german companies showed that manages feel good about it. for the coming months. use the business climate index was almost two points to its highest level since early two thousand and eleven. the index is considered a reliable indicator of germany's economic performance. that was a big story on a sad smile kiss is eight dollars he helps as these from scratch evil business confidence was a very strong surprise for the market at the end of two week trade is called the numbers and testy nobody could expect such a strong rights and indeed some german companies are in a very good shave that the automotive supply get pregnant on income they can be done to you. i could take samples said currency rates to the revenue are too far especially unique and vw is going to invest be against a new models and technology but the stock market reacted ted pretty reluctant to do these good news that after the new all time high in the beginning of the week. in this dispute being too optimistic. toenails and friend phyllis and couldn't understand when the auntie still starting off with the tax which becomes a modest gains that was the tuesday adding about thirty seven percent on monday. pretty soon underway in new york. the town and is pretty much flat here and cut his rating fought one to lead thirty five forty six the major indices firing on all cylinders the nicest guys on and took in l a and z glad until this happened time and diana is the world's largest market gets there is attracting more and more global lyrics. japan was yesterday. china is clear it's that at least as far as buick is concerned. the u s automaker is showing off its futuristic read the aero model incline show. a concept car that runs entirely on electricity. electric and hybrid motorists are taking center stage a the quantum show on the show. it's all about sustainability. it's a bad grade. it's a bet sites it's about having great quality cars and it's about having to write technologies smart tacoma. toyota's luxury brand lexus is premiering latest version of its high grade c t t hundred th. every third lexus sold in china is a hybrid. that's partly a reaction by manufacturers to chinese government policy the team has clinched a sunset nines and promote electric and hybrid cars. but despite all the greenery classic country cars and sports cars are also well represented a poncho. china remains the biggest growth market for top of the range models. commando connecticut ukraine and its dramatic centerpiece is right there for the i should. another she actually see. apolitical it owes its conduct in seo d i i. welcome back the government in ukraine is facing accusations that it buyouts to russian question scrapped plans to sign a landmark trade deal with the opinion he was right hundreds of pro eu citizens took to the state capitol to protest against that the announcement came shortly after lawmakers failed to pass legislation that would allow the ex prime minister who is commissioned to travel to germany for medical treatment. this is one of the hughes' team preconditions for that. more on this the second agencies in student from the german institute for international security fence he only began by asking and just how much support there is in ukraine for close relations with the european union. well in fact there's quite a bit of support both in ukrainian society and in the ukrainian opposition. and in fact there's also support back in the ruling elite for closer relations with it the european union. however i think the calculation has banned because of the recent actions by russia. by the ruling elite would like to balance between the eu and russia and it is now the beach at the risk is too great because russia is this very strongly against ukraine entering into the agreement it is more about that because it is quite a turnaround tuesday just a couple of months in prison yanukovich was saying that a deal with the eu was definitely on. i believe this population has changed out for first because he noticed it at that and the eu is not going to be forthcoming with a instant financial assistance and that's what you're looking for right now because of the dire state of ukrainian economy. and secondly it appears that he might have received some attractive offers from ross and the asa definitely received threats from russia about what will happen if ukraine become economically if it does sign the agreement. and finally i think he was concerned that he will lose part of his electorate that if he signs the agreement and the relationship with russia deteriorates. what about the eu handled this to get nice calculate by linking any deals for the release of units in the center. well i don't think there was a good idea but i don't think it was a decisive factor the decisive factor was the needed dire state of the ukrainian economy and also the combination of threats and offers coming from russia. ccs students thank you very much. more so now the city has seen the final day the un climate conference and is two years of struggling to read some common ground. analysts knew that now she is a two week conference may not still in editing tool. and as an environmentalist activists in a walled town to the school on thursday to protest against the law protects those costs installed on two main issues one country to present their targets were curbing carbon emissions and the funding for poor countries struggling with extreme one negotiators from nearly two hundred countries had come to warsaw to lay the foundations for a new global climate treaty international leaders want to see all the new international agreement by twenty fifty. many had hoped attendees at this year's conference could agree on a general time for any daft idea. unfortunately what we've learned is that they're a number of countries that cd don't want the international community to set out a timeline for them. they want to decide for themselves developing nations also made little progress with their demands. they want developed nations to reimburse them for economic damages caused by global warming. on thursday hundreds of environmental activists walked out of the climate talks to protest the lack of progress. those who stayed here the worst. it is also would be a catastrophe if the fossil fuel industry and other stakeholders use this walkout as an excuse to leave the negotiation table entirely. and at this time more sauce climate conference ends later today analysts fear the eleven day conference may deliver virtually nothing so is that the likely outcome. virtually none. without question to our correspondents for a nosh is that the talks well yes it's actually not looking too good then more so yesterday we've seen an unprecedented walked out to buy into those most in jos. their calm his conference the climate circus and in fact ought to pretty much dead to the pool countries to developing countries. i'm pushing for money. it's actually the big topic here the loss and damage from the one to house the new funds they once that the industrialized world's to get money into a font that would pay for them irreparable combat is caused by climate change the industrialized countries have very much against that and they don't want to be tied by yet another mechanism that would hold them responsible for forming the new comp. so any compensation is so it could very well be that this conference winds from the eyes of sale yet with no tangible outcome and that would have severe repercussions for the time the twenty fifteen conference that his will take place in paris. when a new global climate climate compact suppose to take shape. it's actually right now it's not looking too good. in warsaw last two weeks after the massive typhoon high on through the tulips philippines authorities there are still struggling to restore basic search and today when he succumbed to the needs of roughly four million people being displaced by storm. the most expensive present budget reconstruction is next week meanwhile storms of this magnitude are increasing in frequency and environmental groups are talking back to human activity. one of the most severe storms on record. tycoon high on was categorized as a super typhoon. would it be hurled across the philippines earlier this month. it killed more than five thousand people in a four million more homely. the damage was much more than forecasters had predicted. the harm. and we've tried to establish the relationship between wind speed and it all. it seems quite clear that there's a certain alignment. the thing there is no damage to a certain speed. bought when they get beyond that the amount of damage increases exponentially. not steadily as the wind speeds were asked to explain to that the night was a category five type you mean it had sustained wind speeds of more than two hundred fifty kilometers per hour. while measuring tool when speech is difficult. the us navy's joint typhoon warning center estimates are here and the wind speeds were up to three hundred and eighty km from work. in august of two thousand by hurricane katrina produced peak winds of two hundred and eighty kilometers per hour. it was one of the worst storms to ever hit the united states. the city of new orleans was flooded when the levees failed. for eighteen hundred people die florida engineering was playing for the damage. just over a year ago hurricane stan to hit the us east coast with winds gusting up to one hundred eighty five kilometers per hour. it affected the entire eastern seaboard with the worst damage in new jersey and new york. experts say the damage might have been much less infrastructure and buildings have been adapted. so is the bus we meteorologists can contribute to taking appropriate measures. i'm the type he has an intriguing area. it is the owner mary ann is to develop methods for reducing greenhouse gas emissions. you will be a part of the mind to achieve this on a global scale. solid agreements are crucial. no one finger the human activity is believed to be causing global warming. that something is responsible for the intensification of many natural disasters around the planet. rising sea temperatures increase the amount of energy that tropical storms can unleash many experts warn that in the future hurricanes and typhoons could become even more frequent and more powerful with devastating effect. finally i made a mission to best understand the magnetic field is getting a blank space european space agency use long range battle for us now in orbit movies provide the most accurate measurements ever made of our magnetic field. the mission called swarm is trying to provide smiles is why the field has changed. and constantly bombard the earth constantly but many more come from outside the solar system the magnetic field. like most of these particles are taking my father. solar and cosmic radiation. it's the idea that the invisible bubble is getting weaker this core mission objectives is to match the sources and strength of the earth's magnetic field. using three identical spacecraft. when you have a satellite that can measure the earth's magnetic field precisely the measuring device has to be placed somewhere with a little distortion. war has been used to it. like my mind like this sensitive measuring devices have been mounted at the end of the maps are away from the satellite onboard electronics which also generate magnetic fields. one satellite would not be enough to examine all the input of the magnetic field sources that's like three have been launched to mention the entire magneto here among the strongest of the earth's magnetic field is generated from deep within the planet. by the movement of molten iron. it forms the outer core. this field is especially interesting to geologists engineers physicists it i'm not that field is generated from the earth's atmosphere from which a link to current spiral. a direct charged particles in the atmosphere when they collide with stellar weekend the phenomenon of the northern lights occurrence. however these currents can be dangerous satellites. because the damage their electronic systems and distort the reception of navigation signals. fan the truth be told and also create a magnetic field with their parents but it's very small this is what we want to be able to match or more precisely the scientists hope to understanding the oceans magnetic field will help them ensure ocean currents and how much warmth the transport this will help them to better predict trends in the current climate ordination is again due to my mind years. there's always time for thanks much for joining a small and use it the air. focus documentary series from place to go captivating documentary said reports cover business and finance alternative ancient historical and present day events as well as sports and leisure. in focus saturdays and sundays at four thirty pm the veto. so riveting that separates us with a camisole top model. the cinema miss out. visit the new digicam with habitat for an encore to be hopeful that he was. each beach. asked. she going to hit you on the up to the ddt activity. all you need. even on the screens and one heck of a boss. maybe that'll be it. badminton is here the kids were misled over so my mom agrees she still says it over with oprah went off at seven this level. would you do it. when the robot. he is. as in his will. you lu lou will who will win. is you it's six won fourteen euros with grind up some of the chevron bp a lot. well all released on bail over suspected slavery in london marshall was among three tiny tube been beaten and held it invisible hand cuffs for threead
. over my career i've got answers like the parking here is good or we can do better than that. this is one fits almost of the u.s. economy and competition just seems to be at the wrong level and patients are frustrated. another reason i wrote the book is that doctors are getting crushed right now. they have got declining medicare payments. they have got increasing overhead, hospitals have more expenses. malpractice rates are going up. the burnout rate is 46% and doctors are getting crushed right now and i just felt like we needed a voice out there and it's okay to talk to the general public. >> host: so you make the point that medical mistakes for the third leading cause of death in the united states. that is a shocking figure. can you talk a little bit about that? >> guest: it was shocking even for me as someone interested in the skill and quality to put it in that way. medical mistakes. we kill as many people from medical mistakes as we do from car accidents and other three, four and five causes in the u.s.. i guess i've never really thought of it that way because we don't really talk as openly and honestly about mistakes as we showed in our profession, to be very blunt. think about number one heart disease. the number one cause of death in the u.s.. we spend a heck of a lot of time and energy on hard prevention and heart disease. cancer, a lot of money going to cancer. we are just now beginning to recognize that this is number three and some people have told me, after i wrote "unaccountable" there is not really a medical mistake problem in the u.s. and i think we are starting to to just now accept that this is something we have got to start talking honestly about. >> host: so, we know that there is tremendous care that is received here in the u.s. and certainly at the institution that you trained at but this concept of kind of equality and disparity of quality. you got interested in it during her doctoral program at harvard. can you talk a little bit about how you came into that and what your interest was in really where did the field come from? >> guest: well, i think it just started to be recognized as a field when i was a student. it was sort of a right time, right place kind of thing. i had this frustrating experience with a patient of mine that i was assigned to follow. her name was missed his tanks and she is in the opening of the book. she really didn't want anything done for her cancer which had spread all over. the doctors clearly wanted to do something. they essentially bullied her or talked her into it. they overstated the benefits and understated the risks, something we know from research happens especially those of us to do procedures. it just didn't seem right to me. it seemed as if the profession wasn't telling the truth. it seemed as if the profession of medicine had long strayed from its original mention -- vision. it's not why went into medicine and its why i quite frankly quick. i started school and public health where i met david gates who -- >> host: i'm sorry to interrupt. so you were in medical school and you have decided you had had enough and you went to the school of public health? >> guest: i basically explained what mrs. bankston wanted. the they torme upside down for explaining this to them, that she didn't want the procedure done and they basically implied, didn't matter what she wants. this is what she needs and this was to me a sign of a culture that i had observed from the outside but didn't want to be apart of and i quit medical school. then i started graduate school for public health because i heard of a track three could focus on quality and there were people now interested in medical mistakes. the first time they were describing studies were they were looking at handwriting resulting in patient harm and it was a radical concept at the time. david bates put a big study out and he describes the head of one of the largest doctors organizations in the united states calling him and basically saying, what are you doing this