 perfectly on time so it's um uh i'm going to take the floor and it's my pleasure to introduce um my friend and our colleague from the north um sarah rodriguez who will be giving today's talk the love surgeon a story of trust harm in the limits of medical peer review sarah rodriguez an associate professor of instruction in the global health studies program in the weinberg college of arts and sciences she's a lecturer in the department of medical education at the feinberg school of medicine and a core faculty member in medical humanities and the bioethics graduate program at north western university she teaches courses in global global global bioethics international perspectives on reproductive and sexual health and in gender and global health for the global health studies program and seminars on the history of medicine the history of women in medicine the history of epidemics for medical humanities and the bioethics program she is a medical historian whose research focuses on the history of women's reproductive health the history of health care especially surgery and the history of clinical research ethics since the early 20th century and how history has framed current discourse her second book the love surgeon the story of trust harm and the limits of medical regulation is from rutgers university press her first book female circumcision and cladrodectomy in the united states a history of medical treatment was published in 2004 dr rodriguez is currently working on the history of the standard care debate regarding the 1990s trials to reduce the likelihood of vertical transmission of hiv from mother to fetus and on the history of a pisiotomy as a standard of care her next project will concern the history of international confederation of midwives and maternal health sarah earned her undergraduate degree at the university of iowa went on to to get a master's in history of science and medicine at wisconsin and earned her phd at the university of nebraska she did two postdoctoral fellowships at northwestern one in medical humanities and bioethics and the other one in the onco fertility consortium sarah is a highly sought-out educator and has taught and mentored graduate undergraduate medical students at numerous institutions including northwestern rush university of nebraska and demoine osteopathic medical center and on a personal level i can think of no area in medical history that is as dynamic interesting practical and relevant as that of gender sexuality and women's reproductive health and it's my pleasure to introduce our colleague and my friend dr sarah rodriguez to give us this fascinating talk on this topic that i promise will be an interesting lesson for all thanks sarah i'm going to turn it over to you thank you so much for that beautiful introduction i'm very humbled by it so thank you so much mendy for that introduction and thank you so much for having me speak about the love surgeon and i'm going to talk today mostly about medical peer review but also about consent and informed consent and changing ideas about informed consent to a certain degree too um oops so i'm going to start off by saying other than as mendy said i do have a book that just came out last year about this topic so that is my um that's my one disclosure for today and then two i'm just going to post briefly the learning objectives for this lecture so i'm going to start off by telling you a little bit about the love surgeon who was actually a man by the name of dr james burt dr burt was a um a physician an obstetrician gynecologist who began practicing in Dayton Ohio in the mid 1950s um and he began calling what he performed love surgery on women after they gave birth and he developed this he claims he claimed um as a variation of apesiautomy repair and he started developing what he then terms love surgery in the late 1960s through the 1970s now for those of you who don't know apesiautomy is the cut physicians made at the opening of the vagina going down we'll either directly down or um directionally down uh toward the rectum and it was done during the second phase of labor with the intention that it would open up the vaginal canal and open up the entrance of the vagina to better facilitate the birth of the baby more rapidly facilitate the birth of the baby and these were then stitched afterwards and the idea behind apesiautomy was that it was easier to repair than a tear these were incredibly common in the united states in the 50s 60s and 1970s so the fact that he was doing a variation on this and um and sewing it up wasn't the uncommon part of this necessarily what was perhaps uncommon is by around 1975 Burt begins significantly has significantly modified the apesiautomy repair and i'll show you a picture of it shortly beyond what he was now calling an apesiaum repair and he starts now calling it something different he starts calling it the love surgery and he starts offering it he had been performing it just on women who couldn't giving birth that he was delivering um but he now begins by about the mid 1970s he begins offering it as a surgical elective and this surgical elective upon for women upon whom he was not delivering a baby although he continues to perform it on his obstetric patients until probably the late 1980s we know that Burt performed love surgery until about 1987 though by the late 80s he definitely dropped down his performing of surgery in general but in specific this one and in October 1988 a group of women upon whom he performed love surgery who were suing him for malpractice accused him on cbs's primetime news show west 57th of operating on them without their informed consent uh receiving an operation that resulted in their having chronic pain chronic east infections and other infections and for some an inability to have vaginal sex after receiving this negative national exposure the ohioi state medical board charged burt with multiple violations and set up a hearing regarding his medical license under pressure from the lawsuits and now the medical board in january 1989 dr burt voluntarily surrendered his medical license and stopped practicing medicine altogether now as i know at the beginning i published a book on this story last year uh but years before this book came out um in 2013 to be exact while i was still researching this book i had an article published about dr burt that appeared in the archives of sexual behavior my abstract for this article appeared in pub med when the publication appeared in print in november 2012 jezebel which is a feminist blog picked up on my not yet published article implored from the pub med abstract so per erin rollery ryan who's the author of this blog post and was writing for jezebel um ryan latched on to part of my abstract the part concerning the local medical communities writing that quote perhaps the worst part of this story is how other doctors and medical professionals knew what dr burt was up to but did nothing and quote so ryan in addition to writing that physicians did nothing she further pulled from my abstract that initially the hospital where burt operated did not initially require him to use a consent form per ryan the hospital quote didn't require medical consent forms for the procedure for the first 12 years it was being performed and quote now ryan did not interview me for this story and obviously she didn't read the entire article because this was the pre publication abstract that she was reading um though she did nicely tagged the pub med article uh and this someone could have at some point gone and done that um she did however follow the typical reporting on james burt which has appeared in popular accounts about him since the late 1980s there was a wealth of coverage after the cbs show um in the next about six months after that october cbs show people magazine covers him and um good housekeeping covers him so there's a lot of and the new york times covers him there's a lot of sort of popular press reporting about him and she definitely follows what in particular was the sort of angle in those magazines directed primarily for women's audience and that is that women experience an experimental surgery without their consent and in particular that other doctors in the community knew about it and did nothing that they in effect abdicated their responsibility to protect them from a bad and errant doctor essentially they knew that they had a provincial around responsibility and regulating their peer and they abdicated doing so so you can see that like i said and this is a red book article and i'm sorry this is this is my those in hindsight as a historian i really should make two copies of things before i start i'm old school where i have to print it out and like highlight as you can see so in hindsight i'm wishing i would done like another copy and used a different copy for showing people but now you can see work in progress of how i was thinking about this article but indeed this was a thrust of articles like this my gynecologist butchered me um a woman's day article my gynecologist from hell this was