 So next, I would like to introduce Dr. Alex Langerman. He's an associate professor at Vanderbilt University School of Medicine with faculty positions in their Center for Biomedical Ethics and Society in the Vanderbilt Institute for Surgery and Engineering. He's a fellowship trained head and neck surgeon. His research focuses on the intersection of ethics, management, and data science in the operating room. He's published on topics such as surgical ethics, video and data recording in the operating room, operating room efficiency, and the clinical care of head and neck cancer patients. In 2011, Dr. Langerman was nominated the first faculty scholar of the Bucksbaum Institute of Clinical Ethics, and he completed the McLean Center's Clinical Medical Ethics Fellowship, as well as a master's degree in clinical and administrative data science at the University of Chicago. He was previously a faculty member at U of C, where he also formed and ran the Operative Performance Research Institute, which was a multidisciplinary think tank and investigative unit focused on improving surgical care. He has been awarded the Distinguished Faculty Award for Program Innovation for this work, which implemented major operating room efficiency improvements and broke new ground on the use of video and data collection in surgical settings. Today, he's going to be talking about transparency and ethics in the operating room. Please join me in giving him a warm welcome. Well, privilege to be here. It's one of the highlights of the year. And I want to thank people who have supported me and funded me both in the past and currently. The cool thing about the McLean Conference, congratulations on the 30 years, is that with such an intense focus from the claims and the Bucksbaum Foundation on the doctor-patient relationship, this incredible diversity of topics that we're hearing at this conference, every single one ties that thread through. And that is not seen at other places. And I think that's really special. Mark, you're awesome. So I also actually want to mention Dr. Gordon's talk, which I thought was awesome and really interesting research. And one of the things that it shows is if you just scratch the surface of what patients might want to know about what goes on sort of behind the scenes, you not only discover amazingly sophisticated questions and probably way more information than you ever thought might even need to be shared, but you also see this diversity of patients. Patients who really want to sort of make these decisions on their own and think through every nuance. And patients who really just want to trust in the system and say, please take care of me, this is complicated. And so I think that reflects a bit on the talk today. So starting with a historical perspective, the operating room used to be a wide open place. Nothing was hidden from what happened there. And there were not only professional observers, the students who were learning or other colleagues, but the public or even family members. And to the point, sometimes, what I had to design furniture to keep the onlookers away from operating surgeon, because it was such an interesting spectacle. When medicine discovered that it's probably a good idea not to have a bunch of random people breathing on the patient who's being operated on, shutting down the ORs, they created glass table onO, which also means operating room in Spanish, was the original sort of transparent operating room where you could see through. And that's the Marquis de Busto who developed it in Spain. And this continued when we think of the operating theater. In fact, it was designed much like this room is, but with a glassed-in shell to allow the surgery to take a stage. And even family members would be welcome into the operating room. This is something that seems kind of crazy to us today, but there's the wife of that patient sitting there, observing her husband's thoracoscopy. People spent a lot of time trying to figure out how can we extract the information that happens here in the operating room, so that we can use it for training. We can use it to educate the public. We can use it to make surgery better. And the American College of Surgeons even displayed live surgery during their clinical converse every year, up until the 1960s. And then things stopped. We stopped seeing the operating room theater. We stopped seeing this sort of free flow of information out of the operating room. Why was that? Well, one, surgery became a little less interesting. It was routine, it was safer. And so you could not get as excited about many of the cases. In fact, a kind of manufacturing mentality came over surgery with time and motion studies and this idea of how can we fit as many operating rooms into a space, because this was a huge moneymaker for the hospital. And so those things combined to create this kind of sequestered environment in the operating room where nothing was really shown. Now, there's another reason that everything was shut off. I think it's obvious to people in the room, but it was malpractice. Suddenly, this data became a liability. And so it was not something that people were necessarily medical practitioners 100% comfortable sharing from fears of being sued for something that might be seen and perhaps misunderstood. And so that's how we got this closed off operating room, authorized personal only. So it's very unusual to have anybody other than the staff that are supposed to be operating on that patient in a room. And it makes it very hard to gain information out of the operating room. And this means that things like teaching, errors, the logistics of the OR and efforts to be efficient, these things used to be out in the open and these are things that were reined hidden for a long time. And