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Who's in the Video
Dr. Zuckerman is chairman of the Department of Orthopaedic Surgery at NYU Hospital for Joint Diseases and the Walter A.L. Thompson professor of orthopaedic surgery at the NYU School of[…]

A conversation with Professor and Chair of the Department of Orthopaedic Surgery at NYU’s Hospital for Joint Diseases and 2009 President of the American Academy of Orthopaedic Surgeons.

Question: Why did you become a doctor?

Joseph Zuckerman: I remember the specific reasons I wanted to become a doctor. This is going to sound a little foolish maybe, and I've said this numerous times before, but it was the TV show, "Ben Casey." When I was a kid, I guess I as maybe eight, nine, ten, 11, or 12 in that range. I used to watch "Ben Casey." And I thought that he was the absolutely coolest person I ever saw. Right? And he did things for people and he was able to accomplish things, made people better, and sometimes not make people better, but it was a very powerful experience for me as a kid, and it stayed with me. Now, you may recall, at that time, back in the early '60's, there was another doctor show, Dr. Kildaire. So, you had Ben Casey and Dr. Kildaire. I didn't like Dr. Kildaire that much, but I liked Ben Casey. But that's what really kind of turned me on to it.

Now, I'm going to fast-forward 40 years later. My long-time assistant, for my birthday two years ago, got me all of the Ben Casey episodes on DVD. I have to tell you, I watched a number of them and it brought back fond memories. But Ben Casey is not the doctor that I wanted to be. That's for sure. It's a whole different model of being a physician. First of all, he's a Chief Resident of Neurosurgery at a County Hospital, but he seems like he's running the whole hospital. Chief Residents don't run hospitals. In addition, he is the most out of touch, in terms of human emotions and what you have to do to talk to people and recognize their feelings and emotions, that you can imagine. Occasionally, there is this flash of light that you see some empathy or humanity in him, but for the most part, he's just kind of a brooding, stereotypical surgeon. No tolerance for anybody. Yelling at the nurses, it was really not, ultimately not the physician I or anybody else should really be.



Question: What have been the key breakthroughs in your field?

Joseph Zuckerman: Well, I think they come in two areas. First of all, over the last 20 or 30 years, the innovations in treating arthritic joints have been astounding. I mean, basically we now can take arthritic, worn out joints, replace them with artificial joints, and provide patients with 95% or more certainty that they will have a successful result, be relatively pain-free, improve their activity, improve their quality of life. I mean, that's a very powerful thing to do.

Now, keep in mind that orthopedic surgery is a specialty that, for the most part, doesn't deal in life and death situations. We deal with quality of life situations. So, we focus on improving people's quality of life. And whether it be hip replacement or knee replacement, shoulder replacement, or even elbow replacement. These types of procedures take patients who are terribly disabled and allow them to become more mobile, walk, play athletics, do the things that they want to do when they really didn't think it was possible before. So, to me, that's a very powerful thing.

Now, that's on the treatment side. There's a lot of research being done on the prevention side preventing joints from getting to that point where they need a joint replacement. You know, that has to do with manipulating the genetic basis of articular cartilage and the structures around the joint and I think that holds great promise. It's not here yet. Ultimately, things like that may decrease the need for joint replacement.


Question: How is longer life expectancy a challenge?

Joseph Zuckerman: Well, the key element in joint replacement is longevity. Taking a person who needs a joint replacement and giving them a replacement that will last the rest of their lives.

Now, when joint replacement first started being done in the '60's, or even the '70s, it was reserved for people in their 60's and 70's, or such because there was concern about the longevity. However, over the last 30 years, advancements in the design, the materials that are used for joint replacement have allowed the joint replacements to last longer and longer. So, it's possible now to take a 50-year-old, or a 40-year-old, replace their hip or knee, and anticipate that they will have that replacement in place for the rest of there lives. So, the rest of their lives is different when defined as 30, 40, or 50 years as opposed to maybe 10, 15, or 20 years. And I think that's where the advancements are going to come, in the materials that are being designed and to a certain extent the design.


Question: Which joints get the most attention?

Joseph Zuckerman: Well, it's interesting. Hip and knee replacement has tended to get the emphasis in the area of joint replacement because hips and knees are really necessary for your mobility, the ability to walk, work, do the things that you have to do each day; to get out of bed, walk to the bathroom, walk around the kitchen, to do all the things that are considered necessary. Your mobility.