very much the angle particular magazines directed at women and this narrative was used again by ryan 24 years after these sorts of stories appeared and i'm going to say this narrative plays really well because it sounds right it sounds correct to us but frames the burnt story as a horror story in particular any woman could experience and we can see that again this per 1989 article from red book with the title my gynecologist butchered me as well as from the beginning of a mademoiselle article that started quote this is a story about a group of women and the doctor they trusted but it could be about any of us end quote so it plays then into many fears we have regarding doctors okay in particular that doctors will do something for their own benefit that will be asleep and we won't know or we won't understand what's being done to us that we the patient won't know and this plays in a lot of fears that we have and i'm showing you this because i it's it's a couple blocks from where i live and i kept walking past it with my dog and think this plays on this sort of this this halloween display plays on that fear of not knowing and having a doctor do experiments on us or having them doing something unknown to us on our bodies that is a that is a cultural fear that this exhibit obviously plays on but more seriously that the burt so response to burt was also responding to this and this fear is compounded by the idea that doctor other doctors will know about this and do nothing to stop the errant doctor um so this then sets up some interesting questions and i'm going to say when i first entered the burt story which was a while ago when i started researching this i went and also expecting like all the things i was reading um about being published that were primary sources these newspaper articles and these journal articles and women's magazines in particular going and expecting that that's what i was going to find to that this was going to be a story of doctors abdicating their responsibility to not stop a peer who is behaving in an abhorrent manner um and as historian susan reverby has noted it's it is difficult when you're a historian to write about historical events that actually draw forth really strong emotions such as my guy in college butchered me really these really strong emotions um it's difficult to escape from this as she puts it quote this moral outrage and the stock assumptions about what had happened and quote so the stock assumption of course regarding burt has been that he was a case this was a case of a lone clinician acting outside the norms of medicine by experimenting on unsuspecting women who did not give consent while other doctors looked on that is what the burt story is supposed to be about but beyond being historically problematic framing the story in this way leads to a dead end where this frame fails to include questions the burt case does bring forth historically as well as still today including questions in particular about medical peer review and regulation and these questions still persist so in this talk i'm going to start to unpack some of these stock assumptions regarding burt in particular per ryan the stock assumptions that other doctors and medical professionals knew what dr burt was up to but did nothing that burt performed an experimental surgery out of normative bounds and that consent was not obtained instead examine the story from a more nuanced perspective or perhaps for what we call as a historically more messy perspective that it places his love surgery practice within the historical context of consent to medical procedures particularly routine hospital procedures in the 1950s through the 1970s within normative surgical development and within normative medical peer review among clinicians before considering the limits of peer oversight as illustrated by the burt case so i'm going to begin though with a little a brief overview of how burt developed love surgery and then talk a little bit more about the implications of the surgery so as an obstetrician in the 1950s burt regularly performed in epizotomy and like i already said epizotomies were incredibly common commonly practiced in this country with some hospitals reporting rates of as high as 85 percent particularly for new moms and with national rates ranging between 50 to 90 percent through the 1960s and 1970s but because the cut the epizotomy cut was made went into the vagina and a pzi repair stitched both the outer tissue on the woman's brennium as well as the immediate internal part of the vaginal tissue so stitches made during the repair could also essentially tighten the entrance to the vagina between 1954 and 1966 approximately burt began to make variations on a pzi on a repair upon his obstetrics patients adding a few more stitches to make the vaginal opening smaller and tighter and then 1966 according to burt he discovered two things first was the important role played by the clitoris in female sexual response thanks to the recently published information the recently published book by william masters in virginia johnson that it dedicated a whole chapter to the importance of the clitoris and female sexual response and pointed out it was the only organ in the human body of any human either male or female bodies that's sole purpose was sexual second addition to him breeding this research in the sixth 1960s was that according to burt his patients were telling him that they had better sexual response after birth and they did before and he claims he had not told them that he was doing anything different than a normal a pziotomy repair these discoveries then led burt to conclude that women's bodies women's bodies were not an anatomically ideal for heterosexual missionary position penetrative sex in particular burt decided the clitoris was too far from the vaginal opening for that organ to receive adequate stimulation from the penis during heterosexual missionary penetrative sex so burt began building up skin tissue between the vaginal opening and by doing so he found he moved the opening closer to the vagina closer to the clitoris and organ he also by sometime in the 1970s starts circumcising so again not removing the clitoris but removing the clitoral hood to expose the clitoris so by 1975 burt claimed to have performed love surgery in one of its various stages on more than four thousand women i'm going to say the veracity of that statement is entirely reliant upon burt saying that he did this on about four thousand women as a note though he was a very popular obi gine in Dayton Ohio so even though i can't verify that it was four thousand women the fact that he was a very popular obi gine makes me feel that it probably is within the realm of possibility that that's how many women he operate upon so in her jezebel post concerning burt ryan stated that the hospital where burt performed most of his surgeries did not provide a consent form for it for the first 12 years he practiced it meaning the years before july 1979 when the hospital began requiring a special surgical surgery specific consent form for this surgery so i'm going to return to the surgery specific consent form shortly but now i want to focus just on the issue of whether upon women where he was performing love surgery on um and whether he should have had some sort of specific informed consent before this 1979 requirement um whether there should have that should have been happening whether it had been normative for a physician to have acquired such a consent form and i'm going to say if by sort of thinking of consent as we're thinking of it now um i very much doubt that that would have been it would have been the same as a problem before then okay burt did stated that he did not tell or ask his patients he was doing anything different from a variation on a pz armor repair and that in itself is not was not something that was not not normative that in itself was actually fairly normative that burt did not ask or seek um or tell his patients he was even doing an apesia otomy would have been completely normative in the 1970s as well this was not something physicians requested permission to perform an apesia otomy for indeed the burt did not inform his patients or obtain their consent was also rather normative behavior for within medical practice from the 1950s through the 1960s and into the 1970s burt performed a pz armor repair in the hospital following birth and both the apesia otomy as well as as a repair were considered such a normative part of giving birth few would have considered the necessity of asking permission to perform an apesia otomy or asking permission to perform a repair indeed because of its routine nature this was probably true of apesia otomy apesia repair until at least the 1990s and perhaps to the turn of the 21st century back to 2006 survey revealed that of the 25 percent of women who had undergone apesia otomy 73 percent said they were not asked if they wanted one or not so apesia otomies like a good deal of medical care happening at a hospital during this time was conducted without