 Good afternoon and welcome to the 25th anniversary of the Lowell T. Kageshaw lecture. It is my great pleasure to introduce you, first of all, to this lecture and secondly to our lecturer. This lecture, as you can tell from the title, is a lectureship in honor of Dr. Kageshaw, who we will have an opportunity to hear more about from today's speaker. But Dr. Kageshaw, in addition to having served as chairman of our Department of Medicine, spent more than a decade serving as Dean of the Division of Biological Sciences. It was during that period of time when Dr. Kageshaw became known as the Dean of Deans. And he was invited by the Association of American Medical Colleges to chair what became a blue ribbon panel to outline the future of American medical education in this country. And so in 1965, with the support of the Association of American Medical Colleges and a grant from the Commonwealth Fund, Dr. Kageshaw penned a very seminal report in medical education entitled, Planning for Medical Progress through Education. In 1965, when that report was published, there was a second year medical student at the Pritzker School of Medicine named Dr. Mark Siegler, not yet a physician, but an honors graduate of Princeton University. Dr. Siegler would go on to graduate from the Pritzker School of Medicine and complete a residency and chief residency in our Department of Medicine. That was then followed by a one year stint in London, England at Hammersmith Hospital where he served as honorary senior registrar in medicine. Fourteen years later, after his initial appointment as Instructor of Medicine, he rose through the academic ranks to become Professor of Medicine. And since 2000, he has served as the Lindy Bergman Distinguished Service Professor of Medicine and Surgery. Dr. Siegler's first decade as a member of our faculty included him serving in many jobs simultaneously. He was the director of one of two inpatient general medicine services. He was the director of the Medical Intensive Care Unit of the Medical Consult Service. He was the acting chief of general internal medicine and he was the director of clinical ethics. In addition to his robust clinical service, Dr. Siegler was also a very active and engaged teacher. During the decade from 1982 to 1992, he was the director of the history taking and physical diagnosis course, a course in which I was the student sitting in the classroom with Dr. Siegler as my teacher. In 1991, he took over the directorship of the doctor-patient relationship course, a course that he continues to serve as co-director today with Dr. David Rubin. And in 2014, one year ago, he invented a brand new course through his work with the Bucksbaum Institute on becoming a doctor. In 2011, Dr. Siegler became the founding executive director of the Bucksbaum Institute for Clinical Excellence after a $42 million gift was given by the Matthew and Carolyn Bucksbaum Family Foundation. And 30 years ago, in 1984, the University of Chicago established the McLean Center for Clinical Medical Ethics. Today, this center is the largest clinical ethics program in the world, having trained more than 300 physicians and other health professionals. It has trained the directors of many clinical ethics programs around the world, including centers throughout the United States and in Canada, Europe and China. In 2013, the McLean Center received the Cornerstone Award from the American Society of Bioethics and Humanities for outstanding contributions from an institution that has shaped the field of bioethics. In addition to Dr. Siegler's very active and busy clinical schedule, he continues to be an avid writer. His textbook, Clinical Ethics, A Practical Approach to Ethical Decisions in Clinical Medicine, is now in its eighth edition, having been translated into nine languages. In addition to that textbook, he has written four other books, he has authored 50 book chapters and more than 200 journal articles. In fact, it would be a lecture in itself for me to detail the many papers that Dr. Siegler has authored, covering a vast array of topics in medicine and in medical education. But for the purposes of today, I will highlight only one, a paper published in 1992 in the journal Academic Medicine. That paper entitled, The Future of American Medical Education, The Legacy of Lowell T. Kageshaw. And so I think it is only fitting and appropriate that there is one man whose name is associated with clinical medical ethics in the world. There are many fine bioethicists who come from the fields of philosophy, law, political science, sociology, religion, among many other fields. But there is only one name associated with clinical medical ethics who is a physician. Please join me in welcoming Dr. Mark Siegler, who will speak on 50 extraordinary years at the University of Chicago and the development of clinical medical ethics. That's an impossible introduction to live up to, Holly. Thank you. I want to begin by thanking Dean Polanski. Can you hear me up there in the back? Good. Dean Polanski and Dean Holly Humphrey and Dr. Everett Vokes for inviting me to present the 25th Lowell T. Kageshaw Memorial Lecture. This lecture focuses on medical education and recognizes Dean