25PHCA – KALAMAZOO 13 years ago Bill Burnett 33 minutes Last Updated on April 16, 2022 by Lee Burnett, DO, FAAFP——Ok, we’re running a little bit behind so the three of us will do our best to get us back on schedule here. First before we begin, Jay Lee sent me a message on Facebook saying “Hello, I love you all and wish I was here.” So now I’ve got that obligation take care of, well we can move on.Ok, so, those of you who were with us in Kauai last year, might remember that I stood before you with two fabulous women to tell you about a new disastrous introduction of family medicine residency to a federally qualified health center. And here I am again with two fabulous women to tell you a little bit more about that. And you probably remember Denise Crawford and thinking it’s good to see Denise again, you know she was a real addition to the conversation that we had last year. And you might be remembering Dr. Saffold and looking over and saying damn girl, I need to speak to your personal trainer.So this is not Dr. Saffold, this is Dr. Dixon who’s joining us now.You had to be there ok, you had to be there.Really.Alright, so, we’re representing, or at least two of us are representing the Western Michigan University Homer Stryker School of Medicine. Two months ago we had that little piece inserted into our name, so we have a new name now. So I thought it was important that I say just a brief introduction about Homer.Homer was a graduate of Western Michigan University way back when. Graduated with a teaching degree; went on to teach high school up in the Ketone Peninsula in Upper Michigan; so a peninsula of a peninsula; way up there. After he did that for a few years he enlisted in the army and I think went off, and I think it was World War I. Came back and went to University of Michigan’s medical school, graduated, and he became an orthopedic surgeon.You might, those doctors among you might recognize the name Stryker. You see it anywhere in your hospital in terms of beds and equipment. Homer used to like to go to his workshop and mess around with things, and he invented stuff. And he made a lot of money, and he formed the Stryker Corporation. So a couple months ago, the anonymous donors to Western Michigan School of Medicine, the $100 million that we got were announced as Homer’s granddaughter and her husband. And they decided to name the medical school in his honor. So that’s where we get Homer Stryker.Ok, so enough little history. I’m going to turn you over to Denise who’s going to talk to you a bit, and then I’ll be back with you in a second.Thank you.Just clip right, well is that good? Thank you.Well good morning and thank you so much for the fabulous Happy Birthday song. Thank you Dr. Willkie but it really was heartwarming. So despite everyone else, in full disclosure, I feel a little out of reins; I’ve never actually been to an event where people actually had the ethics to disclose. I’m usually meeting with other CEOs and politicians so; I feel the need to jump on board and in full disclosure, I am an administrator. I’m trained to tell you exactly what you want hear. And I would not trust me.So, moving forward, recap of last year’s events for those of you who were not with us, Dr. Willkie was quite nice in saying it was a bit of a disaster. It was like, interesting. So, to bring you along with that, we had received during the stimulus grant we had received a $10.3 million facility improvement grant, the largest grant in the state of Michigan. And of course in doing and preparing for this, we had written this wonderful grant to combine the federal qualified health center within Kalamazoo County, the only one there, with the family practice residency program. Phenomenal grant, we all, one of the requirements in doing is that you have to get all the partners involved to sign off. So we all graciously signed and wrote these letters, you bet, you send us 10.3 million we’ll make it happen. And low and behold it happened. And then the real work started.So the 10.3 million arrived and we had to start combining a federal qualified health center with the family practice residency program. As Dr. Willkie indicated there was really very little work being done. The program director for the family practice division at that particular time resigned as soon as they heard of it. And the other DO director took an early retirement. So needless to say we were planning moving forward and things weren’t quite going exactly as to what we had told the Obama Administration.So the initial plan for the introduction and the residents and throughout this process, thank goodness Dr. Willkie was hired and so the work started to move forward. But a lot of things had already been put in place that didn’t quite gel with the whole, once again plan to the whole Obama Administration. So, it was very ill conceived and poorly implemented. Interestingly enough the original plan was to send us four PGY1s cause that’s just set up for success. And as a complete ignorant administrator, I was