David Asch on Behavioral Economics and Health: Designing Health Programs for Real People

At TEDMED 2018 David Asch shared how he advances individual and population health by improving how physicians and patients make decisions in health care and in everyday life, including the use of medical treatments and personal health behaviors. Watch his Talk “Why it’s so hard make healthy decisions” and read his blog post below to understand more about the role irrationality and predictability play in decision making and why behavioral economics is such a powerful tool in health.

Health programs are more likely to be successful if they reflect how real people make real decisions.

If everyone did what was in his or her own best interest, no one would smoke, everyone would wear seatbelts, and most people would skip dessert. The simple observation that plenty of people do things that they know in their hearts isn’t good for them is partly a story about the limits of human willpower. It’s also a story about the trap of assuming that people are rational. We fall into that trap when we believe that helping people understand how to improve their health is enough to help them actually improve their health. Often it isn’t. We often do things that compete with our own best interest not because we don’t know what to do, but because even though we know what to do, we don’t do it.

Do any of these examples sound like you?

Sally is at an event where chocolate cake is served for dessert. Sally knows that the cake will throw her off her diet, but it is right in front of her, and it looks so luscious and, well, the diet can take a break until tomorrow…

Joe knows that regularly taking his high blood pressure medication is one of the best ways to avoid the kind of devastating stroke that dramatically changed his father’s life. But as he heads to bed for the evening and realizes he didn’t take his medication, he decides not to turn around and head back to the medicine cabinet…

Sally and Joe have present bias—meaning that they pay more attention to the outcomes that are right in front of them (like that chocolate cake) than the even-more-important outcomes that are in the future (like losing weight). They aren’t alone. I have present bias, and so do we all.

Consider Reggie:

Reggie buys a lottery ticket on his way to work every day, and he always plays the same number. He dreams about what he’d do if he won, and although the odds are small, people win all the time. And he never misses a day because what if his number came up on just the day he missed buying a ticket!

Like Reggie, each of us sometimes overestimates small chances—focusing on the outcome rather than its likelihood. And each of us sometimes has regret aversion: we hate that feeling of missing out, that life would have been better if only we had done things differently. If only we had bought that stock when it was low. We all feel this way sometimes, just like we all overestimate small chances, and all focus too much on the present and not enough on the future.

Sally, Joe, and Reggie are not behaving in ways that best help them achieve their goals. But they are making the mistakes we all make.

So why do we continue to design tepid health programs based on a belief that people will do as they should? We do so because our first assumption is that people will behave with their own best interests in mind—that they will behave rationally. But often, we are irrational.

Behavioral economics is based on this recognition. We don’t always do what is in our own best interest. Our decisions are subject to emotion, to framing, to social context. But the key contribution of behavioral economics is recognizing we are irrational in highly predictable ways. It is the predictability of our psychological foibles that allows us to design strategies to overcome them. Forewarned is forearmed.

That’s why behavioral economics is such a powerful tool in health. For example, we can use behavioral economics to help people take their medications as prescribed. Perhaps we offer rewards to help them to do so—making the benefits of taking medicine seem relevant today, unlike the potential avoidance of a stroke years down the line. We can set up rewards in lottery formats because the difficulty interpreting small probabilities makes lottery incentives even more potent. We can make patients eligible for rewards only if they took their medicine the day before, harnessing the human tendency to avoid regret.

These approaches work because they see past how we would like people to make decisions and toward how they actually do so. They work because they hitch our health care wagon to the behaviors and mental approaches we already follow. They make the right choice the easy choice because they harness our own, predictable, irrationality instead of trying to compete with it.

Q & A with Mitchell H. Katz

TEDMED: In your TEDMED 2018 talk, you shared that you believe that healthcare in the United States is built on a middle-class model that often does not meet the needs of low-income patients. In your opinion, what are some of the assumptions made in the current model?

Mitchell H. Katz: Health care in this country assumes you can take time off from work to see the doctor, that you speak English, that you are literate, that you have a working phone, a safe home and healthy food to eat. 

The current model is simply not designed to be responsive for people like one of my patients who developed partial blindness in both eyes but didn’t come to see me until days later because he had to work in order to pay the rent. Or my hospitalized patient from West Africa who spoke a dialect so unusual that we could only find one translator who could understand him.  That translator only worked one afternoon a week. My patient needed to communicate every day. Or the diabetic patient who is homeless and has no refrigerator to keep his insulin or steady supply of food to keep his blood sugar under control. 

