Physicians, nurse midwives, registered nurses, and medical and nursing students significantly improved their ability to estimate obstetric blood loss after they were given pocket cardswith images of measured volumes on common materials including tail sponges, Chux pads, peri pads, bed pans, kidney basins, and delivery drapes, researchers report in an article published in April Obstetrics & Gynecology.

Lisa C. Zuckerwise, MD, and colleagues from the Department of Obstetrics, Gynecology, and Reproductive Sciences, Section of Maternal Fetal Medicine, Yale School of Medicine, New Haven, Connecticut, found significant improvements in all provider types in estimation accuracy for 4 of the 6 test volumes after participants received the reference card, and without any type of teaching exercise.

According to the researchers, postpartum hemorrhage occurred in 2.7% of deliveries in the United States in 2006 and was associated with 12% of pregnancy-related deaths. Both underestimation and overestimation of blood volume are problems. The former may delay potentially life-saving interventions, and the latter can lead to unnecessary interventions and costs.

The researchers assessed visual estimation of blood loss in 151 participants for 6 test stations: tail sponge with 30 mL, Chux pad with 100 mL, Chux pad with 200 mL, peri pad with 100 mL, peri pad with 250 mL, and delivery drape with 500 mL. Participants estimated the blood loss for each station. They were not given feedback about their accuracy after the initial test but were simply given the visual aid and told to repeat their assessments.

The investigators used the McNemar test to determine whether there was significant improvement.

Accuracy improved significantly (P less than .001) for all provider types for tail sponge, both volumes on peri pads, and delivery drape.

“Our study demonstrates that before use of our visual aid obstetric providers significantly underestimated the blood volume in a saturated peri pad and underestimated that three saturated peri pads contain blood loss of almost 1,000 mL,” the authors write.

Estimates for blood volume on Chux pads did not improve. The authors suggest that these pads might not show predictable, visually assessable blood absorbency and might require weighing the pads and closely monitoring vital signs to detect clinically significant bleeding. They also suggest that Chux pads might be improved by incorporating markers for saturation.

Years of experience did not correlate with accuracy except in the peri pad 100 mL station, where practitioners with more than 20 years of experience did best.

A posttest survey showed that 90% of participants thought the visual aid improved their ability to estimate blood loss.

“Our study demonstrates that a visual aid depicting known volumes of blood on common obstetric materials significantly improves obstetric provider accuracy in blood loss estimation. This benefit appears independent of provider type or years of experience,” the authors conclude.

A PDF version of the pocket card is available on the Yale Department of Obstetrics, Gynecology & Reproductive Services Patient Safety Web site.

I think this is another good article for our readers. 

Physicians engaged in patient care generated $1.6 trillion in economic activity and supported 10 million jobs nationwide in 2012, according to a new report by the American Medical Association (AMA).

The study found that physicians had a greater national economic impact than counterparts in higher education, home health care, legal services, nursing, and residential care.

“Spending on physician services grew more slowly between 2009 and 2012 than at any time in the last 15 years and accounts for only 16% of all health care dollars spent in the US in 2012,” the AMA said in a statement. “Yet expenditures for physician services have a ripple effect through the economy. Every dollar applied to physician services supports an additional $1.62 in other business activity.”

“Physicians carry tremendous responsibility as skilled healers, trusted confidants and patient advocates, but their positive impact isn’t confined to the exam room,” AMA President Ardis Dee Hoven, MD, said in the statement. “The new AMA study illustrates that physicians are strong economic drivers that are woven into their local communities by the jobs, commerce and taxes they generate. These quality jobs not only support the caring role of physicians, but also generate taxes that support schools, housing, transportation and other public services in local communities.”

Data from the Medical Group Management Association was used to estimate physician economic data on jobs, wages, and benefits. “Given the changing health care environment, it is paramount to quantify the economic impact physicians have on society,” the AMA said.

The report measures the impact of 720,000 patient care physicians in all 50 states and the District of Columbia as of December 2012.

Output: Each physician supported an average of $2.2 million in economic output and contributed to a total of $1.6 trillion in economic output nationwide.

Jobs: At the state level, physicians supported a median of 93,392 total jobs and a mean of 148,980 total jobs (including their own), the total of direct and indirect positions. On average, each physician supported almost 14 jobs.