just happy that we were now at the point that we were actually sending residents and doing what we said we would do.I never quite realized that residents were kind of ranked. Cause you guys kind of keep that to yourself. And I’m sure it was purely coincidental that of my four, I was getting number five, six, seven and eight, real, real opportunity here. So then they decide, once this came into verition. I said well ok, come on, we need full disclosure, we have to make this work, this you know, we’re talking about individuals’ lives, etc. And they said absolutely Denise you’re right. We’re going to send you two PGY2s. And again coincidental that was number seven and eight.So now I’ve got the challenge leading the challenged and caring for the most challenged and vulnerable population that there is. So we decide, Dr. Willkie decides, we need a new plan. And it was interesting.The new plan was to take all 24 residents and split them between the two sites. So there was still the main family practice residency site where they had number one, two, three and four of each class. And then there was the family practice site, excuse me the federal qualified health center site. So effective July 1, we indicated we’re going to split them off; let’s share the love so to speak. Interestingly enough, as fate would have it, then our CMO resigns. Because God really does have a sense of humor, but really this speaks to you as family practice practitioners. And I really have the utmost respect for you and I sincerely mean that.Now this was interesting, and often times as administrators we do this; we get a little ignorant at times, I should probably speak for myself, but the rest of them are worse than me; so we get a little ignorant at times. And this particular individual, which I whole heartedly continue to respect, phenomenal very well trained individual. Of course showed up with all of the impressive credentials, the Harvard, the Yale trained, that had worked private practice, subspecialist their entire career; and wanted to end their career making a difference with the underserved. And I believe that she sincerely meant that.Right up until, towards the end, she, I remember we were having one of our regular meetings in my office and she said “Denise you know, this primary care, this sucks. This is so unfair. I mean, they send us the most difficult patients, we send them to the subspecialists, they send them right back after running all of the tests that we had already ran, with on their fancy letterhead saying basically, good luck with that; they’re yours.” And she said “you know we’re expected to do all of the hard work, we’re expected to make a difference, we’re dumped on, etc., etc.”And then like two weeks later she resigned. So, in true fashion, I think; this is hard work.So the hospitals and I have a meeting and by this time, I’m pretty much, you can probably figure out I’m not a real quiet person, so by this time I figure I don’t really have a whole lot to lose. So they call me in and they say “Denise, wow, you’ve got a problem. You’ve got the residents there, you’ve got Medicaid expansion coming, and you really don’t have any medical leadership. We just are kind of interested as to what’s your plan. What are you going to do about this, cause this is a lot of lives, and gosh forbid the show up in our emergency room.”And so by that time I just kind of redirected that conversation and said “No, no, no. We’ve got a problem. We’ve got 30,000 active patients, poor and underserved on Medicaid and uninsured by the way, and 93,000 visits. So we need to figure out what we’re need to do. Because it’s also a primary healthcare shortage, family practice physicians have finally figured out they got a seat at the table, and everybody is aiming for their own positions, so it’s not like a whole lot are coming in the flood gates.So every hospital has this, and gosh forbid, thank goodness he’s not here, I absolutely love him, and it turned out to be wonderful, but you know every hospital has, because again, administrators often times are ignorant. And so we all have in the hospital that one individual who is extremely well trained, they’ve done the John Hopkins, the Harvard’s, the etc. and we bring ‘em in as administrators and we give them a really high fluting, fancy salary, and then we realize, oops, they’ve never touched a patient. So they’re really not making the impact with the physician community that we wanted.So the hospital says Denise, we’ve got just the guy for you. We’ll send you one of our VPs. And we’re desperate, so I say ok, bring him. Well probably one of the best things we did, which Dr. Allen is going to take you into; is this VP arrives, and he says Denise, and I’m telling him oh my goodness the doctors are shook up the residents aren’t working, this is crazy, healthy Michigan is coming; what do we do? Just help us work, help us make it work. And he says, got the perfect plan; you know Lean Toyota has gotten some systems and they’re moving into