 All right, hi, everyone. Welcome to the noon case conference. Today it is my pleasure to introduce Dr. Peter Angelos. Peter Angelos, MD PhD is the Linda Kohler Anderson professor of surgery, the chief of endocrine surgery and the director of the McLean Center for clinical medical ethics here at the University of Chicago. He earned his MD and a PhD in philosophy at Boston University, completed his general surgery residency at Northwestern University, and his endocrine surgery fellowship under the direction of Norm Thompson at the University of Michigan. As one of the pioneers in the discipline of surgical ethics, he writes, speaks and teaches widely on ethical issues and surgical practice and how to best teach medical ethics to surgical residents. As an accomplished surgeon and past president of the American Association of endocrine surgeons, Dr. Angelos has published more than 250 peer reviewed papers and dozens of book chapters on his research into improving outcomes of thyroid and parathyroid surgery, minimally invasive endocrine surgery, and best practices for thyroid cancer treatment. He has trained 12 endocrine surgery fellows, hundreds of surgical residents, and has been an inspiration to the over 80 surgeons who have completed the McLean Center fellowship in clinical medical ethics. A very skilled and patient surgeon, thoughtful mentor, and all around exceptional human being and friend. It is my pleasure to introduce Dr. Peter Angelos whose talk today is entitled the value of clinical ethics and contemporary medical care. Thank you, Dr. Apple wait for introducing me very nicely. I appreciate it. Thank you all for being here. I was. I'm happy to get a chance to give this talk today. I know that this has been a large series of talks and so in some ways, this could have gone at the beginning could have gone at the end. But it's in the middle. And so that's because there was a speaker in May who couldn't come in May but I thought it would be good for you all to hear him so he's given the last one and that's why mine is in the middle. I, with that said, I will go right ahead, assuming that I can. And now suddenly I cannot. Interesting. Okay. So, I have no disclosures. And so by way of outline, I'm going to talk about really three things what's distinctive about clinical ethics. So a little bit of time talking about the mission of the McLean Center this is a work in progress, but I think it's valuable for you all to see how we're thinking about it. And then I'll talk a little bit about moral distress and clinical ethics and how I think those things are related in just a couple minutes about future directions. So, by way of contrast, I want to think a little bit about the difference between bioethics in a sort of general sense and clinical ethics, and, and to quote the Britannica online, a reputable source, according to some bioethics is a branch of applied research that studies the philosophical social and legal issues arising in medicine and the life sciences, chiefly concerned with human life and well being, though it is sometimes though it sometimes also treats ethical questions related to the non human biological environment. So, obviously a big topic, and an important topic. And so, so, and here I'm quoting from Edmond G how who has been the editor in chief of the Journal of clinical ethics since 1990. This is 1990 volume one issue number one. Dr. How wrote the focus is not on armchair ethics, ie the theoretical exploration of ethical views, but on the application of ethical inquiry to solve problems at the bedside to help clinicians and patients. And it's really this focus on at the bedside, helping clinicians and patients. I think that was sort of the driving force of the founding of the McLean Center, and, and the founding of the McLean Center is completely to the efforts of Dr. Mark Siegler and Dr. Siegler I appreciate you being here today it's really an honor that you're here. So, Dr. Siegler was on the editorial board of the Journal of clinical ethics from day one. He had a series of articles in the very first issues of this journal that help define clinical ethics. And, and so, so it is important to think about this distinction of clinical ethics being a very applied discipline as opposed to a more theoretical bio ethics. Now, I would say that the purview of clinical ethics has widened over recent decades. And certainly, I think we know that the focus is not purely on the patient caregiver interactions. That's been the case I think for a while now, and clinical ethics today does need to attend to how the decisions we make on multiple levels of health care impact the outcomes of patients. So I do think that we can talk about big system issues, and it's still clinical ethics, if our focus on the big system issues is really, well what's the impact on patients of those decisions. The role of clinical ethics ought to be the improvement of the care of patients regardless of where among the many levels of a system the changes are being made, at least that's what I've suggested. So, I do think that there's something that's distinctive about the focus of clinical ethics. The argument that I want to make now very briefly and I won't go into a lot of detail, but I think it's not just that the scope has changed. But that there's a little bit of a different series of things that we think are important when we do clinical medical ethics as opposed to sort of theoretical bio ethics, and I'll try to explain that a little bit. So, so the attention to how we answer what should be done is different in these different