 So for anybody who doesn't know me, I'm Eric Hansen, one of the faculty here at the Moran. And today's Grand Rounds is part of our ethics series, which I took over, I guess a couple of years ago now, was my second completion of my second year. And this ethics talks is probably not gonna be as fun, as exciting as imagining COVID if it was a blinding disease or some of the other really interesting thought experiments we might have had or other presentations. And so I'm just giving you that headway as we go into it. But hopefully it still stimulates some discussion. And my goal for today's Grand Rounds is actually to collaboratively kind of come up with a vision of an actual series that has a structure moving forward to continue to do these in a way that provides a lot of conversation around salient topics in ophthalmology, particularly focused on ethical dilemmas in medical ethics. When Jeff asked if I would take on this role and take on the ethics Grand Rounds series, I took it with a fair bit of excitement and not because I, then very sincerely, not because I have any particular conception of myself as particularly suited or an expert in medical ethics, nor because I like to get up and give talks. I really don't like doing it, but it's part of the job and I've learned to deal with it. But I do have just a personal interest abiding in kind of persistent personal interests in ethics, moral philosophy. And I thought it'd be really cool to try to imagine how could I, with the collaboration of others, particularly residents, fellows, or people in our university community, come up with a way of, in a structured way, really interrogating these concepts and yeah, bringing something, or I guess my own personal stamp on the series as Jeff had done a really good job and I remember some really amazing and lively presentations we had that deal with artificial intelligence. Of course, there's a global ophthalmology talks that we've had that always provide a lot of interest, federal policy, and so anyway, so that's kind of the lead into this talk. Even though this is kind of trying to create a vision and identify some a way to move forward with this that is a little bit more collaborative or involving the residents, I still want people's input. So there's gonna be times when I'm gonna ask questions. I would love for people to respond and for audience participation, even for the Zoom audience. I don't have any disclosures relevant to this talk and I kind of want to start with what probably seems like a big question or maybe a silly question and if you've watched my talks, I often start with like a why or a what and maybe I've read the book, start with the why too many times or something, I don't know, people have their own opinion of that book but why are we even talking about ethics? And this is a question I'm posing to you, like why are we doing it? Why is it important to do it? What's the purpose? And it can be just your own, you can be trying to think more broadly. So fine, go ahead. I think personally it provides some checks and balances for ourselves. We're fairly sort of on our own out there in this world of medicine where we are in a trusted position with the patient relationships and how we treat them and what we document and how we bill for our encounters. And so I think one, it just kind of reminds us to check ourselves and make sure that we're doing things appropriately. I think number one. The second is, I think a lot of the ethics that have really hit home for me is kind of treating people fairly regardless of the situation. And so when someone comes in who doesn't speak my own language, I need to take extra steps and efforts to make sure that they're receiving appropriate communication. Just something off the top of my head that hits me every day. So those are the two thoughts that I had to start some discussion. You know, one way to look at ethics is ethics are guardrails. And so they want to keep us within a certain standard way of care of how we take care of patients of what we do. So I look at them as guardrails. And the other thing that's important when you're looking at ethics is we as a profession need to set our own ethics before outside governmental or whatever you will outside entities provide us with these guardrails. And so I think it's important that as a profession as an ophthalmologist that we set our own set of ethics up that we can follow as professionals before others from the outside actually put those upon us. So my thought is that, you know these discussions about ethics, questions that come up kind of just force a sort of introspection that, you know, might be lacking in just day to day getting through clinic, moving through patients, the busyness and forced us to ask sort of difficult questions and identify our own biases, our own tendencies to whatever, do whatever it takes to just, you know, get through our job and I think that introspection is something that comes up particularly in discussions around ethics. Yeah, so I think, oh, go ahead. There's one other comment here. Well, I think at the end of the day talking about ethics and ethical patient care also directly influences patient outcomes, you know, for our ethical practice of medicine is gonna influence how different, what kind of care different patients receive and could potentially affect their outcome, you know. And so at the end of the day ends up being a question of justice as well of making sure that, you know, every individual has access to care that we are providing that they can't provide for themselves. Very good. So I think those are all very insightful