 Hi. I now wish to introduce the moderator of the second panel, a panel called Clinical Medical Ethics. The moderator is Peter Eubel. Peter is the Manch and Dennis T. McLaurin University Professor of Business, Public Policy and Medicine at Duke University. Peter is also an associate of the Duke Initiative for Science and Society and a member of the Duke Cancer Institute. As a physician and as a behavioral scientist, Dr. Eubel's research and writing explore the influence of values and preferences in healthcare and decision making. Many of his writings, books and articles focus on how both rational and irrational choices shape human behavior and society at large. The speakers for this second panel session today will include Susan Toll, Andrew Hantel, Laura Roberts, Gretchen Schwarzie and David Schiedemeier. It is my great pleasure and honor to introduce you to Peter Eubel, who will moderate the second panel on Clinical Medical Ethics. Please join me in welcoming Dr. Eubel. Thank you. So, Peter Eubel sends his regards that unfortunately he had a dental emergency arise today. So, he's probably in a dental chair right now. And so, we wish you well, Peter. I'm Marshall Chin. I'm a general internist and an associate director of the McLean Center. And I'm pitching in as the moderator for this particular session. And so, we have a great session that five outstanding speakers. We have Susan Toll, Andrew Hantel, Laura Roberts, Gretchen Schwarzie, David Schiedemeier, Clinical Medical Ethics session. And so, our first speaker will be Susan Toll. And just to give you a heads up that we're going to have each speaker give their talk. Then we'll have a half hour at the end for all the question answers in this discussion. And so, as questions come up in the question and answer part of your screen, please put in your question. And also then, you have the opportunity to upvote different questions. And so, if we get a lot of questions, we're going to prioritize the ones where there's the most general interest among the audience. And so, again, like our first speaker is Susan Toll, who was a professor of medicine, an expert in internal medicine and geriatrics and the director of the Ethics Center at Oregon Health and Sciences University. Really an international expert on end of life care who has improved care and outcomes of thousands of people through her post program. And she'll be giving a talk about one of the most recent updates and aspects of the post program. Susan? Thank you so much for including me in this program. I want to give a very special hug to Mark Ziegler. Wish I were there with you. Wish I could be with all of you. And I'm very grateful to Eric and to others for finding a workaround to the OHSU firewall. We have such a high level of security that I can't be on VMAX like everyone else. And I'm very grateful to be with you today. We'll be talking about an aspect of post that has become very interesting as other states have followed a different path than the one Oregon initially launched. We'll talk about should serigids be required to sign post forms. And the Oregon Pulse Program do not accept gifts from health care industry sources. We never have and we intend never to do so. We believe it's important for the Pulse Program that we are able to have someone equally want medical treatments and not and honor either and not benefit either way. In today's talk, we will talk about three major things. We'll examine the burden on some serigids that they feel when they actually physically sign a Pulse form. We'll explore the degree to which signing ensures informed consent. Does it actually accomplish our goal? And talk about alternatives to being sure we respect autonomy without a serigid signature. I'd like to talk to you about a couple and help illustrate the issue. This picture was taken before the pandemic. Mary has been taking care of Jimmy at home. They've been married 51 years. Jimmy had moderate cognitive impairment and completed an advanced directive and appointed Mary. That was several years ago. He now has advanced heart failure. He has moderate dementia. Mary still cares for him at home. He developed severe abdominal pain and rectal bleeding. He was brought to the hospital and it was discovered that he has metastatic colon cancer. Mary has talked to the healthcare team about how many times Jimmy has said he wanted to be at home and be with her. Plans are to discharge him home for home hospice. The physician talks with Mary about completing a Pulse form. She agrees that Jimmy would want comfort measures only and do not resuscitate. But the physician asks her to sign as the serigid and she says, do I have to? It feels like I'm signing his death warrant. This is an Oregon Pulse form. Oregon was the founding program to launch Pulse. Other states have copied portions of the Oregon Pulse program in form. From the very beginning, now more than a quarter of a century, Oregon has not required a serigid signature. We require that you say in section C of the Pulse form who you spoke with, but we do not require a serigid to sign. Now, of course, some want to. They feel strongly I'm standing by what dad wanted. I'm glad to sign this. I know and I'm charged with representing him, but there are serigids who feel like Mary, who feel why am I signing a medical order? Why am I the one putting a signature that limits Jimmy's treatments? Why do I need to sign? The form allows for the signature but doesn't require it in Oregon. That's also true in Tennessee and in Maryland and with healthcare professional witnesses in New York. But the majority of other states have the word required or mandated for this serigid signature. In a systematic review, looking at the effect on serigids of making treatment decisions for others, there has been a careful understanding over a long period of time now that for a number of serigids, there are long term consequences. Over one third of serigids report serious symptoms of personal distress, waking up to 30 in the morning, wondering, did I do the right thing? Doubt, guilt. People say things. We've done well over a thousand interviews with those who have made decisions at the end of life. And they say things like, I wouldn't wish this on my worst enemy. Or this is the hardest thing I've ever done. And tragically, sometimes they say, I feel like a murderer. So we know that there are times and there are serigids who really struggle with the burden of this decision. It's both the decision itself and the signing. The signing verify informed consent has occurred. We do require verification for procedures that informed consent has occurred. And we would ask serigids to sign. We would also ask them to sign research protocols. But these are not medical orders. These are not the orders themselves. We don't ask serigids to sign a do not resuscitate order or an order to withdraw a ventilator in the hospital. We don't ask them to sign antibiotic orders. What is different about a post form or a post form? It's a post form as a medical order that they must sign. And we know that increasingly people are trying to create exceptions in many states so that virtually people can sign because of telemedicine in the pandemic. Another concern raised about the value of serigid sign is a study by Stevens from California in JAMA internal medicine that looked at several nursing homes where almost all of the residents had a post form. And most of the serigids that they interviewed did not remember having an advanced care planning conversation or signing the post form. We all sign things. If you want a new cell phone, you sign a many page agreement. We don't read every word most of the time. We want the cell phone. We know that's the only way we can get it. There are many things we sign without carefully reading simply because someone has signed certainly does not assure informed consent occurred. There are alternatives. There are other things that we can do. Sometimes all that's needed is supported or assisted decision making that people are actually capable though Jimmy would not have been. To make a decision if someone helps them, supports them, informs them and expresses their wishes. And so in many cases a person could be assisted to make a decision that they wouldn't be able to make on their own. Decision aids help. They are useful in helping be sure. Attend to help literacy, cultural differences that people understand what is being offered in choices on a post form. The Oregon Post Registry where over half of people who die in Oregon have a post form in the registry at the time of death. The registry sends out a confirmatory packet for every post form it receives. It reminds you of what your orders are, even how we spelled your name. It also includes a decision aid, a lay booklet that explains what each option means and tells you who to call if something isn't right or you want your post form changed. We think that this method of confirmation offers a significant addition to being sure as a safety measure that people actually know what was signed and it verifies that independent signing can't be happening. The added challenge of virtual visits means the ability to physically sign a post form is much more challenging and for many technologically possible, not possible with regard to the technology the patient or family may have available. So allowing post forms to be completed because of the need in the pandemic for telemedicine and virtual visits by phone is certainly an argument for why signatures shouldn't be required. I am hoping that compassion is also an adequate argument. We have additional resources about the Oregon Post Program available on the Oregon Post website and the Oregon Post registry has additional resources. Just two weeks ago the Oregon Post registry launched a whole new platform to more efficiently load post forms but also to offer opportunities that will take us into the future. Such things on the horizon are pushing post forms out to ambulance dashboards and other innovations that will allow us much more access to quality data and to continue to assure that post is used in the right population and that people indeed have had informed consent in the process of completing post. Thank you so much for inviting me to speak today. A big hug to Mark Ziegler and I wish I were there with all of you. Thank you so much. Thank you very much Susan for the terrific talk and for working with Eric to break that national security encryption code to get through Oregon's firewall to be able to share your great talk with us today. So our next speaker is Andrew Hantel who is one of our Chicago owned that trained in mental school in Loyola was an internal medicine resident, Hemong fellow, Fx fellow here at the University of Chicago and is currently a postdoc and instructor of medicine at the Dana-Farber Cancer Institute at Harvard or as we native Bostonians and temporary