 Thank you, Mr. Miller. Good morning. I am Dr. Teresa Gonzalez, the executive director of the American College of Dentist, your American College of Dentist. And I would like to officially welcome you to this interactive webinar developed by a distinguished faculty cohort from the American Society for Dental Ethics. As is customary, our annual meeting includes a special ethics course and these highly acclaimed courses are generally open to a modest number of individuals due to space constraints. Therefore, utilizing our virtual format, we have opened the gates to a much wider audience. And now, as our prevailing technology allows, we are ready to engage with our four panel members. I'd like to briefly introduce them. The panel members include Dr. Tony Ruka. She is the associate dean for academic affairs at the University of Illinois College of Dentistry and the American Society for Dental Ethics Liaison to the American College of Dentist. Also on the panel, Dr. Fred Moore, the executive director of the American Society for Dental Ethics. Dr. Carlos Smith, who is the Virginia Commonwealth University School of Dentistry's director of diversity, equity and inclusion, and has been recently named to the board of directors for the Virginia Dental Association Foundation. And last, but certainly not least, is Deight Geary. She is an associate professor in biomedical sciences and comprehensive care at Indiana University. Now the workshop utilizes the power of stories to illustrate principles of ethics. Narrative ethics explores the intersections between the domain of stories and storytelling and that of values. Narrative ethics regard such values as an integral part of stories and storytelling because narratives themselves implicitly or explicitly ask the question, how should one think, judge, and act, either as the author, the narrator, or character, or as a member of the audience for the greater good. Now I have to remind you that this is an interactive presentation and that requires your participation and all of you who have joined us through the question and answer. We will pay great attention to that. We're interested in what you think. Welcome to the presentation and welcome to this format. And I would like now to turn it over to the panel for this block of instruction. Thank you kindly. Bye-bye. Good morning. I'm Fred Moore. I'm welcoming you to this live panel with a lovely large audience we can't see. It's nice to have you here. A special shout out to anyone in California. Good luck. We'll send Ivy coffee for you. Here on the east coast, it's 8.03 a.m. I want to acknowledge that we're presenting from Wisconsin, Dr. Rooka, Indiana, Dr. Agarri, Virginia, Dr. Smith, and I'm in Connecticut. So I noticed in the panel that some of you have attended our courses before as he has had the privilege of offering a special ethics course for many years and it's a great privilege to do that and we're glad to have you back. For those of you who are first timers, we're glad you're here. A special shout out to you and we hope that you'll continue attending our courses at future college meetings. So with that said, I'm going to start our presentation. What a knowledge that we have no conflicts of interest. I've always wished that I could give you a long list of entities that paid me obscene amounts of money for things that I do but the fact is no one does. So here we are and we have no conflicts. We are all fellows in the American College of Dentist. We're very proud of that and we all serve on the board of ASD. So ASD has been around since the late 80's as an organization began as an organization called PEDNET. In 2007 ASD became a section on the American College. We're very proud of our section status and very proud to be part of the American College of Dentist and contribute to the mission of the college. The mission of ASD is to lead education and scholarship and dental ethics and as time goes along that conversation becomes more and more broad and it's a very exciting conversation to be part of. I noticed that many of you in this session teach ethics at some level and we're glad we hope that you'll find this presentation useful. We also noticed that almost all of you used a model for ethical decision making and it had some level of understanding with using a model for ethical decision making. Sorry I just got a text. I hope you can see me if there's any issues. Awesome. Thank you so much. I feel very reassured. So we have four objectives today. One is to explain how stories impact student learning. This is a really interesting and novel way of doing the ethical decision making, ethical teaching that we do. We're going to suggest how Neury of Ethics can build empathy. We're going to demonstrate. We have a lot of cases in our presentation today so we hope that we can demonstrate how Neury of Ethics can be used in teaching ethics and to analyze ethical scenarios. So we did a presentation about excellence and we established a word cloud and I've always liked this word cloud because it shows the things that we hold as important and interestingly honesty seems to stand out. Given our present climate and conversation in our country as well as throughout the world, honesty seems to take on a special resonance and in itself is a great conversation. What is honesty? How rigorously honest do we need to be? What's the expectation of us? Integrity also stands out, respect, ethical empathy. So these are the things that we seem to hold as important. So I do want to point out that I'm the oldest member on this panel and I seem to be given the opportunity to talk about tradition. So I'm going to in this section kind of recap the so-called traditional view or traditional way of teaching ethics. You know it's kind of a knee-jerk response to the word traditional, maybe not in furniture style or clothing, but especially in an intergenerational audience. The word traditional seems to denote how our grandparents did it or our parents did it. It kind of suggests that maybe it's a bit past say. I want to toss out though that in fact what it really could do or what it can really represent is a time-honored reliable way of teaching ethics. Or creating the conversations around ethical reflection. And I think that we have resources like the American College Code of Ethics, the American Dental Association Code of Ethics, and many specialty organizations have codes of ethics. We all have grown up with our personal codes of values and beliefs. Traditional way of teaching ethics, the way we've done it for many years, provides a really interesting and useful platform to engage others in ethical reflection and to deal with ethical dilemmas in a really systematic way. So an ethical dilemma is when we're caught between two competing obligations and we have to weigh options to resolve it. And at many times those options are not compatible. Taking a stand on an issue where you might alienate others and taking that stand. Taking an action with a patient that may cause the patient to leave a practice. Taking a view on an issue that would hold a colleague accountable for something that they have said or done with the possibility of losing the friendship of that colleague. There's a number of elements in a dilemma that can be very troubling for those of us when we face it. We have to choose between alternatives that may pit one objective against another, respecting the autonomy of an individual versus doing the right thing. Taking a stand on justice are examples where ethical principles may become in conflict. And most often when we face these dilemmas, they're really not a matter of clinical skills or scientific judgments, they're moral assessments, things we ought to do when a situation arrives. I'm sure that none of you are unfamiliar with an ethical decision-making model. There are many that are useful and I know we all use them. This is I think a really great example of a generic decision-making model that kind of places as a general theme how these models work. Beginning with this defining the ethical dilemma. And I would say as a footnote that sometimes it's very challenging, especially for new people with this activity, to define what the dilemma really is. So we begin with identifying what the ethical problem is. We collect information. Sometimes information is easily available. Sometimes we can assume it. Sometimes we can ask. Sometimes we really don't know. And so we just have to move on. So we collect information. We state options. What choices do we have in any given situation? Often we can apply ethical principles of those situations and we can further make judgments based on, make choices based on that. And then we make a decision. And many times we suggest making more than one decision because we often don't get what we want as our first choice. And then we implement the decision. And it's a cycle. So we go back and collect information. How does this work? What has the response been? Are we satisfied? This is my favorite graphic for the structure of professionalism. So professionalism is the overarching cap for empathy, humanism, accountability, altruism. Obviously we don't teach these in classes. Empathy is a quality that is internal. Motivation can be intrinsic. Accountability is really an interesting value. And being willing to be held accountable is one of the signs of someone who's truly comfortable and mature. And altruism. This is an audience that does not need to be talked too much about altruism because this audience is a very service minded audience that provides really inspirational service into the profession. Professionalism is built based on ethical and legal understanding, understanding the legal parameters that can affect our responsibility. The ethical understanding that we're here about today. Communication skills, gaining those skills to be able to take stands, to work with others, to convince others, to teach others. And of course clinical competence, which is a given but so often gets called into question. This is simply one example of a decision making model. This is a six step model, identifying the problem, collecting information, stating the options very similar to the model that I presented before. The American College Handbook, which is an amazing resource, talks about autonomy, beneficence and justice, which are ethical principles. Also talks about compassion. Compassion is an amazing gift for someone who is providing care for another person. Competence, integrity, professionalism, I just finished talking about, tolerance. We've had so much experience in recent years learning about and seeing examples of intolerance and having the willingness to take a stand for tolerance and acceptance. And veracity, truth telling. These are all solid core values that will guide us in our work. So I'm going to use this case and also Tony is going to use the same case in the next segment to contrast how we apply the narrative structure to a case. So I'm going to read this case. It's called Veteran's Affairs. Dr. Tim D. is a dental resident at the Veterans Medical Center in Indianapolis, Indiana. He provided care to veterans. He felt a strong sense of pride treating those who had served in the military. Dental clinic patients were not financially responsible for their treatment because everything was covered by the U.S. government. It was an opportunity for Tim to do treatment planning and to try techniques that might be challenging for patients to accept in private practice. There were six eligibility levels for VA patients and not all patients were eligible to receive comprehensive care. One morning Angus B., a new patient arrived, he was wearing a Chicago Cubs t-shirt, Go Cubs. Tim immediately made a connection because the Cubs was his favorite sports team. Angus was a nice man and had not seen a dentist in many years. He was only eligible for a limited treatment because he was homeless and ineligible for comprehensive care. Tim completed a comprehensive examination and determined that Angus had extensive dental needs, including several extractions, root canals, crowns, and prostheses. Angus's eligibility only permitted extractions. Tim saw a great learning opportunity for comprehensive care to gain more skill and provide a valuable service to a patient he liked. Tim was caught between following the rules or doing what he felt wasn't the best interest of the patient. So this is actually a key place to stop and point out the fact that really what Tim is fighting is his intent to do what was best for this patient and following the rules. Justice versus beneficence, it's not clear in this case how invested Angus was in the solution, but certainly autonomy is a case in point as well. After considering the alternatives, Tim chose to do the treatment without verifying eligibility and figure he would simply lie about the circumstances if it was challenging. Tim completed three extractions, three root canals, six crowns, and two partial dentures for Angus. He was never questioned about the patient's care. As a post-grip and probably in a traditional format I would leave this out, but I would add in as a