Wages and benefits: At the state level, physicians supported median total wages and benefits of $7.4 billion and mean total wages and benefits of $12.7 billion. At the national level, physicians contributed $775.5 billion in direct and indirect wages and benefits for all supported jobs in 2012. On average, each physician supported an average of $1.1 million in total wages and benefits.

State and local tax revenues: At the state level, physicians supported median total state and local taxes of $440.4 million and mean total state and local taxes of $938.3 million. At the national level, physicians supported $65.2 billion in local and state tax revenues in 2012. On average, each physician supported $90,449 in local and state tax revenues.

Worth in More Ways Than One

“I think the AMA data is valid and is in line with studies we and others have done,” Tommy Bohannon, divisional vice president of Merritt Hawkins, a leading physician search and recruitment firm based in Irving, Texas said. “The AMA wants the small independent practice model to continue so it is putting out data stressing the worth of doctor practices to the overall economy.

“The timing isn’t accidental,” he said. “This comes as there’s more publicity than ever about Medicare payments to doctors. You’ll see articles about millionaire physicians but not as much about doctors going bankrupt. The AMA wants to show that doctors don’t make that much money, especially compared to what they generate in economic activity.”

A Merritt Hawkins study backs up the AMA data. “Little takes place in medicine that is not ordered by, reviewed by, or performed by a doctor,” states the 2013 Physician Inpatient/Outpatient Revenue Survey that quantified the financial impact physicians have on hospitals. It averages to $1.4 million in revenue per year per physician.

David J. Zetter from Mechanicsburg, Pennsylvania, a member the National Society of Certified Healthcare Business Consultants, applauded the AMA for “trying to make the public and Congress aware that physicians in private practice employ others, utilize vendors, etc, to assist them in the practice of medicine. Cutting reimbursement or passing laws that make it harder to set up a private practice is detrimental to the economy.

“Physicians run small businesses and small business drives the overall economy,” he said. “Physician impact on the economy may diminish, though, as hospitals continue to buy up more practices. That means there will be fewer physicians to employ people to assist in running their practices.”

I thought this was an interesting article I wanted to share with our readers. 

Changes in Healthcare Make an Impact

Medicine is undergoing significant changes — some for the better and others less so. Compensation has increased slightly in 19 specialties; the income gap between men and women is narrowing; ACOs are making their impact felt; self-employed physicians earn more than employed ones; and cash-only practices, while still a tiny percentage of all practices, are gaining some traction.

Those are some of the highlights of Medscape’s Physician Compensation Report: 2014 Results. The report is based on an extensive survey of more than 24,000 US physicians representing 25 specialties.

Who’s on Top?

Orthopedics ($413,000), cardiology ($351,000), urology ($348,000), gastroenterology ($348,000), and radiology ($340,000) are the 5 top-earning specialties, as they were in last year’s survey. Radiology has moved down in rank a bit compared with our earlier surveys, and anesthesiology has been knocked out of the top five, where it ranked in earlier surveys.

Primary Care Income Has Gone Up Very Slightly

Compensation for both family physicians and internists is up 1% over last year. While physicians overall have been concerned about income declines due to healthcare reform, this was not the case in 2013 for 19 specialties which saw relatively modest increases. However, inflation in 2013 was 1.5%, so for many, income did not keep up with inflation.

For primary care, some of the increase was probably due to the 10% bonus paid to primary care physicians who see Medicare patients, as stipulated in the Affordable Care Act. And despite the modest increase, family physicians and pediatricians are among the lowest-paid specialists, as they have been in our past surveys.

The Income Gap Between Male and Female Physicians Is Narrowing

Among physicians, men earn more than women, as they have in all past surveys. However, that picture appears to have improved. In 2010, male physicians earned 40% more than females, yet in 2013, males earned 30% more. Those percentages vary by specialty; in primary care, the disparity is smaller and it hasn’t changed much. In 2013, among internists, men earned 13% more than women ($195,000 vs $173,000); in family medicine, men earned 19% more ($187,000 vs $157,000).

Although men make more than women in almost every specialty, women tend to be as satisfied as men with their compensation or, in some specialties, even more satisfied. For example, female ob/gyns make $229,000 compared with $256,000 for men, but 47% of women are satisfied with their compensation compared with 38% of men. Female gastroenterologists make less than male gastroenterologists, but 55% are satisfied with their income vs 46% of men.