healthcare. And I think you have got to be kidding me. We’re dying and you want to bring in a production, lean production systems, what?! So we’ll tell you the rest of the story.Meanwhile, because God does have a sense of humor, HERSA the federal government decides to come in and evaluate all that they’ve invested in. So they show up, you know these visits really are unplanned, and they just kind of arrive. So HERSA shows up and they want to look at things. And we’re thinking this cannot get any better. Interestingly enough, because of our work, because of our hard work, we actually hit 19 out of 19. So they measure you on 19 requirements. That is very difficult to do and it places us in the top two percent in the federal qualified health centers nationwide. They start looking at us for best practices. Which between you and me was kind of scary but we rolled with it.Then it’s time, in the midst of all of this, that then patient centered medical home runs in, so you know then they’re telling us you know you need to be patient medical home certified. You need to be NCQA etc., etc. The hospitals want to know how we’re doing with NCQA and low and behold, we reach level three at our Sheridan site. And of course my lovely friends at the hospital say, “You received level three patient centered medical home.” “Yeah.” “With NCQA. “ “No Mickey Mouse” So again, Dr. Willkie’s hard work; we’re moving forward.So then Medicaid expansion comes, because this has to keep coming, and we realize April 24, I mean excuse me, April 2014 state of Michigan decides we’re going to do better than Medicaid expansion. We’re going to do a healthy Michigan which is really Medicaid with a few Republican humps and hurtles which involve very interesting things.So, one of our requirements with the Medicaid, and I don’t want to go into the detail because my time is coming to an end here, but it’s a four year maximum. So they get the insurance for four years. They have to complete a readiness to change document; which is very interesting stating, I will stop smoking on this date. I will lose weight and this many pounds by this year. Yeah I’ve been saying that for the last 10 years, good luck with that, but in any event.And so the hospitals realized we have 12,500 individuals in Kalamazoo County alone that are eligible for healthy Michigan and we decide where in the world are they going to go? Meanwhile the residents are unhappy, they’ve decided they really don’t like serving two masters, and it’s very difficult to be at one site as well as the other site. Which we get, they don’t have enough time to get their notes done; they’re kind of doing a half assed job at both. Imagine that. They like the increased OB at the family health center with the federal qualified health center, but they really don’t like our EMR, gosh forbid, they’d really like to have epic. They feel like they’re treated better. They really like, see you can relate. I would really like epic, what about Next Gen? It’s only 5 million. But they feel like they’re treated better at the family health center.So in typical resident form, they come to us with a proposal. And they say how about we move back to old site where we have our patients that are kind of the prettier Medicaid, they’re not really, really challenged, but we’ll come back and see your OB patients to make sure we get our OB requirements in.So we’re thinking, OK, minor detail, back at the old site they don’t have enough room for all 24 residents. And it’s not brand new and completely remodeled to them. So we have a few options; nothing can change, we can move back to their main campus and reduce the residents to 18, or we can move all residents to the family health center at the federal qualified center.So Dr. Willkie and I go have a beer. We have some of the most interesting conversations over beers. A beer, we’ll just stop at a beer; it’s never more than one beer to get us through it. And together we present a proposal to Dr. Burns. We bring in our best CFO and put together a phenomenal Performa and we send it to the medical school to move the entire residency program to the federal qualified health center. It’s approved by the medical school on March 1st and the transition team goes into work.And at this point I’ll turn it over to my fearless partner, Dr. Willkie.Thanks, OK, I’m going to pick up some lost time. How many of you know the Toyota production system. OK, so I can run through this pretty quickly. Bill Mayor who was the VP from Bronson Hospital who joined us as CMO; Bronson had been doing this internally and he decided that, that’s what family health center needed so we’re going to do it.So real briefly just for those of you in the audience who don’t know, it’s been around since 1948. It’s also known as lean, or just in time production.Where’s my, excuse me.I’m sorry.And mainly its founded on waste reduction, over production, time on hand, transportation, etc., etc. When it’s applied to healthcare it’s entirely patient centered. So it’s not waste of