Shoulder and elbows have generally taken a back seat to a certain extent primarily because, if you can't do something with one arm, well you can probably compensate for it with the other arm. So, it tends to get less attention. In addition, there's the perception that the shoulder and elbow is not a weight-bearing joint like the hip and the knee. And that's true to a certain extent, although there are significant forces that are generated across the shoulder and the elbow such that when they're arthritic, they can be very painful.


Question: How do sports spur injuries?

Joseph Zuckerman: Well, athletic injuries have really increased in incidents over the last 20 years in a very rapid rate. Now, why is that? Well, I think that first and foremost, the reason is that more and more people are involved in athletics, that's just the bottom line. You see athletics as being organized athletics starting when children are just in elementary school. It's extensive throughout all the elementary school, middle school and high school. There's an explosion of college athletics in all different sports. And then there is recreational sports. More and more people are involved in it. In addition, they are also involved in it to a much greater degree in later years. It's no unheard of to have people in their -- It used to be that if somebody tore their anterior cruciate ligament, which is a key stabilizing ligament to the knee, you expected that to be someone in their 20's, maybe the early 30's. And then you would consider replacing it. Now, I see my colleagues operating on people in their 40's, even their 50's with anterior cruciate ligament tears who need to have the ligament intact in order to participate in the sports that they want to.

So, there has been a great growth in the athletic participation. Now, you add to that, what's also done is, it's not just men that are doing it; it's women. Women are actively involved in athletics. So, we've now seen kind of a blurring of the lines between who gets what kind of injury now. Now, it's true, men tend to be much more involved in contact sports so there are certain types of injuries there. But women are more and more involved in athletics, and we've found that certain aspects of women's anatomy predispose them to certain injuries.

For instance, anterior cruciate ligament injuries in soccer players, or other cutting-type sports. There’s difference in the female anatomy that has led to an increased incidence of what we call, non-contact ACL tears, Anterior Cruciate Ligament tears. Whereas, in men, oftentimes it has to do with a getting hit injury, a pivoting injury on a football field or a basketball court, but with women it tends to be non-contact. The more we understand that, the more we can hopefully develop trends to prevent it.

But then the third area is the fact that kids are involved in so many sports, but they tend to focus on the sport year round now. But when I was growing up, you played football or soccer in the fall, played basketball in the winter, and then played baseball in the summer, or in the warmer weather in the climate of New York. Now, if a boy or girl is good in basketball, well, they are playing on an AAU team in the fall, then their school team in the winter, and then they’re going back to an AAU or a travel team in the spring or summer. So, they're playing one sport now and that takes its toll on the specific body parts involved.

For example, some of the problems with baseball players, elbow injuries, tearing the collateral ligament, the ulna collateral ligament, which is the ligament on the inside of your elbow here. The so-called Tommy John Surgery that's necessary to reconstruct that ligament. It used to be, before Frank Job did that procedure on Tommy John, it was almost unheard of. Now you start to see these injuries in high school players, sometimes even younger because they're playing these sports year round and it's taking its toll. The mechanics may not be exact, increased stresses.

So, that's one thing you have to be very careful of, the athletic stresses that we subject children to during their growing years and the impact to the skeleton as well as the soft tissues.


Question: How does obesity affect joints?

Joseph Zuckerman: Well, obesity is a significant problem in this country. You see that in the newspapers and the medical journals, it is an issue. And I say that to you now two days after my own physician told me that I needed to lose 10% of my body weight. So, I'm speaking from experience here. But there is no doubt that obesity takes its toll on the wear and tear of the joints. Clearly there is a risk factor for the development of degenerative arthritis, but even more so, all right, let's say you develop degenerative arthritis in the knee or the hip and you have significant obesity. A successful hip or knee replacement is certainly possible, but the risk factors are greater. The chances of complications are greater in patients that are obese then those that are not obese with respect to cardiac, pulmonary, or other complications. So, it has an impact not only on the development of the problem, but also on the ability the effectively treat it and have a successful result.



Question: What are your five tips for healthy joints?