explicit consent by the patient medical professionals essentially here speaking just of birth expected once you've come to the hospital to give birth the sort of normative routine practice of giving birth was consented to by you being at the hospital to give birth and so something like an apesia otomy was such a normative routine part of hospital care nobody was getting consent for something like that or very rarely shouldn't ever say never very rarely was a physician getting consent for something like that james burt then when he was performing his version of apesia repair through the mid 1970s would not have been out of line with normative routine parts of practice of medicine by not asking or telling his patients apesia otomies repair were routine parts of childbirth in hospital and being routine required no special attention but does it matter that as you're seeing here this was not routine apesia otomy repair this was a different thing all together he's cutting things he's moving things it was not a normal part of apesia on repair and i'm going to say does it matter that it wasn't standard i'm going to say probably not and to understand why we need to explore more how changes in surgical practice occur beginning in the mid 1950s whoops i'm sorry beginning in the mid 1950s next thing through at least the mid 1970s dr burt made variations on apesia on repair and variations on standard surgery were not uncommon during this time and he'd remain part of surgical purview it appears james burt's apesia repair however was by the mid 1970s beyond the variation of standard apesia repair based both on burt's outline of what it involved as well as the opinions of other local doctors physicians who later examined some of burt's patients so the genitals of these women look entirely different the opening of the vagina was smaller and had been moved about an inch closer to the clitoris by around 1975 then burt's apesia on repair was seen by burt as well as other physicians in the community to not be a variation but rather an innovation on a standard surgery but an innovation to a surgery does not necessarily mean that innovative surgery is an experimental surgery a surgical innovation can still be regarded as non-experimental so long as the outcome is considered to be as predictable and as beneficial as the standard surgery from which it is derived making innovations to standard surgeries was and remains an important method of improving surgical care if one patient has a better outcome following innovation the surgeon may attempt to replicate what was done on one patient in other patients following these patients outcomes to develop a case series as a means to track and evaluate innovative method one of the most valued aspects of surgery is that chance observations often become validated clinical therapies moreover surgical procedures very often become and be sorry became and become acceptable based on good outcomes from observing a series of patients many surgical innovations become part of the standard medical practice after only limited but sometimes no formal evaluation for the procedure safety or efficacy innovation through deviation from standard surgery is how surgeries improve and the monitoring of these surgeries is how often they are evaluated on whether or not the deviation is an improvement surgical bell development then has largely been experiential so at least until 1975 bird's version of a PZR repair could be considered a surgical innovation on a standard surgery the use of this new procedure perhaps warranted a discussion with his patients before the surgery informing his patients about his innovative surgery and asking whether they want to undergo it he did not do so prior to July 1979 but that he did not do so was also not unusual at this time indeed still today patients may not be told that they will be or have undergone an innovative surgery so to summarize that James Burt did not get consent for his innovation on love surgery was not and may still not be unusual and that the way he developed love surgery was also not and still is not unusual indeed one could call both normative but this does not mean that his peers were ignoring what he was doing regarding love surgery and probably a no small part his peers in Dayton Ohio especially other OB Guines and other surgeons were not ignoring it because in the 1970s Burt began talking about love surgery a lot and in public for in 1975 he decided to he decided to his applicability of his love surgery was not just limited to his obstetric patients but that actually love surgery could essentially every woman could benefit from love surgery because he regarded the female body as pathological when it came to heterosexual missionary position sex so his theory was in 1975 he should open this up to be an elective surgery because every female body actually stood to benefit from this surgery so he tries to he goes on to promote this surgery in one as you're seeing this is from the inside jacket of the book cover for a book he supposedly co-wrote with his wife Joan over though I think he just wrote it and he self published and it was called surgery of love he promote this was one of his routes of promoting the book he sent the book to the medical schools he sent it to some other physicians he knew as a way to sort of push the surgery out I'm also going to say as far as this book goes in many times as you can see from this is from the caption that ran alongside the photo Bert very much wanted himself to be seen and regard and respected as an expert on sexual health he really wanted to be essentially another William Masters in many ways so he's pushing us out there and he also in some ways has his couch just being something that is a feminist surgery at some level but this book and a lot of his writing is very much this is about the male ego and this is very much sort of a benefit not so much the woman as it is a benefit to her male partner because he very much sees as sexual responsibility lives with men and men give women orgasms so he writes this book he sends this book out he also hires a public relations from ab new york city to help him publicize love surgery in 1976 he begins offering as an elective for $1500 plus hospitalization costs Bert and his surgery were featured in both local and national print news rarely critically and broadcast media including favorable articles both in playboy and playgirl and this work apparently paid off according to Bert between 1976 and 1978 he had two women come from around the United States so we're beyond Ohio patients now around the United States to come and elect to have this surgery so perhaps if Bert had kept to performing love surgery on just as obstetric patients or perhaps if he had not been so publicly and I'm going to say aggressively for this time this was incredibly unusual at this time to be so aggressive to promote your practice like this so aggressively seeking new patients to elect for this surgery his medical periods may not have considered his altering of a standard surgical procedure as anything about which to concern themselves however Bert's apparent lack of decorum when it comes to sort of pushing his surgery out as well as increasingly his lack of selection for who should undergo the surgery in 1978 Bert himself admitted to only turning down three women for the surgery perhaps if he'd contained that it would not have aroused the concern of his peers by 1976 the case that apparently really aroused the local peers his peers in Dayton Ohio was apparently one a handful of obstetricians had seen what prompted them to what prompted this handful of obstetricians to act it was the case of a 19 year old woman who had been married for about a year who weighed less than 100 pounds and whom Bert had scheduled for love surgery speaking anonymously with a reporter in this article from 1978 about this case one of the concerned physicians stated that it was quote inconceivable that this operation is recommended for women who plan to have babies and quote the young woman scheduled for surgery the anonymous doctor recalled was young quote young timid and she thought and he Bert made her believe she was sexually inadequate because she couldn't climax at the exact same time as her husband and quote like this particular woman young woman the doctor went on to say quote women who think they're inadequate are very susceptible and quote after telling the young woman that love surgery should not have been recommended the physician was able to convince her as to cancel the surgery as well as convinced her to write a letter to the Montgomery County Medical Society as well as the hospital where Bert um exclusively operated because it was the only one that actually at that point let him have full surgical privileges St. Elizabeth Medical Center the physician then added her own letter and those of several others regarding Bert's non-selective use and aggressive pushing of love surgery so in response the county medical society looked into love surgery including by asking the