realms, although they overlap. And so let me use a case to help illustrate that difference because I'm hopeful that the case will make this more clear than I've been able to so far. This is a case from the University of New Mexico trauma service I was there as a Disney professor a couple months ago. And the trauma team told me about a patient I won't go into all the surgical details because they're not relevant but the the important things 22 year old man was involved in a high speed motor vehicle collision. He suffered multiple fractures and had severe traumatic brain injury. The patient so social factors that are important. The patient is not married. The parents were the surrogate decision makers there was no controversy about that. He had no advanced directives. So the things that we might ask about in clinical case conference. I think those are important things so a few more details. He was found to have really no significant neurologic function over the next few days testing confirmed death by neurologic criteria. Again, you know, you, you have heard many discussions about what that criteria is and whether there's controversies about that. For the sake of discussion of this case there was no controversy. This patient met the criteria for brain death. Important parents don't speak English through an interpreter. They're found to have very poor health literacy. So the parents response to the news that the, that the patient that their son had died was, and you know this is not a it's in quotation marks but it's via translator so it's not exactly a direct quote but it was essentially, he looks just like he did. When he left the house that morning before he got in the accident, don't stop the ventilator, or you will be killing him, and we won't allow you to do that. And the, the, the, there was a discussion about organ donation and you know that all of the things that generally happen when a patient is declared dead by brain death criteria. They had no interest in that because he wasn't dead. And the father said, it's, I'm going to become violent if you turn, if you think you're going to turn off the ventilator, it's not going to happen. And I'll make sure it doesn't happen. And so really did threaten violence and, and people were concerned that he was really very serious about it. So, the question and, and you know when you're visiting professor one of the fun things is that people get to ask you, you know, the tough cases, and, and you know if, if I'm a visiting professor for endocrine surgery they asked me about well what would you do for this thyroid cancer. If I'm invited more for ethics than it's a case like this. So, you know, what should be done. And, and, and I do think that, you know, I said well what do you all see as the problem. And so they said well there's a brain dead patient taking up an ICU bed in a busy urban medical center. We feel as though this is inappropriate use of resources were squandering resources. And, and this idea that the parents are refusing to accept brain death as death, certainly problematic. And as is my general practice when I'm asked tough questions is to ask a lot more other questions to the people there. And so ultimately, they told me what they did. But let's pause before we get to that. Let's think a little bit about what would theoretical bioethics answer what should be done here. And this is perhaps, you know, an unfair strongman argument but I'm going to make it nevertheless. I would say that bioethics would say hospitals treat patients. When you're brain dead, there's a body, but no longer a patient. And there's no dilemma. You turn off the ventilator and you make the bed available for a patient who needs it. And it's sort of like, what's the problem, because from a theoretical point of view, we don't really have any responsibility to bodies other than to treat them with respect, but certainly not to keep them in ICUs taking up bed space from someone else. Now, in contrast, the clinical ethics perspective which interestingly enough was what the trauma team did. And this was, you know, if this case had happened long before I was ever there so I had nothing to do with it. But there, what they did seem to me very much fits with the way we think about clinical ethics. And their thinking was although there's a need for beds immediately turning off the ventilator would be traumatic for everyone. So traumatic for the parents, traumatic for the doctors, the nurses, everybody involved in the care of this patient. And they felt that they had some responsibility to the parents, interestingly enough. They should think a little bit about the parents' well-being and not solely about this issue of what do we do with bodies and hospitals when we need beds. And their sensitivity to the parents and other caregivers, they felt that that warranted a delay in the removal of the ventilator. And, you know, you could argue with what they did, but what they did was they said, in three days, we're going to have to turn off the ventilator. Now, why three days rather than two or four? I don't know. I didn't make the decision. I wasn't caring for the patient. But their idea was we have to give this family a little bit of time to grieve, to sort of come to grips with what was happening. And during that time, they had multiple family meetings. They tried to explain what brain death meant that he, despite how he looked, was never going to be waking up, was never going to be going back to the way he was. And they looked at this as an opportunity. The trauma team said to me, well, we can't