visitors like Gretchen Shorsi would say Andrew is a doctor at the Faba at Harvard. Please donate to the Jimmy Fund. So Andrew is working in an incredibly interesting important area, the scarce allocation of resources within Hemong such as medications. He uses mixed methods, quantitative, qualitative normative techniques to decide these issues and has had a variety of important papers including a high impact paper recently on JAMA internal medicine on this particular topic. But looking forward to your talk, Andrew. Andrew Hantel. Thanks so much, Marshall. It's nice to be here and thanks to Mark for the invite and also congratulations to Mark for his well-deserved award after all these years. So today I'm going to be talking a little bit about a simulation model that we are beginning to develop to look at the ethical allocation of scarce chemotherapy and kind of the impact of different strategies on patient outcomes. I have no disclosures. And just to start off with some background about drug shortages, they're unfortunate but a commonplace occurrence in the United States and mainly involve low-cost sterile, parentarial medications such as generic chemotherapy. As you can see here in the chart on the left, shortages increase significantly from 2006 to 2011 and there have been at least 140 new shortages per year since 2011. Despite the number of different shortages per year decreasing slightly since the early 2010s after the Food and Drug Administration had enacted the Safety and Innovation Act that kind of was able to stop some of the low-hanging fruit of shortages, there have been increases in the length of shortages over the past several years which you can see as the number of active shortages per quarter increased since about 2017. As you saw a second ago, I'm going to pull up the reasons for why shortages are happening and this is based on an FDA report from 2019 that convened a panel of experts and they discussed that there was a lot of pharmaceutical industry conglomeration which caused decreases in the redundancy of the supply chain. There were and continued to be lack of production incentives for generics because why would you make a low-margin medication when you could make a high-margin medication? In addition, there were lack of rewards for high-quality supply chains so there are a lot of quality control issues when the FDA has to shut down production lines. And then finally, there's a lack of transparency in the supply chain which leads to things like medication hoarding. And on top of that, the report cited three potential solutions for scarcity. The first two are the promotion of sustainable private sector contracts to help drug companies be able to continue to make low-margin medications for the longer term, quality rating systems to kind of promote higher quality supply chains. And then the last one, research to improve shortage management because the first two are kind of longer-term solutions that will take significant legislation and time to get through. And so that is where our research is focused today on improving drug shortage management in the current climate. And as it specifically relates to chemotherapies, there are 19 active chemotherapies as of September of this year and there is a well-publicized and severe shortage of vincristine which is what we based our model on for around nine months of last year and this happened at multiple institutions, academic and not throughout the country. And I'll note for everybody who's not an oncologist that vincristine is a chemotherapy that's recommended in the frontline treatment of multiple cancers such as leukemia, lymphomas, sarcomas and some brain tumors and it's almost always used in combination with other chemotherapeutics. Prior chemotherapy shortage research includes large physician and pharmacist surveys including the one that we Marshall mentioned in my introduction that demonstrated the impact of shortages at drug costs, quality and safety as well as some heterogeneous management and rationing practices that frequently occur during scarcity. Additional studies, mainly retrospective analyses of single centers and some multi-centers like one just published in JCO earlier this year have demonstrated increased mortality due to drug shortages. Unfortunately though the true impact of shortages is difficult to evaluate because they occur unpredictably and they affect hospitals to varying degrees and there's because of the lack of transparency I mentioned regarding supply, purchasing, distribution that you basically have an inability to match up kind of national shortage data when specific hospitals are severe in their shortages enough to require rationing and so you don't really have an ability to use big databases to accurately measure shortage related outcomes. And finally you have an inability to perform more prospective research because one of this lack of information transparency and then two it's also logistically difficult to do anything prospectively and then you also have a constantly shifting equipoise because you don't know when the shortages are happening or when they're going away. And this is going to be a rather simple slide for most people here but just to make sure that we kind of have a firm background and where we're going from for the model. We have a number of scarce resource allocation principles that people think of to distribute resources and prioritize people or patients and this is just eight of the more common and accepted principles here. You know we did interviews with patients and oncologist stakeholders about chemotherapy shortage specifically at least in those interviews and in some other surveys the lottery and the social usefulness principles were not generally accepted as mechanisms by which prioritize patients for scarce chemotherapy. Acknowledging that they're useful in other situations of scarce medication allocation a lottery for chemotherapy where the scarcity is dealt with at a hospital level would be very logistically difficult to implement and additionally there were a lot of normative concerns about the social usefulness criteria to prioritize patients by. So we begin our kind of conceptions of the model thinking about the remaining principles that you see here and just a few notes about how these five principles apply to chemotherapy shortages while many argue and I think in the climate of recognizing how much social determinants of health have to do with outcomes during scarce resource allocation first come first served can unfairly favor those who are well off. I think the reason that we thought about it in this situation was one it's the comparator it's the default it's what people use without thinking about it. Second in the context of chemotherapy shortages the worst off principle can be thought of in several different ways and we in for this model we chose to consider worst off as those without efficacious alternative treatments. And finally because the evidence for the use of chemotherapy comes from clinical trials they consider overall survival over time and chemotherapy is delivered in specific doses. We consider the lives and lives saved principles somewhat together in terms of this scarce drugs efficacy or overall survival per volume of that drug. But despite the several reasonable principles we don't really know how to use them when to use them and the consequences of what happens when we apply them to particular situations. Simply put when are shortages fear enough to matter and which strategies might be best for patients when they do. And this is kind of why and and the outcomes that we wanted to look at with building a model. To very shortly and quickly take you through the model we built what's called a discrete event model which kind of looks at different stepwise processes. And I'll show you kind of a conceptual model of that here where we think about patients kind of arriving at some arrival rate. In our case it was kind of how often patients at our hospital might meet with Christine and they would enter a queue and in that queue they could be assigned a score and ordered against other patients in the queue and each time a new patient came in you could have scores that were reordered. To start off for our pilot we thought of those operational equivalents of the different allocation principles that we thought of that you can see here. And then we created a very simple score based on these and it was just an additive score with each of those principles and you could kind of weight them with those W, X, Y and Z coefficients that you see there in order to exclude a principle entirely by putting a zero as whatever coefficient up to one and kind of continuously weight them in between if you'd like. And so after you kind of came up and decided on which queue score you wanted to use as you being the modeler you kind of would assign patients and they would be ordered according to that score. And then based on if they were at the head of the queue based on when there was enough FinChristine available they would get their FinChristine treatment and then go on to survive or die after some time period. And if there was not enough FinChristine treatment we looked at different times to treatment for patients with the different cancers that were involved and if they didn't end up getting FinChristine by a certain time they would kind of time out of the queue and get their next best alternative treatment. And then kind of the same outcomes and on top of that there was a small chance that they would die actually while waiting for treatment. So which data did we use in this and kind of how did we validate the model. The data for the simulated patients mainly came from an institutional database of around 1700 patients that we had treated at our institution and we abstracted their FinChristine treatment regimens and used published clinical trials that they were based on preferring those cited in the NCCN guidelines which is a national treatment guidelines for all different types of cancer. And we used those to kind of calculate drug utilization and survival probabilities for the patients. And then we also assigned the patient's best non-FinChristine containing alternative regimen based on those same guidelines for each disease and stage. And then we also used different risk stratifications for each cancer involved in order to adjust survival probabilities as people went through the model. And after we did calibration and sensitivity analyses that I don't have time to show you here we ended up looking at what our model showed in survival for patients with enough FinChristine against the CR database which is an epidemiologic cancer survival database and saw that our outcomes were statistically the same for each of the cancers we were interested in compared to that database. Our primary outcome for the model was three-year survival and essentially we