comments. And I think they all hit on different aspects of how I also was trying to consider or imagine what all ethics encompasses or why we talk about it. So thinking that as a check and balance on ourselves but also ourselves as a profession, right? We are professionals, so we are incumbent to, you know, evaluate into basically police ourselves, you know, individually, but also as a broader society of the professionals. And it's interesting, you know, I don't have the, you know, the duration experience within medicine to comment deeply on it, but when you hear people talk about medical ethics in our profession, you can sense that there's been a shift over time where there's been more and more, you know, governmental regulation of our profession and a little bit less or giving up some of that self-regulation. And perhaps that's because maybe we've failed over time in certain ways, right? And it might also just be a broadening of government oversight, but, you know, hearing that, I think that that should, you know, at least provide a look in the mirror where we say, okay, we need to make sure that we're continuing to do this and continuing to uphold ourselves to our very high standard. That, you know, looking at it as a way of looking in inward gaze to evaluate how you're behaving within your profession, but also behaving clinically. And I think that's a very important part of it that I'm gonna get at is, you know, ethics is not just this kind of abstraction that we look at to say, you know, like to look at the big decisions, right? The end of life care, that, you know, the things that we think of with, you know, autonomy and patient self, you know, self-determination. But it also informs some of our more day-to-day mundane tasks that we do maybe without being consciously aware. Jeff, are you gonna say something or? Okay. So another thing I wanted to bring up is ethics are ingrained into what it takes to become a physician as far as our education. So the ACGME clearly defines medical ethics and knowledge of ethical principles as an important part of residency education. We all remember in medical school maybe we do, but, you know, how we were taught ethics and it's interesting to think, I was thinking about my own journey and I remember very well our ethical classes and our ethical discussions. A lot of them happened maybe in our small group settings when we had our mods in medical school or maybe there was larger presentations and they tended to deal with the four major principles and the, you know, the really classic scenarios maybe, you know, a patient with a different culture who doesn't want care or, you know, it was Brian mentioned the language barrier and it was interesting when we were doing residency interviews this year. How frequently that answered was bullied as a medical, like, you know, you've found yourself in an ethical dilemma in medical school, describe it, what did you do? Actually the question didn't even detail that it had to be in medical school. It was just like in your life and like, I think 85% of them were had to do with language. The, you know, the attending didn't get an interpreter. I was like, okay, clearly this is bothering people and it's a very real thing. Like patients cannot have autonomy if they don't understand, you know, they can't have informed consent if they don't understand. But anyways, I say all that to say residency and fellowship for me, you know, the continuation of that ethical education and deeply ingrained in how it relates to the profession, the subspecialty you've entered to within medicine. I think it's very important, right? Like some of those same big medical ethical questions that we maybe have got an ethical committee involved when we were on boards, you know, those don't always apply as, you know, saliently to us in ophthalmology, but we also have very real ethical questions that our profession has managed over the last few decades and continue to confront today. And so if you look at here again back, just going through the ACGME, like what is required in a curriculum, you can see that some of these things that were brought up are justice, you know, patient autonomy, you know, informed consent, equity, these things are supposed to be and should be. And I think in our residency are a part of a residency education, not just for medical school. But the other thing that I kind of think of ethics is, and this is kind of where, this is kind of the basis for what I want to, would like to see happen with this ethics theory, is ethics is also a framework for how we make decisions. And what's interesting is it's not only a framework for how we make these big, difficult decisions, it's also a framework for how we make day-to-day clinical decisions. Like some of the things, even just like which drug do we prescribe to a patient? Right? Do we offer surgery? Do we, you know, observe how we have that conversation? Are we leading them one way versus another? How we're billing? How we're coding? All of these involve ethical questions and ethical decisions. And so I think that, you know, understanding ethics as a model for making decisions, and then when, you know, you have the bigger, you know, ethical questions that come up that are really challenging, you've already developed that sense and that intuitive sense of what is my model for making these, you know, making these decisions? And I think that's an important part. It's like, how many just curious feel like they've developed a model that they could articulate for resolving ethical conflict in their day-to-day life and their clinical life? Jeff and Randy, would