help the patient, but we can help the parents. And in their assessment, that was a reasonable way to justify the use of resources. Now, it's pretty expensive. No question about that. We could have conversations about that. But other family members were involved in the discussions and ultimately helped the parents to accept the death of their son. And so they turned off the ventilator. There was no violence. The father was not happy. But how could you be happy in this circumstance? So, so what I think is important in this case is not so much about, you know, could they have done things differently? Could they have tweaked things? But was the outcome a success? Now, from a bed utilization perspective, one would argue, you know, right, you kept an ICU bed occupied and unavailable to someone who could benefit from it for a period of time. But there was no violence. That seems good. And although the, as I said, although the father remained upset, other family members helped him accept the inevitability of the discontinuation of the ventilator. And I do think that in this sort of family's narrative of what happened to their son, waiting three days had value. And I would argue that it had value because it allowed them to come to grips with this in some fashion and allowed them to then sort of tell the story of what happened to their son in a very different way than would have been the case otherwise. And I would argue that this case hopefully illustrates to some extent that the scope of concern in clinical ethics appropriately is cognizant of some things that might have been missed if we were taking a much more theoretical approach to the problem. And I do think that as we see on a weekly basis, decision making in clinical ethics necessitates attention to not only the patient, but to those who care for the patient. And those who care for the patient are sometimes the family, the surrogates, and also the professional caregivers in the hospital. And so those who care for the patient, I think it means both of these sets of people. And if you look at this, I would say for those of you who may be familiar, this seems to sound a lot like what has been described as a care ethic. And so for those who may not be as familiar with it, I'll just say a couple words. The ethics of care developed largely in response to principalism and Carol Gilligan 1982 book is sort of largely credited with sort of starting this idea. The ethics of care rejects a hierarchical view of ethics in favor of a more relational one. And it's sort of, I guess, anthropologically grew out of what she would Carol Gilligan described as a feminine view of how decisions are made which are as much less hierarchical. And the argument goes something like persons interact in networks of relationships rather than in isolation and the relationships and human connections matter. And so when you're thinking about what's the right thing to do those relationships then become very important. And rather than taking a deductive approach from ethical principles a care ethic looks to the specific situation again sounds a lot like clinical medical ethics and solutions to conflict are sought in the context of the parties involved. And the goodness of a decision is determined by the manner in which it enhances the relationships. So we say, well that was a good decision. If there's been some sense in which we have strengthened the bonds, the relationships of the parties involved. So obviously one could spend a lot more time delving into an ethics of care but I do think that this idea of what things we think about when we make decisions. You know, why is it that in Dr. Siegler's book clinical ethics that the four boxes, the four box model, why does that include the family and surrogate decision makers. Well, because they are important in the decision making. And so that those relationships then I think are matter and good solutions according to a care ethic resolve conflicts and improve relationships. So, let me turn now to the second of my sort of three major things to talk about today. And that is the evolving mission of the McLean Center. And so, certainly the mission of the center has grown in recent years. And in the last several months. There's been a deliberate effort to revise and update our mission. And I do want to really give special thanks to associate and assistant directors. For all listed here, Marshall Chen, Megan, Applewhite, Micah, Prohaska, Monica peak, Lori Zoloft, and broad knee Julie core Valerie Coke and will Parker, all of whom have been involved in some of these discussions. And so, I do want to just share with you a draft version, we're still working on this this is a work in progress. And certainly we'll have more formal opportunities to discuss it but I thought it would be a good time to have a preliminary conversation. So, the mission then of the center as we're thinking about it going forward is to innovate and excel in clinically driven ethics inquiry education and service that improves care, transforms systems, advances equity and informs policy to improve health for patients and communities. And it's not different, but perhaps a broader view, and the vision statement is for fair just and equitable care of individuals and communities that maximizes their health and well being. Now, there are then a number of ethical commitments then that we would be making if we're going to actually have this mission and the end this set of values. And that is to engaging collaborative trans disciplinary inquiry and education that integrates ethics and clinical biological