Joseph Zuckerman: Well, I think that we are an active population, and we should be, and maybe we should be more active to avoid some of the problems with obesity. But what I found is that exercise is important. I think people should exercise every day, or at least three, four, or fives times a week in some way, shape, or form. I do think that you have to aware of the affect of repetitive impact-type activities. You know, the continually running on hard surfaces. It's one thing is you are a high level athlete training to do that, but more for the recreational athletes, the people who are just trying to maintain their own health. I think you should do things like cross-train. You want to run one day, the next day use an exercise bicycle, switch to an eliptical. In other words, don't subject your joints to the same type of wear and tear, or impact activity on any one day.

Secondly, now, that's talking about the joints, but don't forget, there is a large area of soft tissues. Soft tissues refer to the non-bony parts that connect the joints and that are in the joints. So, for a knee, it's the ligaments around the joint, the anterior cruciate ligament that I mentioned before, or the menisci, the semi-circular shock absorbers in the knee. You also have to make sure that as part of any exercise program, you have to stretch, warm up, make sure these soft tissues are ready for exercise as opposed to going at it cold. So when you walk through Central Park, or anywhere else where you see people exercising, you see them pushing against trees, or with their back against the fence, they’re stretching. And there's a lot to be said for that as I think that will do something to prevent injury. I think that's critically important.

The other aspect of this is, what do you do after you exercise, right? So, you do have to have some effect of not just stopping suddenly, but you do want to cool down afterwards and make sure that you give your body a chance to recover. There's something to be said for the fact that exercise does cause some potential injury and the body needs time to recover, so you need to have some periods of rest. So, when I say exercise everyday, if you exercise different muscle groups and do different things, you give certain parts of your body a chance to recover as you exercise other parts of your body.

I think a third suggestion that I think is important, I think that all of these aerobic exercises should be combined with some anaerobic, or strength-type exercises. You know, weight lifting, things like that, to really maintain not only muscle tone, but maybe increase muscle size a little bit. I'm not talking extreme body building I'm talking about doing things to maintain that part of your muscle health as well. I think that is important.

I'm a believer also, personally, in using some anti-inflammatories in association with exercise. As I've gotten older, right, I've used over-the-counter anti-inflammatories because I think it has an anti-inflammatory effect and decreases some of the aches and pains you may develop as part of your exercise program. I think that's very important.


Question: What should women be concerned about?

Joseph Zuckerman: Women bring a certain different set of issues that have to be considered. And for women, I guess the big issue is osteoporosis, or osteopenia. And we know that as women, as they go through menopause and they're hormonal balance changes, they tend to develop some weakening of their bone, osteoporosis.

Osteoporosis is a condition that means that you are losing bone mass. Osteopenia is a description of a lesser condition which you are progressing to osteoporosis. What that means is that because of various factors. Inactivity could be one; your genetic makeup as well as the hormonal issues that I just referred to, you're decreasing bone mass. That predisposes to a risk of injury, easy fracture for relatively minor type falls. So, there's a big emphasis on maintaining bone health, particularly in women.

Now, osteoporosis and osteopenia occurs in men also, but to a lesser extent. Now, the interesting part here is that if obesity has any positive effect, and I'm not suggesting obesity for anybody, but obese men and women -- older men and women, tend not to have problems with osteoporosis. The reason is that their body weight subjects their skeleton to sufficient weight that bones respond to physiologic stress. So, if I just lie in bed and I don't have a weight bearing force on my bones, well, the processes that resorb bone, or take away bone, outstrip the processes that deposit bone. When you're up and active and things, the processes that deposit bone because of the stress exceed those that resorb bone, or take away bone. But if you're not doing anything, or inactivity, that's going to predispose to more osteoporosis. So, being active is important. And if you have a lot of weight on it, all right, that tends to be positive. But, that's not the message here. The message is, activity and evaluation of osteoporosis is the problem.

Most women think that this is a problem that develops after menopause, but the real time to treat this is at the age when you think you may enter menopause. So, looking at it then, evaluating it, and getting treatment at a time so you prevent yourself from getting osteopenic as opposed to finding out afterwards and than have to kind of try to move your way back to a more acceptable range. So, bone health is a very important thing for women.



Question: What does healthcare reform mean to you?

Joseph Zuckerman: So, today is November 25th, 2009. We are not probably six months into the healthcare reform debate. In the next two months, will be critical in determining what healthcare will look like in the future. As President of the American Academy of Orthopedic Surgeons, we have been actively involved in the healthcare debate because we represent our members. There are 18,000 orthopedic surgeons practicing in this country.