you guys mind briefly talking about it or describing? Yeah, I'll start and I'll bring the mic up. Randy, you know, this, it goes back to the four principles of medical ethics. And actually, if I have a situation, I'll visit each of those. And then the next step is I'll then look at the stakeholders from each of those perspectives. I'll give a very kind of quick example. This just happened last week. I was in Tanzania and we've got these baby ophthalmologists that are, they're kind of like a resident, like 20 fake goes in, except they're free to operate on anyone and everyone that in their system, they just don't have that background competence yet. And yet they're able to do surgery. So it's our last day. It's kind of winding down. We have three tables. We have three more experienced surgeons, Charles Cole from Cornell, Susan McDonald myself, Charles and Susan were teaching the two African surgeons there. And you've got two patients waiting and they're just kind of watching what's happening. And then a monocular patient comes in with a dense white, you know, advanced cataract. And so you've got these two people sitting there in the queue waiting and they're watching these two cases go long, you know, 45, 50 minutes on the teaching tables. You've got this person walk in who's ready to have surgery and it's a monocular patient. And you're really choosing between if I do the surgery, perhaps kind of a one to 2% complication rate versus probably approaching a 20% potential complication rate depending on what's happening on the table. And I'm sitting there and I'm watching this situation unfold. And I think about those principles of medical ethics for the patient that just walked in who's monocular. I think about the two training surgeons who need this training. I then think about society as well and about what they're interested in in having me do this surgery for this patient versus working with these two training surgeons and trying to teach them, you know, and leave those skills in the building. And then you've got the two sitting there waiting who if I take this patient and just do, I'm gonna finish in 15 minutes. These other two tables are gonna be working. And those are the two tables that they're going to and just wondering what's happening in their minds as they think about. And then you've got the dynamics of the, you know, the only white surgeon operating and, you know, not reinforcing the perception that, you know, their surgeons are inferior surgeons. So that just last week, that was, that framework came into play and it really was looking at the different stakeholders that started to help me think about it a little more clearly. So, you know, as we follow all of this and I just point out that a lot of this is a reaction indeed to abuses that occurred in particular that became and came to light from World War II and forward. I just to show you how things have changed, I was enrolled in the Salk clinical trial for polio. And I was in second grade, Wasatch Elementary here in town. Our entire second grade class was enrolled to be in the study. There was no informed consent. There was no permission from our parents. We just all got injected. And I later found out I was in the placebo group, which I remember as a six-year-old, seven-year-old was just a horrible thought that I had to go through three shots again of those old, dull needles they used to use. But, and then I think that the Tuskegee experiment which really blew up and came available. And this is not ancient history. We're talking about, you know, in the late sixties, early seventies when this whole thing kind of fully came out about how horribly people have been treated. When I have a difficult situation, I have found that all these ethical principles discussed are important, but the single guiding principle has helped me the most is this one. If this were my mother, what would I want to have? I think that clarifies things more often. It kind of cuts through the nuances. Honestly, just say what would you want to happen to somebody that you really love? And if what you're considering is something different, then that's probably an unethical decision. I found that helps clarify things much more than a lot of the nuances that you talked about. Yeah, so I'd say I want to kind of continue with that line of thought that you just said. But first on what Jeff said, I think, you know, it's my experience in our previous discussions in global ophthalmology, it's so clear that that is such a fertile ground for considering ethical decision-making and conflicts, how they conflict in certain situations. And it's really, really challenging to rectify those all the time. But something that was really important about what he said is that he utilizes these principles, these defined principles, and that's where the concepts come into play. And we'll keep going with that. But I think that it's very important if you're going to create a model to have those principles in your mind and to understand them in. And I think that takes continuing education or continuing consideration of the concepts, the definitions, where do they exist in our modern line of thinking with medicine. One thing that what you said, Dr. Olson, is I get that question so much. I mean, I'm sure everybody does. If it was your mother, if it was, you know, like what would you do? And sometimes it's very straightforward. And if you're like doing something that, you know, maybe there is like a, there's a gray area of what is moral or ethical, it certainly helps with you. But sometimes I find it more challenging because that can conflict with this