were looking at three-year survival for each of those other strategies compared to the operational equivalent of first come first serve which is weightless time. And then we also wanted to see the supply thresholds above which each strategy maintained survival compared to adequate FinChristine supply. Some bounds and assumptions of the model were that we just looked at one institution and one supply of FinChristine so we couldn't transfer patients. We dedicated FinChristine to a patient. And then we looked at those reductions because we didn't have adequate data to look at toxicity and kind of when people would have toxicity and how much. And then not all diseases have good non-FinChristine alternative regimens. And so for those diseases we kind of assumed that you would use the same regimen take out FinChristine and we chose 80% of the probability of that regimen as their survival outcomes and that was based on the rest of the regimens kind of comparative survival with FinChristine. And so very quickly I can show you kind of what actually happened in the scenarios that we looked at and kind of how we did that. So because FinChristine was scarce for nine months we wanted to model patient survival and other important outcomes over a nine month period at every possible shortage amount. And so we randomly sampled a thousand different nine month cohorts from our dataset. So these were each about 250 patients in size. And then we ran these thousand cohorts through the model at specific levels of FinChristine and with the same Q score each supply level and score. We repeated this process for each Q score at a given level of FinChristine and here I'm just showing you 2250 milligrams. And then we went on to perform a nova testing followed by a pair wise comparisons in order to evaluate kind of which score was significantly different from the wait list time strategy at each of those supply levels. And we repeated this for the whole process for every 50 milligrams from zero all the way up to 4500 milligrams which is where everybody could receive FinChristine. And here are the results for the individual allocation score terms alone with the mean number of patients alive on the X axis and the level of FinChristine supply on the Y or on the number of patients alive on the Y axis excuse me the level of FinChristine on the X axis. And you can see by this shaded box that there is a large range over which the efficacy based score requirements are for the wait list time score in purple. There weren't any significant differences between scores based on alternatives or age alone compared to the wait list time score alone. And we also looked at where there were a great where there was a greater than 5 percent absolute increase in the number of patients surviving which is our pre-selected threshold of clinical meaningful difference compared to the wait list time score. And while it's a shorter range basically what happens if we combine different score terms. I didn't have time to show you the sensitivity testing but it also showed that the alternative base score had the potential to improve survival. So we next model the Q score that included both of those efficacy and alternative terms at the same time. And initially we assumed that there would kind of be an averaging out of the gray and the red lines since you you were using both of those. So we increased the efficacy or excuse me further increased the primary outcome. And so with this end over testing we found significant differences over almost all the supply ranges that we could test between this blue score and the purple score the efficacy and alternative score versus the wait list time score. And then doing that same kind of 5 percent we saw that there was quite a large over 60 percent of the range that had survival and the lowest level of supply was that each score could maintain a statistically similar survival compared to the number of patients surviving without any shortage. And you can see here that the that combination score of efficacy and alternatives was able to maintain survival for about 15 percent more than the wait list time score. And while I don't have to go time to go through this today I wanted to make sure that you know we recognize that right now we're focused on promoting the youngest patients or promoting those who have worse alternatives and we did do those calculations I don't have time to show you them but at least for the age compared to the efficacy alternative score there is a less than two year mean age difference between surviving patients and there were almost no differences in the wait list time between the wait list time score and the efficacy alternative score and that's what I wanted to show you here. So I'm sorry I can't show you all that today we can get to it in the questions but this is just the pilot model it's kind of the first iteration that we are doing of this and I think it has a lot of applications both for the United States and for other developing countries who have these problems even more frequently than we do. So I can kind of pass by my conclusions again thank you for including me in the panel. Thank you very much Andrew very cool using the techniques of health services research to study important ethical issues wonderful work. So our next speaker Robert's Laura chairs Stanford's Department of Psychiatry and Behavioral Sciences. She's also a member of the Bucksbump Institute's advisory board and she is one of the preeminent international publishers. She has published a number of publications like hundreds of publications and unbelievable 25 books that she has either written or edited so incredibly prolific. She's also won the distinguished psychiatrist award of the American Psychiatry Association as well as with Susan Tola on this particular panel both have won the McLean Center's highest prize the McLean Prize. So Laura will be talking about the wonderful introduction and I'm so delighted to be with everyone today. I want to give Mark and all of the people of the center my warmest hug just like Susan Tola and it's so nice that we can be a community when we're at a distance in this difficult time. So I'm going to talk today about moral injury and academic medicine and I have three kind of core ideas that I would like to share with you. So the idea of moral injury was it's kind of an ancient idea. Shay compared the experience of post traumatic stress and the tragedy of Achilles and the Iliad to the idea of moral injury. So Achilles suffered from post war grief and regret and alienation a rupture of disability derived from belonging in a natural or intelligible order. And moral injury was explored for its clinical significance by Camillo Bica who was a medical philosopher and himself a Vietnam war veteran and he noted that some soldiers suffering from really unrelenting post traumatic symptoms were observed to have experienced a threat not only to their physical safety but also to their sense of safety. So the idea of moral injury was that because of these actions and more that were contrary to their moral beliefs. So that's the idea of moral injury and the process of moral injury is some action or failure to act that an agent either directly is involved with or observes and there are emotional and cognitive events afterwards that are of moral importance. So appraising your behavior, attributing motivations, concerns, the sense of dissonance and a struggle for meaning that comes after this morally injurious action or failure, these emotions that are stirred and thoughts that are stirred and then there's either some kind of resolution some sort of action that leads toward recovery or a sense of being permanently damaged and this is the idea of moral injury. And the observed impact of moral injury includes shame, feelings of shame, guilt, social withdrawal behaviors, self-condemnation, transgressive acts related to the syndrome include self-handicapping, self-injury and demoralization. Examples of morally injurious events in conflict, the veteran or military example include mistreating a civilian or combatant, feeling betrayed by one's or failing to prevent immoral acts. Our understanding of moral injury is evolving. It first rested on this implicit notion of a harmonious belief system that can be damaged in events that transgress deeply held values and expectations of life but it's increasingly recognized that there are moral tensions and threats that are inherent to the overlapping roles that we often have in life. And I think one of the elements of the soldier and civilian is illustrated in these beautiful photographs that I wanted to highlight this week with Veteran's Day this week. But also as a physician and a person these are roles that can be complex and the duties associated with our different roles can be intention. And when you think about the medical setting for all of us moral injury occurs when we think about how things ought to be our own sense of how things ought to be accompanying by a sense that those with authentic and legitimate authority have acted in a manner that lacks integrity or has failed to protect or preserve things that truly matter. And when you think about all of the roles that we fulfill whether it's in our personal life so life partner, parents, sibling, child, grandparent, friend, citizen, just a person and then all of the roles that we have in academic medicine is a physician, scholar, educator, administrator, faculty member, departmental leader, institutional leader, national academic leader and for some a societal opinion leader. There are many ways in which these roles can be intention and have conflict. So in some this idea of moral injury it occurs when we experience a rupture and how things ought to be that those with authentic and legitimate authority including possibly ourselves have acted in a manner that lacks integrity that we've failed to preserve or protect things that truly matter and we're at risk for moral injury when a harmonious belief system is damaged and when there are moral tensions or threats that arise across our many overlapping roles. So that's the concept of moral injury about the relevance for academic medicine and for all of us. The relevance of moral injury in academic medicine, I actually have four examples I'm going to share with you that are in these three different categories. First is a clinician's diminished sense of purpose, emotional exhaustion, distress, erosion of professionalism, what's commonly referred to as burnout. The second category is systemic failure to serve and fulfill who we are in academic medicine. And then third and one that is very salient and has been so deeply felt this year is the experience of inequity and discrimination in medical education and academic medicine. So we'll work our way through this. So the first example is around clinicians diminished sense of purpose, feelings of