There are some basic tenants, some basic principles of healthcare reform that we think are important. The first is, patients should be able to have access to physicians that they want to see. And for us, that means specialists. As orthopedic surgeons, we believe, and we know that we're the experts in the orthopedic and musculoskeletal problems. And we think, in this country, patients should be able to see specialists who can provide the care that they need.

So a system that allows them to do that is a good one. A system that makes it difficult to do that, or decreases access to a specialist would be one that we couldn't support because you're taking a step backwards from the development of medical care in this country, which has developed to such a great extent and really is at some of the highest levels in the world. And I do believe that the medical care provided in this country is the most up-to-date, innovative found any where, and that's important.


Then you get to the issue of coverage of those Americans that aren't insured and we also think that's important. The uninsured in this country should have insurance. But it has to be in a system that can support it. So, it should be affordable with the appropriate access. One of our concerns is that the system, as it is currently constructed in this country, doesn't make it easy to add 20, 30, or 40 million new patients to the system. Medicare is a good example of it.

 Medicare, when it was introduced in 1965, was a new program, there was a lot of resistance to it, but it's proven to be a very important healthcare insurance program for the seniors, people over the age of 60 or 65, depending on eligibility. That's very important. One of the issues is that each year we hear that Medicare is getting closer and closer to being insolvent, bankruptcy right? Because there are so many people who have Medicare now and there is only a limited number of funds available and Congress has not been able to enact a long-term solution to the Medicare problem.

Now, if you add, as I said, 20, 30, or 40 million more people for healthcare coverage in this country, you're stressing a system that's already been excessively stressed. And I know that current legislation in the House and the Senate has ways that they are going to pay for this and such, but my concern is that on paper, it looks good. Five years from now, it may not work out exactly as they envisioned. Just like Medicare didn't work out exactly as they envisioned way back when, when they first started it. So, I think that's also a concern.


Another area that we think is particularly important is in the area of liability reform; doing something about the explosion of liability cases, malpractice cases in this country, frivolous cases. It's gotten to the point where any physician, not just orthopedic surgeons, any physician, practices medicine in a defensive way, so called "Defensive Medicine." Do I really need to get that CAT scan? Do I really need to get an X-ray on this patient? Well, probably not, but you know there's a small chance it could be there and if I miss something, there could be a suit against this and such. So, that's what we've come to and so much of that adds to the cost of healthcare and it's very disconcerting and disheartening to us, our organization, that in the two main pieces of legislation, the House and now the one that is going to be introduced into the Senate, that there is no meaningful liability reform, which is astounding to me because the Congressional Budget Office, a non-partisan group said that at the very least, over 10 years, we would take away $54 billion from the cost of healthcare in this country with some very limited liability reform issues. So, that's another very important one that I thing we're just missing in this.


Question: Why is healthcare reform so contentious?

Joseph Zuckerman: Well, we do have different types of coverage for different parts of the population. We are one in this country where most of it is employer-based coverage and all employer-based insurance that is provided is different. The level of coverage is different, the deductibles are different, and the out-of-pocket insurance is different. So, I guess if you’ve seen one health insurance plan, then you've seen on health insurance plan because they are not the same.

Then you have Medicare, which insures, I think at last count 50 or 60 million people in this country. That's a very big program. That's a government program. That also has undergone some changes, but it does not have the oversight or the monitoring that you see in the private insurances, the HMO's, the managed care companies.

Medicaid, as you know is the insurance that is provided for the indigent patients. People that are at a certain level below the poverty line that's federally supported or state supported, that's a different level of coverage. So, you've got this amalgamation of different types of coverage that together insures, you know, 180 or 200 million people in this country. Then there's the uninsured, which again, have another -- no insurance, but tend to go to the Emergency Room, or pay out of pocket for these things.

So, even in countries that have had national health insurance, government induced across the board, what develops in those countries is a private insurance system that allows people to augment their coverage, you know, have access to different doctors, better coverage, maybe different hospitals, all those things. We don't have that here because we don't have one consistent system. That's why it's so hard to reform healthcare because you're not reforming one thing. You're reforming a system that has multiple different parts. Very challenging.


