 Our next speaker is Preston Reynolds. Dr. Reynolds is the Professor of General Medicine, geriatrics and palliative care, and a core faculty member of the Center for Biomedical Ethics and Humanities at the University of Virginia. Dr. Reynolds received her MD and her PhD in history from Duke University and then completed residency in internal medicines at Johns Hopkins University. Dr. Reynolds served as a member of the American College of Physicians Board of Regents and the ACP Health and Public Health Policy Committee. Chair of the Human Rights and Education Subcommittees of the Society of General Internal Medicine, and member of the Board of Directors of Physicians for Human Rights. Dr. Reynolds led a national campaign in the early 1990s to reform medical education and the medical licensing system. Dr. Reynolds' research has focused on the history of race discrimination in healthcare and medical education. Dr. Reynolds has also been involved in the effort to bring genetics into generalist clinical practice and national policy efforts to reform healthcare in this country. Today, she's going to be talking, taking the four box model to Nepal. Welcome, Dr. Reynolds. Well, I will have to say that it's an amazing process to come to the McLean Center, be part of this group, and find yourself taking the things that you learned here really to a very remote part of the world. I first went to Nepal in 1994 and I've been back there numerous times since then and I was invited to be on the International Advisory Board of a newly established medical school there. It's a Patan Academy of Health Sciences. It is in Kathmandu. It's a 13th medical school created in the country and I believe it really is a model of innovation. It has tapped into the creative energy of people around the world and these are some of the International Advisory Board members at our meeting in 2011. This is an invitation to come back in 2012 but you can see that these are really master educators from just about every continent here around the globe and it's really been a privilege to work with them to bring what we believe as a vision of social justice, clinical excellence, best practice in medical education to shape a new generation of health professionals in that country. Patan Hospital was Nepal's mission hospital for 40 years and it attracted to this institution missionaries from, again, all over the world and so it always had a philosophy of caring for the disadvantaged and when Arjun Kharky, he was the founding vice chancellor, decided he wanted to create a new medical school in this country, he decided that Patan Hospital had already the values that he was looking for in dedicating a school to addressing health disparities and the needs of the urban underserved and particularly the rural, very underserved population in this country. The first matriculating class was 2010 and 2015 we enrolled our fifth class. Here you see at the top Rajaj Gangal who was the founding dean. Arjun Kharky was the founding vice chancellor and here in the bottom is our new dean who succeeded Rajesh. It follows the British model which is six years and I'm gonna focus on the preclinical and the clinical years and to say that this is the first medical school in Nepal that has created a longitudinal ethics and professionalism curriculum and I was invited to serve on the International Advisory Board to in fact create this program with some of the faculty who were there. What makes Patan Academy of Health Sciences different but one it's mission and vision that it really is absolutely dedicated to training health professionals to take care of the poor and vulnerable and to meet the needs of the rural population. We have a very, very innovative selection process that takes preference from people from disadvantaged and rural backgrounds. Everyone has to successfully pass an entrance exam but then there is social preference and inclusion preference to take those students from disadvantaged and rural backgrounds as I just said. It strongly is weighted toward a community based curriculum with a law with a six month placement in the district hospital in year four and then teaching methodologies it's the first medical school in Nepal to implement problem based learning as well as case presentations as a way to teach the basic sciences. They get exposure very early to a patient and they longitudinally follow patient with a chronic illness, a patient who is palliative and dying and then a disabled child. And as I said, this is the first medical school to institute a longitudinal ethics and professionalism curriculum. They have an electronic portfolio so all of the things we're gonna talk about and ethics goes into their portfolio. They have frequent formative evaluations and feedback and there is very, very close and intensive mentoring. I should also say that in terms of the inclusion process and we'll see that we have enrolled students from all over, all over the country and as you can see, 77% of them have a rural background. What's also important to recognize is that even in the first class in 2010, we admitted students from the delete class which are the untouchables so that we have really committed ourselves to be inclusive economically, geographically, ethnically and culturally. 60% of the students are on scholarship. We were able to arrange with the Nepali government that they will not get their license until after they have fulfilled a period of service in exchange for the scholarship. So if they're on a two-year scholarship, it's two years of service, it's a four-year scholarship, four years of service, well they will go back and practice in a rural area and help meet the needs of the disadvantaged population who live in the very remote mountainous and district areas. So I'm gonna now focus on the ethics piece because that's what we're here to talk about and I'm gonna focus on the preclinical years and this is the material that I've been engaged in helping the faculty develop. In the first block, the introductory block, the students are really immersed in the mission of Patan Academy of Health Sciences with this commitment to social justice, the social determinants of health, community-based practice and care of the poor and vulnerable. We then move into two years of their preclinical clerkship and as I said, it's primarily problem-based learning and what we've been able to do is create four problem-based learning cases that they work on as well as they get an introduction to these ethical topics as part of lectures and case discussions and we would all consider these really core to an ethics education. Then we move into the clinical sciences years and this is where I'm really amazed at what they have dedicated themselves to