emotional exhaustion, distress and the erosion of professionalism. And I've noted for years that 30 years ago we were talking about the erosion of professionalism and the emergence of cynicism in medical education. And recently there's a wonderful paper by West Derby and Shana Felt looking at rates of burnout symptoms which exceeds 50% in studies of physicians in training and practicing physicians. And Talbot and Dean describe burnout as a constellation of symptoms that include exhaustion, cynicism and decreased productivity. But burnout itself is a symptom of something larger they argue, a broken healthcare system. And later they argue that moral injury describes this broken healthcare systems consequences, namely the challenge of simultaneously knowing what patients need but being unable to provide it due to constraints that are beyond our control. And they argue that physicians aren't burning out their suffering for moral injury. And the idea of being unable or failing to meet patients needs may translate into an experience of moral injury for all of us. And this has adverse outcomes on adverse effects on patient outcomes as well as physician well-being. A second example is systemic failure to serve and fulfill the public trust. We saw this last year in the closure of the Hahnemann University Hospital. It kind of was overshadowed by what happened with COVID. But Hahnemann University Hospital is a Philadelphia hospital. And this beautiful building, the University Hospital was sold for condominiums. And Hahnemann University Hospital matters because it was a critical safety net hospital in an urban area that we had dire need. And it really threatened the experiences of residents and medical students who were there. But clearly the biggest example of systemic failure to serve and fulfill the public trust has been our experience with coronavirus as noted in the New England Journal editorial in October. Our current leaders have undercut trust in science and government causing them damage that will certainly outlast them. Instead of relying on expertise, the administration has turned to uninformed opinion leaders in charlatans who obscure the truth and facilitate the 2.58 million cases that were confirmed of individuals with coronavirus infection and 242,000 deaths in the United States. And as the editors of the New England Journal commented, the U.S. came into this crisis with tremendous advantages, manufacturing capacity, a biomedical research system, that's the envy of the world, enormous expertise in public health policy and biology and that expertise into new therapies and preventive measures. And much of that resides in governmental institutions. And yet our leaders have chosen to ignore and even denigrate experts is what they said. And we're all keenly aware of the profound rupture of trust that accompanies the observations of health disparities. People of color are disproportionately affected by many different health conditions and certainly are dying at a rate much higher than those of other privileged individuals in our society. And it's a very serious concern and rupture of trust. The inadequate response to COVID-19 for health care workers is another example where there's been insufficient protection of health care workers, insufficient approaches to the distribution of PPE that would allow health care workers to save the lives of patients. And there's illness stress and damage to the lives of health care workers. And it's been a real last year for academic medicine that our commitment to strong health care professions workforce to biomedical discovery to clinical and educational innovation and to a national public health strategy informed by science and humanistic values has never been greater or more necessary than at this moment when COVID-19 threatens the health of the world. Another example is gender based inequity in academic medicine and the AAMC graduate questionnaire. Everybody knows I think that this is a questionnaire that's distributed to first year residents across the country allowing them to reflect on their experiences in medical school. And 7% of these interns describe how they felt that they received lower evaluations or grades because of gender rather than performance. 6% endorsed having denied opportunities for training and 1 in 5 graduates report that respect for diversity was inconsistently shown in the conduct of their faculty teachers. And when you look at the experiences of medical students belonging to underrepresented groups they have much higher rates of mistreatment that they report. Another area of gender based inequity is the continuing under representation of women and leadership roles in academic medicine as shown in this pie last year by the AAMC about the gains and momentum but also the challenges that remain for women in leadership roles in academic medicine. But what's shown here is the large proportion of non women who are in leadership roles and how it's much much more challenging for women who have a second non-majority identity in leadership roles. So bias discrimination and an exclusionary culture really do persist in academic medicine despite our good hearts and ideals and intentions. And you can see these in a number of areas. The over reliance for example on standardized tests which are known to be biased in terms of the ability for some individuals to perform from some groups to perform well that's independent of their ability. And these adverse forces result in inequity, distress and negative professional and personal consequences among historically underrepresented groups in medicine including women. And these enduring burdens and disproportionate kind of discriminatory practices based on gender identity are not just and they're antithetical to the values that we have in medicine. So let's just talk for a minute because it's full of suffering it is full also of the overcoming of it and we're reminded of how every challenge is an opportunity that we should take on and a right action in the world. And let's remember that academic medicine is entrusted with transforming human health providing evidence-based equitable care and ensuring a better future through many different methods science, education, clinical innovation, community engagement but it's humbling to think that there are fewer than 200,000 faculty in academic medicine in this country and a country of over 330 million and a country that leads or potentially can lead the world in medicine. So it's a big responsibility that we shoulder and it's important for us to keep this core idea of moral leadership in our minds as we embrace this work. And I think that piece talked about how the success of academic medicine and ultimately all of the medical profession depends on clear demonstrations of altruism and only by recapturing moral authority can we hope to be influential and in constructive waves. And Talbot and Dean in this lovely article from 2018 said we need leadership that is willing to acknowledge the human costs and moral injury of multiple competing allegiances and has the courage to do so. We need leaders who recognize that their result, that this work results in thoughtful and compassionate results for our world. So it brings us to Mark. Mark is a moral leader in my view. His work with clinical medical ethics I think has been phenomenal and it's his focus on how the everyday realities in medicine and his insistence that ethics questions are amenable to empirical health or scientific inquiry that in my view represents his greatest and most enduring contribution and I would say Andrew's talk which we just heard is a beautiful example of using evidence to answer morally vexing and difficult clinical question. And I'd also say that Mark really helped shift the field. There was such antipathy toward ethicists as watch dogs rather than enablers of great a great doctor-patient relationship and great work. So let me just conclude by saying that academic medicine is dedicated to transforming human health through combined efforts in research education, clinical innovation, community engagement and effective moral leadership that Mark Seigler embodies this and I'm so grateful to be part of this community and I want to thank you all so very much. Thank you very much, Laura. And I want to highlight what you said at the end that Laura is the editor-in-chief of academic medicine and both through her own writings and editorials as well as what she's prioritizing in terms of the editorial decisions of the journal. She has shown major light on the issues she talked about in her talk, the issues of inequities in gender, in race, disparities, moral leadership. And I want to thank you all for coming to this area. And also I think what you said at the end that like if you look at all the speakers so far that we've had, what Susan and Andrew yourself and then Gretchen and Shirley David, it really is this nice melding of the infusion of ethics into clinical practice and policy and operations and structures. Such an important role. And I know that for Mark Seigler probably his proudest achievement during great grandchildren. I think that's very much embodied in this panel as well as the rest of the conference. So reminder for folks as we're starting getting closer to the discussion session to put in questions in the Q&A section and also to upvote those questions that you have particularly interested in. Our next speaker is Gretchen Swartzy. Gretchen is the Morbridge endowed professor of vascular surgery at the University of Chicago. She's the first person that she overlapped two years at the University of Chicago as a fellow in vascular surgery as well as a clinic ethics fellow. And she has emerged in the past decade as like one of the preeminent, if not the preeminent surgical experts in shared decision making between clinicians and patients regarding surgical issues. And Gretchen will be talking about this for a long time. And I think it's extraordinary so it feels really privileged to be a part of it. And I also wanted to say congratulations, Mark. And thank you very much. Mostly, you know, the McLean Fellowship changed my career and I wouldn't be here without you. So thank you so much for all of your support and everything you've done for so many of us. I'm going to be talking about and also express my displeasure with my husband who again has this company that doesn't make any money still and it's still on my disclosure slide. So in the late 90s, the support study, the study to understand prognosis and preferences for outcomes of life sustaining treatments was actually really well done study. And as many of you know, they randomized almost 9000 patients with life limiting to an intervention that I think all of us would say checks most of the boxes of where we thought communication was going wrong and why people were having over treatment at the end of life in