Healthcare, being a physician, can be a small business. Right? And that's what it is for the vast majority of the physicians in this country. You have an office, you have expenses, you have to generate revenue to pay your expenses, and that's different than a Kaiser Permanente, or a large healthcare system like the Mayo Clinic, or others like that that are all encompassing. And if you consider an episode of healthcare from the time a patient decides to go to see their physician, or comes to the Emergency Room, until they're now cured, or no longer a problem, they will see multiple practitioners along the way, physicians, non-physicians, physician extenders, therapists, pharmacists, a whole variety of healthcare providers.

In most systems in the country, each one of those providers could be part of a different system, so there's the lack of coordination. A place like Kaiser manages all the episodes of care, the entire episode of care and all the different pieces to it. You can certainly do that more effectively and more efficiently. The question is, can you extrapolate that, or build that into all different communities in this country, and that's hard to do because it's not set up that way.


Question: Why aren’t doctors well represented in the healthcare debate?

Joseph Zuckerman: Well, physicians have organized themselves to a certain extent, but they haven't organized themselves as much as they should. So, if you look at this current healthcare debate, if the government considers the American Medical Association as their spokes group for American medicine, right? Well, what does that mean? I'm not a member of the AMA. I think only 17% of physicians in this country are members of the American Medical Association. So, do they represent the physicians in this country? Probably not. And that's why there has been such push back, and sometimes significant decry about some of the positions the AMA has taken.

Thirty years ago, when the AMA was "the" medical organization in this country, it was more reasonable, expected, anticipated that they could be the spokes group for American medicine. But now it's changed. There are large physician organizations, the American College of Surgeons with I think 60,000 members. Our organization with almost 20,000 members. But not only do we have large numbers of physicians represented based upon the specialty involved, but in addition, every group has a legislative office. In our organization, we have 14 full-time people working our in our Legislative Affairs office. We are actively involved in the legislative process, pushing for the principles of practice and reform we think are important. So many groups have that because they are large enough and they have the resources to do it. Now, what you really effectively need is coalitions of groups to work together. One of the groups that we are involved in with the American College of Surgeons is, a coalition of surgical societies representing surgeons and other specialists trying to pursue a common agenda in this healthcare reform debate.

So, the fact is, it's very hard to organize physicians because the physician groups are now so well-represented within their own specialty and they have lobbyists, or legislative affairs office in Washington D.C. that they can go it alone, so to speak. So, is there a need for organization, probably because you can speak with a louder voice, but we've learned that, what worked 30 years ago when there was one organization, the AMA, is not the case any more because other organizations want to speak up and be heard because they're opinions, or their needs and priorities are different than other organizations.


Question: Why should someone become a doctor today?

Joseph Zuckerman: I'll speak personally now. It would always bother me in the last few years as practicing medicine has become more bureaucratic, more difficult, more red tape, more paperwork and such, and maybe not as financially rewarding as it used to be in the past because things have changed. When I hear a colleague say, "I would never tell my son or daughter to go do medical school now. It's just too hard; it's not what it used to be." Well, I don't want to seem too Pollyanna-ish here, but I think being a physician is one of the greatest things you can do.

I have a son who is a second-year medical student at Vanderbilt University School of Medicine, and when he told me he thought about going to medical school, I thought it was the greatest thing in the world, I encouraged him to do it. He could do whatever he wanted to, but would I ever discourage them from ever being a physician? No, I never would. Because all these other things, notwithstanding, everything we hear about from the time you walk into the examining room to talk to the patient to the time you leave, that is an opportunity to be valued and cherished. Right? Because the relationship you develop with the patient is very powerful, is very meaningful. The people who should be physicians should recognize the power of that relationship and that interaction. If you do that then we would never even think about discouraging somebody from being a physician.


Question: What trends concern you in your field?

Joseph Zuckerman: I think the trends that concern me in orthopedics are probably those that applied to medicine in general. Because of the changing nature of healthcare you have to see so many patients, more patients than before, in order to basically balance the books of your practices and things that it takes away from each and one of those interactions. Each one of those individual interactions, and I think there is something that is lost there.

There is a tendency for surgeons to be seen only as procedurists; operate, take care of them and then were finished. Right? It's great to be able to operate and improve someone's quality of life like we do, but it is the interactions that I think are important. I'll see 30 to 35 patients in the day and it's a long day. But when somebody tells me they see 60, 70, or 80 patients in a day I say, boy, I mean, that's difficult to do in a meaningful way. So that concerns me when I hear that.