there are challenges to times when things get hidden. First of all, you have a perception disconnect, between the patient and what actually happens in the OR. And then secondly, there are truly no checks on what happens in the OR, which is its own problem. And it's one of the benefits of transparency because what you don't want is for people to discover something that was going on and everyone thought it was okay who was doing it, but the public wasn't comfortable with it. And this is a scandal that rocked the surgical profession in 2015. The Boston Globe released a spotlight report on overlapping and concurrent surgery. One surgeon has two rooms operating at the same time. I've done research on this. We're not gonna talk too much about it, but the point is that this is but one of the scandals that has rocked medicine and also all of our other professional institutions. This idea of sort of trust in institutions over the years to the point where the general American confidence in the institution is pretty low, on average about a 32% sort of confidence in any given institution. And we got in just above the presidency, so that's how I do. And I think another aspect of this is because it sort of wasn't just out there and always sort of understood that residents sort of doing portions of procedures is part of surgery. It's been a part of surgery since the very beginning. I think that there's, when you get the idea that it actually might be happening to you as a patient instead of saying, well yeah, because that's kind of how things happen here, it's rather, oh, I didn't know that. Well, I suppose I support that idea, but I'm not sure I want it happening on me. And study after study has shown that patients are not really aware of the role of residents in surgery, nor are they 100% comfortable with the idea of someone, quote, learning on them. So I did some research looking at overlapping surgery and interviewing patients, but out of this research, we had some other interesting insights that I want to share today. So basically what we did was we showed, here we go, we interviewed patients one-on-one, they had a research assistant, and then we developed some themes out of that and then later replicated the study in a larger survey. So this is data from both of those that's pretty consistent. And what you see is I showed them three scenarios. One is you're getting your thigh right out and we spent a lot of time explaining everything to the patients what the different surgery means, the other thing is if you're giving informed consent. And then we explained there's gonna be a resident and an attending doing your procedure together, and when you get to the end of the case, the resident's gonna close the incision and the attending is gonna watch. And then we asked them to rate that on a 100 point scale of how comfortable they were with that. Then we gave them two more scenarios. So one was a same scenario, but now instead of the attending being watching the resident, the attending was out of the room doing some paperwork, they could come right back. And then the third scenario was that actually the attending had left to go to another procedure and had assigned a cross covering surgeon to sort of be there should the resident need any help. And this is a really common sort of surgical scenario. And also, I think it's worth pointing out, we're talking about an incision closure, not even a really complicated part of a procedure. And we asked patients sort of to rate their comfort with these three scenarios over time. And what we found is that on a scale of zero to 100, there was a group of patients who were relatively comfortable with kind of all three scenarios, not much change. And then to get sort of dissatisfied and it was really unhappy with this idea. And what I think is useful for this, not so much as to pre-classify patients in any way, but this is a signal. This is that there's some dissatisfaction or some desire to have something different. And I think those are interesting people to study for that reason. And so what we found when we surveyed subgroup C in the larger survey, that they scored strongly on distrust of trainees and teaching questions. So these were questions that we pulled from different validated studies. And you can see that you better be cautious when dealing with teaching hospitals or I wouldn't want any trainee working on me. And so I think those are important people to study. And one of the things we found was that when we asked them about why they felt that way, they discussed themes of control and fear of the unknown. There's this person operating on me that I don't even know who that is or how do I know that they're well trained or I haven't met that person so I don't know. Or the other theme that really came out was this idea as well if the attending is there, nothing's gonna go wrong. They're gonna make sure that nothing goes wrong. And this idea that it was a proxy for good outcome that like the only way to get a good outcome is if you had the attending surgeon there. So this sort of begs this question. If we reopen sort of the doors of the operating room to everything that goes on, is it gonna harm training? What are patients gonna want if they have more knowledge of what happens? And can we reintroduce this then in a way that supports training and advocacy? And so one of the ways that you could do this is through video and audio. And I'm gonna talk about three ways. So for video, we did another step, general medical patients. What do you think about if we recorded everything in the O or like, would that bother you? Would you wanna give consent for it? And what do you think you'd see if you watched a video of your own surgery or a loved one surgery? And these knowledge and control