That’s one of the reasons why it’s been so difficult for us to close the disparity in health care that exists along economic lines despite the expansion of health insurance under the ACA or Obamacare.  

TM: Being aware of these assumptions, what are some of the actionable ways that providers can better meet the needs of their low-income patients?

MK: We need to redesign the system to meet patients where they are and remove obstacles. We need to provide what they need, not what we think they need. The right prescription for a homeless patient is housing. For non-English speaking patients, translation is as important as a prescription pad. And for people who do not have a steady supply of food, there is a variety of solutions. In New York City, we hired a bunch of enrollers to get our patients into the supplemental nutrition program known as Food Stamps. Other health systems are including food pantries at primary care clinics, or distributing maps of community food banks and soup kitchens.  

But more than anything else, I think low-income patients benefit from having a primary care doctor.  They need a team of people who can help them access the medical and nonmedical services they need.  So many are disenfranchised from other community supports, and they really benefit from the care and continuity provided by primary care.  

TM: Having run the safety net systems in San Francisco, Los Angeles and now New York City, you have an in-depth knowledge of the health needs in each area. Are there any striking similarities or differences between the needs in each city?

MK: One of the most obvious differences I’ve noticed is that in New York City, people don’t use primary care – they rely on specialists for every part of the body. I like to joke that folks here have left earlobe specialists and right ankle surgeons. That means there is less focus on prevention and wellness. That’s why I’m particularly excited about NYC Care, our new health access program for people who are not eligible for insurance. We can guarantee NYC Care members a dedicated primary care provider and a first visit in two weeks or less to help keep them healthy. 

TM: In your experience in creating housing as a public health response, what resources need to come together to provide the necessary support, financially and otherwise, to achieve this? 

MK: In Los Angeles, we housed 4,700 chronically homeless persons suffering from medical illness, mental illness, addiction.  It really takes a village to make this possible. We need non-profit developers whose mission is to serve. We need health care providers and community based organizations that can provide onsite services, state and local governments that prioritize housing as a public health issue, supportive neighbors who welcome instead of fear and protest the influx of formerly homeless or substance users to their communities. And we need banks willing to finance these non-traditional construction projects.   

TM: What is your hope for the future of the U.S. health care system?

MK: My hope is that people recognize the vital role of primary care in delivering high quality health care to diverse populations.  That means valuing primary care doctors, both financially and spiritually, so that medical students want to become primary care doctors and truly meet the needs of their patients. 

Healthcare Accessibility: A Look At The Numbers

At TEDMED this year, we will hear from three Speakers and Innovators who approach health care through the lens of economics. Through their work, we will explore different ways to think about allocating our finite resources in a world of limitless possibilities.

A natural experiment is an observational study that allows for the random—or seemingly random—assignment of study subjects to different groups. These kinds of experiments are rare but important when studying ideas that are impossible or unethical to recreate in the setting of a controlled experiment. Former Emergency Department social worker-turned-Medicaid researcher Heidi Allen seized the opportunity to study one such organic experiment in 2008, when the state of Oregon decided to expand its Medicaid program. There were 90,000 people who signed up for the expanded program, but as a result of limited funding, only 10,000 people were chosen to participate by random lottery. This unique circumstance provided Heidi and her team of researchers a randomized controlled trial with which to study the effects of Medicaid coverage.

The experiment’s results were complicated in terms of their impact on the newly-covered patients. Some outcomes were clearly positive—such as patients experiencing declining rates of clinical depression and financial stress as their medical debts decreased. Other results were less desirable. For instance, data indicated that the newly covered patients’ physical health markers—such as blood pressure, cholesterol, and cardiovascular disease—did not significantly improve. Along with these results, valuable lessons were learned. Heidi’s landmark research helped uncover truths about the role that health insurance plays in the lives of low-income Americans with limited access to coverage.

Even for people with health insurance, trying to understand or predict the costs that will accompany health care can become overwhelming. Often, it’s impossible to ascertain the cost of medical procedures in advance, and it’s not unusual for surprise bills to arrive months after your appointment. Eligible co-founder and CEO Katelyn Gleason wants to take the mystery out of medical billing. By integrating with existing medical systems, Eligible offers patients up-front information on the price of their procedures and co-pays, allowing them to pay at the time of service instead of waiting for months to receive a bill. Eligible not only benefits patients, but also physicians—who are saving valuable time not having to track down patients’ payments, helping them to collect up to 700% more revenue at the time of service.