for? this is not a problem. i realize that realized that we have had these explosions of knowledge in medicine but we have not coordinated care and all the services that we have end up having so many cracks that the cracks are as harmful as the diseases that we are treating and you have got to step back and ask, you know, are we hurting people overall on a global level? what are we doing sometimes and of course now we have got this reports saying, 30% of everything we do may not be necessary health care. when we step back, 30% of all the medications we prescribed and the tests we order and the procedures. this is something i think which is, for the first time, really being called out as a problem. people out there in the general public have been saying for a long time, we don't like the closed-door culture of medicine. we find medicine even sometimes to be an arrogant industry. we feel like we don't connect. i remember in medical school being told that a nosebleed is at at the status. i citizen than a nosebleed? what else could at the stacks as the? it's like a whole different vocabulary. and that disconnect has a think created an issue with our trust in the public and this issue of overtreatment now has further strained the public trust that medicine has. it's a great job and it's a great profession. you are in health health healthe and everyday you see folks have tremendous results, the byproduct of phenomenal advances in technology and the art of medicine with compassion. it is a great profession that when we have got the institute of medicine saying 30% of the time we miss the mark, we have got to study this. we have got to make it a discipline of science and say how can we look at this like we look at cancer? where are the cracks? where the mistakes? that was the main reason i decided to go down this path. >> host: that statistic of 30% in quality, waste and variability is a stunning statistic. why do you think that, and you mentioned culture a little while ago. what is it about the culture of health care, where those types of activities have been allowed to go on for such a length of time. if you look at any other industry, 30% waste or 30% error rate really would be unacceptable. how does that occur within health care? >> you know it's a great wondered why people tolerate 30% waste and health care but they wouldn't tolerated in any other industry. i saw a statistic recently in a report, the average income of an american in the united states gone up about 30% over the last decade. the increase in health care costs that they are paying have gone up about 68% over the same time period. essentially we have offset the increases in income with increased health care costs so you wonder why is it that we tolerate this? i have talked to business leaders who say you know, every contractor we pay we have some metric of how well they perform except for one, health health c. we keep throwing money added and patients say the same thing with their premiums and their new high deductibles. we keep throwing money at it. what more are we getting for our money? there has been this culture of medicine that has respected the art of individual autonomy, but at the great risk that some best practices never get standardized. in my own field, pancreas auto transplant where we take a pancreas out of somebody, treat the cells and give the cells back to the patient. we need a laboratory to treat the cells. medicare at one point paid a bonus of 20,000-dollar payment to hospitals for doing this on top of what they were already charging. it became a very profitable business. we have a laboratory at johns hopkins in the operating room and we have the patient asleep under anesthesia, take a pancreas have intrigued the cells and give the cells back right then and there, same operation. hospitals across the country started doing this operation, taking the pancreas out but because they don't have a laboratory, put it into a cooler and send it by jet to another city, have it treated at another facility in another city or state, have it flown back and then cut the patient open up again for second operation. why would anyone have that done? they just don't know about the other option. i'm not talking about hospitals. i'm talking about to the top 10 hospitals in the country do this. we have got smart people, good people working in a bad system where the financial incentives lure people to do things that just aren't right. i think if hospitals are accountable for their results the results and the patient satisfaction is scored in the patient outcomes and the complication rate, the volumes in the readmission rates, all the basic metrics in health care performance that doctors are endorsing as valid, they were available to the public, people could choose where to go based on who performs the best like any other free market works and like any other uses to reduce waste in their field. >> host: so the issue of patient choice about where they seek care and what has been out there and certainly the health care literature and discussions amongst leaders for a number of years, where many people advocate that if indeed the patient had the opportunity to see the quality and see the individual physician, hospital infection rates etc. they would naturally gravitate to those institutions. there's another school of thought that says, you put all the information out there but that won't really happen and patients will naturally gravitate to it. you reference in referenced in your book where patients seek their care. i go there because my mother was born there or because it's two miles from my house. talk to me a little bit about the balance there and how if indeed all of the quality is a factor, how do we get patients informed as to how they can seek this information and will it make a difference and where they seek their care? >> guest: well you know i have got some patience you tell me., whatever you want to do you just tell me and i will do it and they have total blind trust to the doctor in the system. baby for that, that's okay but more more patients now want to know the options and they want to know something can be done minimally evasive. if they really need to take the medication a medication or affairs a holistic or naturalistic or preventive means, maybe they can do physical therapy to avoid something. they want to know now. we have an informed public and increasingly we are seeing that. one critic of the book told me you know, if you put stuff out there people will never use it and it won't reduce health care ways. four weeks after the book came out, a study in the journal of the american medical association showed that when there was public reporting of heart procedures -- we are talking about stenson angiograms, the overall number of procedures went down by 14% and there was no difference in patient outcomes. a big study, jama, four weeks after the book came out showing the public reporting reduces waste and has no impact. the patient did just as well. i think increasingly we are learning about the impact of public reporting and look, all of us know.there's this should not be practicing. one national conference i was at, they asked the audience how many of you know that doctor that shouldn't be practicing in every single hand went up. i think it's because we all recognize there is going to be some bad apples that are going to respond to financial incentives and there is little accountability in general and health care. the hospital seven miles down the street from my house had a doctor put in at least 500 unnecessary hearts fans. now, if those procedures would have been recorded and given to the patient on a thumb drive as they advocate in the book in general, that doctor wouldn't have gotten away with putting in stems and arteries that were never even blocked. there would would have been some oversight like when we had speed traps with cameras at an intersection. everybody follows the law. in the compliance rate we are trying to get everyone to follow the speed limit and forget raids it's been horrific. since we have had automobiles would have been trying to do education. education doesn't work to get people to follow the speed limits. what works is when somebody sees a camera or an officer on the side of the road and then everybody is compliant. lean health care have a lot of room to increase accountability and quite frankly i think it'll really restore the trust that has been broken with the general public. >> host: so let's go back to the culture question again. i was riveted when i was reading the book about your account when you are a net room and everybody raised their hands. in fact as you describe it, you were -- to raise your hand. there was a senior position next to you who looked at usaid really, you don't know anyone? but what about the culture do you think has led us to this point where we actually said -- where we no harm is occurring or we have a sense of it that we have gotten to this point where people are afraid to speak up and afraid to criticize their peers or the institution? you make a point a number of times in the book that, and actually in your opening chapter, where you talk about the fact that you know, go to where the people in health care, the nurses and the doctors and administrators at that hospital, where they would be. how is the culture proliferate what you have been talking about, or the public, how did they seek that information out? >> guest: you know i once told a friend the best way to find out about the quality of a hospital is to ask an er nurse who works there. a nurse knows more about the quality of the hospital than probably anyone else there, and for that matter any industry, front-line worker, providing the services be it creating products probably knows more than any of the administrators of the institution about the culture. the reason is that culture drives everything we do. in economics there is this phrase, no one has ever washed a rented car. they don't own it so why would they? a sense of owning the delivery of care is a critical important element. that is what bothers me about sina statistics now, that 40% of.org zinni nida states are burned out according to mayo clinic. they did a study three weeks ago. when we have 46% of front-line providers in any industry burned out, of course the quality is going to be poor and of course mistakes are going to happen and of course people are going to fall through the cracks. when people don't feel that they own the service -- code docs tell me when i go to conference is an speak, i often know how to health care -- make health care a better institution and i know out of care -- make the care safer for people but i don't feel empowered. that i think is one of the great divides right now in health care and united states. increasingly, we have some doctors saying in some facilities that there is a chasm between themselves and their unit manager, between themselves in those who are making the policies or those calling the shots on a national level. they don't feel empowered and we are seeing more variability because of that. >> host: you talk in your book about the administrative crack downs if you will, where you get providers of care and senior administrative leaders working a little bit more together or getting the administrators out from their offices if you will. talk a little bit about that in what and what you see the value of that being as well as its impact if you will on the quality. >> guest: you know we all want the same thing. doctors, administrators, insurance companies, policymakers. there is an astronaut from outer space who was asked, what does the middle east look like from outer space? the astronaut said you know there are no lines when you look at it. the lines are man-made and that is what is going on in health care. the lines we have made in health care or man-made. we don't want the same good for the public. we have got good people. there it is sometimes working in this artificial system. we tell administrators, make a profit, billiar beds so they make a profit and they fill the beds. we tell doctors to see more patients so they see more patients. everyone seems like they are doing their job but as don burke said it's like the jobs are designed wrong and we have good people. when my dad was a practicing doctor at sizing or hospital, i remember this administrator named ken ackerman who would come down and sit down with a doctor, walked down the hallway, prop himself right in their office and say, how's it going? what do you need to do your job better? he was not a doctor, ken ackerman but the doctors on the staff said that he was the administrator in a white coat. that is how he got the nickname. he was in touch with the front-line providers. you see it in a kind of industries, be at lehman brothers, be it large corp. delivering a service that is multinational. when the administrators lose touch with the front-line folks, that is when bad things start to happen and that is when the accountability becomes a problem because there is no transparency and that was really the impetus for writing "unaccountable." >> guest: as a hospital president and my struck by the fact that if you want to know where the issues are ugoda the front-line and you go to the operating rooms. but why do you think that we, and many hospitals, perhaps there has been a separate differentiation are defied if you will between administration, doctors, and does it have anything to do with incentives. we talked a little earlier about this so what do you think? >> guest: i have seen both extremes in the united states and the talk about both extremes in the book. i recently learned an emergency room that was built that was freestanding with no hospital attached to it. can you imagine if you had a heart attack and you go to the emergency room and they don't have a hospital to put u.n.? they have two ship you across a floating bridge across a lake the lake to go to another hospital because that is their associate hospital that they admit patients in. in in the united states this happens and you see these doctors saying this is an right and even sometimes administrators will say we know it's not rational but that is the way we get paid. and you realize when things are disassociated the care gets very dangerous. then you see times when they are in harmony. you see when there is transparency of infection data and how the administrators talk to individual provider specifically about infections and what do we need to do to get our infections down? this is a model of management for any industry. in the new york transparency experiment when heart surgery outcomes were publicly reported, i tell a story that mark chesson described where they actually had administrators walking to the unit and asked the doctors and nurses, what do we need to do to get our mortality down? they are asking nurses, how can we decrease at? you don't see that level of common mission around complications except when everything is aligned and there's transparency of data and accountability at all levels for the performance for people who on the system. i remember hearing the story of a nurse saying we have never seen a ceo here in the cardiac icu except when we had public reporting of heart surgery outcomes. you realize these are old-fashioned concepts and these are american concepts. they are not public art -- -- republican or democratic. transparency is american value. we expected at the white house, we expected of congress, we expected up wall street. sarbanes-oxley will have a ceo go to jail if they misreport their earnings for a company. health care is almost like an island. it's almost as if you can misreport infections and there is not that level of transparency and we treated differently. we have to start treating health care like we do any other business to reduce the waste and reduce the cost for everyday americans. people are getting crushed right now. they are essentially paying for all of their health care with the exception of catastrophic care. it's becoming a two-tiered quest -- system. we see primary care doctors now say, pay us a couple thousand dollars a year and we are going to take care of you with housecalls. you have my cell phone. call me at night. its medicine the way they like to practice it and the way we have alternative practicing medicine. is how the patience of a lace trimmed of getting it and they are revolting against this year craddock regulatory system that involves siding with insurance companies and all the hassles that doctors are getting crushed with lately. >> host: let's talk a little bit about leadership and the role that leadership plays. i loved the story do you tell about al brodie and i use that story myself. talk a little bit about that and the role and the example as well of that story and what you think it means to senior leaders in health care? >> guest: you know, i find that many times everybody wants the same thing but there is sort of a break down of communication. when bill brody walked through the icu and started talking to nurses -- >> host: tell the audience who bill brody was. >> guest: he was was a part of this initiative to have all the executives adopt the unit and many of of the executives at hopkins adopted the unit, and icu or warder clinic or operating room area and they would meet with the staff, and we still do. they would say what are the safety concerns here? how are you going to harm the next patient? they anticipate what's going to go wrong the next time with a medical catastrophe and let's face it