post-grip to care the VA with instrumental and changing Angus's circumstances. He is currently employed, has his own apartment, and is working to improve his life. So this is I think a really fascinating case because it presents a realistic dilemma, a dilemma between a desire to do what's best for the patient and limitations that are placed in our way by the patient's resources. In this case, the VA eligibility criteria. This is the way we approach this case. Clearly we have ethical principles we can employ. I think beneficence is a real part of this case. One might wonder if Angus is truly homeless, what his resources are, perhaps potential for harm by doing comprehensive care that may be unable to maintain in a proper way. Part of justice is following rules. I think practitioners have sometimes a real dilemma between limitations placed on them and their desire to do care and limitations of insurance benefit coverage, in this case eligibility verifications. So in the traditional format when we would begin to develop this case, we have the opportunity to apply ethical models for ethical decision making. There's a great opportunity to use codes. Clearly in this case I think the principles of professionalism apply. I'm not sure in this case how court decisions may necessarily help or hinder us. I think that as a resident, Tim in this case might be vulnerable to some discipline if administrators were concerned about not following rules. What are the standard, we don't know in this case if not following eligibility criteria was standard practice in the VA in this center. If others did it, if it was a commonly done or if practitioners rigorously adhered to determinations such as the eligibility criteria. David Ozar many years ago contributed this central values of practice. This is actually really interesting and may be applicable in this case. This rank order hierarchy of responsibilities and values. In this case I think the life and general health of a patient is not at stake. The patient's appropriate and pain free oral functioning may be a factor. We've not had a discussion in this case about the autonomy of this patient. What choice he had participating in this treatment plan. Preferred practice values. Clearly this is a key part of this case because this resident sees an opportunity to do things that he feels would be beneficial to the standard of care that he seeks to deliver. Aesthetic values and costs may not be particularly relevant factors in this case but at times would be appropriate to consider. In this case we talked about some additional facts that we could find out. I mentioned a couple how rigorously are these eligibility criteria adhered to, who monitors them. Tim has made the choice to lie about the patient fitting the criteria. The options of course are very straightforward. One would be simply to do only the care that's recommended. This is where the eligibility criteria fall and if they're fair, if they are fairly applied across all veterans who are coming into the oral health system then there would be perhaps an obligation to follow the rules. I think there's also an element of equity in this case. What is the typical patient entitled to in this sponsored system? I'm not going to go into weighing the ethical values of each option. We would want to do that and I think we could in this case. There's a definite value in providing comprehensive care. Clearly the post-grip told us that in this case it was effective. At least at the writing of this case Tim had not had any negative consequences about not following the rules. If you are a person who is strongly invested with following rules then this case could be troubling. If you're not then perhaps you see even more latitude here. Then we would make some choices about what would be reasonable to do in a case if we face these circumstances. I think that would be a really interesting point for discussion if we were having the opportunity to do that. I haven't made a judgment personally about this case. I think that the decision that Tim made served the patient very well and clearly there was a real benefit in a humanistic way to an individual. In fact it was life changing. A more rigid part of me might think that following rules is important. That would be perhaps my personal dilemma. That's a brief recap of the traditional view of teaching ethics. I know that most of us have done this for many years. It works well. You can construct a case that has circumstances that foster a discussion around either principles or circumstances or both. You can lead a group to coming to a variety of opportunities or variety of options that are worthy of discussion. It's a very fruitful way to engage others in conversation around ethical dilemmas. The narrative approach will afford us a very different kind of opportunity. Good morning everybody. I hope you can hear me. Can you just let me know for sure, piano, that you can hear me? You're just fine. Yes. Okay, great. Thank you. Great. Thank you so much. So why narrative ethics? Why stories? Why do we want to take this approach? First of all, I would just like to add that this is not just about teaching ethics. It's about how you approach solving ethical dilemmas in your lives, whether it's in private practice or whether it is engaging with students and colleagues at a dental school or university. This is a way of approaching ethics universally, really. So I think you'll see as we go through some of our cases later and talk a little bit about why this approach seems to work really well, it'll hit home for you. Remember that everybody has stories. Everybody has a personal story. So when we view an ethical situation through a story right off the bat, it helps us to build empathy with the person in the story. It also helps us to inspire our own self-reflection, putting ourselves into the place of characters perhaps in the story. It gives us an emotional connection with a memory in the story, so it actually is more impactful. And it really does help to illustrate points that way. Medicine, medical education has been using this approach for quite a while. This is relatively new to dental education when we talk with folks teaching ethics throughout dental education, but I think it's picking up some ground for good reason. So it is a different way. It's a new way of thinking about and teaching ethics. Principal-based ethics and the approach, the decision-making model that Fred went through is very useful, but it tends to really force us to try to separate our emotions from our encounter with the case right off the bat. It tries to put ideas into boxes, and we need to start to think about categorizing principles right off the bat when we're encountering a case. Ultimately, we get to that narrative ethics as you'll see, but it's not the first thing that comes to mind as we try to deconstruct these cases. So we do it in a broader sense. We really reflect on the big picture first and then drill down into the various principles. It helps us to think about these scenarios as stories, again, and empathize with others. We're going to talk a lot about empathy today because we believe that that is really important when you're trying to solve an ethical dilemma. And you can't help but to engage with that as we go through these cases. And it does help to actually enable you to have a more thoughtful decision-making process. And the bottom line is this is a much more instinctual way of approaching an ethical dilemma. So people are human. And again, the traditional way of looking at problems is somewhat rigid, and it tries to take the emotion out of decision-making. We need to separate emotion out of decision-making, no doubt, but it's not as easy to do as we would like. And so why not embrace that? Why not embrace that emotion, that first emotion that you encounter with a case because that is just the way that things happen in real life. So this gives us a place, gives us space to process those emotions before making that final decision. So there is a psychology to decision-making, so not just ethical decision-making, but decision-making in general. So as you know, there's a theory that there's right brain, left brain activity, and we may be dominant in one side of the brain or the other. But the fact of the matter is that we use both sides of our brain when we make decisions. One might be dominant if this really plays in our decision-making process. So Daniel Kahneman is a Nobel laureate in economics, and his area of study is really interesting. And even though it's not medical literature, it applies to what we do every day in professional decision-making. So he believes that there are two ways of making decisions, head versus heart basically. So system one thinking, he says, is the fast, instinctive, intuitive judgment that you make in a scenario when you encounter it. That is the first thought that comes to your mind. And then system two thinking is more slow and deliberate, logical. We like to think that we live in that area, especially as medical professionals. But the fact of the matter is he says that we live the majority of the time in system one thinking. And so in narrative ethics and in the rubric that we'll use later, again, we're going to embrace that natural way of encountering a problem. As Fred and I developed the excellence lecture that we did in Hawaii a couple of years ago, we started to develop that idea through all of our readings and our research. And it has really served us well. So we have, we've refined that model, which we'll talk about as we get, when we get there. There's also another interesting book out there that I feel like kind of also complements all of what we've talked about so far. So we're not throwing away principles. We're not throwing away those are so go pad offs theory. We are embracing all of it. But we're also looking at some of the contemporary literature out there again outside of medicine and dentistry. And Dr. Dodie is actually a neuroscientist who wrote this book. And he feels that these are virtues that people should have in mind or embrace in order to make wise choices. And it really does complement all of what we've said so far and what we do. And that if we keep these principles of virtues in mind in everyday life that we will make better decisions. And that we will make more empathetic type decisions. One of the words that he uses is equanimity. And we struggled with that one a little bit. It just means even, even men of temperament, which, which makes sense. But I think for, for our purposes, we would have probably chosen the word empathy here as the alphabet of the heart dictates in decision making. So we know that we have ethical obligations. We are not steering away from any of these things. This is all very complimentary. So, you know, as professionals, we put our patients needs before our own and our monetary gain. It's our obligation to provide quality care to engage in lifelong learning, which is why you are all here today. To maintain our competency. Of course, we have to engage in self-regulation of the profession. The American College does an amazing job with that. And again, one of the reasons we're all here today. And very importantly, we have to maintain that relationship of trust with our patients and society as a whole. So ethical decision making from this perspective really doesn't change a whole lot when we look at the big picture of having to take everything into consideration and pick an optimal choice. But we do have to keep in mind that we do have some, some biases that come into play as we're working through problems. And so just a reminder to everybody that we all have personal experience and upbringing that influences our decision making. Religious beliefs, professional training, where we practice our patients' expectations and societal customs and norms all play into our decision making. And we acknowledge that. And we have to sift through those things. And we do do that in narrative ethics as well as traditional problem-solving methods. So we have to look at outcomes. What are we trying to achieve when we're solving a problem, an ethical problem? We really have to look at what is best for the patient, what is best for the dentist, what is best for all of the stakeholders? So when we think about the Veterans Affairs case, we also have to think about society. We have to think about you as taxpayers. You're stakeholders in that case. So, you know, we have to consider all the angles. We do have to consider principles, but again, principles, obligations, and values. But those are things we dissect out as we go through a case a little bit later on in the narrative ethics approach. And we strive for an optimal outcome. We strive for an optimal outcome or an excellent outcome as we talked about a couple of years ago. So what is an optimal outcome? What does that look like? Do we know it when we find it? Is it measurable? How do we achieve it? These are all really interesting questions because we have to ultimately decide what that looks like. And it's not easy. So, you know, working through a model is important in order to