idea of autonomy, like where my mom is not that person and I'm not my mom. And so when they ask, you know, like, I tell them sometimes like, I would give you the same conversation that I'm offering you now if you are my mom and I would try to let you make that decision for yourself, which is what I'm trying to do. And I sometimes like question, like, is that what they're probably asking for something else, right? They want me to just give them an answer. And I don't know, I don't know your thoughts on that, but like, does anybody else confront that or deal with that situation often? No, I'm the only one. Okay, well, but anyways, it's interesting because it's something that really does come up a lot. So quickly, Ken, I'm sure we can do it together. Name the four, you know, core principles and medical ethics. I know we can do it. Otherwise, we're going back to the basics. I'm hearing justice in the back. Justice. Non-moleficence, do you know harm? Beneficence? Autonomy. Autonomy. And with beneficence, how do you guys think about that one in particular? That's one I want to just give people thoughts on how they think about that and what spheres of thought they have for that, meaning how do they, is it a narrow definition for them, totally related to the patient? Is it a broader definition that related to the patient and the societal context that we all operate within? I think anytime that we interact with a patient, there are risks associated with it. And so we need to make sure that whatever we're doing has some benefit to the patient and I think benefit to society. But I think if there's no benefit to the patient, then we don't have business doing it. Yeah. I think that's really a good, it's an important point that this is a positive facing ethical principle, right? That it's about that needs to provide benefit. And it's often in conflict perhaps with which one, which medical ethical principle. Deborah's got a comment here. Add to that that in research, it's certainly about the risk benefit ratio. If you've got high risks, you should have commensurate benefit. And but research is a very interesting one, right? So there is sometimes no benefit to the patient, right? A placebo, right? Your polio example is a really great example, but there's a massive societal benefit, right? So sometimes again, that was can conflict. And I think that that's one of the things that for me is really interesting about ethics is how to consider these kind of like, you know, more zoomed in or zoomed out perspectives on where the benefit, where the hurt or the harm, because sometimes what we do for somebody might harm somebody else, especially when you start thinking about environmental questions. So I don't know if there's any more comments. But yeah, so I think that those are both very good points. So then the other three principles, I don't know, there's like three other principles that are less like core and I may or may not have learned about them. I don't know if anybody knows of them and they all kind of relate to autonomy. So they're kind of like a little bit of a cheap principle, like, I don't know. Anybody know? Respect for persons, that one. It's confidentiality and form, consent and truth. But I think these are kind of like things that have developed in the literature and they all come from autonomy, but like to confidentiality is a very important thing in our, you know, particularly in our country, in our, you know, medical framework. And one that is often like interesting to consider and like when we're operating in our global spheres, how that, you know, sometimes that might differ as well as informed consent, which we've talked about a lot. But then talking, going, taking those as the conceptual framework, as the definitions and saying, okay, well, what I was talking about earlier, how do those make, you know, how do those work day to day? And so there's actually, there's a lot that is helpful for this. So there's actually a whole book written on how do we apply clinical ethics or ethics, sorry, to our clinical practice? How the things that we're like, what our history we take of patients, our interactions, our conversations with them, that is informing our ethical consideration of their care. Like I think of a patient, you know, where you're trying to decide like, do I operate on this patient? Is this an inoperable? Do I give them a hero surgery? I've had this, you know, in my own practice recently. Like everything that I have taken from those patient interactions, understood about the family, the patient themselves in both in previous interactions and in that moment is informing my consent. And we learned in medical how to do all that, how to take those histories, you know, a social history and why a social history is more than just, you know, do you drink, do you smoke? You know, it's about their social, you know, context, where they live, how they live, what is their financial ramifications, right? When we decide to switch a patient from a non-branded drug to a branded drug, like, you know, that can be a huge impact on their life. And if we're not asking those questions, we might not even know, because some patients just won't tell you that they're going into massive amounts of medical debt for a drug that might have marginal benefit for them, right? And so I think that the understanding that those things we do clinically are truly and deeply informative to ethical practice and which ethical practice is quality practice. That's providing quality care because it's providing the care people need basically by definition, right? I mean, that is no harm, positive