dean of Wright State University's medical school to read the book and I will just say he does not have kind words for the book and his evaluation of it so in parts they start evaluating love surgery in part by having read the book and in July 1978 they decide to label it as quote undocumented by ordinary standards of scientific reporting and a not generally gynecologically acceptable procedure end quote the results of which quote had not been duplicated by physicians and which had only been described in non-scientific literature end quote the society sent this statement to local hospitals including St. Elizabeth's the only hospital again where Bert had full privileges but Bert was already on the radar so to speak of St. Ease which is how it was called how it was known locally or at least those physicians on the tissue committee the hospital committee of responsible for evaluating post-surgical the post-surgical outcomes and when it came to Bert this committee was concerned and not just because of love surgery Bert was also using D and C on young girls on 13 and 12 year olds so they were already and he was because he suspected cancer and for various other they were already concerned about some of his surgical practices so in addition to love surgery there the tissue committee had other concerns about his surgical practices so perhaps then under pressure from the local medical society and a few alarmed physicians including those on the tissue committee St. Ease began to examine Bert's use of love surgery as well I don't have to go I don't have time to go into the back and forth between the tissue committee and Dr. Bert but let's just say Dr. Bert was not pleased that the tissue committee he felt was harassing him so in summary though the tissue committee requested that Bert conduct a scientific study of love surgery to document that it as he claimed benefited women so with the help of a local psychiatrist Arthur Shram Bert conducted a word association questionnaire that women took before and then after love surgery to document love surgeries positive effects on the female psyche I'm going to say one of the questions he was asking and one of the questions he found that there was a benefit was husbands hit their wives less after they'd had this surgery was one of the things he was showing as a benefit so was a word association questionnaire with the executive committee then and the tissue committee at St. Ease was looking for to provide evidence regarding Bert's claim that this surgery was beneficial the record available and I'm going to say that's what's publicly available because of lawsuits which is why I have so much of this information because a number of women sued and went all the way the Ohio State Supreme Court and so all of those documents were preserved then by the court what happens after that actually sadly is not preserved by those sorts of records so it's unclear whether the information from this questionnaire that Bert was giving his patients was enough for the tissue committee to settle their concerns but anecdotally from other things I've found it does not appear that that was truly satisfying for the tissue committee and they kept sort of looking at his work through the 1980s so perhaps not satisfied with the evidence produced from the word association method or perhaps an effort to appease both Bert and his critics in July 1979 St. Ease told Bert to provide quote scientific statistical documentation the results of your procedure represented by a sequential listing of cases over a period of four years in addition St. Ease informed Bert he must use a special consent form to be signed before women underwent surgery here here called female coital area reconstruction and this again this is the letter saying requesting him to use a special consent form the consent form appears largely derived from the statement issued a year earlier by the county medical society and it read dear this is how what you're supposed this is the consent form part dear patient the executive committee the medical staff of st. Elizabeth medical center wishes you wishes to inform you that female coital area reconstruction surgery you're about to undergo is not documented by ordinary standards of scientific reporting and publication not a generally acceptable procedure accepted procedure as yet not duplicated by other investigations detailed only a nine scientific literature and that you should be informed the executive committee the medical staff considers the aforementioned procedure an unproven non-standard practice of gynecology Bert then begins using the special consent form and also begins to accumulate the information desired by the executive committee Bert too sees a benefit in this gathering of information because it would provide him he felt with further research research to show the benefits of love surgery however Bert also saw the insistence for this documentation for what it was as well which is a form of peer oversight one to indicate a lack of trust in his medical judgment and one that he very much vocally resented so the stock assumptions regarding this case that Bert performed love surgery without consent performed experimental surgery on women or that his date and peers abdicated their responsibility by not stopping him do not fully explain what happened in this case indeed the stock assumptions turn out in many ways to be historically wrong or at least lacking appreciation of the messiness of history as I have briefly outlined here there are a variety of actions his peers took and did take ones that constrained in some ways and contained his practice of medicine local peers disagreed for example with his recommendations for surgery of individual women the county medical society issued a statement against it the tissue committee of the hospital where he worked made him both collect data as well as use a very not common surgery specific consent form all of which are forms of medical peer review of medical oversight in some ways then medical peer review of Bert worked if by worked we mean that physicians brought their concerns forward in the expected manner they told each other their concerns they didn't recommend patients to go to James Bert they raise issues with relevant committees and societies they issued a statement critical of an elective surgery they insist on a special consent form regarding surgery as well as data to confirm the surgery did what Bert was claiming it would do but it was the former patients those women who sued Bert for medical non-practice who went on national television to tell their story when the local medical society went to the state medical society was not listening to their concerns who spoke to the local press it was the actions of former patients not doctors and Dayton who forced the Ohio State Medical Board to act so it's a pressure place in the state board from the general public not Bert's peers that ultimately resulted in Bert being forced to give up his license his right to practice medicine in early 1989 so medicine enjoys a great deal of professional autonomy and with understanding with the understanding that it will self-regulate but in the Bert case as is often today its patients or the general public were the ones to raise a complaint against a physician for professional misconduct rather than another physician indeed one recent study found that 66% of complaints originated from the general public compared with only 5% from physicians the Bert story then illustrates this continuing limitation and continuing problem regarding medical regulation and medical peer review so thank you stop sharing so I can see more people yeah thank you Sarah that was a fascinating talk I am sure there are plenty of questions because that it just unravels a whole bunch of interesting sequelae there and that's a really fascinating story I want to give time let me let Luke take the floor since he had his hand up and I'm going to mute while he asks whatever he is interested in thanks I was really interesting one question I have for you is here and there we'll do a delivery a labor delivery and a patient will ask for an enhancing procedure and it's not known as a love procedure but I've heard it in different names and one I think Dr. Kaur not in your head but I've heard of the husband stitch before so how would you handle one you deliver to baby 50% time the first time mom there will be a pair and you're doing a standard repair and the patient will look at you and say can you do a quick husband stitch all right so the woman's asking for the husband stitch I've had that will happen one time I'm not sure Dr. Kaur has had differently but the woman looks at you and says can you please place the husband stitch okay so I actually have a I'm working actually on a history of the husband stitch which is why I'm curious you're saying the woman was saying that because oftentimes it's coming like it's the husband saying would you put in some extra stitches wink wink nudge nudge more commonly it is and I you know I've heard more commonly yes