help us to identify those things. So the approach that we're using, which might be very new to some of you, is called the stakeholder-beholder approach. And this fits to narrative ethics because, again, it plays to our instinctual just habit of making those initial judgments that we find in a case and then drilling down beyond that. So, when you are listening to a narrative of a case, you have to be able to experience it in some way. You're experiencing it just by nature of listening to it or reading it. And so what we would like everyone to try to do is think about yourself and think about the characters and the stories as either stakeholders or beholders. So this is, again, a little bit maybe abstract compared to what you're used to. But the stakeholders in a story are the characters, the entities in the story. In this case, Veterans Affairs, we're going to talk about it more later, but we're looking at Tim, we're looking at Angus. Again, we could identify the taxpayers as stakeholders in that story. But there are also beholders. So you, as the observer, are a beholder of the story. So you're going to judge what's happening from a step back. You're looking at it the whole picture from the outside. Also, the storyteller themselves is a beholder of the story in narrative ethics. So as we go through a rubric, we're going to try to pull these things out. And we're going to look at the perspectives from everyone involved in the case to help us to solve the case and to help us to be able to empathize with all the parties in the case and work through those two systems of thinking. So there are some keys to an ethical outcome to help us to determine whether or not we've come to a good conclusion or solution. One thing I should point out, too, is when we're using narrative ethics, we have a story with a conclusion. We're judging that story in its entirety. So you are going to decide whether or not a good outcome occurred, whereas with the traditional way of managing an ethical case, many times we are stopping short and trying to then decide what is the best option to make. But in a narrative story, it happens. The conclusion is there, and then we need to judge it. So judging the outcome, we're going to look at, is there an absence of flaws? So what went wrong? If everything went right in the story, then there's an absence of flaws. But generally, there's going to be flaws. There's going to be principles that conflict. There's going to be perhaps somebody that is harmed in the story. So we're going to judge it from that perspective, and we're going to look at that perspective from all of the stakeholders and the beholders. Also, for an optimal outcome to occur, someone in the story should receive some benefit from the circumstances. So we're looking at beneficence here. And then we're also looking at non-maleficence in that there is an absence of harm that occurs for an optimal outcome. Now, outcomes are going to be on a gradient scale. So when we look at our rubric, we're going to see that not everything is perfect. And so we have to judge that outcome on a gradient scale to help us to decide whether or not we've achieved what we wanted to achieve or we achieved the best outcome for that particular circumstance. So again, this is a totally different way of approaching an ethical problem. So these are the keys that we've identified. For those of you who are interested, this approach to narrative ethics is more on the utilitarian side of ethical theories as opposed to day ontology. However, there's an element of both in this way of solving ethical problems. But we're looking for really the benefit for the most people in any given scenario to determine whether or not the outcome was near optimal or optimal. So using the rubric that we are going to provide you here, we're going to analyze the story again from the perspective of achieving an optimal outcome through the eyes of the beholders and the stakeholders in the cases. So we are going to apply the rubric to these cases. We're going to refer to the ACD handbook as we need to. We're going to identify the stakeholders in the case. We're going to rate the outcome again from the perspective of each stakeholder. So is it an excellent outcome? Is it a good outcome, average or poor outcome? Using the criteria that we've discussed. And we also want to know how does the story make you feel? Do the circumstances give you a perception of an optimal outcome? This is that system one thinking that we're talking about. What is your initial gut feeling when you listen to that story? How does it make you feel? And then what flaws can you identify? Breach of principles, procedural errors, other ethical considerations. And lastly, this is important. If you had to rewrite this story to make the scenario such that an optimal outcome is perceived by everybody, how would it go? So again, we've kind of flipped. We've flipped the way that you're thinking about these cases. But we think that it is a more intuitive way of doing it. So this is our first case that Fred presented. We're going to present it now in an audio format. And then we're going to work through the rubric next as a panel. Now, if we were doing this live with you present in the room, this is where we would put you to work. This is where we would break you out into small groups and we would say, okay, you need to work through this case, use the rubric, fill it out, and then we're going to talk about it. Well, we don't have that opportunity here. So you will hopefully bear with us as we discuss these cases as a panel and work through them with the rubric. So here's the first case, Veterans Affairs. Veterans Affairs. In the year following dental school, I worked as a dental resident in the Veterans Affairs Medical Center in Indianapolis, Indiana. This was a unique opportunity to improve my clinical acumen because the patients were not financially responsible for their treatment and everything was covered by the United States government. This allowed for some unconventional treatment planning and gave me the ability to try certain techniques that might not otherwise be done due to the typical financial constraints that arise in a private practice setting. I felt honored to be able to provide a service to these veterans, but oftentimes the question of each patient's eligibility to receive dental treatment came into question. There were six different eligibility levels and only certain levels allowed patients to receive comprehensive treatment. One morning, a patient walked in wearing a Chicago Cubs t-shirt. We immediately made a connection since the Chicago Cubs are my favorite sports team. The rapport came naturally. He was genuinely a nice man, but it appeared that he was down on his luck and had not seen a dentist due to debilitating dental anxiety. He was only eligible for limited treatment because he was in the Homeless Veterans Program, deeming him ineligible for comprehensive care. Regardless of his eligibility, I always completed a comprehensive exam in order to get an idea of the current state of the patient's dentition. Following this exam, it became evident that he had extensive dental needs. He needed several extractions, root canals and crowns and prosthetic needs. The only treatment that would technically be covered would be the extractions. I felt as though I had a unique opportunity. This would be a great learning opportunity and it would give me a chance to handle the patient's anxiety and work on my patient management. The ethical dilemma that I was facing was whether or not I should follow the rules or whether I should do what I feel is in the best interest of the patient. In this situation, I chose the route of not asking for permission now and apologizing later if I were to somehow get in trouble for my actions. I continued to have the patient scheduled throughout the next several months and I completed three extractions, three root canals, six crowns and two partial dentures for the patient. Luckily, I was never questioned about my treatment for this patient. What we were able to do for this patient when beyond treating his dental needs, he was able to regain his confidence. By the time I was done working with him, he was no longer in the homeless veterans program, which is also a reason why he should not have been receiving any treatment. And he had successfully secured a job and was on the right track to taking back ownership in his future. It would have been very easy to just apologize to the patient that I could not treat him comprehensively. It wouldn't have been my fault. It was a problem with the institution. However, I know that I am able to look back on this situation and say that my actions were able to positively impact someone without harming anyone else in the process. Okay. So that story comes across a little bit differently in audio form. There are some things that were also changed just because we felt that if Fred were presenting that case, he would have presented it the traditional way as he rewrote it. Because it was easier for him to do so, which is typical of what we do with real life cases when we're using them in class. So here's our rubric. So we're going to work through this as a panel. So panel chime in as we go through this. So can you list the stakeholders in the story? Select on it, and I think as I have, and you will by the end of this presentation, hopefully, you will see that most of the ethical dilemmas that we engage in fact come in the form of narrative ethics. And so in this section we are going to begin our discussion of a much broader conversation around narrative ethics. Tony? In this case? Well, the resident certainly is a prime stakeholder, as is the patient. And audience, you can type in, yep, other patients, right? I would say to the administrator, who's ultimately in charge of perhaps the financial bottom line, it didn't, in this instance, be resident. Other patients have been suggested? In our eyes, there's no consequence on that end, but perhaps the administrator... The allocation of resources from the end of the year and realizes allocation... Her supervisor? Yes, these are all really good suggestions. Someone suggested the dental profession as a whole. We have to think about integrity of the profession, certainly. I can hear you, Tony. Did you say other residents? Other patients, yes. Other... Yes, that was brought up a couple of times as well in the chat. Future patients. Other patients. Yeah, allocation of resources. Question. Anything else? Anyone else? Also in the chat are other residents or other providers? So there are quite a few stakeholders in this case when we really start to think about it. And, you know, we start to think about how it affects all of them a little bit later in this rubric. So was there harm done to anybody? If so, to whom? So I think this is where this case gets particularly complex. I think very eloquently one of the first chat comments was around the issue of equity. And so while there wasn't harm done to this patient, obviously the quality of life of this patient was ultimately enhanced. There was a brought up in the chat about the fact that there was a commonality around the mutual sports affinity. I wasn't like the patient. So what happens if it's a patient you don't like or that, you know, we all have those patients when we meet them for the first time and they say, I hate you, you know, because you're a dentist and those kinds of things. So perhaps you could frame harm around those patients who don't have an opportunity for the rules to be flexible, as it were. Excellent point. Any other harms that we can identify? So I always wonder about... Okay, any other harms we can identify? Who have limited resources. And I don't mean to try to make a judgment about homeless people, but homeless people don't have the same resources and capabilities that I do in all cases. That is better. We all are unmuted, which makes it a little bit harder to right now. I want to make sure that my sound is okay. Is it? I got some. And if by chance the treating resident is not being truthful in the record as well, I mean that ultimately could harm the patient. But we don't know that. Well, I was thinking harm to the resident. Okay, so let's just move on for the sake of pencil. Let's rate the outcome of this story from the perspective of let's pick the major stakeholders. There's the possibility of fraud and so there could be harm to the resident at some point. How would we rate his outcome in this story? Excellent, good, average, poor. It's tough because if we look at the big picture and try to consider everything, but let's see what we come up with. About doing comprehensive care and extensive treatment on people who may not be able to maintain it effectively. I struggle. I struggle with, and maybe it's an age thing. I guess I'm cracked by my age today, but I struggle with people not following rules and a collegial. Carlos, how would you rate it? From the resident's perspective? From the resident's perspective, it would be interesting. I think the resident would rate herself as excellent. She achieved optimal oral