accomplish. As you can see here, there's 18 months of the junior clerkships, which we would consider our core clinical clerkships. Then there's a six-month rule placement which just launched this year. Those students, so I was there a couple weeks ago and went out into the rural districts and met with the students that are in the first rural placement. And then once that period is finished, then they will come back for what we would consider senior electives. The six-month rule placement, 17 of those weeks are done in a hospital and seven weeks are done in the district public health department learning about community sciences and the social determinants of health. Now we're gonna talk about the clinical activities. The students rotate in all of the core clinical areas that we would consider relevant in this country. And as you can see, there is a NICU, a PICU, an ICU, as well as specialty wards. There's OBGYN as well as surgery. The OBGYN dropped off the slide. In the 24 months, the 18 months, ethic clinical rotations, they get seven lectures to start off with. And then every other week, all of the students that are in their clinical rotations come together for two hours and a half discussions using the four box model to analyze ethical dilemmas that they've observed on the wards. Every student is required to write up a case with a PowerPoint presentation before they come to this two hour discussion. These are the seven lectures that start off with that 18 month core clinical block. And as you can see, it's informed consent, confidentiality and circuit decision making, end of life and truth telling, human rights and social justice, the hidden curriculum and role modeling, and then the four box model and reasoning through ethical dilemmas. As I said, every other week, all of the students, whether they're on surgery, OB, pediatrics, intramus, and they all come together. And this is actually led by now, the former dean, Dr. Rajesh Gangal, leads these ethics discussions really as what we would consider in a sense, safe space. What stays in that, what's discussed in that room generally stays in that room. And also the chair of pediatrics, the head of the NICU, and now a general practice faculty member help facilitate these discussions with Dean Gangal. The first 45 minutes are spent in small groups where the students discuss the cases that they have seen and worked up using the four box model. And then each group chooses one that they want to present to the whole group of 60. And then the last 75 minutes are generally spent in discussing these cases per group in terms and a large group discussion facilitated by the senior faculty. And they use the four box model mark. I have case write ups where they actually have this four box model in their Neporaly e-portfolios that we printed out. I've given them copies of Mark's book and it's really amazing to see this as a framework for helping students and now faculty begin to look at ethical dilemmas that they see in clinical medicine in this country. What are the type of topics? Confidentiality, truth telling, informed consent. Who in the family is making the decision? Medical error and how it was handled. Autonomy, disclosure, issues of paternalism, futility. And importantly, issues of social justice and the limitations of resources, primarily financial disparities and social inequities. They have now moved, as I said, into their six month clinical rotations and what we have introduced is a requirement for all students to do two cases that they see in the rural areas and to load those onto their portfolios and in a virtual classroom discuss those at least twice during that six month placement. So then we'll begin to get an idea of the ethical dilemmas that the students are observing now in the rural district hospital area. And this is a typical hospital. I was there several weeks ago when we drove 10 hours out to the Terai, viewed the hospital, met with the students, talked about their experiences, challenges, what they loved about it, what they wanted to improve, and then went back and fed that back information to the medical school leadership. So we're in the transitions of leadership. I really had the privilege of working with Dr. Bruce Hayes who was a missionary from Australia. He was actually working at Patan Hospital for 25 years. He just returned to Australia. And Katrina Butterworth is also a physician. She's from the UK and she is a missionary, has been there for about 22 years and her daughter is about ready to start college. So she and her husband have decided to go back to the UK. We've transitioned it now. The Nepali faculty of the medical school are doing this full time and all aspects of it from the lectures to the case discussions and the clinical awards. And I've been asked to stay on board and help develop this curriculum as part of the senior clerkship and the internship which is required as part of that six-year model. So we're also now building out an ethics curriculum for a to be established school of nursing and a to be established school of public health. Lessons learned, we have found that in fact the four box model is a very, very useful framework for beginning the conversation and beginning skills development and how you work through ethical challenges. But it is very Western, they would argue it is Western relevant and that we need to expand the four box model with the more attention to cultural nuances and particularly how it can be applied in a very resource limited setting. What we've also learned is that the students are seeing that their faculty are not meeting these ethical ideas. And the challenges, what do they do when they see their faculty perhaps not telling the patient that they have cancer, making mistakes when it comes to how they're handling medical errors, not doing proper informed consent. And so the last conversation with the faculty at PAWS was how can the students now become the moral agents of ethical change in this environment and empowering them and strengthening them to really be the transformative change agents not only at this incredible institution but when they get out of the district levels more into rural practice. We found that the curriculum itself is building ethics and teaching competence of the PAWS faculty. The general practice faculty member who's now leading these discussions emailed me and wanted to do online education in ethics. I sent him to a website that actually is very comprehensive. He says, whoa, I think I'm gonna start not so intensively with probably a two year curriculum. So he went to the World Health Organization's website and began to start reading and developing some knowledge in this area. Also the challenge articulated by the ethics faculty is how do