Lowell Kageshaw's many great contributions to medical education. The title of the lecture is the one that Holly told you 50 extraordinary years at the University and the development of clinical medical ethics. I want to begin by also thanking Dean Kageshaw's three children for coming today. They've traveled from Massachusetts, California, and Texas to be here and I deeply appreciate your coming and your wonderful support of this lecture ship over the past 25 years. I ask the audience to join me in recognizing Carol Govan, Diane Zink, and Dr. Richard Kageshaw. I'm also delighted that two of our four children, Dylan and Allison, are able to be here. My wife Anna and Nicole Duchenne, thank you all very much for coming. My remarks today will cover these three topics. I will begin by talking about the history of the medical school and the biological sciences division and by examining the contributions of two important leaders of the division, Dean Lowell Kageshaw and the founding dean, Franklin McClain. Dean Kageshaw was born in 1901 in Saratoga, Indiana. He graduated from Indiana University Medical School, came to the University of Chicago as an intern in 1928 and stayed on the faculty until 1935. He specialized in infectious diseases and was a malaria expert. During World War II, Dr. Kageshaw served as the chief advisor to the U.S. government's malaria project. He was asked to develop a safe, effective, once-a-week malaria prophylaxis, which he did by combining high doses of chloroquine and primoquine. After the war, Dr. Kageshaw was recruited back to the university by President Robert Hutchins and served as dean of the biological sciences from 1947 to 1960. As Holly said, during his term as dean, Dr. Kageshaw was known in academic circles as the dean of deans. While dean, Dr. Kageshaw moved easily and frequently between Chicago and Washington, D.C. and was a special advisor on health matters to both presidents Eisenhower and Nixon. In 1956, in fact, he moved for a year to Washington to serve as a special advisor on health to President Eisenhower. Holly has already mentioned the 1965 report that he authored on planning for medical progress through education. One of Dr. Kageshaw's greatest contributions was that he changed the AAMC from a small regional deans club whose headquarters was actually close by in Evanston, Illinois and moved it to Washington, D.C. to make it the powerful and effective voice for academic medicine that it remains today. Dr. Kageshaw and his wife Becky in Foley, Alabama in 1967. I'm embarrassed about that, but actually it was while I was on my honeymoon. Our honeymoon. I had written Dr. Kageshaw to ask if I could drop by to talk about some of the early history of the medical school and about Franklin MacLean the first dean and Dr. Kageshaw and Becky graciously extended an invitation. Anna sometimes still chides me that even on our honeymoon I was working. In preparing for this lecture and thinking about Dean Kageshaw, I came to realize that during my 50 years at the university I had personally known every dean since the founding of the medical school in 1923 with the exception of three deans I note them here, Richard Scamman, Frank Lilly and William Talaferro who were the deans between 1931 and 1943. So of the 19 BSD deans and acting deans since 1923 to 1916. Let me highlight just a few of these individuals. H. Stanley Bennett was the dean when I arrived on campus for medical school in September of 1963. Leon Jacobson to his long standing regret signed my first faculty appointment in 1971. Sam Hellman was my friend and colleague for many years. Godfrey Getz was for me a role model on how one could successfully integrate scientific research with the medical humanities. Glenn Steele and I taught a course together for five years. Glenn is now running the Geisinger system in Pennsylvania. Jim Adara is now the chief executive officer at the AMA. I have been friends and colleagues stretching back for many years and Ken and I go back at least 30 years we were friends and neighbors on Blackstone Avenue and our friendship was solidified during the two years each of our section offices were being renovated and we were both exiled to a part of the hospital that I ventured to say very few of you have ever seen. It was 0600 raise your hand if you've ever been to 06 oh my gosh I'm taken aback yes in the farthest reaches of the old hospital. Now I suppose it is in strange that after 50 years on campus I would have known many of the deans. But one really surprising thing is despite my apparent youth I actually knew Franklin McClain in this medical school in 1923 91 years ago. I knew Dr. McClain because as a senior medical student and then later as an intern and a resident I was assigned on five separate occasions to care for him during admissions to the hospital. Let me show you a picture of me my graduation picture 1967. This is the man my wife married in 1967. Just two years later as a medical resident I have to show you the other picture. And I said where is the man I married. I responded hey this is the late 60's. But Dr. McClain and I would sometimes talk about the history of the medical school and this wonderful book that