you're right but it's done usually as a joke it's not a very good joke mobile say something like that which I just kind of wouldn't ignore but when the woman says that how do you handle it how to handle it so I guess one could be do you I mean so briefly my read on the husband stitch as a concept because it doesn't it's never medically described right nobody's sort of physically like I've done a study on the husband stitch but it's it comes from a critique that particularly feminist health activists in the 1970s were talking about episiotomy and episioraric repair not shouldn't be routine and it was routine like I said it was there were hospitals with 90% rates for episium episiarum repair in the 1970s so the critique was it's it shouldn't be routine that critique then moves to saying there's something particularly sexist about this procedure and then it's meant to sort of enhance male sexual response that that's really why the underlying sort of insidious reason that physicians male physicians because it's largely male obis in the 70s male physicians are doing this procedure not for the benefit of the woman or the baby but for her presumed male partner so that this has been stitches supposedly like an extra stitch or so in the psian repair there's no real if for evidence we're looking for like again a physician writing about like I've been doing extra stitches and this is the outcome that doesn't appear to exist but to me it's the critique of a psian repair is being not about the woman but about the man that makes it um that's the power of calling it the husband stitch which is why I was saying it's interesting that's the woman because typically it's been a critique of it as being this isn't about my body this is about someone else's sexual response that you're using my body to like achieve that end um I so I suppose I know I've read where doctors like it doesn't exist it's not a real thing this is it's an apesian repair or repair on the tear yeah and I suppose it goes back to you of saying does it actually do anything to say like if I give you one more stitch or I know other doctors I've spoken with are like there's it doesn't really make sense because it's not like you're like adding another stitch it's one sort of movement of stitching so conceptually but I'm gonna stop there does that kind of answer what you're going to say to her I suppose it would my question would be like why um I suppose it goes back to the fear of the other the parallel fear of that vaginas are supposed to be a certain way like they're supposed to be tighter as opposed to thinking the organ is a it's an adjustable organ like it's not a static organ it doesn't just stay that's why it can deliver a baby with the head decided to a bowling ball it can expand to that so it also can contract but I think that's I mean there's this is a very big like what role does cosmetic gynecology have in the field I mean like labia plasties and it's a very lucrative thing and and and I have known very well in intending your gynecologists like just have made this career over doing things and I think that it's fascinating and I think that your gynecology for example novel field and that it's more recent but they have developed like informed consents over this over these procedures and and now he has something called the Mona Lisa which is designed to help general urinary symptoms of menohaws so really kind of marketing kind of women's health as a as more of a cosmetic aesthetic looking field and so I think that it's an interesting thing when of course like I don't think anyone would think Dr. Burke a general mutilation like there's no question about that in my opinion but I think it's the harder question is what it and when this is self requested so I go back though to and I will say there were some a group of physicians were in Dayton Ohio that then go on and write a book about labia plasty and in their book they literally say this is not love surgery so there's obviously some sort of referencing back to James Burke he's not like the he's not a complete outlier that he is his name and what he did wasn't completely that said I've not found anyone claiming they're doing love surgery it doesn't appear to have ever taken off and in his form but to what you're saying to me I draw a parallel with Bert and that both sort of genital surgeries today as well as then both have a conceptualization of there being a correct female body and that surgery can get you a and that's a one sort of correct female body like this is how female bodies are supposed to be which was very much sort of James Burke's idea I mean his whole it was female body female bodies were pathological and he actually calls them pathological in his book so in the same sense of saying surgery can make you better because your body is not correct and I see that as the continuation from James Burke with the current labia plasty. Okay I'm going to open it up to Peggy I'm Sarah I'm glad that you um ended the talk early enough to answer the questions because this is obviously a very uh fascinating area with a lot of um interesting discussion so I'm going to let Peggy take it away so we can get to everything. Um if Julie if you have a follow-up to Luke's question I'm happy to cede to you and then come back to me. Um it's really a bit different so no I'll hold. Okay so so I have two questions the first is I'm just curious um your I don't know rhetorical choice shall we say about to decide to call these things the love surgery and the love doctor and um how you thought about I'm you know I'm sure you thought about that so I'm curious how you came to that and then I have one other question. So I'm using love surgery and love doctor because that's what he called himself. He went on radio shows calling himself the love surgeon or the love doctor his book was called surgery of love he marketed as surgery of love so I'm I am purely running with his own um words not as an endorsement but just to say like I'm using them as how he this is this was his phrasing. Okay I mean it seems it seems a peculiar um amount of uh easily to easily assumed endorsement I mean obviously once somebody starts to read they they don't they see things differently but okay um the the other comment is is it's so interesting to me how this uh in many ways parallels the lobotomy surgery. So lobotomy is is a little different um in a couple ways one is that you know it was it was touted with um probably not current uh standards of of data but it was touted enough that it won um monies the Nobel Prize uh and then it got used by Walter Freeman in a way that um so it was touted or was invented as the leucotomy by monies and then used as the lobotomy by Walter Freeman and Walter Freeman had many of the same characteristics that you're saying about Burt he was aggressive about doing this he was unselective um and what was the third one uh oh yeah he had a complete lack of decorum um you know he was doing this in buses and inappropriate places um and and there it the the patients themselves were actually incapacitated to make a case for themselves so they couldn't um to a certain extent that people around them did um but do you have any thoughts about the parallels there uh it it doesn't have the sex you know the sexism thread um it has a little bit of a thread of I don't know disabilityism um any thoughts there so I'm unfamiliar with the case you're referring to so did did patients come to him or is this that he was saying like oh well he he he went all over the place he went to people that were vulnerable um in facilities um and just did lobotomies on them um he there's a great book by Howard Dully about called my lobotomy he was a about a 13-year-old kid when his stepmother was annoyed with him and um arranged for Freeman to do a lobotomy in the in the doctor's office um he did it with an ice pick it it's it's a it's a gruesome story but it has it has much of the same feel as the Burt story where it there's a there's a way that you could construe it as coming out of science at least at at the start and then all held bricks loose and it's um it can no longer be construed as for the good of anyone so I guess the one sort of and I agree they're not exact links other than sort of thinking that both I'm going to say the person you're speaking of and Burt both fundamentally believed in what they were doing as being something that was actually for the good of the patients and then it sounds like what the person you're speaking of and I'll say with the doctors and Dayton right nobody picks up this surgery as far as I can tell which is another form of peer review right if if the surgery appears to be working one of the sort of scientific process when you talk about a surgery or other clinical forms of care is to say like oh I agree with what you're doing and I see the good outcomes and I don't know about your doctor but I think also obviously it depends we know it depends on who the physician is like if you're a noted sort of person who's respected and well published and high up in their