they happen every year and every hospital in the country. it doesn't matter if it's the best are the worse. they have medical mishaps every year. these discussions create sort of in anticipation that allows people to redesign and manage the hospital system to make it safer and you know the employees, the staff and the nurses feel valued. they feel like people listen to them and when we have got 46% of doctors saying they are burned out and they don't field value and they are getting crushed with this insurance and having to fight with insurance coverage, value goes a long way and not feeling valued by your hospital is a serious way to alienate the very people that are responsible for safety and creating a safe culture. >> host: so, for those of us who our leaders are ceos of hospitals etc., what role should accountability and transparency play in the way that we conduct our daily business? what is your perception of that? where can we improve? >> guest: it seems like it's the old guard of establishment or if you will, the corporation they resist a little transparency but when you talk to the individuals or the people, the moms, the parents, those who take care of patients, these are all people who are also hospital administrators and they want the best and they understand the value of its. they are smart people. they are pushing this and we are seeing this transparency revolution not driven by patients ironically that driven by the doctors and administrators and organizations that see the waste in health care. it bothers the heck out of them and they want to do something about it. we are seeing surgeons, organizations, all these organizations rallying together to save you know we think it's the right thing to do to be transparent about what we do. we are proud of our results. we have got nothing to hide and if we perform well the public should see it and if we don't the public should see it anyway because we are honest and transparent. i once ordered a c.a.t. scan on the patient and it got done on the wrong patient. as soon as i learned about this i ran to the patient's bedside and i said, i'm sorry, you didn't get your c.a.t. scan because there was a mistake and i want to make sure we get it done right away. to the other patient i say, we are sorry we got a c.a.t. scan that was intended for someone else and it was a mistake. i am sorry and i will share the results with you. the patients were not angry like i thought they would be. they looked at me with a sense of appreciation. thank you for being honest with me, doctor. i feel like patience a lot of times just want honesty and they want to be treated with dignity. they want to be treated like they would in any other business and that's what people are hungry for in health care and that is what the organizations and leaders in health care are saying that we need to provide to patients. we did a study recently that looked at the number of national databases follow hospital performances and patient outcome. in my old field of pancreas transplantation there were databases we report our outcomes to. there is a national pancreas pilot transplant registry that follow all the outcomes but the public has no access to the information. in our research study we found there are over 200 national registries that attract hospital outcomes in only three make their data available to the public. most are funded a taxpayer dollars. i think we as a society are starting to ask the question, do we have a right to know about the quality of our hospitals and i think we are seeing leaders step up and say, yes we do. >> host: you have raised some provocative and compelling issues and your book really has i think then truly illustrative in terms of the things that are going on. "the new york times" bestseller list etc.. i'm interested to know the comments of your peers both perhaps younger physicians, older physicians and you have said old guard a couple of times. you put this out and you talked about this. many people are recognizing it. talk a little bit about what impact it has had in how people are feeling from the feedback? >> guest: i've gotten thousands of letters many of which are handwritten. tens of thousands of e-mails that say you know, my mom died because of a medical mistake and we didn't feel we really were a party to the process. we didn't feel we were given all of our options. we think there is a mistake or we know there is a mistake. thank you for sharing the story. is almost as if everybody had a story. i have personal accounts here of people i know orem close to have suffered from medical mistakes. everyone it seems like -- it almost seems like we all know somebody and i think there is this general appreciation for talking about this openly and honestly. younger doctors in particular come from a different generation. medical students nowadays have very little power for not telling the in any aspect of life. they insist on transparency and do it in all aspects. and then there are what i referred to as the old guard, those that say i'm an expert in medical mistakes. we shouldn't be talking about this with the general public, or there was one individual who responds to the book who says there was a typo on the inside jacket of the cover. 30% of health care is unnecessary in the response is, there's a type of? medical mistakes are the number three cause of death and their responses there was a type of? of course there is going to be response. look at the way the politicians have divided the country and polarize the subject. health care is complex. the reality is there are good ideas on both sides of the aisle. i think we need to talk about common sense solutions to health care. all the different ideas we hear about policies are really centered on how to pay for health care differently, how to fund the broken system. we don't just have to talk now about how to finance the broken system. effect to move move on to how tx the broken system. i think that is a fundamental discussion, transparency, patient outcome, patient empowerment. i have lived in d.c. for a while and i know politicians are not going to fix health care permanent way. we doctors are going to do it and insurance companies are not going to do. it's going to be the patients and we have to give them good information. 60% of new yorkers looking up a track record in ratings before they go there, why do they have to walk in for their health care blind about what a hospital c-section rate is or infection raider bounce back rate or how many operations they do or how many knee operations they do. if you want to go to a hospital that you are the only case in five years that they they have scenery do you want to go to a hospital that treats 50 cases a year? these are basic things the public demands in any industry and i think we can provide this through more transparency. >> host: that leads me to -- you use the term reckless health care in your book. talk a little bit about that, your thoughts around how that plays into what you just described. we have 70% of new yorkers who will go on line and look at the restaurants but they will just walk down the street to their hospital without any due diligence. how does the fred flintstone care in the culture if you will of medicine play into that? >> guest: i am constantly flabbergasted about how patients will walk into a doctor's office and the doctor will not mention the superior option to the patient. i think sometimes it's because they're worried about losing the patient to another doctor. we pay a lot of money based on quantity of what we do. that's got to change. we have got to be paid based on quality and our outcomes. we have got to get away from this heavy volume oriented way that we finance our health care system which causes people to a retreat. when we have doctors in the survey why is this treatment epidemic so broad they say because we are so heavily incentivized, usually they don't say themselves, the other doctors are heavily incentivized or there is malpractice concerns and other things. they have the answers but a lot of the doctors out there having answers on how to address this problem, but i hear doctors almost every week that say i'm getting text messages and e-mails from my superiors to do more operations and i feel like i'm doing the right thing for my patient and i'm doing all that i can. they don't like that. that's not the type of medicine and not the type are or professionally went into. i think we need to start thinking about how patients can get the best options by eliminating these heavy incentives, under referred. there are patients that i met as a resident that were not told that there's a superior way to reconstruct a after a removal because the local plastic surgeons don't do it that way. they do it another way. the research in the literature clearly show its superior. is still the standard of care and they are not going to get sued for doing it that there but there are these wide variations. in my own field of pancreas surgery, do you know the small pancreas as the needs to be removed in the tale of the pancreas, the patient walks into one hospital or one doctor's office and they will have a big midline incision have the tale of their pancreas removed and their spleen. they walk into another doctor's office and they will have a small minimally invasive keyhole incision and have the tale of the pancreas removed and not remove the spleen. removing or not removing an oregon based on which door you walk into comedies are all good hospitals and good hospitals with good reputations. removing it colin. they're two different ways of doing it, minimally invasive and an open incision in some say you can do it either way. we have a "new england journal of medicine" study that's over 10 years older shows a minimally invasive is better and it's common sense that it's better but there is a the wild west of medicine that only half of the patients that need minimally invasive we'll ever have it done that way. >> host: you use the term the wild west of medicine and elsewhere in your book you talk about the need to have a new sheriff in town. so, talk to me a little bit about this concept of the new sheriff in town or a con ability or holding people responsible and how that balances with what we frequently hear when we try and move forward with standardization or accountability as an artform and medicine. out of those two things kind of play out? >> guest: i get the artform of medicine. most of the patients that come to see me our complicated pancreas tumors, my own area of expertise and in my own field they see these complex stages where patients are told there's there is nothing that can be done and then they come to me and we say yes, it's high-risk. we will take it on. these are the risks and if you want to go for it we will go for it. and doctors were right for a long time i think to say wait a minute, we can't make our outcome be transparent. doesn't properly adjust to the high-risk nature of the cases we take on here. i agree 100%. as a matter of fact doctors were right to lead the opposition to transparency. for simply make the raw data transparent, we could punish doctors to take on the noble high-risk cases and reward those who discriminate against them. it would actually create the reverse incentive now the doctors are saying we have got valid ways toward better quality. we have created these measures. we have endorsed them. we monitor them with their own national registry housed by the doctors group. we think it's the right time to make this available to the public and for the first time ever, this is an exciting time in health care and with transparency. we have got consumer reports now partnering with doctors groups to make the national registry outcome available to an easy to understand ways that the patient can look up with an app with the risk adjusted performances at the heart surgery center in their community. this is i-4 think the future of health care. it's an exciting time. it's a revolution. i have sort of become an observer if you will or a reporter on the subject. i'm not the leader of the transparency revolution health care is a matter fact, we don't have one leader. this is something we believe in and are as passionate about as the art of medicine. >> host: so you talk about where perhaps a decade or more ago, doctors protected that information because it was misinterpretedmisinterpreted, if you will. then there has been this evolution of thought towards transparency, partnership between the consumer groups and physicians. if that is the case, what impact has that had in terms of our overall levels of quality, safety efficiency? this movement has been going on for sometime some time yet you cite some really challenging cases and statistics that are going on. what is your sense of how things have moved and where's it going in the future? >> guest: is a great point. we have gotten burned with transparency. we have had systems that are local and small. the patients haven't known where to get the information. let's face it, unless there's a central site like hospital safety score.org run by leapfrog or the consumer reports cite, there is no sort of master dashboard. we are not really informing the public and were not really guiding them. the other thing is a lot of times we have created so many loopholes that we doctors have learned how to game the system and that is what happened in new york with the heart surgery program. we saw for for the first-time ceos and doctors focus on a common mission to reduce certain complications in surgery. the ceos were saying here, how about a dedicated anesthesiologist who specializes in hard anesthesiology and the doctors said yes, that is what we need. there's a tremendous teamwork in solid transparency but the system was not perfect. for the first time now i think we are seeing the doctors groups better define what is a complication. they are using independent nurses at a hospital to track the outcomes. early versions we would just ask the surgeon, what is your infection rate? well of course we would understate our publication rate -- complication rate. it was a uniform bias, the nature of assessing your own performance. i think now there is an exciting opportunity. we have got organizations with doctors lined up to say, look at all the sites that we can populate with information. the affordable care act tried to push some of this forward. i believe there is a lot more we need to push forward. its readmissions now that will be available for the public and for the first time this year people can look up a hospital's infection rate on the master site hospital care.gov. for the first time they'll be able to look at a hospital bounce back or readmission rate, the number of people that have come right back to the er. these are what doctors generally considered to be valid, not perfect, valid ways to measure quality. i think were going to see consumers rally around them. they are not perfect and we will have to make them better. we have to refine them, revise them and make them more risk-adjusted but there's a tremendous time right now out there. quite frankly we need fresh ideas in health care. we have been talking about the same stuff for years. >> host: in the field of quality in health care, it's a relatively young field if you will. you talked about the need for patients and consumers to get actively involved in fact you reference that doctors cannot do it. regulators can do it and politicians can do it but that the patients have to do it. talk a little bit more if you will about the role that patients need to have. today i'm struck with the fact that a five google something on the internet, a certain disease or a treatment, i will get hundreds, perhaps thousands of different sites to go to. one thing i have been hearing from patience is they have difficulty navigating that. how could they know what the high-quality data that is out there is. you reference the couple but if we are going to ask patients and consumers to play an active role and help us move forward and change the system, how do they navigate that? what is their role within that? .. >> that we have many moving parts and players where people are responsible with little accountability. what is the role of teamwork that we deliver? what is the role of the patient within that? how do we move forward with physicians, regulators, pati ents? >> everybody seems to recognize t market is part of high quality care but we haven't measured it for a long time. if there is one part of the assembly line that is so shoddy it is a reliable but yet it hurts the entire process but nobody looks into it. there is a survey that measures the quality to ask every day providers would you go here for your own care? do you feel comfortable to speak up? are you part of 15? are your concerns heard? it turns out these concerns are followed by just not available to the public. the government issues the survey on their website as a free download. it collects but there is accountability -- no accountability. but doctors and nurses will say when the team work is good everybody is happy. vendors turnover rate is low, they feel they own the care better, a better place to work. with mine near mess i described the book when i harmed a patient from a mistake that i made in day almost operated and the nurse spoke up that is a save the patient having the of wrong side procedure. the day was crazy busy going back-and-forth with the ico the team dropped the patient and they prep to the wrong side but had catastrophic consequences. then