In our survey, urology was the only specialty in which women made more than men (and female urologists were also more satisfied with their compensation).

Self-employed Physicians Earn More Than Employed Ones

Among physicians overall, self-employed doctors earned an average of $281,000 compared with employed physicians, who earned $228,000. In primary care, the difference was less pronounced; self-employed physicians earned $188,000 and employed physicians earned $180,000.

ACOs Are Clearly Making Their Impact Felt

In 2011, 8% of physicians were either in an Accountable Care Organization (ACO) or were planning to join one that year. In 2013, that percentage had risen to 34%. The growth in ACO participation year-over-year, according to Medscape surveys, has been steady: In 2013, almost a quarter of physicians (24%) who responded were already in ACOs and 10% planned on joining one this year; in our 2012 survey, only 8% of doctors were either in an ACO or were planning to join one.

Cash-Only Practices Seem to Be Becoming More Appealing

While still in the minority, the percentage of physicians involved in cash-only practices rose from 3% of respondents in 2011 to 6% in 2013. This is in line with physicians who are dissatisfied with payments and are looking for ways to practice that don’t entail dealing with insurers.

Medicine as a Career Has Lost Some Appeal

Witness the answers to the following questions, comparing Medscape’s 2011 report to the 2014 report:

• Would you choose medicine again? Yes (2011: 69%; 2014: 58%)

• Would you choose the same specialty? Yes (2011: 47%; 2014: 61%)

• Would you choose the same practice setting? Yes (2011: 50%; 2014: 26%)

Insurance Is a Huge Issue

When asked whether they were planning to participate in a health insurance exchange, more than a quarter of respondents (27%) said yes, another 20% said no, and more than half (53%) said they were not sure. Their caution probably has to do with fears about income; 43% of physicians said they expected their income to decrease if they participated in health insurances exchanges; 50% said they expected no change, and 7% said they expected their income to increase.

In general, although a majority of doctors will continue taking new and current Medicare and Medicaid patients, about 25% haven’t yet decided whether they will or won’t, and a very small percentage (3% at most) will stop taking these patients. In regard to private insurance, 25% said they will drop insurers who pay poorly, while 39% will not.

Satisfaction With Compensation Has Not Changed Much in the Past 4 Years

In 2013, 50% of all physicians said they feel fairly compensated; 48% of primary care physicians feel fairly compensated. These figures are extremely close to the 2011 report percentages, in which 48% of all physicians said they felt fairly compensated and 51% of primary care physicians felt that way.

The specialties that feel the most fairly compensated are dermatology (64%), emergency medicine (61%), pathology (59%), and psychiatry (59%). Family medicine (50%) and internal medicine (46%) score around the middle of the pack. Least satisfied with their compensation are plastic surgeons (37%), pulmonologists (39%), neurologists (41%), and endocrinologists (41%).

Ancillary Services Are Still Popular for Bringing in More Income

The specialties that most frequently offer ancillary services are orthopedics (33%), anesthesiology (31%), and gastroenterology (28%). In primary care, about 23% of family physicians and 20% of internists are offering ancillary services.

Discussing Treatment Costs With Patients Varies by Specialty

Cost is a huge factor in treating patients — in some specialties more than others. Still, particularly in large health systems, treatment costs are most likely to be discussed with the billing staff rather than with the physician. Overall, in Medscape’s 2014 survey report, 32% of physicians regularly discuss the cost of treatment with patients; 40% discuss it if the patient brings it up. Only 19% of surgeons regularly discuss the cost of procedures with patients, while 41% of ophthalmologists have this discussion regularly.

Paperwork Takes Up a Huge Chunk of Time

Not unexpectedly, self-employed doctors spend more time on paperwork than do employed doctors. About 29% of self-employed doctors say they spend from 1 to 4 hours on paperwork per week compared with 24% of employed doctors. And 31% of self-employed doctors say they spend 5 to 9 hours on paperwork vs 28% of employed doctors.

One category in which employed physicians spend more time on paperwork vs self-employed physicians was 20 to 24 hours per week; 12% of employed doctors spend that amount of time compared with 6% of self-employed doctors It’s likely that this situation relates to physicians who are in administration, academia, or perhaps are involved with clinical trials.