career you'll probably be given a little bit more cushion than if you will if you're somebody who Burt was notoriously uh not good with communicating with his fellow doctors like he was he notoriously wasn't good at sort of committee meetings like if he had been a different persona maybe love surgery we've taken off among them because he would have been seen as a trusted peer so for Burt at least part of the wall he put up himself in some ways by not being a trusted peer but to loop back to the scientific process at least with surgery and other clinical care that starts in the clinical encounter sometimes the process is again right that that works and other people pick it up and or that uh that doesn't seem to make any sense so nobody else is going to pick up what you're doing and that again is another form of peer review of saying and maybe the lobotomy too at some level does go that route too right I think yeah it's a slightly different thing because leucotomy was being used everywhere including by all the academic centers it just won the Nobel Prize yeah Fulton for example is a very famous neurosurgeon and he was doing an right left and center at Yale but he was doing a leucotomy in sterile situation blah blah blah I I think it would be interesting for you to see and compare those histories it's it's just um it's striking how parallel they are it does go then too bad then we can write that sometimes it won't because this is one of the doctors I interviewed for for this book told me and I took it to heart when he said you know sometimes it takes a while to figure out that something's not working or you have to see several patients before you're making the link to say like this is what's wrong but you have to someone else has to look at those patients so obviously there's a difference between lobotomy which was being used much more widespread than something like love surgery they both have their problems because one becomes accepted wide really fast before then people are like and really widely before somebody's like hold on we need to look at the data or is this the best idea sometimes it's going to happen earlier like with the case of Burt it still takes a long time but it's largely contained if you will within one city so it to me is just for the and I think for especially and I will say this too I wanted this story being like why didn't doctors do more quickly and went out thinking at a certain level it went as fast as it could have like that but that at the end you still have patients that are suffering you still have decades of patients saying like I was harmed I can't have vaginal sex I have constant infections like I'm embarrassed about my body like that this they're never that hurt is never going to go away so it's just it's just I find it to be and I don't know how to rectify tension I have one idea actually but I rectify this tension of how do you how do you sort of how do you gather data more quickly essentially for something like this to ensure that fewer patients are harmed by it and the lobotomies a different words it seems right away like oh this is brilliant everyone's like this is a good idea it seems to work it gets taken up really quickly in a way that's an opposite problem of how do you take something that's seen as normative medicine and it's a standard of care and pull that back and say okay there's no good evidence to show that we should be doing this and that in itself can take a long time I just taught on um little mind de s and right there's a paper in 1953 I think about de s of being like it's not preventing miscarriages stop using it it doesn't get stopped being used until 71 so there's a 20 year gap between literally there's like there is no evidence stop using this and physicians then being told by the FDA don't do not prescribe this drug for oh and you're you're muted Peggy oh it got stopped being used because of Francis Kelsey from who was a graduate of new Chicago yeah a little I did yeah yeah that's right um I mean I think I I'm gonna stop talking but the one thing I would say is that be very very suspicious of things that make a lot of sense um things that out make a lot of sense can go like wildfire and they they don't necessarily deserve to sounds great I'm gonna turn the floor over to Tarek yes so my question would be is more from me like a policy standpoint that from a procedure or surgery standpoint unlike medication and devices there's no control anyone can do anything and also even you bring the point of informed consent that doesn't work because patient doesn't know enough and that will not save anyone from doing that all over again so the question will be do we need issues similar to obliques or teachers or even policemen there's it's one to one interaction and it's always here say he said she said it never gets settled and just like there's a blue wall of silence maybe the white wall of silence people don't complain so do we need number one a more documentation more like a webcam when people or patient in a physician interact do we need to record all the procedures I can tell you that the surgery that's being done is not that well documented because all dot phrases now they all chip in few words and looks like it looks same and it goes to the same point that the complication one surgeon has even though it's an established surgery is not going to be the same when the other surgeon does because it's a skill thing so that consent doesn't work anyway consent that's documented in the tertiary center or a control trial done by experienced surgeon is not going to be the same who's fresh out so my point would be basically should there be a different speak a program like anonymous where physicians because again nurses are working with them nobody complained look forget the physicians even nurses working with the that surgeon did not complain so the question would be just like ntsb do all everyone need to be audited by independent person not employed by the hospital who have vested interest and keep making the money and should all surgeon physicians should carry a credit rating how much complications they are carrying along with all the surgeries they do which should be public knowledge so patient can access it does nothing change we are not changing the system no point giving anecdotes if you're not changing the system so what's the way forward thank you I was thinking while you were saying this about the informed consent and in the late 1970s I'm blanking on you said this but there was an article I think it was in JAMA where one person said there's no FDA for surgery for your point right there's no sort of you don't and put your point also it matters your skill set on how well you did the surgery which is the point that there's no FDA for surgery it's really difficult to do a surgical evaluation if you've got a variation of skill sets of surgeons or experience or length of doing the surgery to actually give a or bodies because obviously people's bodies can be radically different and you might have to make an adjustment in surgery because of somebody's body so all of that said um I think the issue of informed consent and speaking first about Burt and then more broadly 20 points to me the informed consent form that they used for James Burt was cop out by the hospital I'll put it that way I did learn this from my father who used to be a trial attorney that a consent form at that level in that era was really rare like having something be that consent specific to a surgery like that was not a common thing for hospitals to do and he used to represent hospitals um so to say then that they gave an informed consent unless you know that it matters that it's not been documented in scientific literature and your doctor who you trust is standing there saying you should form this you're not going to say like I mean maybe he could just say like it's haven't published yet right so a lot of times is the bottom line of this it's trust in the physician that the consent form is kind of with that right if I don't have consent I don't have trust in the physician no man of informed consent forms necessarily are going to change whether or not I want to do the surgery or not to one point to your second point Tark I would say um this was suggested to me by somebody or one thing I've given I did a um an obstetrics fellowship program they read my book and then we had a book club meeting about the book and a lot of them were then saying you know do I have to tell my I've thought about this a lot do I tell my patients that I'm using a different type of method for stitching them up is that a different surgery then like how do how do I sort of explain if it's maybe maybe what's different enough to actually say like I need to get a consent for this because it's different enough from what is standard and then even thinking what is standard when we talk about surgery so I recognize all the complexities of that per year sort of how do physicians then go about trying to say like this is this is uncomfortable for me I think this is really beyond