health for the patient, which, you know, was her intended goal in a more limited view, perhaps. I also think perhaps the intention of the narrative, like what we would use this narrative for. I'm thinking around a lot of our groups, the ADA and such that do legislative advocacy, right? So this is a prime narrative that although we might rate it one way or the other, it could be a powerful driver to get additional funding for the VA or for nonprofits or for sectors that, you know, advance kind of issues of equity for more limited financial means folks. And so the use of the story could have a lot of different implications, right? I know it doesn't answer the rubric precisely, but I just was thinking about that, particularly around issues several years ago around Diamante driver, which was an issue in the D.C. area with a young child who had Medicaid but couldn't really find a Medicaid provider. And there was all these issues around a dental home and that kind of thing. And also maybe the little boy died. But I think we could use these kinds of examples while maybe not perfect for patient outcomes or fairness across patients. Could it lead to more equity or more fairness or more justice if we used it with a different audience? So that's just a thought that crossed my mind. So would you rate that then as a good outcome? I think for that instance, I think you could have a good outcome from it if we were to perhaps have increased funding streams or sources from the snippet and from the example. Okay. Just moving on, how would we view it from the patient's perspective? Is that a good outcome for the patient, an excellent outcome for the patient? From the patient's perspective. And we don't know if the patient is aware of the fact that he got free services. And if he knew that he got free services. In a clinical group. Someone just put a really insightful comment in around when we think about the resident putting, when we talk about putting the need of a patient ahead of the needs of our own, right? So the resident's desire to do all these higher end procedures from a learning perspective, from a skill set perspective is that perhaps putting her need ahead of the need of the patient. And I think that's, that's kind of a slippery slope. So I think you could look at it from that perspective. So I think that person is challenging us and saying long term if the resident is constantly thinking about how can I maximize productivity or my technical proficiency. Is that always going to be in line with what the patient actually needs? The narrative she said. I just made this larger because there was a request request to make it larger. So I can't see anything else on my screen, but this right now. So let's move along. So you're the beholder observing this story in one word. How did the ending make you feel and easy, happy, satisfied, etc. And do the circumstances give the perception of an optimal outcome overall? Practice and improve my skills. And I honor that, but is that just for the patient? So we're finding as we work through this rubric, we have some of the same issues that we have when we work through the traditional rubrics and that, you know, there isn't a cut and dry answer. It's not black and white. But that's where the discussion comes in. And that's what ethical dilemmas are all about. So I don't. Yes. I would say that I thought it was uneasy that there is. Does anyone have issues? I've had a lot of issues with the patients that you wrote in and I just go at poor. The patients, the analysts have been taking care of and now the patient has gone on to get a job and do better. But I was uneasy. You are muted. That we have discussed, you know, because of the resident play their needs equating, you know, what they wanted to do in terms of doing the work and improving their technical skills. Equating that with a good outcome for the patient or doing it as a just to tell you that. So just click the drop down there and select disconnect. The good outcome for the patient just to fight breaking the rules. So that made me feel uneasy. So go, go ahead. I think, I think Teresa was asking to get a word in. So part of the danger in this case is, is part of the danger in this case is seeing it. And someone in the chat have pointed this out as seeing this as a binary choice is right versus wrong. And I think one of the advantages of this narrative approach is that we can flush out some of these things. So I'm having a hard time, you know, deciding how I feel as a humanist, I feel great for Angus. As a dental educator, I feel a little wrath towards the resident. You know, I think that as part of a collegial group, there is a collegial responsibility to share resources and apply them appropriately. I have a lot of heart for Carlos earlier comment about DMT driver. We want to try to get that as a former pediatric dentist. I actively use that case to promote, you know, the need for Medicaid, eligible providers and so on and so forth. And yet I struggle. We're going to keep moving along just for time sake and we've got a bunch of other cases to get through. So the next column asks us to, if we had to rewrite the story to gain an optimal outcome as perceived by all stakeholders or the majority, what would that look like? And to be really brief in this column. I don't know that you can rewrite this in a way. And I think this is maybe a helpful realization of the rubric and this narrative ethics approach. I don't know that you can rewrite this in a way that every stakeholder would view it as optimal. And I just think that's a challenge in theory. But I think, you know, perhaps that's the richness of this exercise is that most of us, if not all of us, I would hope got into dentistry because of a certain level of altruistic value and appreciation for altruism. But as you're in the profession, then, you know, you're thinking more about rules and policies and equity and allocation. And so I think it really pinpoints that there's multiple perspectives always. And I think very easily as dentists, because we're so technically proficient, we can often be thinking, okay, two millimeters here, this that we're very technically proficient. But sometimes I don't know that our strength is thinking of other perspectives. And I think this allows us to really see through the eyes of others. And I think it's it's very story dependent as well. It totally depends upon the scenario. Yeah. And then, yes, that right. And or would that have really caused the resident to not be able to do the work? You know, it's kind of like ask for forgiveness later, right? If he would have asked permission and they denied it, then the patient is out of luck. But yeah, but yeah, if it would have all went well and they approved it, that would have been probably the optimal outcome for everyone. Okay, and then the last section here is just to identify the ethical concerns, but we're not going to do that. That's principles and that sort of thing. So for the sake of time, we'll just move on. Tony, thank you for your participation in it. Yes, just wanted to comment and I'm sorry for the muting earlier. I had to just reconnect, but it reminds me of something about stories. I just wanted to share it. Generally, when we tell stories, they're either hero stories or victim stories. We're either telling them about ourselves. If we're talking about ourselves, we generally tell those stories. And I often think of stories of the Second World War with my father that I was probably 13 before I realized he hadn't single-headedly saved all of Europe. So we tell stories a certain way. So I think it's important when you look at these stories from a perspective as the narrator, as the recon tour, as the individual who's hearing the story. Very different outcome, very different outcome. And it makes me think a little bit about the number of missions, and dental access days that I have, you know, volunteered time to assist. And I've always left a little conflicted, not because there wasn't good being done, but there was so much more that needed to be done. So I think most of our audience, I'm looking at the attendee list here, have had this experience. And I think it's a wonderful example of the administrative responsibility you have organizationally, the patient responsibility, and of course, the provider issue. And I think all of the communications that have come through the chat have all reflected that information. Thank you. Thank you, Teresa. Larry Guerrero says, I think it's better not to try to rewrite it for exactly the reasons that Dr. Smith states. The discussion is what brings out these things and makes them personal. And that is really true. When we're teaching ethics, we're trying to get the students to understand what the principles are and why there could be, what would make for a better outcome? Ultimately, you know, what are we striving for? So, yes, we want to take it as it is. We want to analyze it as it is and have that discussion. But then just to kind of close the loop to rewrite it in order to think about from each stakeholder perspective how it could have gone better and how we could have done a little bit better. So thank you for that, Larry. Okay, moving forward here. So this is one of the things we have to think about here. We talked a lot about it being black and white, but it's not. We have to look at compromise. Compromise is a fact of life. We compromise in every single scenario we're in. And we have to think about that as we work through these cases and these rubrics. And so we have to be able to achieve a compromise because every scenario is not going to be perfect. And we understand that. And so I just wanted to point that out as well. So lastly, in my section here, we're going to show a video that really hits home with the power of stories. And that's what we're trying to achieve here. And I think you'll find this very compelling. So here we go. Is it just loading, David? Yep, one moment. Let me try to get this to play. Well, I hope everyone was able to see that. It seems like we may have had some tech issues, but it's a really powerful video that I use with students all the time to just hit home empathy. And to really illustrate, we wanted to illustrate to you all that stories are really powerful. So with that, we are going to take a 10 minute break at this point. So we will see you all back in 10 minutes. Thank you so far for your attention. For those of you still in the room, while we take a quick break, I have added a chat window. That we can use when there is some more interactivity in the meeting. There's a bit of confusion about how the Q&A box works versus a typical chat window. The Q&A box is typically for questions, but you can enter comments in there. However, you and the panelists are the only ones that can see those questions. So if you'd like to enter your comments on these cases into a chat window, I've put that there at the bottom. And anything you enter there can be seen by everyone. I'll repeat that before we get started again. This particular set of circumstances justifying the advocacy that might result from the treatment that was done. So I have some mixed feelings, which is kind of nandy-pandy, but that's how I feel. For those of you who may have stepped away during the 10 minute break, which is just about to end, I've added a chat window to the bottom left of the screen that you may use for the more interactive parts of the presentation. Feel free to use that. There's still the Q&A pod, which is handled a little bit differently. Any question or comment you type in the Q&A pod or window, excuse me, is only viewable to you and the panelists. But anything you type in chat will be able to be seen by all. So if you'd like a quick some interactivity there in the chat, feel free to do so during those times. And I think we're going to come back very soon. I'll let Dr. Ruga kick it off when she's ready. Okay. I hope you can all hear me. We're going to go ahead and resume. We're going to have more on empathy now. Dr. Smith is going to take it from here. Sure. Good morning everyone again. Carlos Smith at Virginia Commonwealth University in Richmond, Virginia. So a little bit more on empathy, right? And why this is important and how that helps us both seeking understanding about ourselves, but also delivery of patient care. So Psychology Today made this statement that telling stories is actually the best way to teach, to persuade, and even understand ourselves, right? So I think what's important here is not only as practitioners and retirees and former practitioners and all the different facets that everyone in the college carries out. We learn about how we can better teach, but we also learn about ourselves. And I think empathy is a great tool for us in accomplishing that. There really are very few other. We just lost Dr. Smith. Anybody else? I think we did. It looks like he's back. Dr. Smith, we still can't hear you unless it's just me. Is there anybody else on the panel hearing him? Dr. Smith, go ahead and disconnect and reconnect your audio. You may actually also need to restart the app, but let's try that