the ICU. And this intervention had nurses who spent time with families trying to elicit patient preferences and the nurses would go and talk to the clinicians in the ICU and try to analyze all of those gaps in order to have a better decision about what to do at the end of life for these very sick patients. And despite a very robust intervention, the study was totally negative on all of the outcomes that we might care about. They didn't show any advantage of this intervention. And so the blowback from the study was very impressive and the support study in the NICU maybe it's a lesson to not name your study support. Simultaneously, I think it's really important to think through what they found and this brilliant comment from Joanne Lynn who had to deal with all this blowback. And basically what she says is the systems of care in which we treat patients may have more impact on the care that they get than our ability to connect and have communication to change that care. And so really we need to examine our professional routines if we're going to change this problem of over treatment at the end of life. Despite the results of this support study and Joanne's very brilliant observations, we have spent the next 20 years developing interventions and testing them to see if we could change treatment at the end of life through communication. And so I think that's one of the things that's really important in this group of slides, but even the best of interventions this one in the top right corner and that's vital talk and Doug White's paper in the New England Journal of Medicine it's kind of like vital talk and even the sick people program really doesn't change that many outcomes that we think we might want to change despite our mental model that the reason we were having is that perhaps doctors got better care because they were able to communicate for themselves at the end of life and my dear colleague Dan Matlock did a study about the kind of care doctors receive at the end of life and basically they receive the kind of care that everybody else in their neighborhood or their local area receives at the end of life. And so I think it's really important to examine this notion this idea that better communication and ability to generate self change end of life care. In my lab we started to call this clinical momentum and the way this came up is we had done some focus groups with surgeons and older adults talking about surgical treatment in a patient who was very close to the end of life and who was unlikely to do well with surgery and at the end of describing this conversation between the surgeon and the patient the surgeons in my focus group said they were going to operate on that patient and they sort of sat there and they looked at each other and then they said you know she's going to have surgery and they started to bring up all of these reasons that even though they thought surgery was a really bad idea surgery was going to move forward because the family thought that surgery was the right treatment because the intensivist had called the surgeon because the patient had to operate than to have a conversation about not operating and I remember sitting in my office with Mike who is also a McLean fellow McLean and Mike said you know Gretchen this is clinical inertia and I said no Mike inertia is holding still this is clinical momentum this is something that is moving fast that surgeons are unable to stop and the way surgeons described it to us is like they're pushing towards them pushing as hard as they can against the train and they are unable to stop it and this is one of their quotes you know this spot this small breast cancer on a mammogram starts this whole rolling of a procedure and the need for surgery when surgical intervention is not valuable to this patient. Another member of our focus group was a neurosurgeon he said you know the emergency patient you've got to come running right quick right away and they forget about the patient around the bleed and when I say you know sure I can get this patient back to an end stage Alzheimer's patient who's completely aphasic and non-amulatory somehow they're kind of surprised that they never thought about that surgery is not the only place where clinical momentum exists this is a really brilliant paper by my colleague Susan Wong the patient who was pre-dialysis but then left the VA on dialysis and she noted that the medical admission got a ball rolling on dialysis for patients for whom they were a little agnostic about dialysis or potentially it wasn't time yet for them to have dialysis but because of the admission because of multiple things that happened in the hospital it was a good time to take an opportunity to get dialysis started or the patient needed to optimize this patient for this procedure or their carotid end artorectomy that things determine dialysis that were beyond a decision about having dialysis this is a lovely paper by Renee Boss at Hopkins she's a neonatal ICU doctor and she did focus groups with clinicians about decision making in the neonatal ICU and I believe the PICU as well and she talks about how clinicians view the care as very much problem focused at the beginning of the children's stay in the PICU and each little problem with the patient gets addressed but over time as the patient's course deteriorates they start to talk about the patient as a child and that the child is dying remarkably the families come in with the exact opposite approach they come in knowing their child as a child but then learn this language from clinicians about these isolated disarticulated problems to fix over time and by the time the clinicians have switched to this story about the whole child the family has really drawn up this story about the individual problems that need to be fixed so how does this happen in our ICU when we talk about things for patients and families we talk about liver function tests chest x-rays, oxygen the peeps better today Jackie Cruiser who was also at McLean Center as a UFC medical student and then came here to University of Wisconsin as a resident worked with our lab to develop this notion of clinical momentum and she put together this brilliant description about a patient who gets admitted to the ICU and respiratory failure with all interventions small diagnoses pieces of what's going on she also notes that many of the things we do are automatic they come reflexively for issues that we have identified and although we're getting informed consent along the way that informed consent is for smaller issues and not for an overall picture of what's going on with the patient and so over time we build this momentum by focusing on the patient today and the care is driven by the speed of this momentum rather than looking at the patient's overall prognosis or what's important to the patient so in our conceptual model of clinical momentum we have multiple components the first is this idea of recognition prime decision making and that's like being a firefighter rather than thinking about what to do if you see it you do it if you see it you do it the fix model is probably one of my biggest worries about how we deliver healthcare we have this notion that being healthy is being normal that medical illness is admiration or an ab domination of normal and what healthcare does is fix the problem which is great if you have appendicitis or strep throat but not so great if you have chronic health problems or illnesses that medicine can manage but aren't really going to fix the state effects and there's no doubt that one treatment can lead to another treatment to lead to another treatment and then finally much like in the setting of economics I think people really struggle with this notion of sunk costs we've already started down this road why stop now but ultimately what clinical momentum is this idea of patterns of usual care and clinical practice norms that lead to a momentum that is very difficult to stop with a conversation about making sure noting how when patients get to the ICU we use recognition prime decision making to stabilize them and then we start using our fix it model to discriminate what treatments that they're going to get over time cascade and sunk costs build up and even though the probability of the favorable outcome has gone down the momentum has built over time so that by the time the patient's been in the ICU for 10 days or so having a conversation about withdrawal or withholding of life sustaining is very challenging for patients and families to get on board with once we've already started the train going this way so how might we study this most of you know I'm really interested in studying patient doctor communication or patient clinician communication in multiple different settings but I do worry that without studying the systemic forces that lead to certain treatments I don't know that we're going to be able to overcome these with strong communication interventions to study clinical momentum in my laboratory and our strategy is to do this in patients with end stage dementia who receive a feeding tube and you may say well gee Gretchen you're a surgeon and you don't know anything about patients with dementia or feeding tubes at this point and you'd be right but what I needed was a clear example of over treatment at the end of life in order to do a simple mix method study to try and evaluate these forces that determine the care that people receive even though we know it's not the right care and so this is a mix method study in order to first understand how these forces play out and then try to identify the forces in the electronic health record so that we could do a large scale study using electronic health records to see if clinical momentum is really a determining factor in patients getting feeding tubes when they should not but I imagine that this is what a story of somebody who gets admitted with late stage dementia looks like if they get admitted with altered mental status they get medicated the nurse notes that they're choking on pills and they make them MPO that's recognition prime decision making and then they place a dub off to because now they can't get their meds and they go on to get a swallowing study which is part of clinical practice norms to figure out whether they can swallow okay the swallowing study is done and it shows aspiration so now we can't feed the patient but we can fix that problem by starting two feeds the patterns of usual care I mean that once the patient stabilized the patient needs to be discharged to a skilled nursing facility and now moments before we're about to discharge the patient to a skilled nursing facility did you place a feeding tube several days ago didn't you tell me we did this because she couldn't swallow so you can imagine how this momentum builds up over time and keeps families from understanding the consequences of these decisions so that's