standard or and someone else suggested this to me so I'm not going to take credit here I shouldn't be up to the individual doctors there should be some as you're saying like outside entity or there should be somewhere the physician then says to maybe their um their employer their hospital or their university and says I am concerned about X and then the institution is the one who then goes for it so the physician doesn't have to be in the process or position because there might be saying like when we this is just how this doctor does it this they get a good result it takes out the physician some of the responsibility to be there and it goes to an institution and that institution that would talk to the other person's institution so in a way maybe like I suggested to me maybe this would reduce some of or actually up the reporting by physicians if they're concerned about a surgery or a or surgery specifically but obviously out of competence levels as well with people performing things I just want to say one thing is that we're going to have a couple of other subsequent lectures um Peter Angelos is going to talk about the role of surgical ethics in the history of surgery and in a few weeks we're going to have Shelley McKellar talking about last resort sentiments so I think those are really interesting and important questions about just you know surgical technique and surgical experimentation and how do you do that in a meaningful way and we're not even get oh there's Peter he's you know just giving a shout out to him but I wanted to finish up I want to make sure Julie and Carolyn get to talk because they were waiting and I'm interested in hearing the view from the guy to call it the OB Guiney so yeah hi thank you so much I am an OBGYN on faculty at the McLean Center two little quick tidbits one is um Thalidomide is linked to has a U Chicago connection as does DES and Arthur Herbst our former department chair was instrumental in identifying the association between DES and um cervical vaginal cancer so um that's another connection and then um as you were describing um the surgeries and essentially including the husband stitch um it brought me back a little PTSD from residency and I was a resident from 2004 to 2008 and I will say just anecdotally um one of the most shocking uh experiences of my residency training was having a female um attending um who still routinely did episiotomies routinely did enemas and routinely talked about the husband stitch um and so um that was certainly fading out of favor but um there are still there at least were some holdouts in 2004 through eight and and I wouldn't be surprised if there were some to this day um but my kind of larger comment is that I do a lot of work um around pelvic examinations and I do see your work is kind of falling into the broader context also of consent around just pelvic care in general and also um linking to um you know the recent cases that have come out of Michigan State um and uh what was it USC um of disclosures of of physicians gynecologists um sports medicine um physicians um and they're uh doing examinations without consent um uh around the genitalia and I think that there is kind of this broader context I I do think it's different than um I understand some parallels to the um lobotomy but I also see that this is is quite distinct in terms of the um kind of the the space around um uh female genitalia but yeah I was just curious to see what your thoughts are kind of in terms of contextualizing the love surgery and and kind of the the um the secrecy around that and kind of the response to the exposure of that um within the broader context of um of pelvic exams and pelvic care so two things quickly with the pzi memory so it's not until 2006 that ACOG says it shouldn't be routine and the fact that there it's still being performed wouldn't it's kind of makes sense and that it's not until 2006 ACOG is like nope no more routine and that's after multiple studies in particularly there was a JAMA 2005 um uh meta-analysis that was like this isn't this is actually potentially resulting in worse tears yeah um to your other uh I will say um one of the one of the the Michigan State I've actually made comparison to the MSU case in part because the comparison because it's actually reporters who are the it's the women coming forward and saying this is this is happening this is a problem and it's the press that finally are the ones like believing them and I see that in the Burt case of saying and originally the local press was very um oh he's amazing the surgery is amazing and then it becomes more of um I'm gonna say believing and sort of discussing this as uh a less sort of this is a great idea um focus point here being it profoundly concerns me as not just a historian but as a person to think that the local press is being eroded because they are another form of pure of medical regulation I mean it's not just doctors that do medical regulation as I've noted right this is patients also saying and per TARC I think brought up nurses they were actually nurses some nurses quit over what Burt was doing um but they had a lot less power in the 1970s in the hospital situation uh so it's there are there are other voices essentially if you will um and I think the press is one of them and going back to the MSU case and the exposure of one it's women coming forward and saying I was not asked if this could be done and I didn't want it to be done and then second also then saying the press actually saying I believe what you're saying and this should get more attention than it's been getting so far I think there's also a failure on our parts as um healthcare providers to educate our patients about what is and is not necessary appropriate um right a lot of people probably in the in the um Burt case didn't know that this was not the norm or was not um necessary um and the same could be said um about a lot of the victims in Michigan state and other places so I think that we as healthcare providers need to do a much better job of educating our patients around public health and um and consent as well yeah and and also feeling comfortable to talk about those issues too which to me is one of the I find one well there's many points the Burt case I find to be distressing but one is a lot of these women were unclear that something had radically changed about them and and and they kind of blame themselves like oh I'm just not recovering well from the surgery or to serve self-blame as opposed to saying like maybe it went how he thought it was supposed to go but it actually I'm I'm having some pretty severe um I mean like I said that a lot of these women are having repeat infections and pain and yeah so not trusting their own bodies essentially I'm not knowing about their own bodies but thank you so much this is such interesting work thank you thank you Carolin you have the floor thank you yeah thanks so much for this talk I was just thinking about this idea you've repeated a few times about um how physicians should be able or be encouraged to kind of come forward more often when they see a problem so I wondered how your research intersects with like evaluations of whistleblower mechanisms and institutions and even in societies um I mean it strikes me as in a medical context that that might actually be more important really than the local press just given the kind of you know sensitive nature of some of these issues I'm just curious about that work so only in the limited area I'm going to say one of the things I did for my conclusion of my book was look and see like how are how are what's the sort of mechanisms education-wise for training doctors to say if I see something I'm supposed to say something and I get that that's uncomfortable because you might not be sure that what I saw was actually what I think it was or this person's higher up than I am and they know more than I do like I totally respect that this is not an easy process um and or that you could have a lot of doubt about maybe you know being unclear that maybe you don't have enough information I totally respect all of that I'm also going to point out when sort of this is essentially taught many places and I'm just going to use the um the blanking on the name but it's the federal sort of board of all medical um state medical boards and I'm sorry I'm blanking on what their name is um but the federal society of all state medical boards on their website where they essentially have anything in there they've got a couple of sort of learning activities and the only mention of this of sort of malpractice or concern is essentially like you student your responsibilities to not perform it there's nothing about my responsibility as a physician as part of peer review right that's why physicians get to self-regulate is the expectation that they will self-regulate there's nothing about that responsibility and I really don't think that's taught enough like that there is a responsibility um and in two or about maybe 10 years ago there was some talk um of concern it was about 2008 because