we ensure the students model these ethical and professional behaviors when they are in practice and when they are in teaching roles themselves. So this idea of taking the virtual classroom out into the rural areas, developing a CME program for the graduates to continue to enrich and strengthen their own ethics competence once they finish and move on. Next steps are developing a method of formative feedback on professional behaviors, continuing the ethics curriculum and case discussions into the senior clerkships and into the internship year, analyzing the cases that the students bring from the rural district postings, creating an online educational research on ethics and professionalism by use by other medical educators in Nepal and hopefully hosting a conference on ethics and professionalism education with medical schools in Nepal and India since many of the medical schools in Nepal rely on India as their model for educational material. So as I showed you earlier, the students think that this ethics case discussion in their clinical years is the best thing they do. As Rajesh told me several weeks ago, he loves leading it. The students love coming together and they find that this interactive format to be very helpful for them also addressing moral distress issues that they experience on the wards. And since the senior faculty are involved in facilitating the discussions, it gives them a very good hands-on idea on how to mentor and shape their professional development. So the International Advisory Board comes together every year for several days and Nepal is now becoming a model for what we would like to have happen in medical schools not only in Nepal but also in the United States and around the world. So the neat thing is that the Nepali faculty are now becoming a model of what we would like to take out from Nepal to other parts of the world through the members of the IAB. And as I just wanna finish, Mark, thank you for giving us something that is so useful in parts of the world that I'm not sure I would have ever expected taking this when I was a fellow. So with that, I just wanna thank you again. That was a very nice presentation. Thanks for sharing that experience. One question I have has to do with the comment you made about the way the students saw the four box model as being too westernized. And so I wondered what insights they gave you outside of the ones that you mentioned focusing on distribution issues because I think that that could be embodied in that four box model as well. Did they give you any insights as to how that model might be expanded or contracted to fit their practice in their area? And also how did the students relate to the traditional four principles that we use in the West? Did they put a primacy on one principle over another or did they suggest introducing other principles for that context? So Bruce, Dr. Bruce Hayes, who started off the curriculum in the preclinical years did teach about principle-based ethics. And when the students are required to write up their cases, they're actually required to talk about what the effect of this ethical dilemma was on the patient, on the healthcare team, and on them to use a four box model to analyze the ethical dilemma and also to address what principle, in terms of autonomy of beneficence, non-maleficence, and justice is illustrated in this case. So they're using what we would consider Western framework to look through, to look at ethical challenges. One thing that is very apparent in a resource poor country like this is that families make decisions because they have to pay the full cost of healthcare. And that drives a decision making process that is very different than what we would experience here. So a child may need to be in the NICU, but it costs $500 a day and that family may have no money and may have to withdraw care. Or they may have a week's worth of money, but after a week, if that baby is not able to survive in a pediatric ward, they will have to take that baby out of the NICU and move to palliative end of life decisions. And a number of the cases that the students raise are around these financial limitations. Also around decision making by families. And I know Bill, when I was an ethics fellow, really emphasized in terms of end of life care, often does, we have to respect that family decision making process. But in this culture, it's a family decision making process. And I think our emphasis on autonomy in this country, they can recognize the need for that more in Nepal, but they also understand culturally, contextually, it's still a family decision making process. So how that process works, case by case, context to context is a very unique set of discussions. Last question. This is on, yeah, just as a related question Preston, I think it is terrific work, but in terms of trying to adapt it to the local situation, I wondered if you could tell us a little bit about the religious composition of the population, of the faculty and the staff, and whether you've considered working with religious leaders as a source of both of what counts as a case and for modifications of the four box model to Nepal. So Bruce and Katrina since they are missionaries are Christian and a number of the physicians there still at Potten Hospital are missionaries usually from a Christian base faith. The Nepali faculty are Hindu and Buddhist. And I think that the combination of Christian Hindu and Buddhism has really enriched the ability for conversations to happen. Addressing various aspects of religious belief. It's interesting though when reading through these cases, the religion of patients does not come through. I think transitioning this teaching from Bruce and Katrina to the Nepali faculty will absolutely ensure that when those issues arise they will be addressed because they are familiar with the religious beliefs of the people in that country. However, it's interesting that religion really does not play a dominant role versus the financial issues and versus the ability of the medical system to respond to whatever the medical needs are of that patient at that time. So since you have a resource challenged environment you may not have an ICU bed even though you have a patient that you may want to admit to an ICU. They have six dialysis machines. So if you have need dialysis but you don't have a machine that's gonna frame the conversation around the ethical dilemma about resource utilization and resource limitation. But I've been fascinated that religion has not come through as the ethical challenge that the students are observing in the case itself. And maybe that's because we haven't delved down enough and what they're looking at is what we would consider traditional ethics. Thank you. Thank you very much.