what we're going to look for we're going to do some interviews and we've tried to make questions that don't directly ask people about the decision but about the way care was done we can understand how this stories play out so I want to save time for David this is the second time I've been right before him and I'm always just so honored by that but I also want to thank my lab thanks everybody for inviting me thanks so much Greshan for a terrific talk it's really interesting hearing like the individual specific case examples and how they relate to these broader issues of shared decision-making ethics so thank you very much thank you so much for having me I appreciate it it's a great set of questions actually a lot of questions and so if you can up vote and vote on the ones that are most interested there is concern by the the ballot overseers that a question named Mark Seagler is stuck in the ballot who currently is sort of at the top in terms of the upvotes so we do want to have a demographic process so please have a look at that so one of the questions of today's panel is David Shiedermeyer was a palliative care physician at theater care in Nina, Wisconsin and for many of us who have been to like the past several of these McLean conferences I think would agree that David's talks have been some of the most brilliant and innovative and creative of the conferences in recent years David he combines basically the arts and poetry and the arts and reflection on specific case examples and stories with end-of-life care and also incorporates music so it's just a wonderful blending of different modalities and I think very powerful and their impact and judging by the David's screen and his accompanying tools I think we're in for a treat today so David better great well thank you so much Mark and just going to tell about the master storyteller J.R.R. Tolkien who at the end of the Lord of the Rings has his mighty heroes board ship together at the Grey Havens then Tolkien tells us the sails were drawn up and the wind blew and slowly the ship slipped away down the long grey Firth and the light of the glass fell that Frodo Bohr Glimmered in was lost and the ship went out into the high sea and passed on into the west such a description seems fitting for the passing of heroes they should capture the light of our imagination even as they leave years ago R.M. Ratzin called great teachers of medicine heroes this is his quote that fragile time between stages of maturity when if only for a brief interval we're exposed to a fresh and stimulating personality who has an easy and firm control over our new endeavor and wishes to let us in on the secret it's a precious time a time when we're prepared to believe and desperately want to listen that fresh and stimulating personality with an easy and firm control over our new endeavor was Mark Siegler the secret fellowship was that precious time we know we're losing Mark as our leader for the same reasons that we lose all our clinical heroes and best teachers although fortunately they live on in the next part of their journey they must sail away from Middle Earth when the fresh wind blows they leave their work after the passage of many years and after long campaigns of battle many wins and some losses it is the natural order of science and medicine but that does not make the leaving any easier to bear those watching Frodo, Bilbo, Galadriel and Gandalf found their eyes full of tears even though their heroes still lived but it seems to me that reflection is needed at such a time not just raw emotion it seems to me as someone who is also leaving my own work soon that I need to remember what made Mark's work great and to a lesser degree my own work good like many of you and like Mark well we've enjoyed teaching medicine on the wards many of us have won a best teacher award what makes a best teacher and what's lost when one is gone why does the parting of a best teacher a program director a mentor like Mark make us lonesome years ago Jim Sebastian and I did a survey of the 18 best teacher award winners in a department of medicine we never published it mostly because we realized general medicine research can be it's just a thoughtful romancing of the obvious there's no need for me to put up any graphs or tables here the findings were what you would expect and are easy to explain the ground rules for the best teacher award were very simple there was one golden apple award each year the residents chose the winner would it shock you to say that we started with the year 1968 we found that great teachers were easily identified by their students the only statistical significant difference the statistically significant difference between the best teachers and the group of controls was that the best teachers wanted to increase their teaching time while the controls did not here are just a few of the things that these heroic women and men said about their approach to teaching and mentoring these are some quotes teaching is part entertaining to maintain interest then involving the student figure out what they want and need make teaching a two way street be confident not arrogant don't be afraid to acknowledge lack of information enjoy relate with basic physiology teaching is like sex it should improve with experience it takes stamina and is more pleasurable to do than talk about I think this was the program director keep current be fair enjoy teaching know your subject be a ham have fun concentrate on the important don't be little students be well read spend time with students it's hard to rush teaching strive for quality care be a role model treat house staff as peers don't criticize in public show genuine interest in students as individuals remain accessible and approachable so if I might summarize a love for an interest in students and in spending time with them as well as intellectual rigor honesty enthusiasm and humor even a certain slowness and cunning our basic themes the best teachers and clinical mentors have a genuine interest in their students succeeding sound like mark they want us in on the secret for our part we are ready to learn about our students and fragile time in our careers sound like the secret fellowship as a young faculty coming from Wisconsin I was poised ready to remember every word mark said here was someone who could teach me to succeed here was a coach with a winning record a players coach who saw patients and taught the physical examination course here was someone who believed in the equal value of the patient's voice and the doctor's recommendation as immediate and concrete evidence of his academic chops marked help me write a successful grant my first to obtain research funding and that support made all the difference in moving our young family to Chicago in 1986 multiply my story many times over truth be told many if not most of you have gone on to more storied careers than my own and it may be a bit late for me to do much more I'm 65 years old it's like one of my superannuated patients said to me once when I asked about her son she said oh he'll never amount to anything he's retired but I do commend to you your own CDs and bios my colleagues on this panel for example those of you who have won best teacher awards started your own ethics centers I think 40 plus of you one time to get grant after grant hundreds of you rose to leadership positions in prestigious universities and I'll just say about this dozens of you are you know who you are but what Mark did for me early on made all the difference even in my modest as a practicing general intern now I had a niche a foothold with a lot published enough to become a full professor no more romancing the obvious I had a new and evolving topic to teach one of great interest and importance I had a place in the clinical ethics world as a Siegler fellow one year with Mark Siegler changed my entire academic life for the better that is the power of a teacher and a mentor they take us from the shire to the mighty ship from the little brandy wine river to the great sea the connection with the teacher even for just a time changes the life Mark gave us all a start a voice and a path Mark's guidance about case writing lives on in my chart notes I hear his words about writing I write about the specifics of the person I see and I describe the disease the diseases that he or she has this is not just a patient this is not just a billable note cut and paste this is a relationship we're in together and I am actually describing the context and the contours the boundaries and the bonds Mark brought all the fellows back every year to maintain the intellectual spirit of the University of Chicago in us he created a real community of this connection during the years throughout all our long lives ours may not have been the fellowship of the rain but it was and is the fellowship of the seaguller the fellowship of the clinical medical ethics and surely if Tolkien's story of unlikely heroes had been filmed here instead of in New Zealand maybe the soundtrack would have been Dylan and the scene where Gandalf visits the Shire knocking on the little round door and then walking down the path maybe it would have had this song backing it I've seen love go by my door never been this close before never been so easy or so slow I've been shooting in the dark too long when something's not right it's wrong you're gonna make me lonesome when you go you're gonna make me lonesome you're gonna make me lonesome you're gonna make me lonesome when you go you're gonna make me lonesome you're gonna make me lonesome you're gonna make me lonesome you're gonna make me lonesome when you go thank you very much thank you very much David I think every speaker who's spoken so far has recognized Mark and what he's meant for us individually as well as for our wider community and I think that if we had an in-person meeting there would be many more of these statements whether informally at the breaks or formal settings but your talk and your song and your poetry I think captures everyone's sentiments in a way that it's like the crowning touch that I think narrative words you can take it so far and your art has added a great component so thank you so much so when I went to the question and answer discussion phase and so everything bring back the whole panel five great talks and the tremendous question answers that have come in Mark's single question still is near the top and there are significant concerns so we're gonna have to do a recount there and so we're actually gonna start with one of the questions that didn't get as much but which I think applies to all five talks so let's start with that question first you know it's Dr. Bob that's the question about moral injury in our times in a sense that for every one of your topics whether it's end of life directives whether it's allocation of resources moral injury or shared decision making and all