Good morning. When they asked me to do this, I felt intimidated by trying to follow in the footsteps of David, Chris, Jim, and others that have gone before in this position.  Meg Wheatley is someone who I've spent a week with on three different occasions and have been inspired by her. She says, "When a community of people discovers that they share a concern, change begins. There is no power equal to a community discovering what it cares about". This is our question today. What do we care about?

I have memories of entering medical school of excitement and concern, and I know those that enter Medical School today share similar thoughts. Those physicians that are practicing have an obligation to help their patients but also receive them as whole people and not just as bodies that are not functioning. For those of us who are getting older and those who are not, this is also about us as whole people.

We can ask ourselves, wouldn't we want someone who is competent for our own care? So the question is, what is competent care? I don't know about you but I would prefer to have a physician led group decide this.

David Korn said, "The challenge of the medical curriculum is to prepare the student for a lifetime of continuing education in our area of human knowledge that is as remarkable for its breadth and diversity as it is in the breathtaking pace of the advancement of its foundational disciplines. Intellectual vigor, curiosity, skepticism, compassion for the human condition, humility and uncompromising integrity. These are the qualities we must seek to nurture in our students today." This was said in the middle '80's and it seems as true today.

Why are we waiting for government and payors to decide this? We as physicians know better. I knew as a young person that something would happen. Right now the signs are becoming clear about the need to demonstrate competency. It seems that there is rising pressure for that. This appears to be another opportunity where we can step up and define the system. Are we going to sit around and ask who else needs to change or are we going to do something?

I've only been to one other of these summits and felt that this conversation is powerful and believe that things can happen. Last night we were to share our hopes and concerns. Mine is that we are able to leave our comfort zones, engage candidly and commit to stepping up to a physician-led change and create a system that will focus on the quality of care.

Michael reminded us last night that we've only been together for about 6 days. There has been a lot of good work done. My job this morning is to try to tell you what we've done over those 6 days. I was reminded of a story about a rabbi who was asked to explain the torah while standing on one leg. He said, "'Do not do unto others what you don't want done unto you'. The rest is commentary." (laughter)  That's about as far as I'll get with this.

I've got a slide presentation here I want to show you. [Click here to open it in a new window.] Our basic purpose here is that we have a social contract with the public. There is some concern that the current structure has degraded and that social contract has degraded.

For the first summit, we looked at significant events over the last 100 years and looked at key factors and driving forces to come up with scenarios. There were certain factors that were common over all of them. Cost and consumer dissatisfaction, a need for professionalism, and some kind of data collection. We came up with a couple of recommendations, including a good medical practice document, forming a national alliance, and some kind of portfolio or trusted agent. The social contract doesn't exist by itself. It needs support. Some of this support is the definition of competence, a lifelong learning portfolio, and developing the right tools and analyses. There will be public reporting needs.

This is the quick introduction to where we've been. Now I would to talk about our objectives:

• Develop a first draft charter for the National Alliance
• Develop scenarios/stories around the implementation of GMP including scenarios for working physicians
• Develop models for how we hold people accountable for behaviors articulated in the GMP
• Develop scenarios/stories about the trusted agent and the implementation/use of a portfolio like process in the implementation of the GMP

I am honored that you have invited us back to participate in this process. I'd like to acknowledge some groups that have done a lot of work since the last summit. As I name them, I'd like you to stand up: The communications plan work group, the good medical practice document edit and review team, the national alliance proposal work group, and the trusted agent/portfolio system outline work group

For the new folks who are joining us, I'd ask: how many of you have joined a rollercoaster in midstream? (laughter) There is a significant amount of work that has already taken place and there is a momentum driving this forward, so we want to be sensitive to and acknowledge that that is a challenging leap some of you will be making.

We need to keep the creative tension as long as possible. Most of us trained in a western modality will try to find the answer to the question as quickly as possible. We need to understand that this is incredibly complex. I would see this that we started out extremely broad and we are narrowing.

The first Summit created potential scenarios. The group saw that we have a seriously unpredictable future. These ideas that bubbled up seemed to be relevant regardless of the scenarios. Right now, we're in the midst of a conversation that is just beginning. There is a difference in the kind of conversation that happens when you look at the broad field as opposed to when you start going narrower.

We're beginning to narrow and we're including more people. This introduces another kind of complexity. In the creative process as you narrow down, there is tension in the number of options.

We simply want to take another step forward. We want to create a system that can ensure the public of having a competent physician. The way we work together is a series of activities in which you will create something. Everything you make will be shared in some way. There will be parallel processing so not everyone will be involved in every conversation.

As designers of these experiences, we design it as a whole experience, so we'll require your full attention at all times. Please be aware of your impact on the group. Differently than previous summits, I'm going to show you an outline of the work we're going to do for today.

How many of you noticed the scenarios on the wall when you walked in? What did you see?

• The timeline is shortening.
• We predicted pretty well.
• They're exceptionally complex which reflects the situation we have here. It has so many details.
• There's a lot of interaction.
• There is so much happening, no one individual or organization can tackle the whole thing.
• The absence of a headline for the National Alliance.
• There is a lot of mention for technology, that element isn't represented here. It still isn't part of the conversation.
• There is a lot going on in the real world on competency. I'm assume we're keeping track of that on a parallel basis. I'd like to be assured that we're factoring that into our conversations.
• I notice that we have a lot of participants with MD after their name. We don't have representation from people who don't come with a medical framework.
• I think it's important to track what's going on in the world around competency. There is movement in the world toward this.
• We created interesting scenarios and yet I hear that different groups recreating this wheel. There is a group reviewing USMLE and it seems that it would be good to have this work available.
• I have a brochure here that offers a workshop on competency.The author of this that says laws will need to be passed to make this happen. We're totally supportive of this effort.
• Should we consider when we go public with the National Alliance?
• Being a first timer and seeing all the work that has been done, it is very impressive. It would be useful to keep the conversation open.
• How many of us are still on the front lines? (about 15 people)
• Many of the folks who have to do what we're thinking about are under-represented here. This has to be factored in.
• I have grave reservations about going to the state legislature to do this. Usually what we ask them to do and the final product do not match up well. I would not support that.
• I'm an outsider to this group. A lot of the problems you're working with are shared by a lot of other groups. They're all dealing with faster changing technological world, more oversight with what they do, individuals who have information that need to be shared and demands for it to be shared. You are both ahead and behind. You are ahead in your ability to articulate these things. You are behind because you have been more isolated in your own groups. I'm a chair on a national academy for bio-defense. All the issues you're dealing with are in the center of that.
• How do we determine, measure competency in physicians? You want to ensure that physicians are competent and then assure the public that they're competent.

Michael: There is a lot of desire on the part of many participants to dive in and get right into the details but I would ask you to hold back for a couple of hours. We're going to start with developing some stories on the continuum of competence. Let's move to the next assignment.