he had co-authored with Ilse Vieth and Astarian a book written in 1952 on the 25th anniversary of the medical school. I call this this wonderful book to your attention. Dr. McClain was born in Maroa Illinois in 1888 actually on February 29 of 1888. He always enjoyed the distinction of the unusual leap year birth date. I show you here on the left side in the middle picture of Dr. McClain in 1892 at the age of 4 or as he would put it at the age of 1. And then on the right hand side I show you a picture of Dr. McClain and his sister Louise McClain Gental who lived until 2001 and dying at the age of 109. Now these photos were sent to me by Mr. Bob Gental. Bob is the son of Dr. McClain's sister Louise and Mr. Gental and his wife and their daughter Rita have driven here today for Maroa Illinois to be in the audience. Please join me in welcoming them. Like Lowell Kageshaw Franklin McClain was a distinguished academic leader. In 1914 while still an assistant professor McClain was chosen for his, I show him in the circle down here, was chosen for his intellectual and organizational skills and was sent by the Rockefeller Foundation to become the founding dean at the Peking Union Medical College PUMC which was the first western medical school in China. In 1903 the Rockefeller Foundation which is a great supporter of this new medical school that we were developing encouraged University President Harry Judson to bring McClain back from China and to appoint him as the founding dean of the new medical school here at the University. Now McClain's vision for Chicago was similar to this building that he built at PUMC and that vision which is really quite unique was to have the outpatient clinic the inpatient beds, the laboratories of a group and the offices of each specialty localized geographically within the hospital to create a system that had never before existed in the U.S. and as far as I know has never been replicated. This is a slide of the original floor plan of Billings Hospital where this integration that I talked about took place. This is the fifth floor and you see that there's an M wing for medicine an S wing for surgery, an A wing for administration and we are currently in P117 the pathology wing so we are sitting in the old original hospital that opened in 1927. Now what were some of McClain's other innovations innovations that helped define the medical school that we are celebrating today? First of all he created a true university medical school completely integrated intellectually and geographically with its parent university. He established a medical school that was not a separate professional school but was part of the Ogden school and later the division of biological sciences thus integrating basic sciences and clinical practice. McClain and the people he worked with assured that the university would own and would operate its own teaching hospital. He helped establish the full-time system where faculty are salaried employees of the university and have no clinical duties unrelated to the university. Dr. McClain emphasized research, particularly research closely linked to teaching and clinical care and he developed a subspecialty system which started when the Billings Hospital opened in 1927. Now many of Franklin McClain's innovations remain part of the organization and philosophy of our current medical school and the BSD. This picture which is the front of Billings Hospital reminds me of one other vitally important decision by McClain. The original architectural plans for this hospital called for it to be located south of the Midway on the corner of 60th and Ellis where Burton Judson now stands. And McClain insisted that the building be relocated or resided to the north side of the Midway where it currently is in order to be closer to the main university campus and to the whole biological laboratories which were then the basic science labs. I show you a modern picture so modern in fact that you can see the CCD over here but showing this incredible geographic integration between the medical complex to the west and the main university campus to the east. This integration still holds. I'm going to turn away now from Drs. Kaga-Shawla McClain and in the second part of my remarks I would like to talk about my debt to the University of Chicago. When I entered medical school in 63 I was delighted to become part of the scholarly environment that had been established by Franklin McClain and carried forward by McClain's successors including Dean Lowell Kaga-Shawla. I think back now on the great teachers I had during medical school. Basic scientists clinicians and ethicists. In later years most of this extraordinary group of faculty became my senior colleagues and mentors as I grew up and worked to develop my academic career here at the University. Here are the pictures of some of the great basic scientists who are my teachers in medical school and afterwards. Charlie Huggins and Janet Rowley, Don Steiner, Leon Jacobson Gene Goldwasser, Arthur Rubenstein, Albert Dorfman Elwood Jensen, Bob Whistler, Frank Fitch, Ruth Reins and Joe Seidhamel. It was Ruth Reins and Seidhamel who pioneered to keep me in medical school and I always thought that Dean