doctor’s time, it’s waste of patient’s time. And I kind of like that. So I’m going to skip right over this, but this is kind of the, what the Toyota way means, continuous improvement, challenge, the Kaizen, which is continuous improvement of business operations, Vinci golusu. You go to the source if you want to find the facts, you as the chief medical officer, the chief executive officer, the chief whatever officer. Go to the source to find out so you can make proper decisions. You respect people, and that’s really important. You respect others, the people we work with, we take responsibility, we work together with mutual trust, we work in a team. It’s all teamwork based.Another way of looking at this is you base your management decisions on long term philosophy at the expense of short-term financial goals. Wow, what a concept.The right process will produce the right results. You add value to the organization by developing your people and partners, and you continuously solving root problems to drive organizational learning.So a few definitions, few definitions just so you, when I start saying them you know what we’re talking about.There’s the genba, or gemba the Romanized version, which is the shop floor. This is where in, when Toyota’s making cars; this is where the cars are being made. This is where the work actually happens. In healthcare it’s at the patient room, it’s at the nurse’s desk.Kaizen is the continuous incremental improvement, which results in kaizen events where you take a day or two in some cases a whole week to focus on a particular process, which people are doing the work, you bring them in, they step away from the floor, and they start working on eliminating waste, and reducing the burden of work because they know how to do it.Standard work, this is the anathema of physicians. It’s my way or the highway. I know how best to do this, I don’t care how Joe Blow does it. I’m going to do it my way. But standard work is an agreed upon, repeatable sequence of work assigned to a single operator at a pace that meets customer demand. Important concept, customer demand; so yeah, if you walk into an exam room, everything, every exam room, you should know exactly where your products are. You should know where your tongue depressors are, you should know where the hand washing dispenser is, so that you don’t waste time looking for things. If you’re going to be doing a procedure, the tray that you get with your instruments always has the equipment you’re going to need; not the equipment that Dr. Michael uses because he does it some way completely different.So, anyway there’s a book, and I brought a long a copy if anyone wants to thumb through it, where this was applied to healthcare up in Seattle at Virginia Mason Medical Center where they went and applied the Kaizen, Toyota method initially.So, Bill set up a number of events at family health center and this is just an example of things that we started working in last September, so we’re talking less than six months now. Ok, open access. We wanted to be able to have a schedule that allowed a patient to show up at 8:00 and be seen. There will always be someone there to see you. Physician led team structure, and what are the roles and responsibilities of that? One of the problems we had was if you called the family health center, there was a good chance you’d never get through, or you’d be waiting for minutes on end. What was the original time, do you remember, 17 minutes?At least 17 minutes.Minimum 17 minutes. It’s down to 45 seconds, just by changing process of work. That’s patient’s time, that’s saving the time of the patient.I won’t go through all of these.But the things that we went through, referrals, we’re now doing gemba walks, or genba walks, gemba is the worksite, right. And a genba walks is where the leadership goes to each area, and one of the people in the area, one of the workers goes through the predefined measures, the things that they’re looking for that the group decides on; and says here’s how we’re doing. These are the areas we’re having success, these are the areas we got to work on; happens every day. We’re also working on open access including our pediatric colleagues and the next thing for the end of this month is the RN standard work and responsibilities.So just a couple of quick pictures; so this is family medicine’s genba board and this is Tiffany. Tiffany’s one of or MAs. Tiffany leads this. This is not physician led; this is led by one of our MAs. And she’s demonstrating to the group here, the stuff that on our genba board the things that we’re following. This is Bill, Bill Mayor’s standing right there.Yeah, I don’t know. That’s OK.In our LPN Ramirez, Patricia’s back there and Wanda heads up kind of our nursing group.This is our board in general; we’ve got four things that we’re following. So we’re measuring quality, productivity, and delivery. So for instance our quality measure was screening for Chlamydia completed 80% of the time. And as you can see, you know, blue is