themes came up again in a subset of patients. Like that the video is helpful because that way no one can keep a secret from me. It'll make sure the team does a good job because they know they're being watched. And we've actually done a lot of exposing of the operating room more and more. And this is through social media and other video technology where people are recognizing that's important. Now, that has a risk. You peel back the operating room and you're gonna have things about it that people might not be 100% comfortable with. Maybe things that we should change. And I think really important topic of discussion. But additionally, there's things like Jovial, you're having casual conversations about life because for surgeons, the operating room, although an incredibly important and sacred act is also a day at the office. And you work with friends and you wanna have chit-chat when things are relaxed. You wanna be able to sort of have a good time in the environment that you work in. And so there can be a challenge there. Also, you can get things like this. This is Dr. Wendell Boutte, a surgeon-ish who yeah, released some videos on social media of her dancing around over the patients as they're being operated on. Now, she claims it was all staged and it was planned. And with that came some other questions about her medical training, et cetera. So I think it became a complicated affair. But when they interviewed her and said, well, why did you do this? There's probably a few reasons. Well, one is marketing, of course. But the other is she talks about the idea of patients having a lot of anxiety around the OR. And when she showed them these videos of her dancing around, she said she felt a more fun place. It wasn't such an intimidating experience. Did I think she handled it right? No, absolutely not. But I think it's an interesting sort of eye into how some people think about the OR and how you can sort of screw up and probably put something out there that's inappropriate. So for one thing we think about, well, video can improve medical quality. Keep it within the profession. If we're constantly videoing everything and assessing our mistakes, we can see how we can make it better. And that's clear. But then you wonder, what are the other potential benefits to society? And one place we can look is in law enforcement. They've introduced body cameras across multiple precincts around the country, departments around the country. And one of the things they found, of course, is that it was really useful for assessing errors or mistakes or training. And that's, of course, the same thing that we saw in the operating room. Another thing that they saw was that, for bad actors, it had a chilling behavior. So departments that were always sort of doing well, they introduced those body cams and didn't really change much. But the departments that had a lot of complaints or problems that started to improve it. The other thing that they, and this is not something that's been formally measured in any way that I can find, but has been frequently reported, is there are anecdotal senses that it improves trust from the community. It's this idea that if there is monitoring, then perhaps the actions of the police officers are more likely to be in line with what they're supposed to do, which fits these themes of what patients perceive would be useful out of the OR. So I think for this first way of transparency, the critical need is determining how do you share these patients? What should we be sharing? Who has ownership rights over the footage and what doesn't intrude on the team or disrupt their activities, but also provides more transparency to patients? So that's an area of active research. So a second way that we can improve transparency is through the consent document. Valerie had an awesome talk yesterday about the informed consent tort reform and really what she highlighted was this sort of mishmash of a bloated document. You saw the old thing where you just signed I'm willing to have surgery versus this giant document that we have here. And actually there's some things kind of hidden in documents like this. This is just about one example of documents that we assessed across the country. And while you find that not only are there things that are sort of, people might really want to make sure that they understood like trainees participating or the doctor being outside of the operating room, but additionally there's certain information of hierarchy in current informed consent. So I might need something done that like I didn't agree to just now. So you might do something else to me. Like that's kind of a big statement. I think it's an important statement and worth lots of discussion, but it's a big statement. And I might have some of the stuff that's removed from me studied and a problem are used for teaching and research. It's kind of interesting. It's not even a checkbox since that. And those sit between, or they bookend before my operation procedure the spot on my body may be marked. Which to me seems like relatively speaking a less important piece of information than the other two. And so I think one of the challenges we have the informed consent document is just really opaque to patients. You think it's like, well, we'll put it out there. We have these disclosures. And patients don't read it. And they often are encountering it when it's an intimidating environment. And one of the patients who was looking at these documents as far as a part of an investigation in patients understanding said, I don't even have a spot. How are they gonna market? Which I thought was pretty funny. So, anyways, so critical need number two is generate a surgical informed consent document that supports this ideal process of decision-making and disclosure