Seidhamel had an ulterior motive because by then he and I were playing squash together on a regular basis. But in addition to these spectacular basic science teachers I had wonderful clinical teachers and mentors. Rory Childers who sadly died just a month ago. George Block Joe Barron who I saw in the back. Joe Lou Cohn, Lloyd Ferguson Joe Kursner. JBK gave this lecture the Kageshaw lecture in 2006 when he was 97 years old. Elizabeth Kubler Ross, Bob Replogel in whose lab I worked for two summers during medical school. Henry Russi who was my advisor from day one of medical school. John Altman, Al Tarlove. It's an extraordinary group. When I turned to ethics, the Chicago campus in the 70s had four of the leading bioethicists in the world on the campus. Jim Gustafson had come here from Yale in 1972 and was one of the founders of the American bioethics movement. Father Dick McCormick who from 1957 to 74 was on the faculty of the Jesuit School of Theology in Hyde Park and was regarded then and later as the leading Catholic bioethicist in the country. Leon Kass and Steven Tullman joined the Committee on Social Thought in the mid-1970s. I can't imagine any university in the world in the 60s, 70s, or since that has had comparable strength to Chicago's in basic science, clinical medicine, and bioethics. In preparing for this talk, I thought back on three important turning points in my career. One involving Al Tarlove, the chair of medicine in the department. Another one involving Arthur Rubenstein when he was the chair of medicine and the final one involving Hannah Gray when she was president of the university. I wonder if you would indulge me just a couple of minutes to tell you the stories. The first story involved Al. I had a meeting with Al in June of 72 to figure out my new assignments. I was joining the faculty as an assistant professor and Al said well you know we've got this new division of general medicine. It only has two people, you and Dick Biddy who is the chief and we'll have an A and a B service. Dick will run A, you'll run B. You'll each attend for eight months of the year and we'll figure out who'll do the other attendee. Other faculty, chief residents and like. I said yeah and I understand that and then Al said and Dick has agreed to do all the house staff programs in the department and so I'll assume that you'll do all the student programs, the junior clerkships, the senior electives and like. I said fine. I was almost ready to get out of the office when Al said I've got another idea. I think we should have a general medicine consult service and you know be available to consult the surgeons, OB-GYNE, anybody who calls us no one will call us, don't worry. You can be the director of that and attend for 12 months of the year. So I was totally got by then I had 20 attending months, 8 and 12 and now I have a hand on the doorknob and I was really just about out. When Al said Mark, I got one more idea. I was worried already. He said you know we need a medical intensive carrier. I said Al, what is a medical intensive carrier? You gotta understand in 1972 there were no medical intensive units in Chicago. There was none here at the hospital. There were no good ventilators. We had these old pressure vents. There was no specialty of critical care. It didn't emerge until the early 80s. So I said Al, what does that mean? He said well we'll break down a couple of walls on W5 upstairs and he said we'll have a unit where five or six people will come. The sickest people in the hospital and everything okay? The sickest people in the hospital and we'll monitor to them and maybe we can do something. So he said no one will come again and no one will come and you can be the director. Now I was holding back to find out how many more attending months. He said you can attend for 12 months. So now I was up to 32 months or something. So that was my first job in the department. But the important thing was during the five years in which I directed the medical ICU from 72 to 76, every important ethical issue came up. End of life care, rationing beds, truth telling, informed consent, medical innovation because everything we did without a rule book. All of the ethical issues were there and I discovered at that time that there was very little literature on this range of everyday problems that I could show to my students or residents in the ICU. And so those five years in the ICU were really important for me and that's where I found my focus and my career direction and those were the years when I decided to spend my career trying to improve patient care by combining ethical analysis with clinical medical practice. The second story I want to tell is about when Arthur and I had submitted a proposal to the Mellon Foundation asking for support of a center of medical ethics here in the department of medicine. And we were invited to meet in New York with the president of the foundation John Sawyer and Arthur and I went with great excitement to find out that Mr. Sawyer had unexpectedly been called away and we were placed in the hands of an associate of Mr. Sawyer's who I don't think really recognized that we were coming that day and hadn't read our proposal, but