 Next we have Dr. Arianna Levin, who's going to talk to us this morning about rethinking the preoperative HMP requirement priority cataract surgery. I'm Arianna Levin, I'm one of the PGY2 residents here. Today I'm presenting the burden of the preoperative history and physical on veterans undergoing cataract surgery. We've heard many presentations here about all of the outstanding service that Moran does around the world. And I think that most people in this room, especially those who have been involved with the Navajo trips, with Fourth Street Clinic, with any of the outreach days would agree with me that global ophthalmology starts right here. Today I want to show you that if our aim is to achieve accessible, affordable and efficient care, then we should reevaluate the current history and physical requirements before cataract surgeries. And in addition to accessible, affordable and efficient care, I want to show you that this topic is relevant to our residency competitiveness on the national stage. I'm going to first show you why I think that this is an important topic. I'll demonstrate to you the preoperative process at the VA hospital that we currently do for those of you who aren't familiar with it. I'll share some data that was collected at our own Salt Lake City VA. I'll propose a few ideas for how I think we might change the system. And then I look forward to hearing your suggestions. Obviously, we know that medical care is expensive. The definition of medical bankruptcy has changed over the years. But an older study showed that medical issues contribute to 62% of overall bankruptcies. A really small proportion comes from patients who have VA coverage. We know that the VA offers a lot of great services. My patients say to me over and over again about how much they appreciate and love the care that they receive at our Salt Lake City VA. But today I'm going to focus on this population and show how I think we can do better there. We also know that over time the preoperative requirements for cataract surgery have changed. Patients used to undergo more testing. Now we have guidelines that tell us that preoperative testing like blood work, like EKGs, are not required. That these may be wasteful uses of our resources. Two years ago, a group at Wilmer put out an op-ed stating that the preoperative history and physical, which for us, unlike the EKGs and blood work, is still a requirement within 30 days of surgery, should not be a requirement for all cataract patients. Why did they say this? Well, they point out that cataract surgery is very safe for most patients. That the day of surgery interventions are more typically hypertension, bradycardia, issues that aren't necessarily picked up in preop screening. And then they suggest that the few patients who might benefit from the preop HMP could be screened for a prior. Okay. Before that slide, let me ask the group. Raise your hand for me if you think that a drive from Salt Lake City down to the St. George area, maybe to Escalante for a weekend jaunt is long. Maybe a drive down Saturday, you drive back up Sunday. Maybe you've done it. I've done it. But it's a long trip. Show of hands. Okay. Several people do. I'd agree. Many of our patients at the VA do this drive for a 15 minute visit and we've seen so far that the value of that 15 minute visit is questionable. Just to put this in perspective, that's equivalent to driving from Wills through New York City to Mass Dioneer having that 15 minute appointment whose value is questionable and then driving back. This is what we do at the VA right now. The patient and often their family member drive to the Salt Lake City VA. One or both might miss work. They find parking that adds 30 minutes to this visit. They sit in the waiting room. They wait there that adds probably more than another 30 minutes. The intern confirms their medical history and the intern measures their blood pressure and then consents the patient. I want to emphasize that there's no eye exam at this visit. The patient does not pick up their drops at this visit. At this point, it's probably time to buy lunch and then the patient and their family drive home. I was interested in looking at what the burden of this visit is on the patients. A lot of prior studies that are behind the current guidelines focus on expenses to the institution. The studies on EKGs and blood work focus on institutional expenses. I was interested in the burden on the patient. I'm showing here survey results from 63 of our veterans. They report that the mean travel time one way from home to the appointment is 96 minutes over 72 miles. Of those 63 patients, three patients reported that they personally had to miss work to attend the appointment. Three reported that they had paid for child or pet care. 13 of the 63 report that their family member missed work to bring them to this appointment. Five reported that the family member had to pay for child or pet care. First about all of these patients report fuel costs driving to this appointment. In addition to fuel, 14 of the 63 report that there are additional costs on top of that. The most common is food. I'll make a side note here that if one of our goals is to also have a sustainable practice then in thinking about sustainability, we should be keeping in mind as well patient travel required to attend these appointments. I wanted to put this data in perspective so I asked patients questions about their financial wellness and if you take away one slide today I'd like it to be this one because these numbers surprised me. 33 percent of our patients reported that they have felt concerned about the costs of their medical care. One fifth of the patients reported that they have in the past filed for bankruptcy. And one tenth of our patients on top of that reported that they have felt concerned about their need to file for bankruptcy. To emphasize this I'm showing shots from several of these surveys. The first one says, food, time involved. My daughter took time off for two days, approximately $300. Spending four days on the road and in temporary housing is really hard on me. How long did you travel from your home to this appointment, five and a half hours? And how long back, five and a half hours? How far, 350 miles? I wouldn't have to have my son fight the traffic and try to find a parking place if I didn't have to do this. So what might we do differently? Here are a couple rough ideas. We could sign the consent form on the day the patient signs up for surgery. We could confirm the medical history, review the preoperative instructions and answer questions over the phone. We could do an H&P update which other surgical specialties at other VA's but also at our VA do on the day of surgery. And is there a role for telemedicine or phone conversations in this? Well I asked patients and about a third of them said that they would be interested in this as an alternative. And what does this have to do with residency rankings? Well, most if not all residencies in the next few years will transition to an integrated intern year. And our integrated intern year needs to stand out. About a third of the intern's time right now is spent on these histories and physicals. If we reduce this there's an opportunity for more clinical and surgical exposure in our PGY1 year. To conclude this is an opportunity to restructure the preoperative requirements to decrease the burden on patients while maintaining superb patient care. It's an opportunity for us to improve our integrated intern year. The number of patients affected by this process might decrease with the Mission Act but these points likely apply to patients outside the VA system, most likely in rural areas as well. Thank you.