physicians were making the same sort of statements of saying okay with the banking failure right the feds were coming in saying we need better regulation there was physician talk about maybe we're going to if we don't clean up our acts so to speak quote unquote the feds are going to come in and start to regulate us and we don't want that to happen so maybe we need to have better mechanisms in place yeah okay before i do tim it's the federation of state medical board thank you thank you like i only wrote about it for how long and i'm like i'm totally blanking on the name we all have those tim you're on deck hi hey thank you thanks so much for a fantastic talk you can tell it was fantastic because you've unraveled so many different problems in the healthcare system and i come at it from the perspective of a surgeon and a large health system chief medical officer you know executive type and system problems do really lie at the bottom of a lot of this and one of the um one of the issues in today's world would be the strength of the independent medical staff at a hospital and if you have a strong independent medical staff then all of like what trich was talking about doing quality assurance and that sort of thing happens actually in a relatively robust manner now that there's an electronic medical record and you can sort of collect all that data relatively easily um you know when medical staffs are small and insular um then it becomes difficult because it might be your partner who you are doing um peer review on and that that becomes really problematic but that's the that's the system that's been set up you know and it failed these women i i think incredibly and my question is to what degree do you impugn the medical staff and failing to perform their duties and it seems as though they really kind of didn't care until he started advertising and getting in their pocketbook and is that too too easy of a jump for me to make and then lastly i want to um lay out an aphorism uh that pathologists who were the tissue committee basically pathologists know everything but um uh too late so they actually kind of it sounds like they save the they save the day because pathologists see everything that happens uh in a hospital thanks so much fantastic thank you and i'm gonna i am actually going to say i think some of the slower response from local physicians had more to do with the fact that burt i mentioned he was really popular he promised pain-free births he was still kind of i was from what i can tell doing twilight sleep but to some level or his variation on twilight sleep so he was promising pain-free memory free births essentially so a lot of women were attracted to that and did go to him he was sort of popular it was popular um but he also then when the women who he was performing love surgery on them would come to him and say like some women did say like hey i'm having pain or i have an infection so he prescribed something or he would also tell them you can't you should not go to another doctor because they don't understand what i my practice um they'll mess it up so he also had a i'm gonna say a um carrot stick approach for lack of a better right he was very sort of nurturing and caring but also was really able to scare a lot of these women and to think they shouldn't see someone else so i'm saying is there's a gap of time essentially a lot of these women stuck with him until some of them were just like i'm no i don't believe you or i'm tired you're i'm not getting better so they would go to another doctor well then other doctors have to see other patients and have to say like the pattern with this is this surgery so i kind of think some of its time but also to your point tim some of it's also some of the women recall Burt or when they go to another doctor doctors and date and say like oh you've been to Burt and kind of leave it as that so there was also kind of a like a i'm not going to go down the route um or there was also kind of like a ha ha nudge nudge he's really hyper interested in sex and he made that incredibly clear a doctor sort of events that he was he wanted to be a sexual guru he wore pink safari suits and he had like red lip couch in his office i mean he was very sort of like look at me i'm um he had swim parties in his pool without swimsuits i mean he was really trying to be like a certain persona in the 1970s um so that said some doctors and were just like oh it's kind of harmless ha ha this is just his obsession but some then obviously did start saying this is a problem i'm going to say the physician who then does actually first say like to that young woman she was a resident so that was the one to say i don't think you should have this surgery so it does start then happening of people saying like okay i'm hearing about this but to my point being sometimes it just takes time and i think that for Burt and i get that for now too like something you have to see a pattern there has to be a pattern that you're seeing before you can maybe say like the pattern is leading here and i see what the problem is okay sarah we're going to have the last question from scott moses so we can give you a few minutes of downtime after this just take a bathroom break so i'm going to let scott take it away thanks sarah i one of the things that i've always loved about your work is the way in which your description of the extraordinary and medical history in general will help us to potentially deal with the ordinary so in your assessment now how would you like us to do the ordinary what is appropriate consent either during the pregnancy or at the time of the delivery when we're doing a repair and dovetailing with that question in what ways do we want reproductive health care or you know i have always toyed with this notion of like what is a vulnerable exam like isn't all health care about vulnerable exams and do we do we wish as people who are interested in this field to think that this is in fact so generous or is it really like every other patient physician encounter um so i think part of it is to me consent i i find consent sort of that like the form with the with the hospital source i hear you need to sign this um to have abdicating the responsibility and that consent is a longer process and that i think too often now we sort of fallen on the paper form of consent as opposed to thinking this is a discussion i also think there's been too much pressure like if i consent it's okay versus the principle of beneficence or non maleficence and saying there's also these sorts of principles as a physician saying i'm going to have a conversation with you about this that these are your options and i realize sometimes that's not a viable option but to say as a sort of working standard of saying of having the patient feel more like a participant or and having sort of a larger conversation about issues and i get that there's a whole host of concerns like limited time and with a patient and but to have it be this would be my one quick answer to it scott of saying there needs to be a larger discussion because at least for me for the burt case and other cases too i think some of it is is an assumption or an assumption that there doesn't need to be a conversation um or that there hasn't been a conversation um and that that and going back to julie's point of sort of educating and conversing but also respecting the patient as being an equal participant now obviously if i go to the doctor i tell my students this all the time it's like i go to the i someone else has done my taxes for 25 years i literally can't tell you because i go to him i trust him he i could end up next year with the you know the feds coming at me and being like you've been but i trust him as the expert right and i'm paying him as the expert so i also get there's a there's part of me if i'm at the doctor i'm in your office because i don't know and i'm probably scared so then also how do you work in a conversation with someone to help them understand their bodies to help them understand their options to help them understand they have choices because hopefully they do have some choices and it's a it's not necessarily a one-time conversation but a continuing conversation and i also get you know you have to have a regular doctor and you have i mean there's so this is in a way sort of expanding out medicine i suppose too yeah sorry but thank you very much for for your first comments i really appreciate them because one of my goals is to say like history does help us think about what's going on now so so i just want to thank you personally sarin give you a little downtime before you come back and meet with the fellows and say that was an outstanding talk and i'm so glad that you gave it because you definitely uh not woke up this group because this is a very dynamic group but clearly got the best out of a group of terrific you know scholars and colleagues and i really appreciate it so thank you very much we'll give you a little downtime before the next session well thank you so much for having me i this was lovely so thank you