realized it is a team sport. more and more nurses say with the surgery boards and to have disruptive behavior of the last three months. and lot of it starts with the respective your leaders 87 so the work that you did so i am struck by the examples list the members of the team and you describe boyd in your book. what past have been for that to become more common? with the operating room equated to what happened to fly a plane where aviation went through for the is decades ago. how was that the market and? >> it is one of the cultural trains it needs to change -- trains in need to change faster. like the military. the rules and procedures the rules to do things and the under in standards to never go above our superiors head. we could be more honest and open of health care to design the way that we talk in the clinic and in the hospital. when we do about -- develop the checklists for the operating room, to have a daily goal sheets and then to popularize the who group represented our experience and it is much bigger than we ever anticipated. but the first item going over the name and the members of further the -- of the team's roles. a simple introduction. and we also the value to make introductions a simple statement of your name and what role that you have. as a critical part to empower people-speak up again. empower people to sit around for a meeting to present something it is easier to speak up again. the first time your activated. so the team members are activated. >>host: what about the patient? do they speak up? >>guest: absolutely. as they add to our understanding but by and large if you can join a family member, go with them. this program called open notes that patients can instantly see the doctor's note to during a visit has been tremendously successful. it will not fix health care. innovation will not solve the health care crisis. but there is enthusiasm because of what represents. the profession bridging the divide to say you are a part of this. even add a line at the bottom to say i a agree. i misspoke. as part of the patients record. one patient with the domino pain she asked a question there is a certain type of been in jerry's ice cream cause this type of pain? by a told her it wasn't related. then she had a suspicion she was sorry i wrote to in the chart. i said here it is. the the bond of trust was restored. >>host: a couple minutes left. talk about leaders, but clinicians, what role does the board of trustees of hospitals have? there's a movement to get them involved. >>guest: i was disappointed when i saw the department of hhs a physician should be on the board. they overturned the intended rule at the last minute. that was a great disappointment. hospital boards and a good ones are focused on the outcome to look at the performance hospitals do well and the board does a great service. but then the culture becomes bad. >>host: this book has had a tremendous impact. you have had a lot of press. will you keep operating? what your plans? >> there is nothing better to say your mom will be fine. but i love to talk about the subject from this position at hopkins. >> speaking at different meetings. >>host: to write another book? >>guest: hopefully. >>host: the book is "unaccountable" and dr. marty makary thank you for being with us today.
it's not a costume. that's the uniform. and he is carrying the weight of the guy he killed -- excuse me. we had a procession about it: under out to the graveyard and we buried him. my sensei doing all that was with trauma, you. the bad staff. and in order to heal from that time you have to dig it up and commemorate it and put it back in the earth. we have literally done that. for the sake they were carrying the war. >> wayne karlin teaches language and literature at the college of southern maryland. he's a southern novelists. this is a nonfiction book. "wandering souls: journeys with the dead and the living in viet nam". professor trained to karlin, thank you for joining us. >> coming up, booktv presents "after words" orientate gases to interview others. this week, dr. marty makary examines dangers of a hospital stay in his book, "unaccountable." the john hopkins surgeon provides an inside look at hospital errors, overtreatment in the closed-door culture that protects medical practitioners. discuss the findings and experience with president of washington d.c.'s sibley hospital, richard davis. >> hi, i'm cheap davis and i'm here today with marty makary, author of "unaccountable: what hospitals won't tell you and how transparency can revolutionize health care." so welcome. >> guest: good to be with you. >> host: you are an expert in this field. tell us about the reasons that you decided to write the book and some of your findings. >> guest: well, two main drivers led me to write the book. number one, patients often tell me when they come to the hospital they feel like they're walking in blind. there's a strike system they don't know how to evaluate. when he asked my patients, why did you choose this hospital, over my career i've gotten answers like the perky near as good. we can do better than that. this is one fifth of the u.s. economy and competition seems to be at the wrong level impatiens are frustrated. the other reason i wrote the book is doctors are getting crushed right now. they've got declining medicare payments come increasing overhead. hospitals have more expenses. malpractice rates are going up. the burnout rate in health care is 40%. doctors are getting crushed right now and i felt like we need to voice out there and it's okay to talk to the general public. >> host: so you make the point that medical mistakes if you alert the third leading cause of death in the united states. that is a shocking figure. can you talk about? >> guest: it was shocking for me if somebody interested in this field of quality to see you put in that way. medical mistakes are number three. we kill as many people from medical mistakes as we do from car accidents and other causes of death in the u.s. i never thought of it that way because we don't talk as openly and honestly about mistakes as we showed in our profession to be very blunt. you think about number one, heart disease. number one cause of death in the u.s. we spent a lot of time and energy on her prevention of heart disease. cancer, a ton of money going to cancer. medical mistakes were just now beginning to recognize this is number three and some people have told me after i wrote "unaccountable," there's not a medical mistake problem in the u.s. and i think we're starting to just now except this is something we've got to start talking honestly about. >> host: so we know there's tremendous care that he's received here in the u.s., certainly at the institutions to train to. at this confab of kind of quality and disparity of quality and you got interested in it during your talk perl program at harvard. can you talk about how you came into bottom what's your interest was awarded the field come from? >> guest: pitches started to be recognized as a field that i was a student. i had this frustrating experience as a patient of mine that i was assigned to follow. her name is mrs. banks and she's in the opening of the book. she didn't want anything done for her cancer, which had spread all over. the doctors clearly wanted to do something. they essentially bullied her or talked her into it. they overstated the benefits and under siege at the risk, something we know from research happens, especially those of us who do procedures it just didn't seem right to me. it seemed as if profession wasn't telling the truth. he seemed medicine have long straight from its original mission and heritage. it's not why it went into medicine and i quite frankly quick. i started school where i met david-based evolution money. >> host: i'm sorry to interrupt. you are an medical school and you had enough and the two school public health? >> guest: i explained it at the morning conference. it turned me upside down for exciting to them she didn't want the procedure done. they basically implied it didn't matter what she wants. this is what she needed. this was to me definable culture that i observed from the outside but didn't want to be a part of. adequate medical school. and then i started graduate school for public health because i heard of a track where you can focus on quality and they were people not interested in medical mistakes for the first time they were describing studies where they were lucky not handwriting and it was a radical concept of the time. david bates but a study or describes the head of one of the largest organizations in the states calling him. and basically saying what are you doing this for? this is not a problem. you realize we've had these explosions of knowledge in medicine, but we have not coordinated care and all the services we have ended up having so many cracks but the cracks are as harmful as the diseases we are treating. you've got to step back and ask, you know, are we hurting people overall? on the global level, but we do and sometimes now we've got these reports saying 30% of everything we do may not be necessary. the tests we order, procedures. this is something for the first time really being called out as a problem. people out there in the general public have been saying for a long time, we don't like the closed-door culture of medicine. refinement is said to be an arrogant industry. we feel like we don't connect. i remember in medical school being told in no sleep with at is. is it not a nosebleed? it's like a whole different vocabulary and that disconnect has created an issue with our trust in the public in this issue of overtreatment has further strained the public trust that medicine is bad. it's a great job, a great profession. you're in health care and everyday you see see folks have tremendous result was the byproduct of phenomenal advances in technology and the art of medicine with compassion. it is a great profession. when we've got better since they 30% of the time we missed the mark we've got to study this. would that make it a discipline of science and say how cool you look at this likely look at can how could we streamline care. i was the main reason i decided to write "unaccountable." >> host: that statistic of 30%, problems with quality, waste, variability is a stunning statistic. why do you think that -- you mentioned culture a while ago. what is it about the culture of health care, where those types of duties have been allowed to go on for some chilling the time? if elected any other industry, a 30% waste or 30% error rate really would be unacceptable. how does that occur within health care? >> guest: you know, it's a great wonder why people tolerate 30% waste in health care, but they wouldn't tolerate it in any other industry. aside a statistic recently. the average income of an american and united species, 30% over the last decade. the increase in health care costs they pay has gone up about 60% over the same time. essentially we've offset increases in income with help care costs. so you wonder why you said we tolerate this? attempt to business leaders say, every contract or we pay we have some magical power will be performed except for one, health care. we keep throwing money at it. patients say the same thing with premiums and high deductibles. what more medicating quakes what are we are we getting for her there's been this culture of medicine that has respected the art of individual autonomy. but it's a great risk for some best practices never get standardized. in my own field, pancreas other transplant, we take a pancreas that if somebody, treat the cells into the cells it to the patient. when is a laboratory to treat the cells. well, that occur at 11-point paid a bonus $20,000 payment to hospitals for doing this on top of what they were already charging. it became a very profitable business. we have a laboratory at johns hopkins in the operating room and the patient asleep under anesthesia, take a pancreas, treat the cells come and get the cells decorate them and there come the same operation. hospitals started doing this operation, taking the pancreas. because they don't have the laboratory, put it in the cooler and send it to another city, how they treated at another facility in another city or state. how the phone back and cut the patient open again for a second operation. why would anyone have that procedure done? they don't know about the other option. i'm not talking tiny hospitals. i'm talking to a news world report and the countries do this. we've got smart people, good people working in a bad system, where financial incentives lure people to do things that just aren't ready. if hospitals are accountable for the results, if the patient satisfaction scores, outcomes, complication rates, volumes i readmission rates, on the basic metrics of health care reform and the doctors and nurses that would, if they were available to the public, people could choose where to go based on who performs the best like any other free-market works unlike any other free-market uses in their field. >> host: the issue of patient choice about where they seek care is one that's been out there and certainly in literature and discussions amongst leaders for a number of years, where many people advocate that if indeed patients have the opportunity to see the quality coming to see individual performance, hospital infection rates, that they would naturally gravitate to those institutions. there's another school of thought that says you can put the information out there, but that won't really happen. patients will gravitate to. you referenced in your book were patients seek their care. i go there because my mother was born there or because it's two miles from my house. talk to me about the balance there anything you quality is a fact there. how do we get patients informed as to how they can seek to set her nation and really will it make a difference where they seek care? >> guest: i've got some patients the tummy talk, whatever he wanted to, tommy and onto it and they've got total blind trust in the system. maybe for then that's okay, but more and more patients want to know the options. they want to know something can be done minimally invasive. if there's a holistic preventive they want to know now. increasingly we see that. one critic of the book told me if you put stuff out there, people will never use it in a won't reduce health care waste. well, for weeks after the book came out, a study in the journal of the american medical association showed that when there is public porting of harpies teachers, students and angiograms, the overall number of procedures went down by 14% and there was no difference in patient outcomes. big study about four weeks after the book came out showing that public reporting reduces waste and has no impact. patients do just as well. so increasingly, we are learning that the impact of public reporting. all of us know doctors who should not be practicing. when national conference i was at, how many of you know that that tradition be practicing because they're too dangerous? everson o'hanlon. and because we all recognize there's going to be some bad apples that will really respond to financial incentives and that there's little accountability in general in health care hospital seven miles down the street from my hospital had a.to put in at least 500 unnecessary hurt since. now if those procedures would've been recorded in giving to the patient on a thumb drive as the advocate in the book, "unaccountable." he wouldn't have gotten way with giving students an arteries that were bought. it would've been over say like when we are speed traps with humorous at an intersection, everybody follows the law. the compliance rate is a want of run to follow the speed limit for decades has been hard to do since we've had automobiles even trying to do education. education doesn't work. what works is when someone sees a camera or officer of the site of the road. then everybody is compliant and i think we in health care have a lot of room to increase accountability and quite frankly, it will really restore the trust that's been broken with the general public. >> host: so let's go back to the culture question. i was riveted by your account to when you're with that room and everybody raised their hand that in fact as you describe it come you were hesitant to pursue research and was a senior position next year will look at humans have really come you don't know anyone and they need to. what about the culture of medicine do you think has led us to this point of where we actually know that harm may be occurring or have a sensor that the we've gotten to this point where people are afraid to speak up, afraid to criticize their peers or the institution. you make a point a number of times in the book and then actually your opening chapter, where you talk about the fact that go to are the people in health care, the nurses and doctors in the restrictors of that hospital, where they would seek to care. how does the closer if you will proliferate what you've been talking about and for the public, how did they seek that information out? >> guest: i once told a friend and i say to find out about the quality of a hospital is to ask an er nurse who works there. a nurse knows more about the quality of a hospital than probably anyone else. for that matter, in any industry, front-line worker providing services could be if sales are creating products probably knows more than any administrators about the culture. the reason is culture trace everything we do. in economics, there's a