impact in the self-interest with the self-determination of the person in an adjust way. So that's good care. I think that is the foundation for good care even with clinical decision-making. And then there's also this one of distributive justice which I think is really interesting to talk about and not the purpose of today. And a lot of that has to do with policy and how our decisions impact the broader ramifications of society, resource allocation, things like that equity, how patients, social determinants of health, these things go into it. And I think we are, or we should be thinking about those even though they don't necessarily operate on those daily routine mundane decisions. But if we're not considering them, I think that's how we continue to ingrain or deepen inequities that do exist. I don't know if anybody has any thoughts on all this. I think that I'd be very curious to hear, I don't know, if this is something that resonates or how you think about this in your own practice. I really like your comment about distributive justice being a little bit off of the radar because it is. It's not present. It's not in the moment decision of I'm doing surgery or not risk-benefit ratio, research risk-benefit ratio that we're really good at because that's just kind of there for us. Confidentiality has become so prominent and dominant that we don't even think about that as an element. And yet the list that you just listed off, those are things that they really don't come up day-to-day. And I'm curious just as you've thought about this, Eric, how should we be approaching those? Is that at a department level, a university level, a policy level? Because they are a little bit off of the radar. Yeah, I think that's a question that we're still trying to figure out, right? I think that obviously has to be considered from a policy level. And I think that existing within this particular institution, we clearly consider it from a departmental level, right? It's something that we have not only stated as part of our mission, but shown through action and walked out that in trying to consider some of that. But I do think there's also a role for just the individual physician. And how exactly that might look. I don't know if I have all the answers or even many of the answers. But I think some of these questions, like a really interesting ethical question to me, like, well, let me finish what I was gonna say first. So it might be an individual provider deciding within their practice how they're gonna provide care for marginalized communities and willingly accepting that. Like that's what we're doing with the ARCHES project and with the teleophthalmology projects is trying to identify and basically help other physicians or other eye care providers to be able to kind of exist within the grander milieu of, okay, there are social inequities. How do I contribute to that while still just being an individual practitioner? But then there's also like really interesting ethical questions that might not necessarily even align with what we're just talking about and trying to fix all that with like, are we, what are the ethical quandaries of providing care to uninsured patients in a different way than an insured patient, right? Like beyond just Medicare or Medicare fraud, like there are real ethical questions that when somebody comes in who's insured but very poor and has a copay, that we do not consider their care the same way we do when somebody is uninsured or uninsurable, right? In my heart, just like I would just give my care away for free every time, right? But that's not necessarily the right answer. And so like those types of questions and how that impacts is more, you know, broader question of distributive justice. Those are the ones that really fascinate me and I don't know if I have that answer. Is that, was that adequate for? So I also think that with these ethical questions and these ethical presentations and series, I think that it should be, as Sean said, both an inward gaze and very much so an intergrace. Like I think if we're not reckoning with ourselves, both as like individuals, but also as the Moran Ophthalmology Department, then we're probably not, we're probably failing in this series, but also it is with an external gaze to see what's happening in, you know, in the context of our profession, in the context of public policy and trying to figure out how we fit in with that or how we can impact that. And I think it should be both and it should happen, you know, in parallel. So I have a few proposed changes. This is the way we're getting. So one thing I'd really like to do, and I think it existed like this in the past because I was going back and looking at my previous presentations and previous ones in the year since I've been here, is I'd like to move this spring one till after OCAPS by a number of weeks because I'd like for residents not to be immersed in the stress of their tests, which is, I think on Saturday, right? So, you know, like trying to get involvement right now, as I told Jeff, it's like trying to sell a Bible at a brothel, you know, it's like it's not happening. So I would like to move that a few weeks after, the November one, I think still works fairly well. And then I would like to pair residents and I've talked to a couple of the residents about how this best work, but I'm very, very, you know, kind of reliant and deferent on what is truly best for that to be a PGY3 and PGY4 who might are out of the stress of the first year. If you do it this way, you do each once for your whole residency. And it's not to be like do another grand rounds. I want this