 Good morning, everyone. It's a real pleasure to have you here with us this morning. My name is Peter Angelos. I am an endocrine surgeon here at the University of Chicago and also one of the associate directors of the McLean Center. And I'm particularly happy to see so many people up so early on a Saturday morning. This is surgical time. And it's only appropriate that we have a surgical ethics session. And so to start out, our first presenter this morning is Dr. Ira Kodner. Dr. Kodner is an emeritus professor of surgery at Washington University School of Medicine in St. Louis. He was the founding director of the Washington University Center for the Study of Ethics and Human Values. He's past president of the American Society of Colon and Rectal Surgery. He's a past director of the American Board of Surgery. And Ira has written more than 150 papers, multiple book chapters on colon rectal surgery, as well as surgical ethics. And was an ethics fellow here, of course, but has been a really wonderful colleague and friend and a tremendous supporter of surgical ethics and getting the word out that ethics is important to surgeons. And I think several of us who are speaking this morning will be reflecting to various extents on some of the work that we've done together with Ira. So it's my real pleasure to welcome my friend Ira Kodner. So good morning. I'm very appreciative of the McLean Center and Mark in the early days of putting up with trying to educate a surgeon in ethics. So unfortunately, I have no financial disclosures. So I'm going to talk about ethics education for surgeons this morning. And I'm going to tell you the Washington University story. It's what we did. And we are not in Washington. We are, in fact, in St. Louis. And many of my colleagues begrudgingly compliment Chicago and the Cubs winning the World Series. So I'm going to talk a little bit about my own story and how I got involved with some of these things. First, in my career, there was preparation for an intended career in academic surgery with an interest in surgical ethics, which started in the mud in Germany for three years in the artillery. And once I learned what this was about, it really helped me in later years with multiple chiefs of surgery. And then I underwent further preparation for a career in colon and rectal surgery with an interest in surgical ethics. And I traveled some, but I always concentrated on my future career. And one of the criticisms was that I was only a clinician. So I had to show that I did have some research prowess along the way. Rarely we do bench research in colon and rectal surgery. So it began for me with teaching what I call compassionate care. And I would advise all the young people in the audience be very selective in how you complain. My complaint was we're choosing the best young scientists, but no one is teaching them how to deal with sick folks and their families. So for the next 20 years, I taught the first year elective, dealing with sick folks and their families. These are the topics of the syllabus. There were clearly no books we had to put together our own teaching material. And it was compassionate care. And it was dealing with diversity. And it was delivering bad news and trying to teach how complicated the medical system was and how it overwhelmed our patients. My requirement for the students was simple, a one-page paper dealing with your concerns, fears, and apprehensions about becoming a doctor. They were all the same. I'm afraid I'm going to personally do harm to another human being. And I'm coming in with altruistic values, and they'll be taken away as I become a physician. It's amazing. And I want to go back and now see if I can get these people who are in the middle of their careers to rewrite the paper. And then there was an American College of Surgeons panel on genetic information, about 2000. Colonial rectal cancer was one of the earliest predictable by genetic testing. And the question then became, what do we do with this information? The panel members included Mark and Mary McGrath from San Francisco. And I ended up, I did a little homework so I wasn't a total embarrassment on the panel. And I ended up with an invitation to co-author the American College of Surgeons curriculum for teaching ethics to surgery residents. And fortunately for my career, I received an invitation to do a fellowship at the McLean Center. Along the way, as Peter said, I was involved with the creation of the Center for the Study of Ethics and Human Values at Washington University. This included all seven schools of the university. So for seven years, I spent every summer hustling seven deans for the finances, for the Ethics and Human Values Center. We did some great things. We brought the schools together. Probably the most important was the allegiance with the business school. In the medical school, we were able to create a palliative care program where it was impossible before. And now it's a very successful program and it's part of routine care. So I did my fellowship 2002, 2003. In those days, mention of a surgical ethical challenge at the Wednesday conference only resulted in diffuse eye rolling by the faculty. As I look around the room, I can see your faces. But it's been pretty much remedied. If you glance at your program, you'll notice that every speaker other than the surgeon has 20 minutes and we have 15. And you'll also notice the category under which I'm standing here as a seasoned surgeon. That's ethics talk for an old guy. We completed the Ethical Issues in Clinical Surgery. That was our goal for this committee to write the book. It was a case-based curriculum in ethics for surgery trainees. It included instructors and a trainee's manual. It was commissioned. And finally, after many obstacles by the college, it was published