first. Select the dropdown, disconnect your microphone and then reconnect it like normal. Testing. Hello. Testing is successful. Please continue. Thank you. Alrighty, so we'll try this again. We all have a story. That's what one of the things I really thought is important to convey here. Not only are we using these stories in terms of a teaching tool, but it's also that we all have a unique story that helps to frame the lens through which we see life, the lens through which we see these cases. Everyone brought about many people had direct VA experience when you look in the chat. So they have a very particular experience and a well suited lens that they're looking through. Some folks have never perhaps worked in environments where there's a more limited resource. So that's a different lens that you're bringing to the stage here. And so I think that's important for us all to realize and for everyone to be able to capture. So how story influences our ethical views, right? So we all come to our point of ethics, what we think is right, what we think is wrong, how we make choices is influenced by all these different factors and even more. So perhaps age, my esteemed colleague Fred likes to point out that he's the senior one among us time and time again. And so, you know, age influences how you might view something. Also education is going to influence your lens and how you receive a story, how you tell a story, how you interpret a story. Your family background is going to influence things as well. Your culture, your religion or the lack thereof, if you're non religious at all. That all influences your ethical viewpoint, your ethical lens from which we see everything that we encounter and everything that we do. Also just experience, your life experiences, your experiences as a clinician, your experiences in the armed services or all the different viewpoints we bring to the table. All of that uniquely influences our lens and what is important as ethics educators is that no experience is really deemed right or wrong, but it is the lens through which you view the world and how you view yourself ethically. So a little bit more about exactly what empathy is, right? It's the ability to recognize, understand and share the thoughts and feelings of another person. That's what was so rich and really a tear jerker about that video that Tony shared right before the break, right? You have all those different views. Everyone's experiencing things. Life is really not a respecter of person, right? In terms of the different things that we encounter. And so it's crucial to develop empathy in terms of establishing relationships and bringing out that compassion that Fred talked about on the onset of the presentation. It really does involve experiencing another person's point of view. Sometimes we're so stubborn we can't get out of our one track singular viewpoint, but we have to really extend ourselves to think of another's viewpoint. And that enables really our ability to be helping professionals. So for those of you who maybe this is a little too soft science, right? I wanted to include something a little more hardcore basic science around mirror neurons, okay? This is really interesting. And then there are a lot of different theories and all of us may not agree around this. But basically there are some scientists who basically have shown and really theorized that these mirror neurons are a possible source of empathy that we have. They enhance our ability to read and mimic emotional signals through facial expressions or any other form of body language. And all of that can enhance empathy. We don't really know if they fully operate this way or not, but it is a fascinating thought to think that what we see in someone else actually impacts how we encounter them and how we identify with them and how we may be able to empathize with them. So there actually is science behind this too, not just sort of lofty, more liberal arts theorizing. So how does story affect empathy? So I'll give a little example in terms of telling a quick little anecdotal story. I have a colleague who teaches ethics at a dental school and I won't go into that specific school, but she tells this story often and it's so rich, right? Because there was an experience where those of us who have been in the academy certainly know and those of us who practice clinically certainly know you sometimes have patients that maybe are not your favorite patient, right? The patient that you could maybe do without seeing or you see that name on the schedule and you kind of just clinch or grimace just a bit. And so there was an instance at the dental school where that patient presented and the patient was always never forthcoming, rude, mean, not friendly. Certainly it shouldn't, it should not influence how we treat people right or how we encounter them, but the bias is there, it does. And so a lot of folks didn't really want to work with this patient. Attendings kind of went the other way. And so this particular attending decided, I'm just going to engage this patient to find out more. Everybody has a story. So why is she this way? Why is she always so hard to deal with? This particular patient, the procedure they were doing, if you can harken back your memory to crown preps in dental school, which tend to be a much more exhaustive process than certainly in private practice. And so the provisional had come off a couple of times with this incident. So she engaged a patient, the faculty engaged a patient and found out this patient was what we would call probably the working poor, right? Which is a lot of our demographic sometimes in dental school environments, not totally, but sometimes. So the patient works, but in order to get to her dental visit, she had to take several different bus transfers, like four or five different transfers on a bus, public transportation that also required a cost, right? And so the cost that she would have to endure for all those bus transfers to get to the dental appointment meant that she did not have money for lunch that day. And it meant that she missed work. So hourly wage earner, every hour matters. Now I'm back at the dentist with this crown that you guys say is better for my oral health, but it keeps coming off. And so that illuminated a totally different light and a totally different way to engage that patient around the experience. And so does it make everything rose color glasses? No, but it has an incites an appreciation for what the patient is going through and what the patient is enduring to get to those dental visits in another way, right? And so I have a picture there of a city bus. And so what's interesting how that tugged at my kind of heartstrings just for a personal story, it made me think about my grandfather. I am from Columbia, South Carolina, which is not a city where public transportation is massed utilized, right? It's not a Chicago, it's not a DC, it's not a New York or something like that. And so I can remember when I was about six years old, and I am going somewhere with this. I can remember when I was about six year old, for those of you that are from southern states, my grandfather's house was across the street from a city bus stop and across the street from a Bojangles, which is like a big place in the south that has biscuits and such, right? Biscuits and chicken and all that good stuff. And so often on Saturday mornings, my dad would take me downtown to where my grandfather lived and I would have time with my grandfather where we would sit and just eat at this Bojangles. Well, one day, again, I was about five or six and he told me, you know what, we're going to get on this city bus and we're going to do a loop around the city because I don't think you're ever going to have to ride a city bus. And I don't remember his exact words, but he was basically trying to build within me, you have to have empathy for people that have less than you or less resources than you. And I'm sad to say, like for many, many years, probably until I actually went to dental school at the University of Michigan where public transportation is more regularly utilized, I didn't have to ride a city bus, I didn't have to use public transportation. So, you know, it's important for us to realize building of empathy is great, but at some point, like I can't fully identify with that narrative about the patient in the crown and the five bus transfers because I don't really know what it is to ride a bus. I can empathize about certain points of her story, but there may be parts of my story that helped me better understand that narrative. Does that make sense to everybody? So hopefully so that's a little aside, but it's also just a story that that's my story and how those things intersect and about perception. Okay. Alright, so we have another story here. A very brief case that we're going to have for everyone around what we have used previously in a bullying format where we're talking about bullying and bias that students may engage or encounter. So let's take a listen at this. One day I was running late for my perio pre-clinic session and I had my white coat on, I had my goggles on and my faculty member that I had been working with for the entire semester. Specifically I had worked with her because she was left handed just like I am. She saw me in the hallway and she stops me and she asked me when the dispensary was going to be opened up and when I was going to bring the supplies, which really upset me. I had to let her know I'm your student. I don't work here. Then I went to the actual class session where my friend who's also African American says to me that when the instruments were finally brought to the session in the clinic, one of the faculty members that she had been working with stopped her and hugged her. She had her white coat, she had on her scrubs and everything stopped her and hugged her and thanked her for bringing the instruments. And again she had been working with this faculty the entire session which led us to come to the conclusion that even with our white coats on because the majority of the people at our school who work at the school behind the scenes as far as like facility management, dispensary, all those things are African American. They couldn't differentiate between the students or they hadn't taken the opportunity or the chance to differentiate between the students who are African American dental students, dental hygiene students either or with our names on our white coats. So that was another very disappointing situation. So let's think about our rubric that Tony presented us with earlier around narrative ethics. In this example, who are the stakeholders in this story? And my panel is our panel is going to talk through this together just like we did the other case. So who are the stakeholders here? I agree. Other stakeholders. Are we private in this room right now? And other faculty it may sour the students feeling about the entire faculty having these encounters such as that. Dispensary individuals that was brought up in the chat. Yeah we have a good comment from the chat. The students, the faculty, the administration, patients, dispensary dispensary individuals, I would say even with the students to may have students who are on the receiving end and have similar experiences. You may have students who are observing these experiences. Some may be oblivious to them, but some may observe them in a similar way but not have an avenue to voice concern over the experience. Stakeholders that we may think about. No. All right so let's move forward. What harm was done to anyone? If so, to whom? So the students, obviously both of the two students in the story were really hurt and upset by that encounter with the faculty. We have a role of this as well as the students and I suppose I love the community of color who would be affected by the students experience. What about the schools administration and the climate that they create in the school? I think what's really interesting and when we use this case in our another presentation on bullying, the impact. Odette, what are your thoughts? That is so true. Students talk. This won't stay within the school. This won't stay within that clinic that day. So our participants are bringing up all kinds of great points, questions about institutionalized or systemic racism, questions about bias training, questions about anti-racism and what that may or may not mean. Anyone within the school, anyone within earshot of these things happening, a loss of respect around the faculty members and so this is an interesting point. It's just kind of a side because I have a formal role in diversity, equity and inclusion. But my core is really with ethics and professionalism. I often try to push people to the point that issues of diversity and equity and inclusion are actual ethical issues. They're not really this separate bag, although we treat them that way. And so this really is an ethical issue. Someone brings up microaggressions, which is an excellent term. So if you're not familiar, microaggressions are little epithets, little incidents that occur frequently, constantly, often they're