to be a collaborative experience where the residents work together to come up with a topic. I will obviously be there helping, moderating, I'll present if they want me to present with them. And to make it something where you really are interrogating these concepts, because I want it to be a focus on these core topics which I'll show in the next slide. And then utilizing these principles, one of the things just to be very frank that I've been disappointed with my own presentations and that is that we don't as much go to those core principles, we don't as much utilize them and try to discuss with that as a framework. And I think that even though that I don't, I don't want it to be rote or didactic, I still think it's important to return to those so that we can all build these models of trying to resolve ethical conflict in our own lives and in our profession. Before I go to the core topics, are there any concern with this or does this feel exciting or is there a bunch of like groans in the back? I'm just kind of curious, Jeff obviously very curious in your perspective on this. Yeah, yeah, that's great. I think the only reason this one's happening right now just because it'd been rescheduled and so we can make that first change, execute it. And largely what we've done in the past and it really in many ways is your second point is it's been soliciting ideas from the residents that they felt are important considerations and that's something we've done through our what's called our program evaluation committee, putting a little bit more kind of formal structure around this just so that they understand kind of timing expectations and what that looks like that seems like there'd be a lot of engagement unity there. So I think this is great. I'll just point out as well that with the residents and doing it, nothing brings us more to life than having some real life ethical dilemmas that they have seen or they see occurring and use that as the springboard for discussion. Because I think often ethics can get to the theoretical point where sometimes it's hard to see the practical implications and yet all of us will face at times just as you talked about periods where it may seem a bit murky and it's a little difficult and then understanding that these principles can help you make that so that it's really less murky and more clear when you face those tough decisions which all of us are gonna have to face in our medical careers. Yeah, absolutely. I agree that I think that the case studies are a great and an easier way. I don't think that these will be a lot of work. I think when you're doing it with somebody else I think this actually can be really fun and meeting and talking. I remember doing these with Jay and Jay is still a part of our ethics series and he still will be as long as he's interested but he will meet with whoever he's working with and try to pull these things out, pull situations like Randy mentioned. So I also like to make things even easier but I don't wanna be rigid and I'm actually open to adding boxes here and that's another question I'd like to the things. What did I miss? But these are the core topics that kind of can like place where the series is. So each one can kind of like focus on a core topic. And these are the ones that I came up with or if I bet if 10 different people there would be overlap, it certainly differences. So research and bioethics. And of course we have the big ones like the Tuskegee experiment that we all, we talked about in medical school that it brings up a lot of emotional reaction to. But there's a lot of other ones with research that we're dealing with now especially with genetic research and the bioethics of genetics even outside of research are really interesting. Informed consent has a lot that you can unpack there beyond just the surgical consent technologies. I was thinking about chat GPT, back when I was in college I was the, I just remember that I totally forgot this actually. I was the president of the honors council for the whole university. And we were like, we're trying to decide and fix policy for both deciding what cheating was and plagiarism but also dealing with it. And we were dealing with like the rise at that time of people being able to just get on the internet like copy Simpsons here and there. And I'm like, what are they dealing with now with chat GPT, which is if people aren't aware it's like this AI writing program that just came out with a fourth generation. And actually Baskin just did a grand rounds where they had chat BGT answer all the questions that should have been posed to the residents for the resident appreciation rig. So the residents were off the hook and then they recorded it to see what chat GPT like how it answered each of the questions. So anyways, lots of technology and then I'm justice inequity and what we're talking about with this distributive justice, social justice and social difference of health but also on an individual level. Here's some like just little things that I've thought about, there's tons more. And obviously I also want to point out that these clearly all interrelate. So if you pick one, you're gonna be dealing with the others, particularly global ophthalmology which is basically not an ethical principle. It's just like, as I said, it's fertile ground for understanding and grappling with these questions. Any other like broad topics that you guys think that I missed or that should be there are things that I've also thought about where I put competency in conflict of interest but you could put competency as his own thing and it's a very, very important part of