space no one has ever washed a rental car because they don't own it. defensive tone in the delivery of care is of critical importance in health care. that's what bothers me about seeing the statistics found that 46% of doctors in the united states are earned out according to the mayo clinic. i did a study three weeks ago. what we've got 46% of front-line providers in any industry burned-out, of course the quality will be variable. of course people will fall through the cracks. when people don't feel like they own service. docs tell me when i go to conferences and speak, i have to know how to make health care better at my institution. i know how to make the care safer for patients. i just don't feel anyone listens to me. i don't feel empowered and that is one of the great divide right now in health care in the united states. increasingly, we have some doctors saying that some facilities that there's a chasm between themselves and their unit manager, between themselves and those making the policies are those calling the shots on a national level. they don't feel empowered and i think we're seeing more variability because of that. >> host: you talking about providing administrative crackdowns administrative crackdowns if you will, where you could providers of care and senior administrative leaders working a little bit work together or getting the administrators out from their offices if you will. talk about that and what you see the value of their while i think impact on the quality and safety. >> guest: we all want the same thing. doctors, administrators, insurance companies, policymakers. as an astronaut from outer space who is fast, what does the middle east look like from outer space? in the astronaut said there are no lines when you look at it. the lines have been made. and that's what's going on in health care. the lines we've made in health care or man-made. we'll want the same good for the public. we've got good people. they're just sometimes working in this artificial system. we told administrators can make a profit, so your bed yesterday make a profit until their bed. we told doctors to see my patients to the tumor. we tell doctors do more procedures in the duma procedures. everyone is doing their job, but as don burke said, it's like the jobs are designed wrong. when my dad was practicing doctor or decreasing her hospital, i remember this administrator named ken ackerman who would come down and sit down with the.there's eared he would walk down the hallway, pop himself right in their office and say how's it going? would you need to do your job better? he was in a doctor ken ackerman, but the doctors on this staff said he was the administrator in a white coat. that's how they came to make make him. he was in touch with front-line providers. you use the amount kinds of industries, via lehman brothers, be it a large corporation delivering a service that's multinational. when the administrators is touch with front-line folks, that is impacting starts happening. that's in the accountability becomes a problem because there's no transparency and that was the impetus for writing "unaccountable." >> host: at a hospital president, i'm always struck by the fact that if you want to know where the issues are as you describe, you go to the front-line. go to the operating nurses. but why do you think in many hospitals, perhaps to become a separate differentiation or divide if you will between administrations about and does it have anything to do with incentives? you talked earlier about misaligned incentives if you will. so what do you think? >> guest: i've seen both extremes in the united states and talked about both extremes of the book. i recently learned of an emergency room of his coat is freestanding with the hospital attached to. can you imagine if a heart attack in the emergency room and they don't have a house of achieving. they have to ship it across the floating bridge to another hospital because that's versus hospital. this happens in the united states nec's doctors say this is afraid. even administrators say we know it's not rational, but that's the way we get paid. they get paid more for emergency visits and private care. when things are disassociated, the care gets dangerous and many see times there in harmony. you see when there's transparency of infection data, how the administrators talk to individual providers specifically about infections. what do we need to do to get infections down? this is a model of management for any industry. the near transparency experiment underwent heart surgery outcomes are publicly reported, i tell a story that mark chesson described, are they headed ministers walk into the units and ask doctors and nurses, what do we need to do to get mortality down? they ask nurses bias the complication rate high on how to we decrease it? you don't see that level, mission about reducing complications except when everything is aligned, transparency and the data, accountability at all levels for performance and people on the system. i remember hearing the story of a nursemaid we've never seen the ceo here and the cardiac icu except when we public reporting of heart surgery outcomes. you realize these old-fashioned concepts here. these are american concepts. transparency is an american value. we expected that the white house. mix it to the congress. we expect it of wall street. sarbanes-oxley will have a ceo could joke they misrepresent their earnings for the company. health care is a compelling. it's like you can misreport infections but there's not that level of transparency and we treated differently. we have to treat health care like any other business to reduce the ways cost for everyday americans. people are getting crushed right now with deductibles. they are essentially paying for all of their health care with the exception of catastrophic care. it's becoming a two-tiered system. we see primary care doctors say just pay us a couple thousand dollars a year from a work to take of you. but with housecall is to have my cell phone. it's medicine the way they practically, the way we dreamed of practicing medicine. it's health care to the only streamed restrictive getting it and they're rejecting, revolting against his bureaucratic regulatory system that involves fighting with insurance companies and other hassell's doctors could crash at right now. >> host: this talk about leadership in the world leadership plays. i loved the story you tell about roper v. i use that story myself. talk about the rule and the example of that story in which think it means to senior leaders in health care. >> guest: jeanneau, i say many times somebody everybody wants the same thing but there's a break down of communication. when bill birdie walked through the icu. host hotel who build rodeos. >> guest: he's president at this initiative to get executives adopt a unit to many executives at hopkins adopted a unit, an acu -- icu and he put the stats and we still do a similar safety concerns here? how are you going to harm the next patient? anticipate was going to go wrong next time i have a medical catastrophe. every year at every hospital in the country, doesn't matter the best or worst has medical mishaps every year. these discussions create an anticipation that allows people to redesign and reengineer the hospital system to make it safer. the employees, staff and nurses will value. the few people listen to them. i went with a 46 of doctors saying they burned out, don't feel valued, getting crushed all part is insurance premiums and had an affair with insurance come means, it goes a long way and not feeling value despite her hospital or leaders is a serious way to alienate the very people that are responsible for safety and creating a safe culture. >> host: for those of us who are leaders or ceos of hospitals, et cetera, what role should accountability and transparency play in the way we conduct our daily business? was your perception on that and where can we improve? >> guest: it seems like it the old guard of the establishment or a few corporation to resist a little transparent tea. when you type the individuals, the people, the moms, the parents, those who take care of patients, doctors, people who are administrators. they are pushing us and we see this transparency revolution not driven by patients ironically, they triggered by the doctors and administrators and organizations to see the waste in health care. it bothers the heck out of them and they want to do something about it. we see thoracic surgeons, organizations, leapfrog, all these organizations rallied together to say we think it's the right thing to do to be transparent about what we do. we are proud of her results. we've got nothing to hide. if we perform well, the public should see it and if we don't, the public should see it anyway because were honest and transparent. i once ordered a cat scan on a patient. it cut down on the wrong patient. this in the senate about this richard patient's bedside that i'm sorry you didn't picture cat scan because there is a mistake. i'll make sure you get it done right away. to the other patient i said, were sorry you got a cat scan. it was intended for someone else. it was a mistake. sorry, all saw the results with you if you want to see them. the patients were not angry that i thought they would be. they looked at me with a sense of appreciation. thank you for being honest with me, don't her. i feel he patients a lot of times just want honesty. they want to be treated with dignity. they want to be treated like they would in any other business. that's what people are hungry for in health care and that's what the organizations and leaders in health care are saying we need to provide the patient. we did a research study recently that looked at the number of national databases that follow hospital performance and patient outcomes. by the pancreas transplantation, their databases we report outcomes too. there's a national pancreas transplant registry. they follow the outcomes at different hospitals that do this. the public has no access to this information. in our research study we found there's over 200 national hospital outcomes. only three make their data available to the public. most are funded by taxpayer dollars in some form. i think we as a society are starting to ask the question, do we have a right to know about the quality of our hospitals? i think we see theaters in health care step up and say yes we do. >> host: you've raised provocative and compelling issues here and your book really has a think ben truly illustrative to people in terms of some of the things going on. and makes "the new york times" bestsellers list, et cetera. i'm interested to know the comments of your peers in this, both younger physicians, older physicians. use the term old guard a couple times. he put this out to, talk about this. many people are recognizing the. talk a little bit about what impact did that and really how people feel of the feet tactic again. >> guest: i've gotten thousands of letters, many of which are handwritten. tens of thousands of e-mails that say my mom died because of a medical mistake. we didn't feel it we were a part of the process. we didn't feel we were given all of our options. we feel there was a mistake or know there was a mistake. thank you for sharing this story. it's almost as if everybody has the story. at that personal accounts here of people i know that had suffered from medical mistakes. everybody had the story. it's the number three cause of death is medical mistake. i think there's this general appreciation for talking about this openly and honestly. the younger.yours in particular come from a different generation. medical students nowadays have very little tolerance for not telling the church in any aspect of life. they insist on transparency in all aspects of their living. and then there are what are referred to as the old guard, some salmon expert in medical mistakes. we should be talking about this at the general public or there was one individual whose response to the book said there is a typo on the inside of the jacket of the cover. 30% of health care is unnecessary and the responses there's a typo? medical mistakes are the number three cause of death. of course there's different responses. health care is a very emotional issue. look at the way the politicians have divided the country and polarized the subject into sound bites. health care is complex. the reality is there are good ideas on both sides of the aisle and we just need to talk about common sense solution in health care. all the different ideas we hear about from politicians are centered on how to pay for health care differently, how to fund the broken system. we don't have to talk now how to finance a broken system. we've had to move on how to fix a broken system. i think that is a fundamental discussion, which gets to the basic transparency, patient outcomes, patient choices and patient empowerment. i've lived in d.c. for a while and i know politicians are not going to fix health care permanently. we doctors are going to do it. insurance companies are going to do it. it's going to be the patients and they've got to give them good information. a 60% of new yorkers are looking up at a restaurant track ratings before they go there, why do you have to walk in for their health care blind about what a hospital c-section rate is or infection rate or how many hip operations we do or how many knee operations they do. if you have lyme disease can i do want to go to a hospital is the only case in five years they've seen or do you put a hospital that treats 50 cases a year. these are basic things the public demand in any other industry and we can provide these things in health care tumor transparency. >> host: so that leads me to -- use the term flood friends don't care in your book. talk about that are your thoughts on how that plays into what you just described, which is 60% of new yorkers who go online and look at the restaurant review, but to just walk right down the street to their hospital without doing any due diligence, et cetera. how is the fred flintstone care in the culture of medicine play into that? >> guest: i am constantly flabbergasted at how patients walk into a doctor's office and the doctor will not mention the superior option to the patient. i think sometimes because they're worried about losing the patient to another doctor. you pay a lot of money based on the quantity of what we do. that's got to change. we've got to be paid based on the quality and outcomes. we've got to get away from this heavy volume oriented way we finance our health care system. we are incentivizing people to overture. are we as doctors in the survey, weise's overtreatment of the epidemic so broad? they say because were so heavily incentivize. usually they don't say themselves. there's malpractice concerns and other things that have the answers. but a lot of the doctors to have the answers on how to address this problem of medical mistakes in overtreatment. i talked to dr. psalmist every week if sandy text messages and e-mails from my superiors to give our operations and if you like and doing the right thing for my patient. they don't like that. that's not the type of medicine or profession they wanted to. i think we need to start thinking about how patients can get the best options by eliminating these heavy incentives to under refer. there are patients that i've met, rotating us a resident there were not told there's a superior way to reconstruct the after removal because the local plastic surgeons don't do it that way. they do it another way. the research and literature clearly shows inferior. it's silly standard of care. they won't get sued for doing it, but there's wide variations. my own field of pancreas surgery, if you have a small pancreas cyst that needs to be removed in the tale of the tanker is, a patient walks into one hospital, they'll have a big mainline station. but the tale of the pancreas removed in their spleen. walk into another stop to stop the symbol of a small, minimally invasive keyhole incision cannot remove the spleen. talking about removing or not removing the organ based on what store you walk into. all good hospitals, good reputations cut radically different ways of doing things. removing it:. there's two totally different ways of doing it. minimally invasive and threw it open incision. some say you can do it either way. we have the "new england journal of medicine" over 10 years old that shows minimally invasive is better and it's common sense is better. if the wild west of medicine would have it that only patients that are great candidates will ever have it done that way. >> host: use the term the wild west of medicine. that's where in your book you talk about the need to have a new sheriff in town. so top name a bit about this concept of the new sheriff in town or accountability are holding people responsible in how that balances with what we frequently hear what we train before the standardization or accountability to the art form of medicine. how did those two things kind of play out? >> guest: i get the art form of medicine. most of the patients that come to seamier complicated pancreas tumors. this is my own area of expertise. justin mayfield they see these complex cases where patients are told there's nothing that can be done at the other hospitals in the come to me we say yes it's high risk. these are the risks if you want to go for it we will go that or survey for a long time for a long time disabling a minute, we can't make outcomes transparent. it doesn't