social and humanistic sciences to improve the care of individuals and communities to explore ethical issues in healthcare through rigorous research methods guided by conceptual models and rooted in clinical relevance to address and engage the ethical issues that impact health outcomes at multiple levels, including patient family clinician organization community and policy to build mutually respectful relationships with individuals including patients families and communities to challenge norms as agile innovative thought leaders to train and mentor the next generation of leaders in healthcare ethics inquiry and service and to be a beacon for humanism and social justice in healthcare. Now, certainly very aspirational, but there's no sense, you know, writing it down if it doesn't give you something to shoot for my opinion. Now, let me turn then to talk a little bit about this third issue. And this is a little bit of a sort of a different idea, which is how burnout and moral distress might be impacted by clinical ethics or our attention to clinical ethics. So we know burnout is an important issue in medicine. And I'm not sure whether there's an epidemic of burnout or just greater awareness, but either way, it's a problem, we should attend to it. And I do think that, you know, we have to realize that burnout is a risk factor for depression and suicide, which are clearly huge issues, not only for the medical profession and everyone involved in hospital care, but for society and, you know, at least among physicians there are about 400 physicians a year commit suicide. So it's this is not trivial. Now, there are a number of factors that have been associated with caregiver burnout. These have been described by others and so again I won't spend a lot of time on a loss of autonomy, a diminished sense of value in clinical activities, some people say the electronic medical record that's the root cause of it all I'm not sure that's true. It doesn't help but it's not the problem in its entirety. Some people have said that inclusive language may actually devalue individual contributions. And so if we talk about providers that suggests a cog in the wheel rather than someone essential like my nurse or my doctor. And so, maybe that has a role I'm not sure. We know that there are certainly personal characteristics that might reduce the risk of burnout. And again, lots of attention has been given to this resilience is something that, you know, we're told we should be more resilient we should be able to bounce back from adversity and that will make us less susceptible to burnout. The capacity, the ability to bear the many unavoidable irritants of daily life with relative equanimity. So having greater capacity in this context would seem to protect us, in some sense, from the risks of burnout. And starting I think around 2018, we started having resilience week for GME for the medical center. I was particularly impressed in the 2019 resilience week happened to fall during the polar vortex. I don't know if you all remember that, but I was really I thought it was very ironic that it was canceled due to extreme call. It seems like that you should be resilient enough. But anyway, that's a totally different thing. But it was all canceled because it was very cold out. So, you know, could there be aspects of providing medical care that increase our resistance to burnout. Well, I think so. And I actually think that by emphasizing the ethical dimension of the care of patients. That may help us as caregivers, as well as helping our patients. And so, just to give you a sense of why I think this is the case. The moral injury and caregiver distress again are things that have been widely described in recent years moral injury is described as occurring when we perpetrate bear witness to or fail to prevent an act that transgresses our deeply held moral beliefs. And whether it's moral injury or moral distress, putting the needs of patients first, I would say is central to the deeply held moral beliefs of most physicians nurses and other caregivers. And every time we're forced to make a decision that contravenes our patients best interests. We often feel a sting of moral injustice and over time these repetitive insults amass to what people have described as moral injury. So, again, you could argue with the definitions, but certainly there is something here to be concerned about. And more burnout and moral injury may be complimentary views of the central problem of clinical distress or clinician distress. Interesting that burnout suggests that it's my problem I suffer from burnout that I lack resilience, whereas moral injury. Describes the challenge of simultaneously knowing what care patients needs but being unable to provide it due to constraints so it sort of pushes the problem away from me and my own personal characteristics now you know there there are some pros and cons of this move. I think it's important to think about how that happens. And some people believe and I think there's some very, there's a lot of truth in it that long term solutions to moral injury demand changes in the business framework of health care. And that there may be limits to what we as individuals can do to mitigate these things in, in the context of the system in which we work. The question that I'm interested is how might attention to the ethical dimension of patient care mitigate this issues of burnout moral distress. And I do think that regardless of the practice setting one is in the individual relationship of a caregiver and a patient is an intensely personal