by the College of Surgeons Committee on Ethics. These are the authors. The majority of us are in the room here. Unfortunately, it was not an instant bestseller. And the dilemma became how to encourage the use of the ACS curriculum and to nurture surgical ethics educators. Along came one of my heroes. This is Mr. Par Kamangar, who describes himself as a grateful patient. He, in fact, ended up creating the Kamangar awards in surgical ethics education. Par was initially a seriously mismanaged patient with rectal cancer, who became suicidal and then angry and then realized that he could do more good by supporting ethical and compassionate care. So he's put as much of his resources possible into teaching students and residents of ethical and compassionate care. He became a sponsor of national level lectureships. And in collaboration with the College of Surgeons at Washington University, established a competition for small grants to utilize the ACS curriculum and to create surgery ethics programs. It resulted in three rounds of annual grants to over 40 institutions in North America. We had three seminars of awarded scholars and surgical leaders to share thoughts on innovation in surgical ethics education. We have another one planned for March 1st, the coming year. And I have application forms with me. It will be done in conjunction with Washington University refresher course and general surgery. So it's an opportunity to work in the area of ethics. And in fact, some of the faculty will be part of that program. So if you're interested, hit me up and I'll give you one of the application forms. We have a few places left that carries a $500 stipend to attend this program. PAR has also sponsored the annual dinner of an expanded group of scholars of the American College of Surgeons to stay in touch, share program accomplishments and needs. And this has been led very successfully by Peter Angelos. And we just had a meeting last month and it was terrific. So we looked at, and this was actually reported at the surgical forum at the College of Surgeons in 2014, the effect of the seed grants on surgical education. It was application-based seed money, up to $5,000 to start or expand ethics education program in the surgical residencies. It included the book Ethical Issues in Clinical Surgery and an ACS-approved instructor to help plan the first training session. So it was a scheme to initiate ethics education and surgery where it didn't exist before. There were 40 grants awarded and after the first two years, it was thought it was calculated the grants affected ethics education for more than 1,200 surgery residents. Were the seed grants successful? They looked at it in the report that was presented to the college. It helped establish surgical ethics curricula where none existed. It advanced the careers for surgical faculty interested in leading ethics education and it aided in publication efforts, gratifyingly many of the people who took these courses are now publishing and getting ready to do clinical research. It helped increase resources available for the resident education. But we found that for the seed grants to become more successful, the recipients needed ongoing administrative and financial support. That gets to be a very high hurdle in surgery education with departments of surgery and it raised the question, should the seed be planted earlier to get these programs started? So how we started at Washington University, Mary Klingensmith is my colleague there. She helped with many things. She actually started with a grant from the Camingar program. Mary is now president of the American Board of Surgery. So the recipient of the Washington University Center for the Study of Ethics and Human Values faculty grants project. Actually it didn't come from Camingar, it came from the center and Mary started the ethics education program and developed effective strategies for teaching human values to surgeons and training. That was our first success. Our early observations at Washington University was that ethical quandaries are frequent and complex in surgery. The trainees need guidance in navigating the waters and the ACS curriculum, ethical issues in clinical surgery is a terrific resource. But every program needs a champion. You can't just send the books in. There has to be a committed person on the faculty to get these programs started and then find some sustainability. Mary started by surveying our own residents. They frequently encounter ethical issues in their daily practice, 100% agree. I discussed these issues with my fellow residents, 60% agreed. I discussed these issues with the surgical faculty, not so often. So that became one of the goals in our own program. The early observations from our own surgical teaching was over time, some topics and things recur. The senior residents took ownership in these conferences. They learned the principles. They helped lead the discussions. The attendees spoke freely and honestly. This was often in the form of a pizza round. We realized that we had created a safe environment for surgery residents to criticize where they may not have before. This was probably a unique experience for residents in surgery. The frequency with which non-surgeons attended and contributed to these conferences increased as we went along and served as an example for other residencies. It fulfilled the ACGME competency and ethics and it was extremely popular with the residents. The critical issues in clinical surgery became the basis for the score curriculum, which is now the current online basis for all surgery resident education. So it was actually people within our own program to a significant extent who modified the work in this book to now go into the online score curriculum. I have to drink something because I'm a seasoned surgeon