appropriately adjust for the high-risk nature of cases we take on here. i agree 100%. as a matter of fact, doctors are right to lead the opposition to transparency. if we make the raw data transparent, we could punish thought there's a take on the noble high-risk cases to reward those who discriminate against them. we actually create perverse incentives. but now that yours are saying with a valid ways to measure quality. we've created these measures. we endorse them. we monitor them with their own national registry house by the doctors groups. we think it's the right time to make this available to the public and for the first time ever, this is an exciting time in health care and transparency. with that consumer reports now partnering with.or scripts to make a national registry outcomes available in easy to understand ways so patients can look up what the risk-adjusted performance is, the heart surgery center in their community. this is the future of health care. it's an exciting time, a revolution. it's sort of become an observer at the wheel or reporter on a subject. i'm not the leader of the transparency revolution. in fact, we don't have one leader. this is the truth, something we believed in and are as passionate about the subject itself. >> host: you talk about a decade or more ago.it is protected that information because it could be misinterpreted if you will. and then there's been this evolution towards transparency partnerships between consumer groups. if that's the case, what impact has that had in terms of our overall levels of quality efficiency and mistakes? this movement has been going on for some time, yet you cite some really challenging cases and to test it's going on. what is your sense of how things move and where's it going in the future? >> that's a great point. we've got burned with transparency. we've had systems that are local and small in the patients haven't known where to get the information. let's face it, unless there is a central site take hospitals safe to score.org run by leapfrog, there's no master dashboard, were not informing the public. a lot of times we created so many loopholes that doctors have learned how to game the system and method have been in new york with her surgery program. there were many successes. we saw the first time cbs and doctors focused on a common vision to produce certain complications after surgery the cpus were saying how about a dedicated anesthesiologists who specialized in hard anesthesiology. doctors say yes, that's what we need. there's this tremendous teamwork with transparency, but the system wasn't perfect. for the first time, we seek out or groups better define what is a complication. we are using independent nurses at a hospital to track the outcomes. early versions we asked the surgeon, what's your infection rate? of course it would understate our complication rate and was a uniform bias. it is just the nature of assessing your own performance. now there is an exciting opportunity. we've got organizations adopt are signed up for sale that could all be saved but we can populate the information. the affordable care and try to push some of this forward. i believe there's a lot more we need to push forward. we are missions that will be available to the public and for the first time this year people can look up a hospital infection rate on the national medicare hospital stay about hhs.gov. for the first time they can look up hospitals bounce back or reignition rates. these are what got us generally consider to be valid ways to measure quality. i think we had to see consumers rally around them. we have to fix them. they're not good, not perfect. we have to revise them and make them more risk-adjusted invalid. quite frankly we need fresh ideas and health care. we've been talking the same stuff for years. >> host: to this native quality and safety health care is a relatively young field. he talked about the need for patients and consumers to get actively involved. in fact, you referenced the fact that doctors can do it. regulators can't do it, politicians can't do it, the patients have to do it. talk more if you will about the role that patients need to house because today i'm struck with the fact that if i google sent it on the internet, acer disease or treatment, i'll get hundreds, perhaps thousands of different sites to go to. one thing i keep hearing from patients if they have difficulty navigating. how do they know what the high-quality data that's out there. you referenced a couple, but if were going to his patients and consumers to play and i didn't grow up to move forward and change the system, how do they navigate the? what is their role within the? >> guest: that's a great question. even with all these hospital safety score, husker du compares, patient satisfaction scores. even with new websites being populated with more and more information every year, nothing substitutes for a great conversation between you and the.your i.q. and a nurse and the doctor's office. there's something to be said for the patient but does the research on google, which is 92% accurate. we've done the research of john top is. people type in operation, conditioned by medication, what they look at is 92% right on. there's something we said for people who do that, bring that into the doctors office and have a conversation. i often tell people if you're going to have some denature like an operation or start taking a medication every day for the first time in your life or you don't know what you're wrong with you and the doctor can't take it out. get a second opinion. those are times when we have to remember that scott showed 30% of opinion are different from the second opinion. we are human beings. in my own area of expertise, i will run things by a partner or an expert in the country. if someone has seen a different variation or different presentation, it is no substitute for good conversations with doctors. doctors are as frustrated with the broken health care system is patients are. when we see ourselves in the same boat, we have a certain appreciation. it's all medical students, treat every patient like your mother or father. i think that's a good guiding principle that was taught to me. >> host: to follow-up on that, throughout the book you talk about the importance of teamwork can you just referenced it now. but i'm struck with the need for teamwork is to move forward and health care reform as well as some of the issues you've identified. stanford u. know talks about the fact we have many moving parts, many players and health care if you will, where we have many people who are responsible, but little accountability overall. so how would you see, first of all, two questions. one, what is the role of teamwork and the care we deliver an importance of that and what is the role of the patient within that? how could we move forward with all the different groups, physicians, insurers, regulators, patients should resolve some of these issues? >> guest: you know, everybody seems to recognize teamwork is a critical part of delivering safe and high-quality care, yet we've never measured it for the longest time. it's almost as if in effect jury you know what part of the assembly line this so shoddiest often on unreliable and it hurts the entire process and yet no one looks at to it. there's now a survey that brian sexton created that measures quality of teamwork. asks everyday providers, would you go here for your own care? do you feel comfortable speaking up? t. feel you're part of the team or concerns are not being heard? and it turns out these results have been followed and tracked. they're just not available to the public. the government even issues the survey on its website, makes it available for download for hospitals and collects the information, yet there's no accountability around that. that's one simple thing we can do differently. often times when i talk to docs and nurses, they say when the teamwork is goodyear, everybody is happy. when the nurse turnover rate are low, nurses are quitting and getting hired. with a turnover rate is low, they feel they own the care better. it's a better place to work. when i had made near miss if you will, i describe in the book a time when i harmed patient of the mistake i made. i described a time when i almost operated on the wrong side in the nurse spoke a bit nuts with it the patient from having the wrong site besieger. today was crazy busy. i was traveling from the icu to do with a quick emergency, came back to the operating room. i team had prepped the patient and they prepped the wrong side. as a minor procedure, but would've had catastrophic catastrophic consequences for me and for the patient. it's one of those things where you release it is a team sport and more and more we hear the nurses say, you know, if we can have more teamwork, less disruptive behavior. we have a study now from the archives of surgery report, 90% of nurses and 40% of doctors have witnessed disruptive behavior and the last three months. we can do a lot to improve teamwork in hospitals and a lot of it starts with the peer respected leaders. >> host: the work that she did really talk about the issues of culture, the importance of teamwork. i am struck with the many examples that you've given and her three years of the importance of the members of the team, perhaps not the surgeon speaking up in effect you describe one in your book. what has to happen for you to become more common in the culture, it actually besieger areas or perhaps we equate the operating room to what happens flying a plane and the need for aviation went through some of these things decades ago and that they took away. from your good, how does the teamwork and enhanced moving forward from what starts at? who has to start at? >> guest: is one of those cultural traits that changes over time, but we need to change it. we look at the hierarchy of medicine and hierarchy of the military. we have rules and procedures, ways of doing things. we have unwritten standards that we never go by their superiors had for anything. i think we can be more honest and open about the problems in health care and redesigned the way we talk in the operating room in the health care setting and clinics in the hospital. when we developed a checklist for the operating room, this is after peter provost has worked in the icu and said we're going to have a daily goal sheet. and go on the vitter popularized , the world health organization group. it became much bigger than we ever anticipated. the number one priority that we made in the checklist was making the first item, going over the names and numbers of the team, going over their roles. deshaies a simple introduction. when gore won the land, he was particular that be the number one item as well. we have setup a value in making introductions, just a simple statement of your name and what role you have in the team to be a critical part not only to be friendly. let's face it that's nice, but that wasn't the goal. it was to empower people to speak out. at your workplace to have a conference room and you're sitting around for a meeting and you have to say something in the beginning our present some pain. it's easier to speak up again. it's almost as if the first time he speak up and say anything, your act debated and that's what we try to do is activate every member of the team. >> host: settee members are activated. what about the patient? >> guest: absolutely. it's amazing the amount of information patient family members added to our understanding of the patient's condition. by and large, a featuring a family member when they see their doctor, go with them. this new program called open nose allows patients to instantly see their doctors note when they see a doctor for a visit has been tremendously successful, not because it's going to fix health care. let's face it. innovation like that is not going to solve our health care crisis. but there's this disproportionate amount of enthusiasm for it because what it represents. it represents the profession of bridging the divide and senior part of this for doctors sharing with the patient in an open and honest way. what you see what our plan is. i want you to see what i wrote down. even at a line to it if you like. say at the bottom i agree or there's a mistake or a misspoke. i don't think this represents me and that will be part of the patient's record. one time i had a patient asking about abdominal pain and she asked me a question i was a little bizarre. something about a certain type of ben & jerry's ice cream over another type caused this kind of pain. i told her no it doesn't. it's unrelated. and then she at the end have the suspicion and it turns out she was worried that i wrote in the chart that she's a psycho or crazy or some thing. i said no, here it is. when she saw the know, the bond of trust is almost totally restored. >> host: we have a couple minutes left. first of all, it's the role of readers and clinicians. what rules to boards of trustees of hospitals in particular -- another spinning the hint around getting them involved. wonder if you can spend a minute talking about that. >> guest: i was disappointed i saw that apart and at hhs in their attempt to make one physician, at least i want position on the board of a hospital and they overturn this intended rule at the last minute and it was a great disappointment to a lot of doctors. ..
we're not going back to the precoronavirus normal anytime soon. crowded rock concerts in giant arenas, sold out broadway shows, football stadiums, filled with 100,000 people just packed next to each other. i think it's pretty unlikely any of those things are going to look how they looked before. we're going to stand further away from one another. we're not going to crowd into spaces. we're going to wear masks. workplaces that can do it are going to try to stay empty as possible, not breathing each other's air, and that principle two that we're not going back to normal, even in places like texas where restaurants will open on friday. those restaurants are only allowed to have 25% capacity. in georgia, famously the most sort of out front on this, some barbers are only allowing one customer in the store at a time. others wait outside 6 feet apart. most people or i would say almost everyone understands that things need to change. those are the principles we all seem to agree on. the question is what is in between those two principles. right? what is a safe responsible way of reopening. we like to call on this show, door number 3. the option that is either an uncontrolled pandemic or economic depression. and i got to say, this should not be some weird culture war question, despite the effort of some to make it some in order to detract from the manifest failures of the president to march people out to sacrifice themselves to the dow, it is a difficult complicated question that the world, every world leader, every state in the union is dealing with and there's actually a specific goal every society is trying to accomplish, and that is this, to keep the rate of transmission of the coronavirus down so that each infected person infected on average less than one other person. okay. this is the key benchmark. if the transmission rate is less than one, the disease is declining. if the transmission rate is more than 1, the disease is spreading. angela merkel who plans to be doctor of chemistry explained as they were gearing up to reopen their economy. [ speaking in foreign language. ] ge first of all, just imagine for a second having a leader that thought of the question of how to reopen society with that level of nuance. but that's what's necessary. when germany started to open up, they had the infection transmission rate down to .8 below that 1 threshold, but the coronavirus started creeping back up to an infection rate of one because this virus is so contagious, so few people have immunity. in singapore, many have covered as a success story because it has been, they are dealing with a second outbreak which is essentially forcing them to enter back into shelter in place, and the reason is because they ignored a marginal community. migrant workers who live packed in dormitories on the outskirts of the city. the margins don't stay the margins for long with this virus. other places like taiwan and south korea have been able to keep the virus, through testing and contact tracing. seattle, with its huge shelter in place order, they have gotten their infection rate down to where they started to lift some restrictions on things like farme farme farmers markets, outdoors, people can buy food. that's what's so important that angela merkel was saying, the margin of error is small because of the way exponential growth works. you can find yourself back where we were two months ago, two months ago, two months ago, february 29th when there was literally one confirmed death. before it spins out of control and we lose 60,000 lives in 60 days. and there are so many deaths that one funeral home is moving bodies if u-haul trucks because they don't have enough room. the question of how and when to reopen society is a hard problem to solve but a worst case scenario would be after we have lost many tens of thousands of lives, and knowingly pushed our economy to the brink of a depression and seen the sacrifice that the unbelievable national sacrifice americans have made in so many ways, after we have done all of that, to squander on some blind hope and culture war propaganda and end up in the same place a few months from now. joining me now is jeffrey sachs, author