good, well blue is, we weren’t there to do any of it, so don’t worry about it. Green is good, red is not good. And you can see we have all blue and green. So this quality measure actually we got rid of, we don’t measure anymore because they’re already doing 100%.This was one of our productivity measures. You’ll notice it has a little red spot there. This is having 70% of the super bills completed within 48 hours of the encounter date. This is not somethingthat residents generally think about as being important. But if you’re going to be billing for your services you’ve got to get the bills in. Even in a federally qualified health center, you’ve got to produce the bills. And we’re not doing too bad here. We were doing pretty well.Here’s another productivity measure that we aren’t doing so hot in. Percent of unfilled provider slots, less than 20% each day. And this is a really important one from the residency stand point, in that as you know if you’re involved in residency education; there’s a specified numbers of visits that residents need to have if they want to you know, if you want to keep your residency accredited. And right now, we’re not meeting those numbers. And that’s an area that we’re working on now with our Chief Operating Officer and his group of schedulers.And this is the last, this is delivery; 50% of delinquent referrals addressed within 48 hours; we’re doing a so-so job on.Alright, so I’m going to pass the baton here to Dr. Dixon.Hi everyone.You be nice, she’s new.I’m sure everybody’ll be nice. First of all I’d like to thank you for inviting me, and Allen for inviting me. This has been a wonderful experience for me.And I’m going to be changing gears a little bit because I actually am going to talk about the plans from the medical school the undergraduate medical education and how we’re going to hopefully implement it when we open our doors.So actually that first picture that you saw was the actual medical school. That building that was on the beginning of Allen’s presentation, and on the beginning of mine; and it should be complete, good news; we’re going to be moving in by the end of June. Our first class is going to be starting in August. And August 18th we will be welcoming 50, between 50 and 54 students. Our plan is to actually increase that number by 10 each year to a maximum of 80.And just to kind of give you a little bit of history about the evolution of a new medical school. In 2007 is when the discussion started. Now the campus in Kalamazoo always had a clinical campus. So they partnered with Michigan State University and we had third year and fourth year students there, as well as, they have very robust residency programs. So they were actually already doing quite a bit of clinical education. What they weren’t doing was the preclinical undergraduate.So the discussion began with John Dunn who’s the President of Western Michigan University along with Bronson and Borgess Hospital, our two major hospitals about why don’t we do this? Why don’t we consider having a full four year medical school in Kalamazoo? We certainly have the resources and there certainly seems to be a need. That discussion then was more, given more fuel when there was this 100 million, I still can’t get over that, anonymous at the time, donation to do this. And now we know that, that came from the Stryker family, hence our new change in our name to Western MichiganUniversity Medical School, wait a minute, Western University, Western Michigan University Homer Stryker, MD. Medical School. It’s a mouth full.The building that you saw in the pictures was donated also, and that building used to be a former of John building, but then was owned by Don Parfet, I mean Bill Parfet who was the CEO of MPI and then they recruited the dean and people came on board and you start the process of planning a curriculum and LCME comes in and says you can do this. So we were granted that we could do this, and we started making the plans.So, how is this going to be helpful in the academic community? There are several colleges in Kalamazoo. We have Kalamazoo College, we have Western Michigan University and then we have the Kalamazoo Valley Community College. You’re training quite a few students in healthcare careers, and what they didn’t have really was the medical school. So having a medical school is really going to enhance all of that. It’s going to enhance the recruitment of undergraduates to the area, which will be great and hopefully they will want to stay in the Michigan area. It’s going to help increase the scope of revenue and research, and it improves the prestige of the university and the area all around.It also gives us the opportunity, and we’re actually doing this, we’re making a lot of plans for centergistic relationships. Lots of medical schools have MD, PHD programs; we’re actually doing that, making that plan. Western Michigan University’s planning to open up a school of public health. That’s going to happen within the next year. And after that hopefully we’ll