Time Spent With the Patient

The amount of time spent with the patient has not changed significantly in the past few years. Comparing 2010 and 2013:

• See patients for 13 to 16 minutes: 2010: 21%; 2013: 29%

• See patients for 9 to 12 minutes: 2010: 16%; 2013: 18%

• See patients for 17 to 20 minutes: 2010: 17%; 2013: 25%

• See patients for 25 minutes or more: 2010:15%; 2013: 13%

Despite the frustrations, most physicians find their careers deeply rewarding. Being good at their jobs, having good relationships with patients, and making the world a better place were cited as key factors in making the practice of medicine worth the effort.

So much attention is paid to whether employees are “engaged” in their jobs or not. But managers at all levels need to periodically ask themselves a similar question: Are YOU engaged in managing your employees?

In an effort to “empower” their staffs, too many managers take a completely hands-off approach, leaving employees alone unless they really need help. But this can create a rudderless ship and, as author Bruce Tulgan calls it, an “under-management epidemic.”

The truth is, employees look to their immediate bosses to get what they want and need at work.

Management is much more than just overseeing people or projects. It’s about leading and negotiating, predicting trends and initiating change, making critical decisions and problem solving in an ever-evolving economy.

1. Get in the habit: Manage each day

The only alternative to “management by special occasion” is getting in the habit of managing every day. Start by setting aside one hour every day—before anything goes right, wrong or average. Concentrate on certain employees each day. The goal is to make these one-on-one sessions routine, brief, straight and simple—15 minutes should be all you need.

2. Learn to talk to employees like a performance coach

The best way to build rapport with employees is actually by talking about work. The most effective managers have a way of talking that is both authoritative and sympathetic; both demanding and supportive; both disciplined and patient.

This special way of talking looks a lot like performance coaching. Specifically:

Focus on specific instances of individual performance.

Describe the employee’s performance honestly and vividly.

Develop concrete next steps.

Don’t wait for problems to start before beginning to coach an employee.

3. Take it one person at a time

The alternative to “one-size-fits-all management” is to customize your approach to every person. The best way to tune in to individual employees is to continually ask yourself some key questions, such as: “What do I need to talk about with this person? How (and when and where) should I talk with this person?”

4. Make accountability real

Employees need to trust that their bosses will establish fair and accurate processes for tracking their actions and tying their behavior to real consequences.

Make sure your employees know they’ll have to explain their actions to you up close and often. Focus on concrete actions within the direct control of the employee. Separate your role as the boss from your personal relationships with employees.

5. Don’t be shy about telling people what to do and how to do it

How are employees supposed to meet—much less exceed—expectations if nobody tells them in clear, simple terms exactly what’s expected of them? Successful managers give concrete directions, goals and deadlines.

Ask employees to think out loud about how they might approach their assignments.

Ask basic questions: “Can you do this? What do you need from me?”

Ask probing questions: “How are you going to do that? What steps will you follow?”

Ask short, focusing questions: “How long will each step take? What does your checklist look like?”

It is simply a fallacy that rehearsing the wrong ways of doing things is a good way to learn how to do things right. The best way to engage employees in adopting the best work practices is to convert those practices into standard operating procedures. Give employees step-by-step checklists whenever possible. Follow up, follow up and follow up some more.

6. Track performance at each step

Knowledge is power: The more you keep track, the easier it will be to keep track. The greater your reputation for being all over the details, the more people will be likely to share information with you and answer your questions fully and honestly.

Monitor, measure and document performance—good, bad and average—with every employee, every step of the way.

7. Do more for some, less for others

You can’t do everything for everybody. But why would you want to?

Be generous and flexible with your time and your direction. Expand your repertoire of rewards and start using every resource you have to drive performance.

Make a point of talking with your best people to find out what they really want or need. Make the quid pro quo explicit and help people earn what they need every step of the way.

8. Solve small problems before they turn into big problems

I thought this was an article our followers would like to read. 

That which walks like a duck, and talks like a duck, is not always actually a duck.

That’s the argument the American Medical Association has been using for decades to block public access to doctors’ Medicare billing records. The AMA worries that people and the press will misinterpret the numbers when they see how doctors bill the government’s $500 billion health care program for the elderly and disabled, and that doctors who are doing nothing wrong could be unfairly accused of fraud.

But the medical association lost that argument last month and now doctors’ Medicare billing data is a matter of public record – dense, complicated records. And those records are beginning to tell stories.

KQED and the independent newsroom ProPublica took a look a close look at one particular type of medical service in the data.