of the "the ages of globalization," also has been writing about this topic as well. dr. sachs, this sort of technical question, it seems one of those moments where looking out in the comparative world and in some ways trying to take it outside of the hot stove of american culture war politics seems crucial. >> chris, thank you so much for the clearest explanation that i have heard on television or the media since this epidemic began. we have heard nothing but nonsense for weeks and weeks from the white house, and we have 60,000 deaths. and the fact of the matter is many countries have suppressed the epidemic. china did after its initial outbreak. taiwan. vietnam, hong kong, japan. you have new zealand, australia, so it's not purely a hypothetical, and it has nothing to do with the culture wars as you pointed out. it has to do with one simple idea, exactly what you said, which is that each infected person must be stopped from infecting more than one other person. that means several things. it means early detection of every case. it means early quarantining or early isolation. you ask, can you be safely at home or will you spread it to family members. if it's too crowded at home, you have to go to a public quarantine, which could be a hotel room, for example. it means that in public, people wear face masks and respect the physical distancing. it means that any place that does open up is monitoring temperature, screening for symptoms. it means that we have a public health system that contacts each case every day, how's your temperature mrs. smith and are there other people you know close by, your family members, your children, your parents who you think have symptoms. we need to contact them. >> right. >> are there people at work that we should be contacting. what's contact tracing. this is straightforward. what is unbelievable in america is we have reached 60,000 deaths and not done the basics, and those countries that i mentioned, chris, have death rates that are 50th of ours or a hundredth of ours, so this is not hypothetical, our country, we have a leader who is the worst president in our history. such an idiot, i'm sorry to say, but americans are dying by the tens of thousands because we're not doing the basics and today, incidentally, the "wall street journal" ran an editorial about our zero, exactly this, but they don't even look at their own news stories, which have the asi asian successes. let's look at how other countries are doing it. we're not so stupid in america that we can't learn from the others. >> you know, i thought that the vice president's visit to the mayo clinic, he's the only person not wearing a mask in violation of rules and protocols. his response was, which was not a crazy response, basically he says, i'm tested for the coronavirus on a regular basis, everyone around me is tested for it. you test for it, and matt igl i iglacious, what if we do that for everyone. the vice president, so he can live a semino normal life. what if we expanded that idea for all of us so we were in a similar boat? >> chris, you know, there's been a problem with testing because our system, our centers for disease control failed. america is breaking down in so many ways because we don't take care of basic government functions anymore, so the testing got way behind because our main institution for this failed, but if you look at those other success story countries, korea has several private companies that immediately got successful testing going. the many other countries, even without much testing went on the symptom basis, people isolated. they went for quarantine, and they had public health officials that were tracing the contacts. this is so basic i can't even tell you. the first page of epidemic control is trace the contacts. when did president trump say one word about tracing the contacts, not until now. 60,000 deaths later. this is what we're facing. it's a mad house that we're having this in this country when there is so much knowledge and experience of what to do, but it's true also, by the way, cities across this country and governors, they're debating the date to open, not preparing the contact tracing, not hauling confirmed cases, not preparing the quarantine. this is the tragedy. we're wasting our time because as you said completely correct, you can get the case load down very far. but if you just open up again because of exponential growth, everything shoots up again, so it's not a matter of the date of opening, it's a matter of preparing the alternative to the lock down. the alternative is what's called public health. you isolate cases. you quarantine, you test. you trace contacts. can we do this in america still? do we have any sense of learning the most basic things when our lives depend on it? that's the real issue. >> jeffrey sachs, thank you so much for sharing your expertise tonight. >> well, thank you, thank you for what you're doing. it's so vital. we need to get the basics out for the public. i want to bring in now the president and ceo of the center for american progress ni nira tanden, appointed to new jersey's recovery mission by governor phil murphy. the center for american progress, the think tank you work at worked at a reopening plan, and aei, which is a right wing think tank, they did their plan. the plans are not that different. it's not like we have got some big, you know, abortion rights level culture war happening among the people that know what they're talking about about this question. there's actually consensus and yet that seems so far from what the political debate has been. >> yeah, no, i mean absolutely, and jeffrey sachs talked about the consensus and it's not just center for american progress and aei, it's every major university, every institution, economists have all said we need to do contact tracing and testing, and separation. and i think the real problem is in the country that we have a leadership people don't trust, and we have a national leadership that hasn't been clear and obvious about what to do, and i think the original sin here was that for whatever reason we didn't do testing right, but the president can't admit to that failure. can't admit for numerous reasons so he has moved to reopen at a time when people are just not prepared. you so eloquently said and is so clear, you risk so much by reopening when you don't have case loads down and enough, and when you don't have the infrastructure to actually even be able to contain the virus, and that is the real danger of texas, georgia and florida, their actions, which is, you know, it's a gamble. that is the problem. it is a big gamble. and that's why i think everyone should be working on tracing and testing and it's unfortunate that they're not. >> yeah, the testing we should just note that one of the things that countries do have in common dealing with that is they test a lot so they have low positive rates. if you're testing a lot, you want to be in a situation where you're not getting half positives or 30% positives. right now, the u.s. we're getting 18% positive, that's way too high, countries like south korea, a numerical capacity issue that we can do. it's america. we should be able to figure it out. >> i mean, the most important thing actually is to be able to test everyone who's sick and really test community test, meaning you're testing places that you haven't seen a virus, you know there's a virus, and you know the virus isn't there. the problem in the united states is that our testing capacity has been so low that people who are sick can't get tested, but we're not testing anyone on the front lines who aren't sick. and the thing that is incredible is that these states are considering mandating people come back to work and not giving them testing. i mean, that is the moral and public health failure because that is where you get the outbreaks. people come back to work, and then they spread it, and then you're just dealing with it at the end when we don't even have an ability to contain it. it is like completely shooting in the dark and hoping no one dies. it's scary, and no country is handling it like this. >> i've gotten e-mails from viewers from both iowa and georgia who have said similar things which is basically, and the iowa governor kim reynolds made this clear yesterday, if you're scared of your health and you don't go to work because of it, you've left your job. you don't get unemployment, the way unemployment works in america, if you get laid off or fired, you can get unemployment. if you quit, you can't. you have a situation quite perverse in georgia and iowa, if you feel like my workplace isn't safe, you're out of luck, and that's not good for epidemics, that's not good for epidemiological purposes whenever you think about the moral aspect of it. >> i mean, the big problem with this virus is that essentially everybody, every single person is at risk, right, so when individuals are forced to make decisions, if a person who is not feeling well is forced to make the decision to go to work for their livelihood, any single person can be a super spreader. so when you're telling people that they should go to work when they feel sick or that they're going to be at work with other people who could be sick, then you are inviting a real possibility of contagion, and you know, it's really almost the opposite of what we should be doing from a public health perspective. >> neera tanden, thank you so much. >> just to make this point. thank you. >> sorry. thank you, neera. appreciate it. >> sorry. it's the miracle of skype that i thought i was done a minute ago. >> we'll talk to you soon. thank you very much. new data from the cdc says we are significantly undercounting the death of coronavirus, the debunking of coronavirus truthers, next. deb coronavirus truthers, next i got this mountain bike for only $11. dealdash.com, the fair and honest bidding site. an ipad worth $505, was sold for less than $24; a playstation 4 for less than $16; and a schultz 4k television for less than $2. i won these bluetooth headphones for $20. i got these three suitcases for less than $40. and shipping is always free. go to dealdash.com right now and see how much you can save. there are times when our need to connect really matters. to keep customers and employees in the know. to keep business moving. comcast business is prepared for times like these. powered by the nation's largest gig-speed network. to help give you the speed, reliability, and security you need. tools to manage your business from any device, anywhere. and a team of experts - here for you 24/7. we've always believed in the power of working together. that's why, when every connection counts... you can count on us. the coronavirus truthers as we call them have taken up this line about the virus, and oh, actually, you know, i know that the obituary pages are full, and no one can buy a sympathy card but it's not that deadly and dangerous as the death toll continues to climb past 60,000, 2,000 new deaths day after day. and every day brings new evidence of how absurd those very claims are. so "the new york times" citing cdc data now reports that the u.s. death toll is actually far higher than what's been reported. now, people of course in america and everywhere, they die of all sort of things every day in this country, flu to cancer to heart attacks, homicides, driving accidents, suicide, and states and cities collect all that data, called all cause mortality. one way we can get a sense of how hard states can be hit hard by the coronavirus is just by looking at those current overall mortality totals and comparing it to the same period of time say last year. that's exactly what the times did. and lo and be hold, they found excess deaths everywhere they looked. some of them were positively reported coronavirus deaths and many others were not, though they were likely due to the virus. each state they looked at has a huge spike, and crucially it is even bigger than what you would see if you took into account the reported coronavirus deaths. look in new york city, the gray lines at the bottom are total deaths in the previous five years. the red line is this year. the overall death rate just shot up so dramatically. if you were looking at the chart and it wasn't labeled, you would say what happened in march. here's new jersey, and michigan, and massachusetts, and illinois. they all have this huge spike, that red line in deaths, again, represented there when you compare this year to previous years, and guess what, the evidence from across the world tells the exact same story. the financial times using the same approach. all cause mortality, found global coronavirus deaths could be 60% higher than reported. the death rate in belgium, for instance, is 60% higher than the historical average this time offof year. in spain, 50% average higher. we are seeing this everywhere. and it's an illustration of why coronavirus trutherism is not just so dangerous but also so deranged. i'm joined by dr. george q.daly, who cowrote an opinion piece in the "washington post." maybe we can start the broadest possible way, which is in terms of two months ago, how scientists were dealing with this new virus, and how deadly they thought this was, and two months later after the ravages, how did those sort of expectations and the data line up? >> well, i think based on what we knew two months ago, we knew this was a highly contagious virus, and the early results out of china suggested that a shockingly large percentage of infected patients were dying. maybe as much as 3%, maybe 6%. and now two months later, we realize that some of the hot spots, italy, new york city, and beyond, have suffered a just astounding burden of death. now, we don't know the underlying complete percentage of individuals who have seen the virus and that's why these recent surveys, these antibody surveys are allowing us to reassess the actual case mortality rate. but even as we have reassessed it down, because we appreciate that many more people are actually have seen the virus than are being counted, the rates are still quite staggering. the burden is very great. >> this point is a really crucial one, so this sort of sets up this debate right now, and it sort of mixes together a good faith debate among experts and the data and a sort of bad faith attempt to do some sort of bait and switch. so the good faith version of this is we know how many cases there are that are confirmed. we don't know how many people have been infected which is a much larger number, and if the multiple is big enough. if it's actually 100 times what we know of the actual cases, then actually the disease is not as deadly as we thought. you're arguing that the idea, the bullish case that like everybody has had, and it's a hundred times is not being born out by what we know. is that sort of the argument here? >> yeah, this is what i am deeply, deeply and profoundly concerned about is the over interpretation that some of these early studies that suggest that maybe tenfold or even in some reports, 80 fold as many people have actually seen the virus, that this is being used to suggest, oh, this is not a devastatingly fatal or virulent disease, but let's anchor it on what we see. in the major cities that have been hit, whether it's in the north of italy or wuhan, china, or new york city, our intensive care units have been overwhelmed with virus. even in the worst flu years, we don't see this rapidity of death. we don't see the bodies piling up in morgues that can't handle them. this is far worse than flu. and we have to be careful as we interpret these early assessments of the percent of people in our communities that have seen the virus. we have to be careful that we don't reopen the economy too early because we will provoke a second wave of epidemic. we will provoke an increased number of infections and behind it, we will see the deaths start to mount. >> yeah, that is the big fear, the one that we're all trying to avoid. dr. george q. daly, thank you so much for making the time tonight. i appreciate it. how is it that the health care industry is crashing, we'll talk about what's breaking our health care system's economics and why right after this. health care system's economics and why right after this nothing quite captures the perverse business incentives that the american health care system in the midst of this pandemic as we all celebrate front line health care workers in hospitals that some of the same hospitals are hemorrhaging money and teetering on bankruptcy, and more broadly that the health care sector of the economy, amidst the worst peck is the leading source of economic contraction in the first quarter of the year. 2.3 percentage points off gross domestic product. how is this possible? to help answer that question, i'm joined by don burrwick, president, and and senior fellow of the health care improvement, who knows the field as well as anyone. i talked to someone i know at a new york city hospital that's been doing a ton of covid patients who talked about losing half a billion a month, and this is hospitals all over the country hemorrhaging money. why are they losing so much money. >> they're getting squeezed too way. their costs have gone up. they have to invest capital hire more staff. they're converting bed spaces, all of that takes a lot of money, and meanwhile, their revenues are down because the normal businesses they depend on for revenue, the elective surgeries, the work of their own emergency rooms for noncovid conditions, that's how hospitals get by financially, and that revenue is