While Katelyn is helping patients and providers demystify health care billing, health policy expert Amitabh Chandra is focusing on the important role that precision medicine will play in the future of drug pricing. Amitabh encourages us to consider the economic choices necessary to fund the next generation of medicine, in which the creation of targeted therapies that apply to smaller groups of people will change the economics of pharmaceuticals as we know it.

Funding and research in precision medicine are booming and for good reason: this approach hopes to maximize efficiency when treating disease. Currently, the Orphan Drug Act and other FDA regulatory incentives provide economic impetus for pharmaceutical companies to pursue precision medicine research. Yet it’s important to recognize that smaller markets, less competition, high technological manufacturing costs, and increased effectiveness could all result in eventual rising drug prices. Amitabh explores how we can incentivize companies to continue making precision therapeutics that patients can actually afford.

We are excited to hear more from each of these TEDMED Speakers and Innovators about their work investigating ways we can maximize our resources in economically sustainable ways. Join us at TEDMED this year to get to know them and their work better.

Why do doctors practice race-based medicine?

by Dorothy Roberts, guest contributor

Biological scientists established decades ago that the human species can’t be divided into genetically discrete races. Social scientists have shown that the racial classifications we use today are invented social groupings. And historians of medicine have traced doctors’ current practice of treating patients by race to justifications for slavery. Doctors I’ve talked to readily concede that race is a “crude” proxy for patients’ individual characteristics and clinical indicators. Countless patients have been misdiagnosed and treated unjustly because of their race.

So why do doctors cling so fiercely to race-based medicine?

BWSyringe2One reason is force of habit. For generations, beginning in the slavery era, medical students have been taught to take the patient’s race into account. Race is built into the foundations of medical education, which assumes that people of different races are biologically distinct from each other and suffer from diseases in peculiar ways. What’s more, medical students aren’t given much latitude to question the lessons they are taught about race.  Without a radical disruption, these students go on to train the next generation of doctors with the same flawed racial dogmas.

Another reason is that doctors aren’t immune from commonly-held racial stereotypes and misunderstandings. Most Americans believe some version of a biological concept of race, and doctors are no exception. In fact, the entire field of biology has been plagued by controversy and confusion over the meaning of race. It is not surprising that the medical profession would be influenced by racial thinking that has been perpetuated in U.S. education, culture, and politics for centuries.

In addition, there are institutional and commercial incentives to continue practicing medicine by race. Starting in the 1980s, the federal government required the scientific use of racial categories to ensure greater participation of minorities in clinical research and to address health disparities. Unfortunately, this effort to diversify clinical studies focused on biological rather than social inequalities and has reinforced genetic definitions of race.  In 2005, the federal Food and Drug Administration approved the first race-specific drug, a therapy for African-American patients with heart failure, that was repackaged as a race-based pill to enable the cardiologist who developed it to obtain a patent. Labeling drugs by race may be financially advantageous to pharmaceutical companies by providing a marketing niche and an avenue for FDA approval. The biomedical research and pharmaceutical industries have tremendous influence over how medicine is practiced.

Doctors are quick to bristle at any suggestion that treating patients by race results from their own racial prejudice. They disavow any connection to blatantly racist medicine of the past—the horrific treatment of enslaved Africans; unethical medical experimentation on African Americans, such as the Tuskegee Syphilis Study and use of Henrietta Lacks’ cancer cells; Jim Crow segregation of medical services; and mass sterilization of black, Mexican-origin, Puerto Rican, and Native American women in the 1960s and 1970s.

Doctors argue that they are using race for benevolent reasons or, at most, as a benign way to classify their patients. But race is not a benign category. Race was invented to support racism and it is inextricably tied to racial oppression and the struggle against it. There is no biological reason to divide human beings into white, black, yellow, and red. Race seems natural only because we have been taught to see each other this way. Sometimes, when I speak to doctors about this topic, I can see their physical discomfort with giving up their reliance on race. It feels like asking deeply religious people to give up their belief in their deity. Race is more than an ordinary medical feature—it is part of people’s deeply-held identities, their sense of their place in society, and their view of how the world is ordered. This is why ending race-based medicine will require a great leap of imagination, a new vision of humanity tied to a movement for racial justice.