for patients. And so then third, and of course, the McLean conference, we get back to the surgeon-patient relationship. So I talked to a lot of surgeons about how they talk to patients, aspects of surgery about treating, about logistics. And I think surgeons have picked up this idea that patients wanna know that there's some control into the OR. And this theme emerged, we saw that earlier in both of the patient interviews that we did. And so it's like, are you doing the case? Well, part of my role is to train surgeons, but they don't do anything without me. Like, everything's under my control. And they also used a lot of analogy. So a lot of like, well, think about it. It's like you're flying a plane and there's two pilots and you're on the more experienced pilot. And there's all sorts of stories like that of ways of like two people driving a car, but ones giving directions and they have all these ways of sort of euphemizing the experience a bit, but also sort of making it seem relatable, which I think is really interesting. And then third, there was groups of surgeons who said, you know, you gotta be cautious about how much you talk to patients. So once you start explaining what goes on, you're gonna get a lot more questions. And I think Dr. Gordon's research shows that really nicely too, you know. You start saying, oh, you might actually, we might do research on an organ and they're like, oh, well, actually, I got a bunch of questions. Now, the surgeons argued this would cause more anxiety than it would benefit anything. And, you know, this harkens back to some of the original discussions about informed consent. Should we even be talking about risks? The mere mention of the risks, something that we now consider absolutely central to a good informed consent, you talk about the risks, you're just gonna scare patients. And that's what surgeons were arguing in the 80s. You know, and so I think that we really gotta think about the validity of that, but also take that important voice into account. One of the nice quotes out of this president's study of informed consent in the 1980s was this idea that, you know, maybe euphemism seems like a good idea at the beginning, but unless you really explain what's going on, you run the risk of causing more anxiety down the road. And they also talk about the fact that what's said, the way things are said is also as important as what's said. So I think the critical need number three here is to find the language of transparency for surgeons. I think ultimately that's where our big solution is gonna be. We can throw tech at it. We can change the way the document looks, and I think those are gonna be really important interventions. But I think you also need to think about how can we best explain this to patients one-on-one. Patients very much rely on the trust that they feel with a physician as they work through their medical problems. And so how can we help enable that trust, but also be transparent about what really happens in the OR. Thank you very much. Morning, thanks. No, I completely agree. And I think you hit on the idea of making it absolutely clear to anybody who might be participating in that, that there is recording going on. And I think, you know, the other sort of question is, depending on the state that you're in is gonna be different flexibility with doing that recording for quality improvement anyways. In some cases it's gonna be completely available to any kind of legal action versus in other states it's very much protected. And so I think that affects how people adopt this. Concept, where residents do get together in their call room or in a work room or wherever and talk, you know, sometimes complain about patients or make joke about medical facts. I mean, I think the question was whether that's ever acceptable, whether it's acceptable if it happens in the backstage kind of component. So it sounds like what you're saying is you would potentially be taking the operating room from backstage back to front stage. So it might raise professionalism, but it might also create so much stress for the people who have to remain on stage all day that it would be worse. And I wonder what you think about if there's sort of a balance between the harms of the surgeons and the other OR staff having to be on stage all the time. I think that's one of the most important questions of this kind of idea of videoing the OR. And in fact, the primary group behind it is Taylor Granchorov out of the University of Toronto. And he's been a huge pioneer in this. And they're now beginning to disseminate and actually have out to other hospitals beyond the University of Toronto. And this gives us great opportunity of sort of assessing a pre and post state for staff. And James Jung, one of his post docs, is studying this idea of physician burnout and senses of negative effects of big brothers, so to speak. And there was a really interesting article that came out. I think it was reported by Harvard Business Review, but talking about TSA employees and the effect of constantly recording them on how they behaved at work. And so I think one of the most important questions is you don't wanna have a negative effect on the OR team. You don't wanna stress them out or you don't want people, as we've seen, performing for the camera. We've done some research on awake patients where you have an awake patient and the team knows that and asks surgeons how they change their behavior. And they obfuscated things. They sort of taught to the patient. They did other things that sort of changed the way they routinely do things in the operating room. And so I think we gotta be really careful about that potential effect. Yes, thank you. We have to cut off, all right. Are you done? Thank you so much, Dr. Langerman.