in reality these aren't cross-sexual issues I mean getting back to David's original start we're talking about storytelling and art that any given topic really is also a creature of its past and its current context and where it might be headed and so if you think about the issues you talked about within this current context and transition point where we have had a difficult period where we divide a country we can't agree upon facts there's been an egregious moral and ethics lapses in the past several years how do you then consider your particular topic and where we move ahead within this context I might start that one if that's okay I mean I really you know I'm so impressed with the work that Andrew did in part because it seems to me for a long time in bioethics we've talked a lot about autonomy and we didn't talk enough about fairness and I worry that we were caught a little on the back of our heels when COVID showed up because all of a sudden we seemed to need to talk about fairness now when there's been problems with fairness before and this is not to suggest that autonomy doesn't matter but I think bioethics could do a better job thinking through what our responsibility to fairness and justice is I feel like you know when I learned bioethics it was sort of like well we'd like to have that but we're in this system so we're just going to talk about autonomy instead which is no dig on Brooklyn Center yeah and following up on that at least from the modeling perspective I think as we've all seen modeling is a great tool to kind of look at those different aspects of what actually can happen on the ground but it doesn't always match what happens on the ground doesn't seem like it's as bad as the polling that happened this year but you can see the number of different COVID models that are continually adjusted over time based on what the differences are between what they expected and what we're seeing in the end and my model while it's a different type of modeling is no different in the fact that we always have to use our best guesses but at the same time when there is no evidence to bring from in terms of large real life data sets you kind of have to use extrapolations to see what would happen and kind of be able to add a different lens on to it apart from the normative discussions that we all love to have so I don't know if it's going to be something where it will kind of fuel the fire of that's your data and your data set but it doesn't apply to me and therefore it's fake news or something I'm not sure it will change that but I think it's just an avenue that needs to be taken in the context of everything else that we think about with regards to fairness and allocation I'm going to specifically call on Laura for that question also because it is a moral injury question so any thoughts on that? Well let's see so the couple points what's different about or special about moral injury is this idea that those who are entrusted with responsibility and right action have failed and that there's a rupture it isn't just seeing bad things it's seeing unpleasant things it's that there's a responsibility that's carried by people special people and special roles and that there's a failure there and so I think that's what's so powerful about moral injury there was a question about whether it relates to deprofessionalization and all that and it could lead you to kind of a cynical or dark set of concerns I guess I would like to flip it around and say that we know that individuals can influence and change the social norms around them change the approaches of their colleagues around them and I think we've got the great experiment of the Center for Clinical Medical Ethics where we go out and we say certain things matter matter very deeply I'd love to comment about how justice and fairness needs to be elevated and go off and have influence healing and teaching is so beautifully illustrated by David is another thing where we can go and shape the experience of others and not have it be moral injury I've already mentioned that I've loved Andrew's talk about using evidence to answer questions that are sensitive and can cause great anguish but we do have ways of looking at it and Susan's entire career is a perfect example of how taking clinical observations and evidence and translating it into right policy ethical fair policy that honors both autonomy and justice I would argue are wonderful so I think Marshall you didn't present this this time but when I saw you speak recently you talked about and demonstrated creativity and education that changes people I mean just listening to David it changed me today it changed all of us and I think it's a great thing to see that I think it's a great thing to see that he's doing it for his role and guiding us from the river to the sea so one person can make a difference we can all make a difference and we can be positioned to address moral injury so great responses and so group two questions together and this is directed first towards Susan and Sergus expressing verbal decisions about end-of-life care and Karen frame your question this is the primary reason for requiring a signature to ensure informed consent or to protect physicians from liability so watch the start Susan thank you so much there are some major challenges with regard to knowing exactly how much each element plays but we do know that if Sergus feel more certain about what someone wanted if they have had extensive conversations if there are written documents then on formal studies of depression scales and stress they do better than people who never had any guidance never had a conversation and are struggling with what is wanted it does matter if you feel really grounded in the decision that you're being asked to make and yes the issue around liability may be a major driver in those states who are requiring signatures perhaps also it's how we ask the question if we approach serigants and we say what do you want instead of saying what has Jimmy told you and here's what we and the medical team now recommend having heard what Jimmy told you lifting as much of the burden as we can and making this more an ascend than a consent can also help in lifting the burden we also know that if you sign a do not resuscitate order in the hospital from very old data which is not common practice anymore there were some older studies that suggested more PTSD with signing because juggling how much is the decision and how much is the actual physical signature it does appear that there is an additional element that I signed I agreed they wouldn't have done this without my signature yeah thanks Susan so this next question is first directed towards Laura and then I think that if anyone else has any other examples that is falling for everyone John Lantos and he says that the Hanuman is an example of failure of moral leadership can you give examples of good moral leadership that reduce moral injury that's great thanks John there are examples every single day I can think of examples from my own institution but I'm sure you can reflect on examples everywhere you know in my place we really conscientiously put together a group that would look at distribution of protective equipment and COVID there are huge investments in community outreach and working with vulnerable populations I mean I think you've only to open your eyes to see examples but the point is to do that and to share that and to support people in leadership roles being in leadership roles I often have to make values based decisions behind the scenes and sometimes those are pretty lonely decisions that have to be defended against many different threats and so I would say open your eyes there are many examples and I would also say give some support to the people who are out there standing in the wind making those decisions because sometimes they're clear and they're right in front of you and you pay a price for it the Hahnemann example I think really bears careful reflection because just to give one example from that residents were treated like a commodity to be sold they were like going to be traded to other institutions and paid a price to the organization that had sold it out from underneath them the sacredness of medical education our responsibilities in medical education were unthinkable we've got both edges we've got brilliant examples of people making wonderful decisions often unrecognized and unheralded but the fact that this could happen at Hahnemann means that we have fragility in our health systems and in our leadership and we really need to address those things Thanks Lara Next question is for Andrew and it's from Will Parker who says outstanding work Andrew is a professor in nursing survival what about treating people equally did any scores create age, gender or racial disparities how do you incorporate equity into the work Yeah I think I mentioned albeit briefly that given the time constraints of the talks I just focused on one of the outcomes that we were looking at but we were interested in all of the outcomes that he just mentioned in his question and so we did other other analyses where we did look at based on each of the scores that we calculated kind of what was the mean age of the surviving patients what was kind of the mean difference between the efficacy of the alternatives and the vincristine survival probability so you could kind of see if the people who were worst off were the people that were actually getting the drugs and kind of what that difference was surprisingly the outcome differences for those were fairly small so between all the different scores kind of the mean age and the distributions of the age were really only by a year or two no matter what your score was and so it didn't really seem like that had as much of a difference compared to the survival differences that we saw I think that's probably the most important point of our talk is that yes I presented it as survival outcomes but all of those different aspects are exactly what I want the model to show in the end because I think when you have kind of that complete information that's exactly what people want to know are the outcomes that we're interested in is the fairness is prioritizing children in some instances if that's what your goal is is that what you're actually doing or is by prioritizing by age are you actually but really not getting it to those people anyway and so I think the idea of the model is more of a tool to be able to take the normative framework that whatever your group is kind of has decided is appropriate for the situation and kind of test it out and see if you're really attaining the goals that you think you are using those kind of normative principles Thank you Andrew so the next question is for Gretchen and is from Karen Devon and Karen's question is Gretchen, once you identify all of the aspects of momentum in your amazing study what kind of