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Global scholar, University of Pennsylvania civil rights sociologist, and law professor Dorothy Roberts exposes the myths of race-based medicine in her TEDMED 2015 talk.

Building Health: Q&A with Robin Guenther

In her TEDMED 2014 talk, expert in sustainable healthcare design and long-time advocate for healthier healing environments Robin Guenther explored the unusual connections between health and environmental design.  We asked her a few questions to learn more.

RobinGuentherTEDMED2

What motivated you to speak at TEDMED?

For the past couple of decades, I have been developing a body of thinking – I’ve spoken and written a lot for healthcare audiences.  I wanted the chance to “step outside,” focus my ideas, and make a direct appeal for accelerating the transformation of healthcare practice and built environments.

Why does your talk matter now? What impact do you hope it will have?

For me, the immediacy of climate change threats, the persuasive science of toxic chemicals and health, and the rise of interest in healthier workplaces are all coming together to drive a fundamental transformation of healthcare delivery.  I want everyone in healthcare to understand that their practices do have consequences, but they have the power to drive practices that prioritize health and “heal” both people and ecosystems. At 20% of the GDP, healthcare has both enormous upstream leverage and downstream influence to create a tipping point for prioritizing health.

What is the legacy you want to leave?

I want to be remembered as being fearless about self-reflection.  It’s difficult to face the fact that healthcare is an industrial system that creates waste, dismal work environments and a load of externalized harm, but it is, nonetheless, true. I believe that only by seeing the system clearly, connecting healthcare practices with their environmental and health consequences, can we transform both healthcare and larger societal practices. I want people to believe that I played even just a minor supporting role in building a world where “health is the aim.”

Is there anything you wish you could have included in your talk?

The quest for “building health” is a global one. I wish I could have shown some examples of amazing work that is taking place globally, transforming systems of care and the buildings that support care delivery.  Of note is the Sambhavna Clinic, in Bhopal, India, that cares for multiple generations of Bhopal chemical disaster survivors and grows medicinal herbs and foods on site.  Another example is the amazing work of the UK National Health Service in transforming care delivery to focus on integrated health in communities.

What action items would you recommend to your viewers?

Join the Healthier Hospitals Initiative or Global Green and Healthy Hospitals Network.  Select a practice that your organization or place of work engages in,  and research its environmental and health costs.  Does it have externalized negative impacts? If so, change it in order to move beyond those impacts, and share your story!

Op-ed: The primary nature of access to care, by Danielle Ofri

The content, views and opinions expressed in this blog post are those of the author(s) and do not imply endorsement by TEDMED. By inviting guest bloggers, TEDMED hopes to share a variety of perspectives that provoke and engage our community in discussion and debate.

Daniel Ofri speaks on the TEDMED stage. [Photo: Sandy Huffaker]
Daniel Ofri opens up about medical errors on the TEDMED stage. [Photo: Sandy Huffaker]
 

“Doctor, it’s taken so long to get this appointment with you.” This is the opening line of so many medical visits these days, and I find myself constantly apologizing to my patients for the delay. Even though both the patients and I know that it’s a systemic issue, it’s still front and center in our personal interaction. They are frustrated that they can’t get a timely appointment, and I’m aggravated because too many medical issues pile up in the interim, making the visits we do have massively overburdened.

The difficulty with access to medical care has been extensively highlighted at the VA hospital system, but is endemic to our entire medical system, even for patients with good insurance plans. Since the Affordable Care Act, some 10 million more Americans now have health insurance. This is an impressive achievement that should be celebrated, but of course insurance is only the first step in improving overall health. Now, these 10 million Americans must find doctors. A survey of 20,000 doctors from the nonprofit Physicians Foundation reports that fewer than a fifth of American doctors are able to take additional patients. More than 80% of doctors are over-extended or at capacity.

What does this mean for American medicine? One possibility is that the Affordable Care Act has placed us on an unsustainable path, something we hear frequently from those who oppose Obamacare. But this only holds water if the prior status quo—allowing a significant swath of America to remain outside the healthcare system—is considered acceptable. Luckily, we are slowly coming around to the ethical conclusion that the rest of the world has already made, that health care is something that all people deserve. Political realities may have forced awkward contortions in our health-care reform, accommodating multitudes of private insurance plans rather than offering a public option—concrete progress has nevertheless been made. So now the health care system must adapt. It can no longer survive on the expediencies of ignoring 15% of our population—it needs to start thinking about caring for all Americans.