one. And, you know, we do ask our patients to trust us individually, as well as to trust the institution. And I do think that responsibility to uphold our patients trust is a central motivator to medical excellence, regardless of sort of the context in which we practice regardless of our specialty, regardless of exactly how we care for patients. And, I mean, I think, to me, if you reflect on why do many people choose to go into medicine. Well, it's the opportunity to help people right that's the classic, you know, interview question for medical school why do you want to be a doctor, because I like helping people. Right. I guess, maybe you don't get asked that question anymore I was definitely asked that question, and I answered the same way. You know, if there's any joy in medicine or surgery, I would say, and I think there is personally but you know everyone has to make their own decision. It's about helping patients. And so if there's no sense in which I gain some joy out of helping patients then I think that's problematic. And regardless of how devalued any of us may feel in our jobs for each individual patient. And again, for me, I'm asking them to lie down in the OR and let me cut their throats. But, you know, in any, anything that we do in medicine, we're asking people to trust us quite a bit with either personal information, or intimate details about their physical emotional psychological lives. And so all of these things, I think, if we realize the impact that we have on patients, that I think that may help protect us against the risk of burnout. Now, how do we then emphasize this this ethical dimension in healthcare. Well, I think that we need to take seriously how well or how poorly we communicate with patients. I think that it's not. So in, you know, in surgery, we talk a lot about informed consent, right, we talk about risk benefits and alternatives. But we know that communication is much more than here is a list of the risk benefits and alternatives. That's not communication. And I think that we need to emphasize the development of communication skills in our optimal education and practice. And I would say we need to acknowledge the central role of trust in the relationships between caregivers and patients. And I think that we frequently don't do that enough. And it was it was striking to me when I was recently reviewing our University of Chicago's informed consent form, the actual form that patients signed before they go into the operating room. And unless I read it wrong, which is possible, I didn't see trust anywhere in there. It's much more of a contractual relationship, which I think goes very much against what we're in fact trying to present to our patients. Now, there are many things that we can control and things that we can't control and lack of control. Without a doubt is a major source of frustration felt by many physicians nurses, everyone who works in large institutional practices today, and probably in every other industry as well. Although I can't speak to those others because I've never been paid to do anything else. Well, I was paid to scoop ice cream one summer. And I used to do professional magic and I got paid to do that, but that was a long time ago. But so so there is, there's a, when there's a loss of control that I think increases our risks of burnout. And the interesting thing is that, you know, in the privacy of the exam room, when I'm there with a patient. When I have control over that interaction. I'm the one who can decide well, how much of an effort do I put into engendering that trust, how much of an effort do I put into ensuring that my communication is actually effective, rather than just I've turned the switch and I'm doing my thyroidectomy spiel in which I talk about risk benefits alternatives. And I do think that despite the time pressures that we have in the care of patients today. There's no administrator that can affect how well or how poorly I engender my patients trust. That's ultimately up to me, and it depends on how seriously I take that as a responsibility. So we know and I'm going to just talk just for a minute about surgeons because that's what I know about. You can think about in other areas in healthcare how much this applies. But multiple studies have pointed out that serious, the serious detrimental impact of complications on surgeon well being. So we know if we have a complication that's bad for patients. It also has a negative impact on the well being of surgeons. And some people have described the surgeon as the second victim of a complication. Now, if you're the patient who had the complication. I'm pretty sure you would say I don't really care that much about the second victim I'm worried about the first victim and I understand that. But from a caregiver perspective. This is a potential issue to think about, and lots of institutions have sought to reduce this impact and there are some departments of surgery for example that have here counselors and so if you have a complication then you know you can call the peer counseling hotline. I was visiting an institution a couple years ago where they have a program where if anything bad happens. Caregivers, no matter what their specialty what at their field is they can call it's referred to as the swaddle program. And so, and I, and I asked the department of surgery that had invited me I said so you know do you get a lot of surgeons calling the swaddle program, and they said, zero is no surgeon says, I need swaddling. So now, you know, that's a problem. There are, you know, worthwhile interventions these