interventions could you imagine to try and flip this? Yeah, I love Karen's question thanks, hi Karen Yeah, I think there are lots of different strategies we might try and as you might imagine even to write a grant you might need to propose some Jo-Ann Lynn who is one of my personal heroes says we need to change the default and identifying care identifying patients for whom default care we might want to change may be a really important way to do that Jo-Ann says in the 60s when people came in to give birth they got put in an operating room and they were given gas and the husbands were carted away and by the time the 70s rolled around they weren't given terrible anesthesia the husbands were in the room they got to hold the baby immediately afterwards and she said that didn't happen because we asked them what they wanted that happened because we changed the default and I love the notion that we could change the default for people who for people with dementia so they could have better care but it's not, you know it's all of the people I'm talking about changing defaults would be good I think hard stops would make a difference and I also think pairing things changing incentives and pairing that with good communication interventions would be another strategy to change the way we treat people at the end of life Great, thank you Gretchen This question is for David and the question here is that very powerful talk both the panel we're talking about ourselves as well as the chat obviously really powerful talk you gave and a very complicated talk and I want to talk a little bit about the creation process for this particular talk as well as the choices you made in terms of the structure and content ultimately into an incredibly powerful effect and so can you talk a little bit about that process Yes, I'd be glad to thank you an important part of when you're doing this kind of literary storytelling is to find the metaphor so it seems to me that I'm in this winter of darkness that the concept of light seemed important and so I was struck by you know Galadriel's light that she had that this was the greatest gift that she could give as you remember to Frodo and it was this vial of light so I thought teaching is like passing light on so the question is how do you build this metaphor around the Lord of the Rings but also teaching and this kind of fellowship so some resonant words it's just like a song you want some resonant words fellowship of course ties into the secret fellowship they don't call it a fellowship for no reason you do your fellowship in GI and cardiology and medical ethics so some of it is just this repeating resonance in a story or a song and of course just like all of us we had to come up with the talk early and I just like that you're going to make me lonesome when you go I like that song I think it's one of Dylan's best songs so simple if you want to spend a pleasant afternoon and look up all the people that have covered that song and all the versions and I challenge you to keep going don't just listen to Miley Cyrus but go all the way down to the people that had ten views ten views then you know you've done it and that's the way to go so anyway I didn't mean to make fun of general medicine research I just I just want to say that you know that if you ask obvious questions you're going to get you can go down a level deeper but sometimes you get obvious answers like who likes to teach who wants to teach so thank you David thanks for the insight so this is a question that it really could be anyone answering is from Christy Kirschner again do you think moral injury might be tied to feelings of de-professionalization and learn helplessness as doctors increasingly become employees it'd be great if somebody else answers that one no? okay well I think you're the expert I think all of us are like yeah but Laurel got a better answer I'm just observing I'm just observing this right, de-professionalization so again I want to challenge us it only happens if we allow it you know this is an identity issue this is a way of being an issue and so this pattern of de-professionalization which I agree we are seeing but it's been worse at other times actually talking about different models for example in the doctor-patient relationship we've seen a kind of a restoration of the idea of physicians as professionals and clinicians as professionals so I guess I would argue that yes, moral injury goes with this pattern but that it's up to us to fight it again we're the influencers we're the ones that establish the values and the norms of our field and we can we don't have to have this done to us we can change the narrative we can change the behaviors we've seen lots of examples we can change the default and it's kind of on us to insist on a different way of viewing and restoring professionalism in our field and then being an employee and the financial dimensions of what we do again it's on us and how we approach that and the integrity with which we approach those quote transactions and those pressures but I would encourage people we all want to be our best selves you wouldn't be at the center for clinical medical ethics if you weren't working hard to be our best selves recognizing hard aspects of humanity but I would just say moral injury is not an inevitable aspect of medicine because of language and hardship and grief and sadness and great things are all in medicine but moral injury is not intrinsically necessary so I think we can take that on so that's a very difficult question which I think is going to require probably multiple people to respond to to get the answer to justice here she asked clinical medical ethics and bioethics training doubles the workload women black and Hispanics force to do one and lose power to influence how do we become both what was that last part could you read it again I was very confused so September asks clinical medical ethics and bioethics training doubles the workload women black and Hispanic force to do one and lose power to influence how do we become both so both clinical medical ethics and bioethics I'd actually love to hear what September thinks about this because it may be outside of this all white panel here our experience so I want to just be respectful of that I don't know I mean obviously I just respect September so much and I'm not sure I totally understand the question but the way I hear the question thinking about my own life is something I've been thinking about a lot lately is really feminist ethics and how women have made so much ground in where they work and what they're able to do and sadly seem to have gotten to higher echelons of places just adopted the culture that was already there instead of bringing the culture of feminism and inclusiveness and resilience and relationality and so I do worry that that I hate the notion that diversifying means we're changing the people who are there and we're not changing the culture of what is there already and it does mean to be to a better place and not just having different people at that same old not so great place I think one of the things we is to address our own power whether it's moral courage whether it's changing the culture we really do need to realize that we can change the culture not about everything and not necessarily overnight but there is so much we can do to make things better and different and it will help relieve our moral distress to actually push on the system especially when you push on it and your success could I just add one thing Marshall you know one of the things I've learned I've dedicated my whole career to inclusion diversity, equity among other things in my leadership roles and in my scholarship but this year I really learned the difference between belonging and inclusion and fighting racism and maybe it's just waiting maybe I'm romancing what did you say thoughtfully romancing the obvious David I wrote it down but really fighting racism and fighting for equity they're aligned but they're not the same and that's one of the things I've really learned this year and I think it's incumbent upon us to do both so I think it's a great question and I think there's probably a lot in the question I'll take a riff on it based upon what Gretchen and Lara said and in some ways it reflects the fundamental tension within the overall field so where one of the center's pioneering aspects was clinical mental ethics so the idea of having clinicians people who understand clinical medicine be at the forefront of these fundamental ethical concerns and issues as compared to a definition of by ethics which you might think about as a variety of social and ethical structures and ideas that are semi outside the clinical arena and so that perspective and in some ways there's false dichotomy there's really sort of overlap among them but one could think of camps like the clinical mental ethicists and sort of the non-clinical bioethicists and the center's point about well in some ways ideally you have the skills in both and can transverse all those different issues it's a lot of work so in this discipline you had a tension it's fair then you became good at clinical mental ethics and if that was narrowly defined as the immediate clinician-patient relationship well then you missed then all of the various sort of structural power issues that I think Gretchen and Laura were talking about that so influenced care and outcomes that reflected like on the first panel answers talk and all so Ergo I think this tension and then this issue then of like there's the time issue and then like the degree to which then people of color and women have been marginalized and bearish put in terms of these structures in place so I think it is a really important fundamental question that this attempt is asking regarding the nature of the field both the thoughts as well as then the disciplinary structures regarding things like what gets published and what's included in the curriculum so it's a great question and I don't know how much if it's just a September's question but I think it does raise a lot of really important questions yeah what you say a teacher is you know when someone's really smart ask a question like that and you don't know the answer you'd say I don't know but I'll read about that and we'll talk about it tomorrow during rounds so we have 45 seconds left so I want to ask each of our five panelists just to leave with like leave us with one word you know based upon the past hour discussion and all any less one word to leave our audience with compassion that's great community I like community too community I would say grace that's where I'm at today thank you I still go with hope I'm hopeful what a wonderful panel great talks, great discussion difficult time I think we have some great people and great efforts going on that will do some good so thank you very much great panel thanks Marshall thank you Marshall