professional ethics and professional self-regulation. Training could also be one but training also kind of goes into some of these. So I don't know if anything that you think there should be a core topic that I didn't hit. I think it has a really nice framework and I'll just say one thing similar that what we've done with M&M where we've really pushed to not just present a bunch of resident, surgical complications really having faculty engagement is important and if you hit an ethical dilemma of real life, just send an email to Eric that on his into his inbox so that he can kind of consider how could this fit? Perhaps it becomes like the core case for us to discuss things. And that's the one thing about we have to be cautious of when we rely too much on residents, you'll get a lot of education-focused things and it allows the faculty to not be as engaged as they would be otherwise. Absolutely and that's like to this next slide and that I don't want by involving residents and I will still want to be very much involved and as much as basically invited but also I want this to be kind of a very open ended way of doing it, right? Like if the residents who are doing it with me they don't want to give talk at all and they want to go invite a speaker, that's totally fine, right? Like that's what they want to do. So I think that, but I just want that to be a process of thinking about it and to thinking what is important and what have they faced that is both salient and inspiring to them. So we could do it in a reverse classroom way where people have to read. In fact, they actually have to be prepared for the ethical, we do that for the residents, we provide, you have to read this book chapter, read these articles, maybe we have to read an article or two before the ethics grand rounds and that way we can participate in a meaningful way. Guest speakers, I don't know if you guys are aware but there's an AO lecture program where they will actually, I hope it's not only virtual now, I know during COVID it was, but they will actually provide in one of their speakers from their ethics committee to an academic institution on invite, as long as we give them basically, three to six months of lead time and they'll talk on basically whatever we find particularly interesting within the ethical context. And I think that's a great opportunity both to connect with AO and also to further the series. Here at the University of Utah, we have a Center for Health Ethics Arts and Humanities which is really active and does really, really neat talks and literature, basically book club type discussions and they do like writing prompts and writing workshops but they deal a lot with health ethics as well. They've done stuff with like, I think even is I think it's next week they have a bioethics expert coming in for a talk on pediatric care and how parental consent and when it deviates from best interests, how to resolve that, they've done stuff on like psychedelic research which end of life stuff. So anyways, I think that they have, they would be a great partner in this and I've already discussed this with them, Jay's a part of that. And then I've also identified some speakers for research. So there's a person who was initially this, I wasn't gonna be the idea for this talk but he's not available because he's on sabbatical but he's very interested in the future. He's one of the university professors who deals with basically clinical research ethics and does a lot of clinical research. And then I think there's a lot of opportunity to do panel discussions. I know in the past Jeff organized one where it was like, I think it was Nick and Alan and I can't remember the other, but they talked about surgical devices and innovation and it was like our own panel discussion. And I think that's a really cool way of doing things where questions can be valid and discussion can be offered. So I think there's a lot of opportunity and a lot of flexibility with it. There's also some ethical issues that I wanted to kind of see where people respond to these. So I think the one ethical situation that's funding sources and conflict of interest. And I think this is an individual, this is a departmental, this is an institutional reality. And it also came up recently when there was an email from Brandon that was talking about our role as university employees is accepting gifts and okay, well, where does that conflict with working with industry or trying to be a partner with industry and doing research. So there's a lot there that can I think be discussed. There's also ethical co-management. We do, you know, ophthalmology. I'm sure you guys could talk more about where this developed. I know that was a huge issue. She's in what like the 90s and 2000s on co-management and co-management ethics. I remember some lectures that I've heard from AO and there's a lot of disagreement and a lot of interesting topics, but it's still a thing that we do. We still co-manage and you can do it ethically, but we need to be talking about that. We need to be talking about what is ethical co-management, competency and scope, you know, there's a lot to be unpacked there, competency with training, but competency also with, we're in a surgical subspecialty, it is rapidly progressing. I think, you know, I don't know if it's the most, but it's certainly in the top, you know, the top quartile of surgical specialties on how fast things progress, both device innovations, but also surgical techniques. And how do you incorporate new techniques into your own practice, right? You're out of training, you know, and you're now basically training again. How