who gave us a very hard time. Arthur and I I remember left the meeting standing on the corner of 62nd and Lexington Avenue and saying this was not one of the highlights of our career and we better think of alternative funding sources for the center but I'm glad we came here and tried. On December 24th of that same year, three months later I received in the mail the thinnest of envelopes an envelope the kind you get when you reject it from college that really thin paper thin envelope and with the melon return address on it and I was almost inclined not to read it because I mean I knew what it was going to say and I opened it up to discover that in fact it was not a letter. It was a check. It's a check made out for $500,000 to me personally December 24th so I quickly get on the phone to call the Mellon Foundation. They're closed for the holidays so I reach Arthur and Arthur says whatever you do don't cash the check. Which I followed the wise counsel but that was so important. The early funding from the Mellon Foundation was crucial. It enabled us to go forward with Mellon support and in our first ten years we got strong support from the Pew Charitable Trust in Philadelphia, the Henry Kaiser Family Foundation in California and at that time we were fortunate that the McLean family became closely involved and supportive of our work. I have to reduce some confusion at the outset. Franklin McLean and the McLean family so far as we know have no family relationship. Although I learned last night they both probably came from the Scottish Island of Mull originally and they changed the spelling of the names and whatever. So two different families. The third turning point I want to talk about was a meeting with Hannah Gray who was president of the university. Hannah is here today. Hannah? I was struggling with a job offer from an eastern university that in those days had the only endowed chair in medical ethics in the country. And Arthur and I had talked about it at some length and Arthur asked Mrs. Gray if I could go over and meet with her and she graciously said yes and I went over. We had a good conversation at the end of which Hannah said there really is only one important question and that is at which of these two institutions can you better achieve your career goals. And once the question was put so clearly is that the answer was immediate. I went home to talk to my wife to make sure that we agreed on it and we totally did. That Chicago was where I wanted to be and I've never once regretted that decision and there were three or four reasons that just jumped to mind as soon as the question was laid out. Chicago was a true university. Unified geographically and intellectually committed and enthusiastic about interdisciplinary work. Second I loved working with patients and I had been in practice at that point about 20 years and I just didn't want to leave my patient population. Third I had been working in the area of clinical ethics here at the university at that point for 10 or 12 years and my plans were supported and encouraged by my colleagues by the department leadership by the university. And finally my mentors were here. Al Tarloff, Arthur Rubenstein, Life Sorensen, Jim Gustafson, Stephen Tuleman and Hannah Gray and they were willing to guide me in my early years as I worked to develop my career and when I thought of those reasons as I say I made a pretty much quick decision with Hannah that evening and have never regretted it at all. This brings me now to the final portion of my talk and that is the question about the development of clinical medical ethics and we start with the question what is clinical medical ethics? Let me say that there are many definitions of it but hey we invented it so we get to define it. Clinical ethics is a new and practical field that applies ethics and ethical analysis to improve patient care and outcomes and at the same time to improve the engagement and satisfaction of clinicians with their work. Clinical ethics focuses on the doctor-patient relationship and helps patients, families and physicians reach good clinical decisions that take account both of the medical facts of the case and as well the patients' preferences and values. In 2014 to be a competent clinician physicians must understand and use the concepts of clinical ethics these issues like truth telling, informed consent, rationality, privacy, decisional capacity and end-of-life care are simply part and parcel of what doctors do. As I said the McLean Center is seen as the birthplace of clinical ethics. Over the years the achievements of the McLean Center have very much been a team effort. I want to recognize and thank the McLean family for their unswerving support for the past 30 years. This is a picture of the late Dorothy Jean DJ McLean in the middle with her son Barry and daughter-in-law Mary Ann and DJ who really was the force behind the McLean family getting involved with us always believed that education was the best way to improve the world and throughout her life her philanthropy supported many leading educational institutions including Yale, Dartmouth her own alma mater Colorado College and fortunately for us the University of Chicago. Following