and probably many others maybe even more effective. I would also suggest that focusing on the ethical dimension of surgical care might also help. And I do think that by ensuring that the adequacy of informed consent is a way to engage our patients in the decision making process and certainly shared decision making acknowledges that the surgeon does not always know best that does not always know best, and that complications can and do occur. And, and I do think that, you know, having had a conversation with a patient to say you know, this could happen to you. It doesn't diminish the physical impact of a complication on a patient, but I do think that it has a significant impact on the psychological implications, both for the patient and for the physician. Because if I say, do you remember when I had that conversation about how I might injure your recurrent laryngeal nerve, such that your voice is permanently a horse. Again, that doesn't make it better, but at least I think it reduces some of the stress associated with that conversation. So, you know, hopefully, I have at least given you a little bit of a thumbnail sketch about why there's value in acting ethically. I do think that patients benefit from ethical surgeons. I do think that caregivers can also benefit from a greater attention to the ethical dimension and again, I say surgical care, but it's everything we do in hospital so it's not limited to surgery. I do think that the attention to the ethical dimension requires caregivers to attend to expertise outside of medical science. If we think that communication is an essential component of being a good caregiver in the medical field, then we should realize that we may not be the experts at communication and other things. So, you know, I do think that increasingly everybody involved in healthcare is faced with a dilemma. And that is that we are increasingly pushed to measure outcomes and quantify results. And you know the movement towards quality in throughout medicine is all about sort of measurement. And that's a good thing. Lord Kelvin said nicely if you can't measure it you can't improve it. Kelvin, right? The guy who, what's the thermometer, I think? Kelvin scale, yeah. I remember that vaguely. Unfortunately, it's really difficult to quantify ethical behavior. We can't measure it in the same way, but we still have to encourage it. And Einstein said it nicely, not everything that counts can be counted and not everything that can be counted counts. So, I'm going to end with just a few thoughts about sort of future directions. And I do think that we have to acknowledge the distinctive features of clinical ethics and embrace this broader role that I think we can have. I think that we have to embrace the value that clinical ethics can bring to patients, families and surrogates as well as to caregivers. I think that we have to endeavor to live up to our mission and that we have to work to make the vision of fair, just and equitable care a reality for all of our patients. And we have to aim to improve the health of patients and of communities. And so a few final thoughts. I've only got 30 more slides, so we're good. It's a joke. I think it's good to be ethical. I hope that that is not a controversial statement. I think that it's good to be ethical because it's just good, right? There's an intrinsic value, but there's also I think a value for patients and caregivers. I do think that the scope of concern for clinical ethics appropriately considers the impact of patient decisions on the families and surrogates. And I do think that the mission of the McLean Center focuses on not only patients and caregivers, but also on the community. So last two thoughts, I think clinical ethics will remain the core of the center's mission, but contemporary clinical ethics must have a broader focus than it did 40 years ago. And I do think that this greater attention to the ethical dimension of care may prove benefit not only to patients but also to caregivers. So with that, I'm going to end and I'm very happy to answer questions. Thank you. I noticed I wanted to slide your condition of the McLean Center. One of the lines is that it's sort of switching from clinical ethics to healthcare ethics. I'm really interested in sort of that, that sort of switch because I couldn't demand healthcare that much for our clinical ethics and doesn't bring into play the ethics of the systems that we want to learn. Sure. So I think that the membrane can sort of play more directly to the resource allocation question, or even sort of business. Yeah. Where are the appropriate products for the healthcare system to expand in terms of sort of making decision more talk about to our community. If I understand this a bit, how does that work? Yeah. And what that means to you when you use the term healthcare efforts? Yeah, thanks. Thanks for asking that question. You know, I think that I believe that it is that clinical ethics actually covers all of that. And so in some ways, I think that there's been, I think, and part of what I've tried to suggest is that clinical ethics should be thought of in a much broader scope than we have in the past. And so it is true that the health system and the policies that impact that health system have a huge implications on what happens with individual patients. And so in that context, I think it is within the scope. And I think it's appropriately something that the center should be interested in and focused on. Now, in some ways, if as I'm suggesting, even things like global warming has implications on what happens in the