and my mouth gets dry. The current status of resident education, I'm gonna talk about residents and students back and forth. This is our current program. The surgery faculty, fellows, residents, and nurses were all surveyed to determine which components of the score curriculum were of most interest and concern. The responses were grouped into six things for a three-year plan. Each year there were two hour sessions built into the surgical curriculum. Each session was led by a chief resident, starts with the basic ethics information, small groups then formed to discuss three cases and then they return all together for an hour of discussion with faculty and any relevant experts for the topic being discussed. Occasionally we have after-hours programs in faculty homes where we concentrate on specific issues. The last was the consideration of paying for kidney donors. The themes were two per year and I'm just gonna recount these for you and show you how the topics broke down. Dealing with complications and poor outcomes, truth-telling, informed consent, listening and surgeon-patient relationship. Clinical research and surgical innovation, the relationship to industry, barriers to practicing evidence-based medicine. Futility, talking about death and palliative surgery. As palliative care grows, we're hoping more and more that surgery becomes a part of that. Allocation of limited resources, transplant, mass casualty triage is a very important ethical challenge for surgeons. Withholding and withdrawing treatment, competence, decision-making capacity, who decides when the patient cannot? Surgical buy-in, we rely a lot on the work of Gretchen Schwarze from Wisconsin when patients change their minds and refusal to care for a patient, confronting problem behavior, including that of the surgeons and DNR orders in the OR, how we handle them. For the students, the current status of the student education has changed significantly. The faculty had created a curriculum and all was going really well. We had it down pat, the faculty had created the curriculum and it was terrific until this guy came along. This is Douglas Brown, who's the surgery ethics coordinator. Doug went off the deep end and created essentially a revolution for the third year clerkship. He let the students choose what matters to them. It was not the same as our faculty chosen curriculum, to say the least. So now each student submits one case to the list of ethical challenges. We now have Doug has banked over 150 incredible cases. And the students know this, they know that they're now part of creating the curriculum, so they've become much more invested in the program. The design is that students receive six basic ethics education sessions at two-week intervals during their 12-week clerkship. The students prioritize challenges identified by the faculty during these basic lectures. And then the students submit one challenging case in their amazing cases. The working group creates a discussion guide that reflects the submitted student input. And then in week nine, the working group, which is senior faculty and residents, meet in small groups with the students to discuss the cases that challenge them on their rotation. Some of the topics of both concern to the students, some of it surprising to us, was failing to be cost-conscious or to follow evidence-based thinking. Attitudes about and perceptions of patients, impact of time constraints on patient care, the rushed surgical rounds in the morning. This one they were really upset about. The attitudes about and perceptions of other physicians in fields of medicine, the bantering and the criticism of other physicians, they found particularly upsetting. Our pressure from financial incentives and motives in the nature of clinical research and surgical innovations. Wash University surgery is very much research-oriented and some of the things that we do with patients seriously challenge the students. We also have a fourth-year student elective where the student chooses a topic, often a case experienced on their own clinical rotations, not necessarily surgery. They spend a one-month reading period with the surgical ethics faculty. The objectives of this course are to strengthen understanding of clinical ethics to learn the rigor of peer review. They finish the elective with publication of an article in either the journal surgery, which is a peer-reviewed journal or the bulletin of the American College of Surgeons with a student as the lead author. It allows them to integrate their understanding of ethics into their future careers, which is very gratifying for us. Currently, we have 26 articles published in the journal surgery with continuing medical education coming from the American College of Surgeons. We have three lead articles in the bulletin of the American College of Surgeons. All of these with the medical student, the fourth-year student as the lead author, which is, I think, pretty exciting. These are just a few of the ones that we've published in the bulletin. The problem of conflict of interest with industry-sponsored trials, transplanted a patient with comorbid psychiatric illness, truly an ethical dilemma, and this one, which most people don't think of, and it's the ethics of sharing clinical photographs, all these pictures that are taken on the cell phone, who owns them, and ethically, what can you do with those images? So in summary, at Washington University Surgery Ethics Education has evolved in a stepwise fashion. We've tried to share with other institutions and to build them as well. We don't protect anything from other people using it. I think the biggest impact came from abandoning our previous didactic formats and creating new forms based on what our trainees determined was important to them. That's home. Thank you all so much.