DJ's lead Barry and Mary Ann served as co-chairs of the McLean Center's advisory board from 1984 to earlier this year. Barry and Mary Ann for 30 years helped guide the center in achieving its mission and expanding its work and under their leadership the center has developed a substantial endowment including five endowed chairs to support activities related to clinical medical ethics and in April of 2014 we were delighted to announce that Rachel Kohler a long standing member of the McLean Center board had become the new chair of the board and we look forward to working with Rachel as the McLean Center moves ahead in its work. Rachel, thank you. The McLean Center has also been fortunate to have a superb team of associate directors both in its early years and currently. Early on Steve Miles joined the McLean Center soon after it started and helped it get launched and John Lantos was one of the earliest fellows at the center and stayed on for many years to help me direct the center and here is, here are our current McLean Center associate directors. Lainey Ross has been teaching me as a colleague and friend what happened? Oh my gosh thank you I'll get to Marshall Dad in a minute Lainey has been teaching me as a colleague and friend since she arrived 20 years ago from the east coast and also mainly from Princeton. Peter Angelo an endocrine surgeon joined us six years ago to develop a new program in surgical ethics five years ago because Dan Sulmasey came from New York to add expertise in internal medicine ethics and end of life care and most recently Marshall joined us to help build our program in ethics and health policy. I also want to thank Tracy Cougler and Dan Brauner who now direct the center's consultation program and I want to especially recognize Ann Dudley Goldblatt who for 30 years directed the center's program in ethics, law and medicine. Join me in thanking all of them. The center has an outstanding interdisciplinary faculty from the BSD, the Law School, the Divinity School the Booth School and from the Humanities and Social Sciences I apologize that you can't read this but I call your attention to the red names because 60% of the center faculty listed in red are graduates of the center's fellowship training program. On the next slide I show you some of the current faculty who have completed fellowship training at the McLean Center. Shola Olapati, Emily Landon, Melanie Brown, Peter Angelo, Savi Fedsen, Larry Gottlieb Bill Meadow, Chris Daugherty, Milda Saunders, David Rubin I know some of them are in the audience. I want to thank you guys My point here is to emphasize the amazing team effort that has helped the McLean center grow. I feel so fortunate to have worked for 30 years with superb and talented colleagues and with a great advisory board. I'd like now to just touch briefly on some of the McLean Center's achievements and contributions both locally and nationally. We helped develop a medical ethics fellowship training program which became the signature program of the McLean Center As Holly has said, we've now trained more than 350 fellows, almost 300 physician fellows, 30 of whom went on to direct ethics programs in the US and abroad. More than 25 of our former fellow trainees have held endowed professorships and the fellows have come from 9 or 10 foreign countries, including the ones that I show on the slide. Second, we helped establish clinical ethics consultations Beginning in 1984, the University of Chicago was among the first hospitals, universities in the world to offer formal ethics consultations. Our faculty and fellows helped write much of the early literature and develop models for ethics consultations We have now consulted on more than 2,500 cases in the past 35 years and despite the complexity and conflicts that often lead to an ethics consult being called, as far as we know no lawsuits have resulted from any of the 2,500 cases seen by our consultation teams Third, as I mentioned, Peter Angelos came to help create a new field of surgical ethics In the six years since Peter came from Northwestern, the center has trained more than 30 surgeons in our fellowship program and we have published in the ethics and medical ethics literature current and former fellows have published thousands of peer review journal articles and I love to say more than 150 books This is not a contemporary picture of me, as some of you know Let me now turn to the question of the impact of clinical ethics on U.S. medicine During the past 40 years, a number of the developments that I will mention were strongly influenced by clinical ethics in the McLean Center. By no means do we claim exclusive responsibility for some of the big changes that have occurred in U.S. medicine, but we are proud to have played a role in some of the changes The first one I'd refer to is ethics committees, particularly ethics consultation services. In contrast to the 1970s and early 1980s, every large hospital in the U.S. now has an ethics committee or an ethics consult service to address clinical ethical issues and to help develop institutional ethics policies. In fact, as you know, the joint commission now requires that hospitals have a mechanism for resolving