develop a partnership to have that combination MD and PH program. We also are working on doing, already, a master’s program for biomedical informatics with the business school and we also are probably going to do an MD MBA combination.So, how does having a medical school impact the community? And really what is the medical school’s mission but to serve the community. And I think that’s probably what attracted me to come to this school. And that is that they seem to have that as a real core for what they wanted to do.So my role as the Associate Dean of Health Equity and Community Affairs is to really be, and I call it the face of the medical school for the community. So I like the idea that they want the community to be involved from the very beginning. That means the community organizations need to have a voice. And so I’m on a lot of boards. I meet with a lot of community, and forming of community board.Allen mentioned Bill Mayor, I work very closely with him. He’s the VP of Community Affairs for one of the major hospitals. And so we work together in a centergistic relationship to really look at what are they doing, what can now the medical student, medical school do to really help that? And the other things that I’m doing is a lot of health equity work, and I’m in charge of the curriculum, which I think is one of the core curriculums, which is the profession of medicine. And the profession of medicine is like the doctoring, clinical skills, humanities, humanism, ethics, all of those things, and also enhancing the diversity and inclusiveness for the environment in the medical school.So our medical students from the beginning are going to be taking an active role in the community. We have a very robust, active citizenship component for the curriculum; where they’regoing to be working in a longitudinal fashion for two years with a community organization. They’ll be mentored by a community advisor, as well as, a faculty coach. There’ll be lots of opportunities for them to do volunteer work, career seminars, we’re planning pipeline programs.We actually, Allen and I were part of an interfaculty learning group for interdisciplinary education. So we’re already planning for the graduate students’ teamwork with interdisciplinary teams for the College of Health and Human Services at Western Michigan University. And there’s whole lot of opportunity for mentorship of the young people in Kalamazoo to really look at having futures in health careers.So, these are some of the core rotation community sites that I’ve actually made affiliations with for the students to work in. And they will be working in teams. Family health center is of course, they’re going to be working with the family with the family medicine residents, they’ll be working with administration, chronic disease management, looking at really understanding from a real work point of view, population health; really understanding what it is, what are some of the challenges, what are some of the things that people are facing, understanding finances so that in the end they’ll be better advocates for community and practice. And so, those are just some of them.In a review of our curriculum; we have a new school, so having a new school gives you a new opportunity. You can start from scratch. That’s also very attractive. Yes, there are some things that we all need to be doing, but starting from scratch we can put in things that are going to enhance primary care training. It’s going to help with; we’re going to be doing a lot of integration of the clinical which we’ll all try to do, but hopefully we can do it by taking all of the advice, and all of the things that we read about, from the beginning.So we’re making an integrated curriculum, also putting innovation, we have a doctrine course that’s longitudinal. I think that’s really one of the key factors that’s actually innovative and helpful, because, just like we talk about the, the things like cultural competence and empathy. It gets lost sometimes when they get to the third year, but if we have this longitudinal opportunity with the course that’s also going to be in the third year, as well as in the fourth year, you can then continue to expand on those concepts as a thread for curriculum. And they’re going to be starting in the beginning with the longitudinal clinical care experience, which again helps to foster what you’re teaching them in the classroom.So we’re incorporating all the recommendations from LCME, as well as, yesterday Suzanne talked about the untrustable professional activities. We are actually going to be incorporating those 13 principals into competencies for our medical students from the very beginning. We’re doing team based learning, I don’t know if you’re all are familiar with that, but that is going to help to put the clinical spill on what we’re doing in the basic sciences, with the students still have one to two TBLs a week. We’re reducing lecture hours to no more than 27 per week. There’s clinical integration in preclinical and