<International Circulation>:You were very passionate in your presentation at this meeting， “Health Care System Performance: New Insights”， if nothing else motivational and inspirational. What is your basic philosophy on practicing cardiovascular medicine， even medicine in general， in the 21st century?

    Dr Krumholz: As physicians， we need to remain as strong patient advocates. We have to have first in our minds， what are patients perceiving and how are they feeling and what are we doing for them. Historically， we have always thought in a very deterministic way – the patient has ischemia so they need to have revascularization and the tests they need and the screening that needs to occur. We made assumptions about how these strategies would benefit patients. Now we are looking more toward patient outcomes and evaluating more comprehensively the results that we are achieving.

    Also， as patient advocates， we need to move towards tailoring or personalizing the evidence for the individual patients to obtain the information needed to work in partnership. I am very optimistic for what the future is going to hold. We have made tremendous advances in cardiovascular disease and we expect to make many more. My basic philosophy is that we need to be out in front in terms of what is best for individual patients. We need to obtain more and more insight into what is good for each individual that we treat and keeping that individual patient in mind in everything we do. We also need to switch from this idea that there is the maverick physician who can go off and dictate what patients should do based on their opinion only - and move to a place where we are a consultant to the patient but， in elective situations where there is time for deliberation， we allow the patient’s preferences to lead to the decision. In this way we get to know our patients and what they value and help them understand their options - and support them in the decision-making process. This approach is not easy - but I believe that patients are often undergoing treatments that they would not choose if they knew the facts.

    And then there is a need for us to develop strong systems that will enhance the performance of the entire health care team - enabling us to achieve outstanding results. We need to work together and make it difficult to err and easy to excel. The importance of individual effort and vigilance will not wane， but there is a growing need for us to perceive ourselves as part of an integrated team - with each member making unique contributions and the work of the group coordinated to a great extent in the service of care to the patient.

    I believe that， within this interest in systems-based care， the emphasis should be on integration across the hospital and the out-patient venue and the ho