hospital, right? So, you know, what choices I make in the operating room about what instruments I use and how many instruments I use and whether they're disposable or not disposable things like that. You know, all of those things you could argue, well, those are decisions that affect an individual patient but also have a much broader implications for sure. In some ways, the question becomes if everything is encompassed within clinical ethics, then what's not? And I guess it's, to me, it's not so much what's not, but how is our focus, you know, what makes it clinical ethics? And that's where I do think that this sort of practical implications at the bedside rather than a completely theoretical framework. I think that's where I would rather try to make the distinction rather than sort of how big is our scope of view, if that makes sense. Dan, sure. Yeah, yeah, it's a great point. And I mean, there is no question that if we, if our focus is really just on who's in the room, who's around the table, as it were, that sort of presupposes a sort of a first come first serve. You happen to be in the bed and so now we're more concerned about you than someone else who, you know, never gotten the bed yet and so we don't know them. So, I think that that is true. There is, there's an asymmetry there, and I'm not quite sure how to manage it. But it is, it's a reflection of the reality and to the extent that it should be, that reality should be changed. I'm not sure, you know, I, but I would agree with you, it's, this isn't, this isn't a solution per se, but perhaps a way to get to a solution. Yeah. Yeah, Mike. There's also an over-reliance on that assumption and what meant that the community could actually stop engaging theirself about, you know, about, I suppose, about whether or not this is going to affect patients. I think I probably made this up, but I feel like Marcus told me about being here when they came up with intensive care units and it was like, you know, well, let's, let's figure out what the right thing to do for the patient is. We'll be on this technological new thing that we're doing feels, in some sense, very similar to the story that you described. The other thing that I think will be very interesting that wasn't quite here, but I feel like there's a lot of discussion about professionals in medicine. Yeah. Definitely amongst the trainees, there's sort of an existential fight about what is professionalism and what's right. Somebody gets into the burnout and I think that that will probably have impacts on our clinical ethics because, you know, many of us that trained in a single generation came up with the idea that there's a way to do things ethically and non-ethically. It can be care of patients and now the professionalism part of that challenge and that may result in, you know, changes to our ethical norms about what we think. Right. Yeah, no, I think absolutely excellent points and, and you know, I do think that that's, I mean, all of those things suggest to me that far from sort of feeling like, well, you know, we benefited from Dr. Siegler's sort of his emphasis on the ethical implications of the decisions that we make at the bedside every day, right? We don't need to get an ethics consult to realize that, right, we're making ethical decisions all the time. But I do think that, you know, your points further emphasize the idea that we're never going to get to a point where we've put ourselves out of business, right? We've solved all the ethical issues. There aren't any more, right? We've got it confined because it's, we now I think realize that the scope is both broader and the impact of the decisions at other levels that have an impact on, you know, what happens in, in a individual patient case. So thanks. Mark. Yeah, I think that you know, for the bioelected, starting in the United States, 1966. 1966 was a year that I graduated from here at the university. The bio-efficers were brilliant, brilliant people, with peer reticions and scholars, legal scholars, they were fantastic. Anybody know what percentage were physicians or surgeons or physicians? The original. And so, by 71-72, as I finished the Chief Presidency here at the university, I decided that it was essential that the bio-efficers who were not physicians and were not directly working with physicians wanted to be added to the bio-efficer mission. And so that's when I started in 71-72, the field of clinical medical records. At the university, we did the first program in front of the medical records. And it spread around the country, all the way into the next 10 years. And in 82-83, we went officially to the commission for our president, the university, who established it. So we should go around the 42nd and 43rd year, and we would have had a great addition to the program. But this is really, really down here. And I'm just so proud of that. Thank you, Mark. Thank you very much. I appreciate it. All right. Any other questions? No? Okay. Well, thank you all very much. I appreciate it. Next week, we have an outside speaker, Dr. Tolkien from, not J.R.R. Tolkien, but a different Dr. Tolkien, from Yale. And I believe that we are in this room, and I believe that lunch will be provided, but only if you sign up. And so we have tried to get this room, because obviously it's more conducive to discussion than P117. But since we almost had to fight off the pharmacists, because they thought they were scheduled in this room, make sure that you check your calendar, because we may be going back and forth between P117 and here. So, all right. Thank you all very much.