clinical years. We’re incorporating a lot of public health with our community health, and we’re really, really emphasizing patient centered care.I wanted you to see a picture, cause this is what like the inside looks like, just to give you an idea. We have two large classrooms that can accommodate I think, each, about 120 students and you can see the design of the tables so we can actually have them turn around, and they actually do this TBLs format education.So our core curriculum foundation is integration of basic science in clinical, preclinical, and clinical a lot of schools are struggling with that. But where our plan is to actually have in between the clerkships week intersessions where the basic scientists come back, so then we can do that core again, reminder of the basic science. The TBLs are throughout the curriculum. We have co-course directors who created the TBLs and who are creating the components and delivering the curriculum in the organ based format that are clinicians and basic scientists. We’re doing a lot of small group learning. We’re doing self-assessment and peer assessment, as well as faculty assessment. Students will be having informative exams weekly so they’ll know how they’re doing. And we’ll also be having longitudinal threads and early integration, as I said, of clinical experience.Our enhancement’s for clinical training is we’re having a really solid core of communication skills training in the very beginning. Bringing in Improv and some of the arts to kind of help with that for a unique way of actually, again, helping students to learn really how to communicate; we’re using standardized patients, and we’re going to be using the model of the standardized patient as the educator as well. And we have a robust simulation center where we’re going to be incorporating that in for student assessment.This is learning spiral, M1 at the bottom, M4 at the top, and hopefully at the end they will be accomplished residents. And you’re building, so there’s expectations, there’s contents and performance standards, there’s assessments, students will be reflecting, incorporating that in they go to the next level. And again that development model with continual self-reflection, with continual adding to and modifying is really going to help us get where we want.The newer concepts for us are, this is one that we’ll see, is that our students are not going to take the USMLE Step 1 until the end of their third year. The change in USMLE 1 to incorporate more clinical we feel that a couple schools, newer schools have done that, and they’ve actually shown higher scores and with our plan of integration in the third year of the basic sciences, hopefully that will also happen for our students.The other is, our students are doing medical first responders so from the very beginning they will be able to be helpful on a more, they’re going to get licensed as medical first responders to be able to hit the ground running to be able to really do work in the community. We have this comprehensive, virtual simulation; we have learning community advisors, which a lot of schools are doing; which I love. Cause that actually helps to have more of an individual focus on the student and really helps to tailor and help them to get to where they want to be.And in summary, we have all these opportunities with a new curriculum to enhance the training and improve quality and access in the end, because you have a better prepared student to go out tobecome residents that will then work in programs and really continue to have those concepts of things that we all feel is really important for primary care.Thank you very much.Mike Breslin, UC Irvine, anybody’s bladder about to burst here? Ok we have time for a rhetorical question, so I’ll ask a rhetorical question; but first a couple of comments. Yes universities love medical schools, there’s no doubt about it. I think of universities as multinational corporations with revenue streams, and medical schools present some risk but they present some opportunity.Happy Birthday Denise. I hope you’re experience in the FQHC hasn’t caused too much bitterness as of yet.No.So I think why Bill asked me to ask the question is we merged a residency program and a community health center in 1985 at UC Irvine. So according to my calculations that’s roughly 29 years ago. We just finished up with our latest consulting group in January to come in and talk about operational issues in the community health center. And so the rhetorical question, I think is, when you look at it, and Bill Burnett tells me that all great ideas come from the 1960s, and community oriented primary care comes from the 1960s. And you think about it, you know, you have input from a community and you develop a health plan and you measure outcomes. What a great place to train family medicine residents. So why is it so hard?Ok, that’s it.That’s it.There’s always Youtube, Youtube videos.(Lots of background talking, inaudible) people found this article helpful. What about you?