In order to get paid, doctors have to label everything they do for a patient with a billing code. Routine visits for established patients are billed on a scale of 1 to 5. A level 1 code is for a short, easy office visit; level 5 is meant for the longest, most complicated office visits, which are also paid at a higher rate.

Office visits account for about $12 billion in Medicare spending every year.

One emergency medicine physician in Newhall, California, Dr. Gary Ordog, billed Medicare for a level 5 visit an average of 30 times per patient in 2012. A number that high raises “huge red flags, really high in the sky, waving their arms ferociously!” says Patrice Morin-Spatz, a specialist in medical coding and reimbursement.

The more typical doctor in California bills for only one or two of these high-level visits per year for each patient. Morin-Spatz says when she sees doctors with coding practices like Ordog’s, she thinks one thing: “I think that they are trying to code based on how much money they want, as opposed to coding with a goal to satisfy the requirements of each particular level of service.”

California’s medical board has tried to revoke Ordog’s medical license for what it called “incompetence, making false statements, and inadequate record keeping.” He is still practicing, but currently on probation, and did not return multiple requests for comment.

Ordog is one of hundreds of doctors in California with unusual billing patterns. In fact, three California physicians are among the top five nationally in billing for the highest number of complex, “level 5” office visits. Nationwide, some 1,800 doctors always billed at the highest level possible for routine office visits.

In Colorado, 71 doctors billed at the highest possible level for every one of their Medicare office visits. NPR tried to contact 15 of these physicians. Most didn’t return the phone calls, but Dr. Marilyn Levi did. She’s director of transplant infectious disease at the University of Colorado in Denver.

“There has to be an understanding and recognition of specialty care that is provided in only a few places. So I think it’s dangerous to lump everyone together and base everything on a code

Levi works in the only academic medical center for hundreds of miles in any direction. It’s where other hospitals in the region send some of their toughest patients.

“And therefore,” Levi says, “the time that is required to take care of them is longer than [for] some of the other specialties in infectious disease … and that results in the higher coding.”

That sort of context isn’t obvious in thehuge trove of Medicare payment data that was made public for the first time last month. Levi is concerned people will misinterpret the information.

“There has to be an understanding and recognition of specialty care that is provided in only a few places,” she says. “So I think it’s dangerous to lump everyone together and base everything on a code.”

Dr. Aris Sophocles, a Denver physician who teaches medical coding to medical students and doctors, says that’s a perfectly reasonable caution. But not every doctor who frequently bills at the highest level is being honest, he says.

“When I see someone in family medicine, I get suspicious,” says Sophocles. “Similarly, in other specialties, such as general internal medicine and gastroenterology, I become suspicious.”

Sophocles is hardly on a witch hunt. In fact, he’s also an attorney, and he helps defend doctors who get prosecuted for having fishy-looking billing practices. He says Medicare does audit doctors, and some have had to pay Medicare back, or even face jail time, which causes them to err on the side of under-coding — charging less than perhaps they should.

“Some, though, are either unaware or unafraid,” he says. “And they tend to over-code anyhow, and the release of this database may indicate who those people are.”

In a statement to ProPublica, Medicare officials said that “it would be highly unusual” for doctors to bill at the highest level 100 percent of the time.

Delayed administration of epinephrine for patients with in-hosptial cardiac arrest is associated with increased mortality, according to a retrospective study in BMJ.

Using a resuscitation registry, researchers identified 25,000 inpatients who had a cardiac arrest with a nonshockable rhythm (e.g., asystole or pulseless electrical activity). Only 10% survived to discharge. Mortality increased in a stepwise fashion as the time to epinephrine administration increased. When epinephrine was administered 10 minutes or more after recognition of cardiac arrest, there was a reduced chance of survival to discharge (odds ratio, 0.63), compared with administration within 1 to 3 minutes. Quicker administration of epinephrine was also associated with increased chance of return of spontaneous circulation, 24-hour survival, and neurologically intact survival.

The authors conclude: “When a patient is not in a shockable rhythm, current standard of care focuses on cardiopulmonary resuscitation only… With such a large proportion of cardiac arrests being nonshockable rhythms, future quality metrics could conceivably focus on shortening the time to administration of epinephrine in these patients.”

Good employers and leaders will create and foster more engaged employees, who help make organizations more productive and successful, according to the Gallup Business Journal.