can you do that? How do you do that in a way where the patient still has true informed consent and autonomy, right? That's an also important consideration. And then also obviously with training and competency, there's also a lot that can be discussed. I did a talk that probably wasn't as good as I wanted to be back when I was a fellow about cost and resource allocation as it dealt with some of these really expensive genetic therapies. I think there's still a lot more that we could delve in there. Social media and physician advertising. I'm not sure if anybody wants to touch that, but I think that'd be really fun to do with somebody. And that's certainly gonna only become more prominent in our world. And then new technologies and devices, you know, I think we've done this in the past, but I think that it's still important to talk about how we're considering these and how we're, you know, like even just our interactions with, you know, with industry, right? Like when they're trying to get us to use something, how would we do that appropriately? Just from a practical, logistical standpoint, going through the VAT, but also from an ethical standpoint. And then finally, I would like to end today by asking what other things are you guys wanting to tackle? Like what should we make sure we hit as we start planning kind of in a, you know, in a more of a structured series for the future? Talk around with the mic. You know, one of the challenges of ethics is our language. It's binary generally. It's either unethical behavior or ethical behavior. And we just had this wonderful overview of every shade of gray there is. And I'd love at least that to be, maybe not entire ground rounds, but hit on consistently because, you know, you hear that, well, that's clearly unethical. And clearly unethical, I think is really fascinating. Maybe your experience back on that honors committee could come into play because these ethics committees that are looking at behavior, intent, conflicts of interest, those are all full of nuance and gray. This one's pretty sort of, I think, low-hanging fruit and kind of maybe on every resident's mind, but in my particular stage in training, probably the thing I think about most is operating on attending patients at the Moran. And it's really interesting to hear different attendings talk about how they go about the process of informing the patient that a resident will be involved and if saying that a resident will be involved is, you know, encompasses a resident doing the whole thing. And I, you know, on the one hand right now, I am in a point where I'm, you know, the person who's sort of the hidden person in the room. And on the other hand, in the near future, I'll be on the other side of that. And that's something that consumes definitely a lot of my mental energy in the OR and thinking about that. That would be an interesting one to hear, I think. Yeah, I think that that topic, I don't, I think that ophthalmology has a somewhat unique experience with that in surgery, in surgical training. And not singular, but in the fact that when you are assisting as a resident and learning, you're really doing the surgery. Whereas like, you know, in general surgery or something is like, there's a lot of like collaboration and you know, like, and when you get to like retina training, you know, the retina fellow is doing the whole case. Like, yeah, you're there and you're, but it can be obvious to the patient, you know, either awake or, you know, and anyways, yeah, I just find that that is like a particularly interesting topic to try to tackle within our surgical subspecialty, how to do it well and ethically. Yeah, and you just stated it and the patient's awake. I mean, that just puts it in a whole different category of management compared to like our general surgery colleagues. So you stated it's very well there. It is, I think, a very unique circumstance for surgical training and ophthalmology with awake patients and basically, you know, like when you turn a cataract surgery over to a resident, you know, a trainee of any kind, I mean, they are 100% the driver, you know, there's, it's just, I just like to say, I just think it's a really unique situation, one that would be deserving of a lot of discussion, you know, how we best do that. Yeah, thank you. One more comment back, probably time for one more comment. I was going to echo it so if someone else wants to say something. I was just going to say, yeah, if we could talk about that, please, please help me with that problem, you know, because, because I like, and ophthalmology is unique because like one person's like doing it, you know, and the word do is such a hard word, but you know, at our faculty meeting, we recently discussed that. And so I've tried like talking more clearly with patients. And if you tell a patient, like, do you want me to do the eye surgery or do you want a trainee to do the eye surgery? It's 0% in my experience that say, can I have the trainee do it? And like zero. And maybe other people have different experience, but for my patients, it's zero. No, I agree that that's, I think that's the challenge. And it's how, then you word it to be, try to be, you know, where it's not zero, where you increase that percentage and then maybe you feel inauthentic, right? The way that you're conveying it. And so what is the exact way to both provide opportunities for, you know, safe training, but also that you should have, you know, true understanding and, you know, informed consent. I think that'll be a great topic and we'll save some of that discussion for that topic. Awesome. Yeah. Thank you guys.