ethical problems. Second again in contrast to the 70s and early 80s essentially every major medical organization now has an ethics committee and a code of ethics Third, scholarly papers in clinical ethics many of them empirical data-driven papers are now published regularly both in bioethics journals as well as in standard medical journals. Fourth, the doctor-patient relationship in a generation of tremendous clinical, political, economic changes, I think that clinical ethics has been one of the forces that has helped maintain the focus on the doctor-patient relationship and on shared decision making. In fact, it was based on the two recommendations of the president's bioethics commission that shared decision making became the prevailing model in the U.S. for the doctor-patient relationship and that 1982 commission report that I show you here drew heavily on the work that we had been doing at the McLean Center. And finally, something I call the democratization of clinical ethics. I think this may be the most important national contribution. Clinical ethics discussions have become a part of the everyday clinical conversation that occurs in outpatient and inpatient settings across the country. In fact, issues as I say like truth telling, confidentiality, informed consent and end of life care are so completely integrated into the practice that these days physicians don't think of themselves as, quote, doing ethics but rather see themselves as doing medicine. It's sort of like realizing we've been speaking prose all our lives, you know, this notion of doing medicine and doing ethics. You no longer have to be an ethicist to do clinical ethics. You just have to be a doc and that's what I'm referring to here as the democratization of clinical ethics. And so to conclude, looking back after 50 extraordinary years at the university, the things that I am proud of are working with great students, residents and faculty colleagues, taking care of patients as a general internist for 47 years, helping to start the general medicine section, organizing the first medical ICU at the university, helping to start the field of clinical medical ethics and working with faculty colleagues and board members for the past 30 years to develop the McLean Center and the Ethics Fellowship Training Program. But I'm not old enough yet to hang up my spurs and I'm ready to look forward. And looking forward, I'll tell you that in 2011, Dean Polanski invited me to direct the Bucksbaum Institute for Clinical Excellence. The Bucksbaum Institute, as Holly pointed out, is a new program in the BSD made possible by a transformative gift from Kay and her husband, the late Matthew Bucksbaum and their family. The Bucksbaum Institute is dedicated to all the things that I have dedicated my career to, the doctor-patient relationship, improving patient care and outcomes through research and teaching, improving communication with patients, improving the process of decision-making. Let me say once again how fortunate I have been to have such wonderful colleagues, students and patients who have made these past 50 years truly extraordinary. In closing, I want to express my deepest gratitude to the university, to the Biological Sciences Division and to the Department of Medicine for tolerating unconventional ideas and for providing the kind of intellectual environment that allows new ideas to develop and flourish. Thank you very much. You've done over a very long and very impactful career that continues to be very, very influential as you pointed out. We have time for maybe one or two questions. So, Samarka, looking forward with your deep understanding of our history, of our culture here at the university and the department, what do you think in times where everything is changing are the things we need to preserve the most? I think we have to preserve those elements that have been part of the tradition of medicine for its history. The relationship between the patient and these days not just the individual doctor, but the team taking care of the patient becomes so important. Often an interprofessional team made up of doctors, nurses and other healthcare professionals. But I think the elements of that interaction, the communication the decision making process, the compassion, the empathy that people express have to be preserved. And I am optimistic. From the time I started 50 years ago Medicare and Medicaid was passed when I was a junior and senior in medical school and everybody said that was the end of medicine as we knew it. Medicine would never be the same. And in fact, as you know medicine has gone through a golden year transition, I mean a generation and a half that has been spectacular in terms of research and care and improved abilities to treat and care for patients. And it has retained those fundamentals. So that's my hope for the future and frankly my optimistic expectation for the future. Not that the Kageshaw lecture is not enough, it's more than enough and we also want to give you the department's Distinguished Service Award for a long career in the department and many, many thanks for everything you've done for us and our faculty, our students. Thank you so much. Thank you.