Gallup examined 32 companies that employed a collective 600,000 people across seven industries, including healthcare, and found engaged employees outnumber disengaged employees nine to one at these companies.

As employee engagement becomes a top concern for hospital chief executive officers, what makes these businesses so successful? A culmination of inspiring workplace leaders, accountability, decisiveness and a genuine desire to improve, according to the article.

Successful organizations, according to the article, almost always:

Employ leaders who walk the walk. Good leaders set an example by modeling positive management styles and checking in with their teams daily. Leaders who constantly and visibly improve themselves will create a trickle-down effect which employees will mimic.

Have HR teams that help leadership learn. Good human resources team will develop capable employees into leaders who make smart, effective managers. At Lehigh Valley Health Network, the hospital identified 160 employees from all realms who displayed strong social and emotional intelligence and put them in a leadership development program, 75 percent of whom graduated from the program and moved into more senior positions than when they started.

Maintain a strong culture in face of adversity. Even when the majority of companies Gallup examined faced a financial slump or cuts within the organization, they kept an open, accessible line of communication and adapted quickly to changes. Culture and employee engagement are two areas leaders can control during shifting industry changes and unstable financial times, according to the article. For example, Dignity Health, which operates 300 care centers in 21 states, chose to keep its doors open at four hospitals in bankrupt municipalities, despite not yielding a profit, because they are a piece of the system’s core mission.

Encourage leaders to trust their teams and hold them accountable. Support middle management by giving them a voice and a chance to prove they can build and maintain their own micro-culture, according to the article. At Hardford HealthCare, the hospital restructured its middle management system and used workgroups rather than departments to create clear and specific goals with a strong customer focus, as part of its “How Hartford HealthCare Works” program. Each work group meets monthly and is led by an assigned leader, who attends a 10-class training session. 

Don’t just engage employees to meet metrics and standards. Successful employers use employee engagement to achieve greater outcomes and create a better product. 

Patients aren’t as likely to have problems paying their medical bills if they get information such as out-of-pocket cost estimates up front, according to a recent TransUnion Healthcare survey. 

According to TransUnion, a medical necessity software program can provide real-time verification of patients’ insurance eligibility and benefits, allowing providers to avoid billing errors and give patients information about their financial responsibilities before treatment. According to the Medicare industry, groups without medical necessity programs face an average of $960,000 in denials each year and an average cost of $53 to $117 per denied claim.

Here are three key takeaways from TransUnion’s survey of 700 insured consumers about upfront cost estimates and medical bills:

1. Of those surveyed, 75 percent said pre-treatment out-of-pocket cost estimates would improve their ability to pay their bills.

2. Fifty-six percent of patients rarely or never received an out-of-pocket cost estimate prior to treatment.

3. Nearly six in 10 (59 percent) said they have been surprised by what they owed when they received a final medical bill.

The wheels of regulation grind slowly, but the US Food and Drug Administration (FDA) last week finally declared that the maker of the da Vinci robotic surgical system has satisfactorily addressed violations listed in an agency warning letter from July 2013.

Among other things, the FDA faulted Intuitive Surgical, the manufacturer of the robotic surgical system, of neglecting to report “field actions” it took to guard patients from accidental electrical burns. The agency also said that company did not comply with requirements for documenting equipment design. The warning letter came on the heels of FDA inspections of the company’s headquarters in Sunnyvale, California, in the spring of 2013.

In a letter an FDA compliance officer informed Intuitive Surgical that the company’s corrective actions in response to the 2013 warning letter appeared to pass muster.

As of March 31, there were 2116 da Vinci systems installed throughout the United States and 923 in other countries, according to a recent company filing with the US Securities and Exchange Commission. The number of surgeries performed with the technology in the United States rose from roughly 367,000 in 2012 to 422,000 in 2013. Almost 57% of those in 2013 were hysterectomies, myomectomies, and other gynecologic procedures.

The computerized technology allows a surgeon to manipulate laparoscopic instruments attached to robotic arms while viewing the procedure in 3 dimensions, just as if it were open surgery.

Earlier this year, the FDA approved an upgraded model of the da Vinci robotic surgical system.

On this Memorial Day, we pause to remember the 1.3 million American soldiers who have died in war since our founding, and the 1.5 million who have been wounded. Thank you. Thank you again, to all who have served and sacrificed, and to those who now serve and sacrifice.