subtle or deemed subtle that are almost like little digs at perceptions or stereotypes around particular groups, identities, ethnicities, racial groups, that kind of thing. I actually, there's a lot of literature specifically around microaggressions and particularly African American females in medicine, particularly physicians. There's a lot of rich literature around that. And one article I read talked about the fact this was a emergency room physician speaking who had been in attending. Yeah, I was thinking about, yes, the climate and students that are considering, you know, attending the school, I think it would have a very negative impact on them as well. And I just thought that was a fascinating analogy because it's kind of like just these little, little, little subtle, not overt, not what we may think of as kind of Ku Klux Klan type of racial lies issues, right? But little digs that, you know, well, if most, in this particular instance, if most of the staff are black or brown folks, then the assumption that anyone I see on the hallway, even in a white coat with their name embroidered on it, that person must certainly be a staff member as well. Not really relegating staff to any kind of lesser hierarchy, but let's think about just in general how hierarchical dentistry can be just generally, right? So I think that's an important thing to think about when we think about where was harm done. And also I just would be remiss if I didn't plug that there's lots of research around diversity education, inclusion education. The benefit is not only for historically marginalized groups, right? The benefit, and that's why it's a quota standard. That's why it's one of the things we have to talk about in dental education is because that research actually shows there's enhanced benefit and increased learning for everyone, not just folks who are marginalized historically. So I think all of those things are really, really, really important. So let's look at the, how would the outcome, we don't really know the outcome of the story, but how would we rate the outcome of this story from the perspective of each stakeholder? I think, Carlos, for me, I think the first thing that comes to mind for me is that the initial gut feeling I get from the story, you know, when we talk about what is your reaction, I know that's in the next column, but that is one thing that frames my thought process for the rest of this story. And for me, as it is told now, I don't see a positive outcome for those students at all because what are their choices? What, you know, what is their course of action? Maybe they could come to you, come to somebody like you and talk about it, but what do they do in the moment with that faculty member? It puts them in a really tough spot. So I would rate the outcome very poorly for the students in this scenario. Yeah, and I think that's important too, Tony. It intersects a lot with wellness too, and our well-being. There's a lot of research and literature that different ethnic groups and different people generally, whatever box we check, right? It doesn't have to just be a phenotypic thing necessarily. But however we identify or choose to identify, different groups of people can encounter the same experience and have a totally different experience, although they encounter the same thing, right? There's a lot of research around professional education, particularly in the medical and law arenas, not so much with dental school, but that they encounter those experiences very differently. I wanted to bring out some good things in the chat about self-awareness, so that's really strength. There also is the perspective, which I think is worth noting, did the instructor simply just make a mistake? It doesn't necessarily have to be intentional, but again, getting back to our point with the other case, the richness of ethics is the conversation. And so we bring to light these issues so that because there's a ton of stuff about bias, whether that's unconscious or conscious and all those kinds of things, but it's worth raising the issue for us to be introspective and have that self-awareness to say, okay, how do I encounter people? How do I think about people when I see them? Am I making these judgments or was it just an honest mistake? Should I take the time as a faculty member to do better at learning students' names generally? Irrespective of race or ethnicity, right? So I think that's a good point that was raised as well. Anyone else on the outcome before we move forward? So in one word, we're thinking about this story and one word, how does it make you feel? Uneasy, happy, satisfied, full? It's not a one-off. It's an impact that's going to stay around for a while and label. And I just want to add as an aside that I really want to thank the people in the audience. I'm going blind trying to follow the chat. So in the chat, someone feels, does not feel hopeless. They feel like they have an opportunity to initiate change. Yeah, the chat is really rich, disappointed, angry, unimportant, so unseen, right? I don't feel seen perhaps. I know for me, when I hear this story, because I think this is something as folks in a minoritized skin is so unfortunately part and parcel for experience, I hear a commonality. Like, for example, for me, I've often, so I'm the only black male full-time faculty at our dental school, and I've had other faculty tell me sometimes, not in a rampant way, but, you know, in the hallway, And so it's like, I'm literally the only full-time black male faculty. How do you mistake me for anyone else? But when I hear this story, I actually feel encouraged because I think it presents such an opportunity for us to have these discussions. I think that's one of the rich issues around a lot of the unrest and perhaps racial reckoning that has happened in our nation this summer. Depending, you know, I know folks are all over the place and I'm not attempting to politicize it, but I do think it creates such a rich opportunity to have these discussions and understand where people are and also connect this to ideal patient care and patient outcomes. Because as clinicians, we have to connect those dots. If we as clinicians aren't well, we can't deliver optimal care. And so I think those connections are really, really rich. And so there's some other good comments, frustrated. Change needs to happen. Opportunities to educate the faculty. And so one of the things that this does delve into, you know, you know, as ethics educators, sometimes ethics is one tier and what's legal or the law is another tier. And those things may help one another or they may oppose one another. And so I know we're, we're having conversations as I'm sure at all universities around. I felt angry. Angry. That some students, you know, have to, or some of us have to go through this and that there's such a power difference. So that it is very hard to say something, you know, when you are a student and you see something like this, you know, happen to yourself or to another. Some other schools. So there were a bit of helplessness around ethical questions around these kind of topics. All right. So if we had to rewrite this story for a more optimal outcome, is there a way we feel like we could do that? I would say it would never have happened. That would be the optimal outcome. We're really and adding a lot of value to this. So thank you so much. We've tried to highlight a number of them. And so just very little bit more with narrative medicine. Also in medicine, they write narratives, right? They do their notes and narrative forms. So sometimes it's a little bit easier that they have some more robust research in that. But it allows us to have an open mind for really including patients needs and beliefs in their language as a part of each encounter. And narrative strategy. I did want to just point out that this can actually be helpful to those of you in private practice as well. Because although we're talking about ethical dilemmas and we're talking about dental education and private practice, if you take a narrative perspective on how to mitigate staff challenges, right? Or staff tensions, often in a private practice, you may have issues where you have the front desk staff versus kind of the back clinical staff, right? Or maybe there's some issue, or maybe there's a territorial issue of this is my operatory as I'm the hygienist that always operates in this operatory or something like that. So I think if you hear people's stories and hear people's narrative and use narrative technique in that way, it can also help you on the ground and mitigating business owner relationships and some of your private practice issues as well. And now Odette is going to take our next case. Yes, you sound great. By asking you about an episode in your life some years ago, you were sitting in a dentist chair and the dentist had a very sharp instrument a couple of inches from your mouth. What happened next? He stuck it in and carved my gums. But before he did that, he felt it was important to check off on his list something that he had to say to me before he did this operation. The procedure was one he had invented and he was kind of proud of it because he was taking out a front tooth that was kind of dead and that would leave a socket. So he had invented this method where he would draw down some of the gum over the socket to give a blood supply while it healed, which was a nice idea except he felt he had to explain to me what he was going to do. And he wasn't real clear about it. He had the scalpel really inches from my face and he said, now there'll be some tethering. And I said, there'll be what? He said, tethering. I said, tethering, tethering, tethering. He started barking at me. And I was over the age of 50 and I should have had the nerve to say, put that knife down and tell me what you're going to do to me. And I didn't do that. I think I was in awe of his surgical gown and he seemed to know what he was doing. And so I let him go ahead and do it without knowing what he was talking about. By the way, to this day, I don't know what tethering meant in that situation. But he did the procedure and I was making a movie a couple of weeks later. And I had a smile in the scene. So I gave this big, hearty smile. And after the shot was over, the director photography said, I thought you were going to smile. I said, I did. I said, no, you were sneering. I said, no, I wasn't. He said, go look in the mirror. And I looked in the mirror and I smiled and I was sneering. So he had done something. He cut off that little tissue between your upper lip and your gum. And my lip just sort of hung there. But the only good thing about that was that I was able to play a whole range of villains really well. But, you know, it's interesting. It was another example in that situation of not great communicating because I called him and told him that what had happened and that I was disappointed. And he started getting very defensive. Never said, I'm sorry that you felt mutilated. And in fact, he said, I told you there were two steps to the procedure. I don't really remember if I went back for another step. I was afraid to let him in again. But then he sent me a letter telling me why he wasn't responsible for anything. And it was a defensive letter that set him up for his defense in case I sued him. And I had no intention of suing him. I just wanted him to know that one of his customers wasn't happy. For me, Odette, one of the main characters here is the profession because somebody who has this public stature, this persona out there has a lot of power when they tell a story like this. And I think the profession is a huge stakeholder here. Thank you for your part. Yeah, I've been an advocate for these issues for most of my career. So I must say my first response the very, very first time I heard this was really feeling hopeless. I think harm, the story is tough. I think harm is done to other patients that would be hearing this story that maybe have a periodontal procedure coming up. Or have been told they have periodontal disease. And it kind of places a black eye on not only the profession, but just the knowledge base of the... So this is, can everybody hear me okay? The procedure we want to do, we have patients that are like, oh, do I really need this scaling and root planning? Why can't I just have a profile? I just want a cleaning. Just give me a cleaning. So this is an excerpt from... Now we have an additional barrier to overcome and explaining to them. So I think harm is potentially done to the patient. He recounts an experience that he had with his dentist. Agreed. And did public trust? This experience actually made him write a whole book about communication. But we'll listen to it and then we can discuss it. Well again, the profession gets a black eye because here's a public figure using dentistry as a part of a joke or a story. And we've seen this from Tim Conway to dating myself. Our panelists and also the participants to chime in. So the stakeholders in the story. So the stakeholders, as Tony mentioned before, you know, the participants, the characters in the