Question: What does it take to be a top surgeon?

Joseph Zuckerman: I think that a lot of it is, talent, but character is a very important thing. Now let me take you about professionalism in medicine. We can teach individuals we have one of the largest residency programs in the country; 12 residents a year, 62 orthopedic residents in a five-year program. Almost without exception, we can train them to know what they need to know to be an orthopedic surgeon, learn how to operate and the important procedures in orthopedic surgery, and we can even teach them a little bit how to interact with patients; however, you can't teach them to have the ethics and the professionalism necessary to be a physician. They need to come to us with the ethics, and their parents have to do that, and we layer on to that the professionalism of being in orthopedic surgeon. You can be as talented as anybody but if you don't have the professionalism, the interactions with patients, the ability to understand what you're doing and how to care for a patient and how to interact with patients, then he you've not fulfilled the responsibilities you have of being a physician.


Question: What advice do you have for the next generation of doctors?

Joseph Zuckerman: My advice is that you should always recognize what it is that attracted you to being a physician. And what I think should have attracted you to being a physician, surgeon, or an internist or any other medical specialty, which should have attracted you is the ability to make patients better. To interact with patients and to take somebody who is ill and make them better, somebody that can't do what they need to do and help them to do what they need to do. That's a very powerful thing. And the next generation of physicians should see the power in that and the attraction of it because when all is said and done it's a very satisfying part of being a physician. And with all the difficulties we have with the bureaucracy and managing practices in healthcare reform, that's a constant in this, the relationship you have with your patients. And I think that goes a long way to making for a very satisfied physician for many years.


Question: What’s the worst career advice you ever received?

Joseph Zuckerman: As I mentioned before, my father was an accountant and he told me don't become an accountant because I have to work too hard. But I remember him working how I work, but then again, I'm glad he told me not to become an accountant because I couldn't have.



Question: Who are your heroes?

Joseph Zuckerman: The real heroes in life are to me, people who have problems, have medical problems, have personal problems that have to persevere against significant odds. When I get up early in the morning and go to work, I'm happy to go to work I have not had to deal with those things, but I see it in a lot of my patients, I see it in a lot of people in the hospital, you know, patients in the hospital. It is very challenging for them to do that. People that can persevere in a situation that makes life difficult, even tragic, all right, those are my heroes.


Question: If you could have dinner with anyone, who would it be?

Joseph Zuckerman: Let's see now, who would it be? Boy, that's a tough one. That's a tough one. Who would it be? I think I would have dinner with Babe Ruth and Lou Gehrig. Just the three of us. I've read their biographies, multiple biographies on both. For some reason I find that era very interesting and I think it would be very interesting to be able to talk to two of the greatest legends in baseball. On the other hand, it may not be the most stimulating conversation.


Question: What keeps you up at night?

Joseph Zuckerman: What keeps me up at night is thinking about what I'm going to do the next day. I operate on Tuesdays and Wednesdays, so Monday night and Tuesday night, the day before the surgeries next day, those are the times that I've probably stay up longer in bed, trying to get to sleep thinking about the cases of the next day, what I'm going to do, making sure I’ve got all the bases covered, making sure I am completely prepared.



Question: What would say to someone who doesn’t like doctors?

Joseph Zuckerman: You know, I think that there's an expression I think, my father used to use this, "One swallow does not a summer make," or spring, or something like that. I guess there's maybe a million physicians in this country and like any other group, not everyone may function in the same way or may be a shining star. There are probably some exceptions to that like there is in any other profession, but you don't want to judge the whole profession by that because I think for the most part, the vast majority, 90% or 95% plus of the physicians in this country are out there taking care of patients, trying to make their lives better. Right? There are probably some exceptions out there, absolutely. Right, like any other profession, but this is a healing profession, this is where you take care of people and try to make them better. As I said, that is a very powerful thing. And if you maximize the opportunity, as I said, from the time you walk in the door to the time you leave, from the time you show up in the Emergency Room to see a patient until you finished taking care of them, that's the opportunity. That's the opportunity to have patients recognize the value of what physicians do, the importance of what we do, and to cement that patient-physician relationship which is so important, which is really the foundation, I think, the foundation of medical care. Not only here, but anywhere.