A first step is considering how we allocate our existing clinical resources. The Physicians Foundation survey reported that doctors spend 20% of their time doing non-clinical paperwork. If you visualize that statistic carved out from the total number of doctors, it’s equivalent to about 170,000 doctors whose stethoscopes are sitting idle. This is a mind-boggling waste. To not be able to get an appointment with your doctor because she is spending a fifth of each day doing paperwork would sound ludicrous if it weren’t so dangerous. But patients and their serious medical conditions are getting short shrift as their doctors and nurses drown in metastasizing paperwork. Freeing up doctors’ time to see patients—a true measure of efficiency!—could make a real difference in the access problem. Amputating off even half the paperwork would be the equivalent of 85,000 new doctors available for patients.

A second step is to start planning ahead for healthcare that fits the needs of our patients, now that we are getting serious about taking care of all patients. For that, we need to delve a little more deeply into the access issue. Other countries have access issues also, but their long waiting lists relate primarily to specialties and procedures. What is uniquely American about our access problem is that it is particularly difficult to get primary care. Our inability to provide basic medical care for all Americans is what torpedoes the net efficacy of our medical system. Despite our superior technological advancements, we rank dead last in overall health outcomes compared with other developed countries. There is no secret about how to improve this—it’s tending to the basics. Research shows that the more primary care patients receive, the healthier they are and the longer they live. But the American system is not set up for this. Going forward, the only way to have a significant impact on our nation’s health is by improving access to primary care. Expanding training slots in family medicine, internal medicine, geriatrics, gynecology, and pediatrics is a necessary step, because the sheer growth of the American population means that we will need at least 20,000 more primary care doctors, if not more. But alongside increasing the pipeline of primary care doctors, we have to rethink the way we value and reimburse medical care.

It is an embarrassing truth that in the United States access to medical care relates to how lucrative that care is. It’s much faster and easier to get expensive tests and procedures than to take care of your general health. The fee-for-service system has consistently weighted procedure-based services (surgeries, endoscopies, MRIs) as having more “value” than cognitive-based services (treating diabetes, asthma, or heart failure). This absurd and patently profit-driven assessment means that we end up with more procedures and higher bills but poorer health and ultimately less access to basic medical care. Newer payment systems—bundled payments, pay-for-performance, accountable care—have the potential to jigger the balance somewhat. But our fundamental hierarchy remains completely backwards. Until we reverse this and make primary care, well, primary, getting an appointment with your general doctor in the United States will be the Achilles’ heel of medicine. Unless, of course, that heel needs a botox injection.

Danielle Ofri is an internist at Bellevue Hospital, an associate professor of medicine at NYU, and editor of The Bellevue Literary Review. Her most recent book is What Doctors Feel: How Emotions Affect the Practice of Medicine. In her TEDMED 2014 talk, she makes a powerful against-the-grain case that one of the things medical professionals are most resistant to doing would lead to dramatic improvements in care and undoubtedly save many lives. 

Healing Metaphors – A Q&A with Abraham Verghese

At TEDMED 2014, physician and author Abraham Verghese shared a compelling and original perspective on the impact of language on medicine. In the Q&A below, he reveals more about how embracing our creative selves can help preserve the humanity in healthcare.

Abraham shares why it's important to breathe life back into medical language. [Photo: Kevork Djansezian, for TEDMED]
Abraham shares why it’s important to breathe life back into medical language. [Photo: Kevork Djansezian, for TEDMED] 
Why does this talk matter now? What impact do you hope the talk will have?

I was struck by the colorful metaphors that peppered medical descriptions in years past – the “strawberry” tongue, the “Mulberry” molar, the “Apple core” lesion of the colon, and so many more. I’ve found it so hard to believe that – with the avalanche of new diseases, new science and new technology – we simply haven’t developed new metaphors quite as colorful as the “saber-shinned tibia” or the “crackpot’s skull” of years past. It’s a peculiar atrophy of the imagination at a time when our scientific imagination knows no bounds. I think our right brains are churning, wanting to label and make colorful and to connect, but the imagined constraints of science and data have introduced a peculiar self-consciousness. I’m hoping that my talk encourages us to create more eponyms, more metaphors, and more colorful ways of capturing this incredible time we live in.