story. Okay, the profession. I think, you know, also the patient, you know, Alda, the dentist, who any other, can we think of any other stakeholder? There's an interesting comment about one of the stakeholders, the patient who is, you know, seen as a customer in the story also. I think if I were looking at this from the traditional standpoint, I would probably have stopped the story prior to the actual procedure happening. Let's go into the next column. Like freeze frame, the dentist is standing over the patient with the scalpel. And it's so to whom? You know, kind of thing. What should the patient do? So that's how I would think of it as that's kind of the traditional way of looking at it in my mind. But we've seen this for many years and this is just another example. So I get there with an interesting question on the chat asking. So the profession, the profession is definitely harm. Yes, was was harm. Well, I think it's obvious that there was some harm done to the patient, you know, to Alda and not just physically, you know, when he talks about his life, you know, just hanging, but I think also professionally and there was a section of this rubric for the sake of time. But when we teach this in dental schools, we have to remember we have to pull those things out because our students need to know this information. Obviously for accreditation, they have to be able to apply the principles. And so we're just glossing over it here for the sake of time and for this new approach to solving problems but just so that the audience realizes we do have to pull these things out when we work with students. I think informed consent, which has been brought up in the chat and by other panelists communication. I do a scenario ethical scenario with my students here around a case where someone is diagnosed with periodontal disease by general dentist and the hygienist performs the scale and root planning which all of us as dentist would think oh that's normative like that seems far for the course right. Well, the patient's complaint in this scenario is that no one ever told them the hygienist would be performing this, this procedure. And so I think sometimes we take things for granted. Just because this is what we do every day all day that we have to actually expressly communicate to patients and folks for informed consent and I know Larry Garetto has done a lot of work around informed consent so there's some rich things there. I did want to bring out in the chat one comment that is talking about both the Should I answer it or should I let us all work through it? And so I thought the panel might want to discuss that. The chat says narratives can all too easy to manipulate it. Sometimes the best manipulators tell the most compelling and I know that we've all been bamboozled by a good empathetic story teller who makes When I teach ethics in the traditional way that is the hardest step for the students to identify. They have a gut feeling that there's something about whatever case they're reading about or they're listening to narrative ethics. They have a gut feeling that something is not right but sometimes it's very hard for them to identify what exactly is my ethical concern here. And most times I find several concerns within the stories or within the cases. For me the ethics in the traditional way that goes at autonomy and informed consent and that could be one of the ethics. The chat on this item from our participants is truly engaging. Thank you for all your comments. I think that's one of the really, you know, he's a famous person that he would have the confidence to just ask away. He says he's afraid of asking questions and he lets the dentist do the procedure without being sure about what's being done. There's definitely a sign of vulnerability of us and so to me that is the ethics concern. The panel is trying to interpret these stories because we are we're taking a softer touchy-feely approach to this. Then we would normally just, you know, put these ideas into boxes. And so there is that vulnerability and there is a chance that we can be, you know, deceived by someone who's a really good storyteller. But I don't think that that should detract from what we're trying to do with those stories. We have to interpret them as we see them, you know, as we encounter them. Yes, I'm sorry, I just decided to advance the rubric just to show you know the way in which we probably would do this as an analysis. But yes, I'm sorry. The storyteller is telling their story and probably want to look good or avoid looking bad. And so the listener has the opportunity to sort out all of the nuances of the story they're hearing. You know, this is how we practice ethics in everyday life. Someone tells us a story about a telemedicine experience and then we begin... Bad apple, but when a dentist does something wrong and it makes a national news, it reflects so quickly on the profession. Unless I'm just ultra sensitive to it, but there's probably a little bit of truth there on both sides. Let's see if we can get anything in the chat. I have the experience and form attitude about it. It would be really interesting if the dentist in this instance were able to provide his or her vantage point, right? My first reaction. We all have encountered patients that would describe their experiences with us in some wild, particular way. It's just interesting. I think so much of this, though, is really an exercise around perspective and being able to empathize and understand. Even if we don't get to a point of agreement with another person, but understand their perspective. Because as dentists, we have all these anxious patients a lot of times, but we don't agree that they need to be anxious, hopefully. But we can have an enriched perspective in how to then provide optimal care for them that is acknowledging the truth of their experiences or the truth of their perception. It's their perception, so it's true to them. That doesn't make it actually fact for us. So I think we have to kind of hold those things in tension together. What I was thinking was that the, I guess it can be an advantage and a disadvantage that there is a role for emotion with stories and narrative ethics. We're opening space to feel emotion, to reflect on the emotion that we're feeling, and to use our emotion. But as was very insightfully pointed out, that also can manipulate the story in a certain way or another. So I think it's an advantage and a disadvantage. But I think it makes for a richer discussion. If we go back to the, I think we were at the outcomes. So from Alda's perspective, the outcome was poor, even if the clinical procedure was a success. And then, of course, from the dentist's perspective, we think he probably thinks it was a good or excellent outcome if just looking at the clinical side of it. But if the dentist were to consider the documentation. We don't know Alda's emotion in telling the story the way he tells it. I mean, he's an actor. What about how the story makes everybody feel? And several have made this comment in the chat. And so I made the comment, it would be fun to have students rewrite this story. What I've been thinking as I listen to this story and try to keep up with the chat is that I've never heard a dentist say, I'm not particularly good at doing informed. So embarrassment, maybe. I'm not exactly an ethical human being. Trying to scan the chat. I think most of the, so should we try to rewrite the story? Do they pick up on the informed consent aspect? In class. I've never used this case in class. Yes. I think I saw an interesting comment about what would the dentist's perspective be. If he heard the story. I think some of. A few of the comments here pick up on the richness of, I think, I think I saw Dr. Bell, who's from my home state and city of Columbia, South Carolina pointed out about the importance of listening. And also listening for the unsaid. So those things, the patient doesn't actually say when we, you know, ask, do they have any questions picking up on verbal cues and all those kind of interpersonal communication skills. So I think that's wonderful comment. I also think it's important, you know, as the American college, of course, we're all perfect. We're great, right? We're the pinnacle of ethical duty bound for a segment of the profession. But if you remember, like our website and all our information, we're 3% of the profession. And so we have to acknowledge and make room for the fact that there are perhaps some dentists who indeed are not very great communicators or don't always obtain an information. Consent in the best way, someone in the chat even mentioned that there are some dentists who assume who maybe not on paper, but in their mind assume you're sitting in my chair. So you're consenting, which is an interesting perspective, but one we have to agree. Thank you, Carlos. I see a good comment. Interesting. That patient should be given permission and encouraged to ask questions. And then dentists must learn how to intentionally listen for the unsaid. So I think it's a good point. You know, we have to be aware that sometimes people may not be asking, but we can look at them and tell that they didn't get it or they didn't understand it and not give that impression of, you know, if you don't get it, it's your problem. And the common ends with that the profession, that this is the profession's reputation and that we need to rewrite that story. The profession's reputation of perhaps not listening well to patients' questions and concerns and not being aware when they don't understand procedure fully. 5 a.m. The chair, monitor and air water syringe were all covered with the protective plastic. I had grabbed the films for the radiographs, the examination instrument kit and the prophy materials. I sat down to take a breather and check the scheduler. My patient's name, Betty Wilson, flashed red. She was checked in. I got up and found my white coat, buttoned it up as I walked into the atrium area. Sunlight beamed in from the floor to ceiling windows. There were 50 patients checked in and seated around three seating areas. I stood in the first section of seating. I said, Betty Wilson, no movement in the crowd. I moved toward the second section of seating and repeated the name a little louder this time. No movement. I repeated these actions one more time in the last section of seating. I didn't get a response so I moved back to the beginning point and spoke very loud. Betty Wilson. From behind me I heard a shy and small voice. Right here, a small white-haired lady no more than five feet tall stood behind a walker and was slowly walking towards me. The first thing I noticed was a black bruise under her eye. A man, I assumed, was probably her husband, walked with a cane. He was an older man, a little taller than the woman, and he walked behind her. I had to run to the bathroom before, she said. It's all right, I said. How are you doing? Are you ready to go into the clinic? Before she could answer, her husband said, how long will this take? I said around two hours. He said he wanted to come along with us into the clinic. I told him there's not enough room and most patients' families wait out in the atrium area. He's a little reluctant but agreed to stay. Betty and I walked back slowly to get back to the clinic. We took about five minutes to get to the cubicle and sit down. I tried to build rapport during this walk, but she was quiet. Eventually, I learned that she and her husband had recently gotten a puppy. She was really excited to talk about the puppy. We even stopped for her to show me a picture of the puppy. She gave me information from her doctor, and I reviewed the extensive list of medications and medical concerns. I asked about the facial bruising, and she told me it was from falling during her stroke. I remember reading she had had a stroke, but it was six months ago. At the present time, her doctor determined she was healthy enough for dental treatment. After entering her history, I asked to take her blood pressure. I asked that she take it off her coat to get a blood pressure reading. Once she took off her coat, I saw multiple bruises on her arms, as well as scratches. I asked about the bruises and scratches. She said that the puppy is not trained, and it had scratched her and the bruises were from falling. Now I felt like there were multiple stories, and something was not right. At this point, I had to discuss the patient with my attending doctor. She shared my concern about the bruising, like there were multiple stories, and something was not right. At this point, I had to discuss the patient with my attending doctor. She shared my concern about the bruising. She asked me to probe a little more. I went back and told Betty this is a safe environment, and she could tell us anything she wanted. Anything she told us would be kept confidential. She nodded but did not say anything. I pressed a little and asked if anyone was hurting her at home. She said no. I asked, how long has she noticed the bruising, and how did you fall? The answers were not lining up. They were different each time and didn't make sense. I was