gone. the other part of the problem is on their insurance, we have a frail and chaotic insurance in this country. we're trying to put patch on it in the covid epidemic but it's coming home to roost that a lot of people don't have coverage. all of that means they're losing tons of money, and i have talked to hospital leaders that give me the same numbers you just quoted, chris. >> i want to talk about what we call elective surgeries. it sounds like cosmetic surgery. this is a huge category of things, and my understanding is when we say they're a big problem of the bottom line of hospitals, elective surgery, they are the margin, basically. i mean, they're a huge part of how the finances of the hospital work. >> yeah, elective doesn't mean cosmetic. it means nonemergent. a lot of surgery, even cancer surgery, you don't have to do the day it occurs as you do for a trauma victim. hospitals call that elective procedures. they can be scheduled. we are in a fee for service based health care system where the way hospitals or doctors make money do more things. the more they do, the more they make, that pays the bills. the normal business models of the hospitals are simply in shambles. they're not working, and we'll see whether they're able to dig out after the covid epidemic. god willing, and get back to something like square one. >> so i feel like i have two twin contradictory impulses here. i'll talk about the first and the second. the first is this makes no sense, and we have to deal with the situation as it exists, the system that we have, the hospitals we have. these hospitals really have done remarkable work on the front lines of this, and how do we basically, what should we did doing at a first order tri age policy, that we're the no seeing huge abrubankruptcies for nursed others, and hospitals. >> you're exactly right. there is a short-term issue here which is they don't just don't the money. they're running out of money, and we need something like a bailout like we're doing for airlines and other industries. the hospitals need the cash, and that's the short-term solution. i don't know of another possible one. in the long-term, this does reflect a basic set of defects in the way we're funding health care in america. one is that it's all fee for service or motorist of it is no. we're trying to move toward paying hospitals to be there to take care of hospitals. that would have helped if we were there sooner. the second is the problem of a broken american health care insurance system, which essentially everybody has to run ragged in order to stay in place, and the payment is all chaotic, and it drives costs up, and really leads to a lot of vulnerability for hospitals. there's a short-term fix, bail them out, and a long-term fix, let's think differently about how we should be funding health care in the first place. >> the first one, you know, there has been money for hospitals in the last two bills. the democrats had to push for it. originally moitch mcconnell did not want it. the conflict is this. hospitals have been as a kind of lobbying force often a quite reactionary force in the politics of american health care because they want to keep the fees flowing in, and the fees are their bottom line sources of revenue, and when you try to talk about creating a country that isn't going to have 17% of its gdp spent on health care, the hospitals are one of the big obstacles, there's something perverse about the moment of here's money to bail you out, make you whole, and next year you're going back to stopping us from keeping health care costs down. >> yeah, until the next pandemic. of course they're scared of change. we hooked ourselves on this gerbil cage of do more, get paid more, do more get paid more. people aren't plotting to do unnecessary things. the dynamics and economics are not favorable. that's how we set it up. if we want to switch to something which would be far smarter, global payments for hospitals to take care of populations, or systems to take care of populations, everyone has to face the changes. i think we're going to go bankrupt as a country if kwoowe not careful in the longer run. we can have all the care we want and need, we just can't have it the way we're paying for now. that's going to involve changes which means political dialogue. we're going to have to fight through a better health care payment system. >> don burke who is humble enough not to mention he's one of the foremost leaders, precisely how to implement that in ihi, and the center for medicaid and medicare services. thank you, don really appreciate it. >> my pleasure. up next, why the government rescue of america's businesses should never be a jump ball between your local dry cleaner and the l.a. lakers, the way to fix the ppe program, next. ay to fix the ppe program, next. do you remember the food stamp surfer dude who ate lobster. in 2013, fox news tried to make him a government grifting star. >> we have ahi, salmon, eel, yellowtail with rice and avocado, and then they had lobster on special, $200 a month, and you just go boom. just like that. all paid for by our wonderful tax dollars. >> that was part of a whole gross war that fox waged against food stamps and food stamp recipients and motivated by the idea that someone somewhere was getting over and buying food they shouldn't be. that's one of the most animating reactionary forces in all of american life regarding the welfare state, that when we try to have the government do something, in this case, feed people, someone must be taking advantage. someone's getting over. the wrong people are getting the money, and we are seeing that right now with the payroll protection program designed for small businesses and their workers. there have been a lot of surfer on food stamps eating lobster headlines from that program, and i will admit, they have made me mad too. the l.a. lakers, an nba franchise worth over $4 billion was given a ppe loan before they gave it back. shake shack got $10 million before giving it back. the ritz-carlton of atlanta, using the paycheck protection program to stay afloat. it is outrageous that it appears to be a choice between say the beloved grocery store or laundry mat on the block and those folks, the ritz-carlton and they're the ones benefitting. but i think that's a false way of thinking about it, and it is created by the flawed design and appropriations for this program, ppe. the point of the program is not to choose which are the best and most worthy and deserving businesses. the point is to offer a blanket protection for all small businesses under a certain size who meet the criteria to retain their workers with pay and basically put the economy on ice so it doesn't die while we're fighting the pandemic. the problem is there's way more demand than there is money appropriated. so the funds are claimed within minutes every time they open it up, the architects of ppe have unleashed an all against all for deservedness, leaving the mom and pop businesses squeezed out, which is unjust. here's a solution, make the criteria clearer, and make the appropriation open ended like unemployment insurance. if you qualify, you get the amount of money you qualify for. that's it. there's tno rush over fight ove who's deserving. if you're asking me should we bail out the ritz-carlton of atlanta, during normal times, no, right now, they're a business with employees. the most classic american bait and switch, while we are focused on who is getting the one or $2 million loans, the big boys program for the major large corporations worth 500 billion is being run through the fed with far less transparency, and zero strings attached in terms of whether they have to retain workers. how about small businesses and their employees get rescued and we put requirements on the nearly unlimited credit spigot that's been opened up for the largest corporations. that's been opened up for the largest corporations these folks, they don't have time to go to the post office they have businesses to grow customers to care for lives to get home to they use stamps.com print discounted postage for any letter any package any time right from your computer all the amazing services of the post office only cheaper get our special tv offer a 4-week trial plus postage and a digital scale go to stamps.com/tv and never go to the post office again! across america, business owners are figuring things out. finding new ways to serve customers... connect employees... and work with partners. comcast business is right there with you. with a network that helps give you speed, reliability and security. and enough bandwidth to handle all your connected devices. voice solutions like remote call forwarding and readable voicemail. and safe, convenient installation. when every connection counts, you can count on us. get the connectivity your business needs. call today. comcast business. throughout the entire me too era, there have been moments, i think for many of us, all of us when we have heard about accusations against someone who we find ourselves desperately wanting not to believe. whether that is because we have personal admiration for the individual or their work or political admiration, someone on our quote unquote side but part of the difficultlesss lesson of me too era is not that everything is true, and should be true on its face, you have to fight that pulse, to take seriously what is alleged and what is the evidence, and that is the case of an accusation of tara reade. last year she told a california newspaper that in 1993 joe biden quote touched her several times making her feel uncomfortable. at that time, reade was one of several women who came forward around that moment of acquisitions of inappropriate over physicalness, touching, kissing or hugging that they say made them feel uncomfortable. then last month she made a much more serious allegation telling first a podcast and later "the new york times" that in 1993 joe biden pinned her to a wall in the senate building, reached under her clothing and penetrated her with her fingers. reade told the times she filed a complaint about what happened with biden, quote, she said she did not have a copy of it, and such paperwork has not been located. reade also said she complained to biden's executive assistant as well as to two top aides about harassment by mr. biden, not mentioning the alleged assault. all three of those people who were interviewed by the times deny having a memory of a complaint. a spokesperson for joe biden says the allegation is false and they have strongly denied it. this week, there was also a new development in the story, and that is that tara reade's former neighbor at the time went on the record with her name telling "business insider" in 1995 or 96, reade told her she had been assaulted by biden. nbc news reached out to her neighbor who confirmed by text message the story, the on the record reporting by a neighbor, contemporaneous of the story, has rightfully had a new round of scrutiny, and tension in the progressive coalition about how the biden camp should or is responding and more on that, i'm joined by rebecca tracer writer at large for "new york magazine" who published this titled the biden trap. take me through how you have tracked this story over it development and your sort of evaluation of it. >> well, i have been watching it and reading about it with, i mean, obviously intense interest. it had a sort of reverse course from some of the me too reporting that broke through in the fall of 2017, the reporting done by megan twohey on harvey weinstein that it didn't start out as a massive investigative report. tara reade first made the full accusation of assault in a podcast interview with katie halper. initially, it didn't have the sort of full, we have talked to 100 people, we have gone through these documents and that sort of happened in reverse in this case. and so i have been reading with great interest as sort of different portions of the story have either been denied or seemingly confirmed, and i think it's one of those cases where there's going to be more reporting and we're going to learn more about what we think of these claims with every story that's done, and i bet there are a lot of reporters. i know there are a lot of reporters out there working on it right now. >> in terms of the sort of, i think one of the things that happened in the me too era was thinking about how to evaluate claims like this, and what evidence is sort of corroborative and what's dispositive and the fact that in almost all cases it's extremely difficult to arrive at some definitive counting in the sort of evidentiary record. i will say that in following this, one of the things that happened in me too and a piece of evidence that has risen in how i evaluate these stories is a somewhat contemporaneous disclosure to a trusted person who then tells a reporter about it. that is what has happened here, and to me, that has been in terms of what the evidentiary record has raised it a bit in my own view of this. >> i feel the same way. i actually thought that the "times" reporting which was inconclusive on the assault claim corroborated for me something which was her claim that she had complained about her harassment and then suffered a professional consequence while working in biden's office. "the new york times" reporting on this story actually backed that up for me a couple of weeks ago because it found a couple of interns who she had supervised who remembered her suddenly being taken off of, you know, suddenly and without explanation no longer supervising them. that was pretty persuasive for me on that count. the assault claim, you know, obviously i'm waiting for more reporting on it, but as reporters and as readers, this is what we look for, you know, for journalistic corroboration, as you say a contemporaneous, somebody who's willing to go on the record. the other thing about the neighborhood, linda, reade's former neighbor, she's a biden supporter and still intends to vote for joe biden, so that sort of addresses the question of is there a political motivation here for her recalling this, and yes, i think it's a very strong piece of corroborating evidence. and you know, it was persuasive for me too. >> this point about, you know, obviously what hangs over this is that joe biden appears to be the nominee for the democratic party, that he will be running against a president who has bragged about sexual assaults, who has been accused of sexual assault by a dozen and a half women. right now there's a woman e. jean carol accused him of raping her, and two people on the record contemporaneously saying she told them the story at the time, one urged her to go to the police. she's currently suing him because he dismissed the story, and of course that is not exculpatory for the facts of joe biden, but in the political context of how progressive and feminist and liberals think about it, it's inescapable and also sort of impossible, your though thoughts, rebecca. >> and in addition to the claims made against donald trump, the person is donald trump's record of and promises around governance. he is in a position if reelected to appoint people to the supreme court. he already has. that's a generation's worth of law making in this country, is going to, if donald trump makes those appointments, going to be terrible for women and especially women, particularly in vulnerable communities. you know, his record on the environment, enfranchisement, the democracy is imperilled and women, and in particular vulnerable women are imperilled so progressive feminist women have every reason to support his opponent. however, what this is creating is a kind of perfect storm where the women who are being asked to support his opponent are now also being asked to answer for these charges, in part because of the vacuum created by joe biden who is not yet really directly answering these questions and certainly not doing what i wish he would, which is to say please direct your questions about these allegations to ne ame and not t women that are out there offering their support to my candidacy. >> yeah, the man in question, the nominee, the former vice president is going to have to address them and not have stacey abrams or anyone else or kristen gillibrand to do that. your piece was fantastic and thank you so much for making some time tonight. that is "all in" for this evening, the 11th hour request bri -- with brian williams starts right now. liams starts right now. lit up tonight in blue for the workers of the mta who keep the buses and rails moving through the mostly stay-at-home city of the new york, good evening administration. 188 days now until our presidential election. and on this day spoken out loud to reporters in the white house, the president said this, and we quote. "this is going away. i think we're going to come up with vaccines and all, but this is going away. it's going to go. it's going to leave. it's going to be gone. it's going to be eradicated." indeed the president's son-in-law, as you'll see here in just a moment, today called what we are living through a great success story. for that today his proud father-in-law called him a genius. the president said we'll soon see some astonishing testing numbers, and he quickly followed
Where in the world is Brendan Burke? It's a fair question. With less than two weeks before the NHL drops the puck on its 105th season, tracking where and when the former Utica Comets' radio voice is working isn't as easy as even the most ardent of hockey fans could experience difficulty finding him on TV.