What is the legacy you want to leave?

I’d like to think that, in the era of tremendous advances in science and in medicine, I tried to keep us from losing sight of the patient, that vulnerable human being who gave us the great privilege of being with them at their time of need. What that human being needs in addition to our robotic technology, our beautiful diagnostic tools, is a caring relationship with another human being. I’d like to think that I spoke strongly for that and that I introduced a generation or more of students to the bedside and to that special privilege.

William Osler is quoted as saying that he desired no other epitaph “…than the statement that I taught medical students in the wards, as I regard this as by far the most useful and important work I have been called upon to do.” I don’t know that he actually used that on his tombstone, but I understand the sentiment. Every single student I work with at the bedside (even though the process might seem inefficient to be working with just one or two students) has the potential to go out and, in a lifetime, care for hundreds and thousands of patients. So, if you influence them well, you truly have leveraged something in the best sense of that word. I’d like my legacy to be about that work, both at the physical bedside but also metaphorically, and having brought readers and listeners to that sacred space and having perhaps conveyed in every manner that I could, the romance and passion and privilege of being in medicine. It’s not a business and never will be. Even though it enriches a lot of people, and even though it seems to be very much a business, medicine will always be a calling.

What’s next for you?

I have in mind the shaping of something I am calling “The Center for the Patient and Physician,” which I think of as a place to explore every aspect of the patient-physician relationship. At one level it will be pedagogy, teaching at the bedside and refining methods for teachers. But it will also be bringing in folks from a multitude of disciplines. For example from anthropology and ethnography to look at the patient-physician interaction, or tapping into bioengineering and design schools to look at the spaces where we interact. Perhaps, using population health sciences to look at influences on large populations of certain styles of physician-patient relationship. Or serving as a locale where postdocs and scholars who are interested in any aspect of this, can develop their craft – from studying empathy, compassion and caring to developing the next generation of pocket tools.

Are there any action items that you want your viewers to take?

Invent a metaphor that captures the work you do! If something could be named after you, what would it be? Go ahead, don’t feel shy!

How ultrasound became a disruptive innovation

Resa Lewiss, Director of Point-of-Care Ultrasound and Associate Professor of Emergency Medicine and Radiology at the University of Colorado School of Medicine, unlocked imaginations about ultrasound applications in her talk at TEDMED2014. She explained why and how ultrasound at the bedside has become a game changer for clinical care.

She recently took a moment from her duties in Denver to share more about her work and impressions of TEDMED.

Resa Lewiss: How Ultrasound Has Become a Disruptive Innovation
Reas Lewiss at TEDMED2014. Photo by Sandy Huffaker for TEDMED

What motivated you to speak at TEDMED?

I attended TEDMED2013 in Washington DC. I was inspired by the people, the space and the vision of TEDMED. I believe that the arts inspire creativity and innovation. And innovation begets innovation. I live the aphorism mens sana in corpore sano, [a sound mind in a sound body]. TEDMED does too.

Why does this talk matter now? What impact do you hope the talk will have?

This talk will hopefully deconstruct healthcare silos. Point-of-care in partnership with ultrasound can be a concept that is difficult to comprehend. I hope to have connected the dots between the technology and the resultant improvement in patient care- for health care providers, people in tech and people in the world. The safety profile, time efficiency and cost effectiveness are self-evident.

Tell us about the top 3 TEDMED2014 talks or performances that left an impression with you.

Jill Vialet: Sobering reminder for ourselves and loved ones. Play is healthy.

Barbara Natterson-Horowitz: Back to basics, obvious and inherent and yet never quite articulated in this way before.

Bob Carey: Honest and emotional. Much respect for his willingness to show his vulnerability; a sobering performance.

Robin Guenther: She hit it on the head. Who is looking out for the healing and healers? Thank goodness she is. Mens sana in corpore sano.

What is the legacy you want to leave?

One of quality, integrity, justice, honesty, excellence, and mindfulness.

Contact Resa to learn more about how to encourage point-of-care ultrasound curricula integration at all medical schools and for all providers.

Resa Lewiss at TEDMED2014. Photo by Sandy Huffaker for TEDMED.