trying to ask more questions, but she was not willing to open up. At this point, I felt her tense up and close up. I reported to my attending doctor. She told me to give Betty the pain... Sorry folks, I think we just lost sound for a moment. Let me try to reboot this real quick. One moment. I asked that she take it off her coat to get a blood pressure reading. I asked that she take it off her coat to get a blood pressure reading. Once she took off her coat, I saw- Can anyone in the panel- I asked that she take it off her coat to get a blood pressure reading. I am not. Once she took off her coat, I saw multiple bruises on her arms, as well as scratches. I asked about the bruises and scratches. She said that the puppy is not trained, and it had scratched her and the bruises were from falling. Now, I felt like there were multiple stories. Sorry about this folks. Just going to reload the- Try to pick it up where we left off. I saw multiple bruises on her arms as well as scratches. I asked about the bruises and scratches. She said that the puppy is not trained and it had scratched her and the bruises were from falling. Now I felt like there are multiple stories and something was not right. At this point I had to discuss the patient with my attending doctor. She shared my concern about the bruising. She asked me to probe a little more. I went back and told Betty this is a safe environment and she could tell us anything she wanted. Anything she told us would be kept confidential. She nodded but did not say anything. I pressed a little and asked if anyone was hurting her at home. She said no. I asked how long has she noticed the bruising and how did you fall? The answers were not lining up. They were different each time and didn't make sense. I was trying to ask more questions but she was not willing to open up. At this point I felt her tense up and close up. I reported to my attending doctor. She told me to give Betty the patient abuse pamphlets with contact information in case she felt comfortable contacting someone else. My attending explained that we are not at liberty to contact anyone unless Betty gives us permission. I returned to my cubicle and gave the information to Betty. I told her if she wanted to ever talk about anything we would be available to talk to her. She said thank you but did not really glance at it at all. She quickly just put it away in the seat of her walker. We finished the profi and the rest of the appointment. I had found two new cavities so we decided to schedule some appointments. She wrote them down in her little planner. I took her back to the atrium with her husband. He didn't have any questions or talk much. She paid for the services for the day and said see you soon. Betty's next appointment time came and I called the night before to remind her. There was no answer. I left a voicemail. The next day I waited for her to show up but she was a no show. I tried calling again. Betty's next appointment time came and I called the night before to remind her. There was no answer. I left a voicemail. Betty's next appointment time came and I called the night before to remind her. We get sort of the gist of the case hopefully. We're having some technical difficulties here and some folks are pointing some really nice things in the chat already around acknowledging the difference in states and how jurisdictional laws can be around our duties to report elder abuse and all those kinds of things. So there's a lot of robust chat already happening. Why don't we get started? So who are the stakeholders here? I don't do compassion or empathy. Thank you very much. We all see ourselves as skilled in what we do. Talented and engaged. Patient obviously is a stakeholder. Responsible and attaining informed consent. And so the interesting conversation this has been brought up by other panel members too. Part of the opportunity with the narrative approach is creating a conversation around best practices and testing if those best practices are effective. And by the way I'm not a real fan of Alan Alder anyway. Oh the student wants to do the right thing and help the patient. That's a really good question because in the scenario itself nothing really happened other than the exam. However the student we have to think about the student potentially being harmed by this experience or at least having an emotional a strong emotional response to it. You know what's interesting when I have used this story with students and they don't know who he is. So well it's boring on one side because you know in case you think you know I'm a lot older than and they are then but but I think added you know that added factor for us of knowing who he is and you know he's famous and all these other things. So it brings on an interesting side because for them it's just somebody making the assumption that the husband is the abuser or if she's being abused. So I think perhaps if she's being abused I think that there there could be you know there could be trying to go to the typically they do when we go over you know what are the specific principles I think they sat around perhaps call if they do recognize that the patient economy was not respected and they wonder about how good I think this is really important for us to think that was obtained as the age population typically they talk about also non-maleficence you know harm was done to the patient and to the profession. So it has been used for may not be with the students I think it's one that's easy for them to analyze. But turning folks and issues around capacity this raises a lot of potential questions that we could think through I think the story didn't really end but basically the student tries to call the patient several times and never can get the patient back on the phone. I think we do have to give room to the fact that perhaps now we've put her in more um not necessarily assuming who the abuser is if abuse is happening but that now raising the questions whether they saw the pamphlet or even if she just was if someone inquired with her what types of things did you guys talk about back there since I couldn't go with you those kinds of things too. So how we frame the best way to respond to patients that we suspect in this issue is really important. I think this is a great case because any other thoughts around this rubric? I think this is a great case because this is a topic that we have to touch on in dental school the students have to have this information and you know I have this discussion so it's a great way to present it as opposed to reading reading a scenario. Dr. Ruka? Yes ma'am. This is something that many faculties require and I think that you've hit upon an important point. I've always with my relationship with the military with forensics I've always mandated that my students fill out a report with the systems in the state they're going to practice in. We do one for vulnerable adults with a simple concept that silence is complicity. So we always fill it out and we fill out one for domestic and or child abuse and what is amazing I asked the students as a reflection to think about someone they suspected was either neglected or abused they didn't have to know the outcome the law protects them in that regard but not to make frivolous reporting but rather to advocate fiercely for society because we know the numbers of abuse are woefully underreported. It is a mandate in custodial care it should be a societal mandate and each of the students it's just amazing of all the reflections I've ever read from students these are simply the best because it is very personal to these students and I think putting them through that experience notionally is always a good educational arrangement. You might want to let your state know that you're doing a test fire. I've had this experience in South Carolina if you're going to do a testing you might have to let them know in advance that these are code test reports just to establish the system and the reporting algorithm over. I should add that I know we're going to move to the panel here now but I should add that all of these stories that you're hearing today were written by students and that is one way of approaching this is not to give them necessarily the stories but to have them write a story because it's so much more powerful when they write it and then I have other students read them I don't have the students read their own stories I have other students read their stories but I just wanted to point that out. There could be other people involved in this children so I think we need to be a little careful about making the assumption that the husband is the abuser and I think it's interesting that someone posted a link to the Illinois law which I don't know Tony you'd know it and New York has a law for mandatory reporting of elder abuse but not all states do it as points been brought out so there's a legal responsibility for reporting so we're down to our last few minutes of this session and we're going to we're going to shift to a panel and also invite your questions too. Kind of in summary you know our goal and our objectives was to explain to demonstrate to analyze and not to offer the end all of of how to do narrative ethics and we expose you to a number of cases and a rubric to apply and we'll supply some of the references to the resources that we have applied and I have to say that for all of us this is our first live virtual presentation and I'll be very objective in sharing with you that we were scared to death because of all of the potential pitfalls that we role played out as we rehearse this over the last period of time and so I have to thank the gods of technology for saving us and letting us make it through this presentation without any major glitches and I hope that you had a reasonable experience with it too. I also have to point out that if this were a live presentation and the chat was actually going on live during the room there would be this din of noise because the chatter then scrolling like the credits at the end of a movie when you're trying to find a makeup artist and it's going by so fast you can't see it so your participation has really exceeded anything we could have expected so thank you for that um so if you have questions um put them put them in I mean is that with the question we've got a couple of prepared questions um so there could be some so one is um the presentation is interesting and I would like to learn more about narrative ethics what steps would you recommend um but yeah uh Carlos do you want to start with us more specifically well this presentation will be posted too for reference later so you're welcome to use any of the resources and also um you're welcome to contact us and ask questions you can't hear you tori there's a question in the chat there was a question in the chat about I think it just scrolled up um using the term stories and I think interchangeably are there nuances between the two terms we're using them interchangeably here for our purposes so they're really not different because I think the story resonates with people you know even if he's exaggerating a lot of people have felt that you know whether it's at a dental office or with a physician you know where you're not sure of what's being done and and the power differential is such that you're afraid to uh to ask so um here's one okay go ahead sure um because of time we have to progress with all students but the first time I used it I used it with graduate students because I felt like they had already you know the principles the knowledge of the principles um of professional obligations all of that because I think that's a great point there are so many uh very nice compliments thank you for those compliments I missed that question this is like I think um level type of uh approach so teaching it could you describe your first experience using narrative ethics with your students what was your biggest challenge de-identify me I know you've used it a lot so could you want to start you know I explicitly said all of this has to be de-identified and I had to go through them all with a fine-tooth comb to make sure that that was the case because with a small group of residents they can pick up on things you know when we're dealing with different specialties and small cohorts it was easy to identify who wrote the story so um that was the biggest challenge for me but it's it's a really great way of doing it and the students love it they love it Betty Wilson I think Carlos is going to lead us to this discussion the patient's heartbreak story telling quite a bit um and um we haven't really mentioned it but the video series that Larry Guerrero did at Indiana with the American College although um it's a little more in our traditional way of analyzing it it really is presenting narratives um in those videos and so uh I use that uh very much in my teaching I think one of the challenges is similar to that happened in our exchange um to get all the all the different perspectives in the group and in the room is what's most rich um so that you get multiple viewpoints because I think people can easily um be swayed to one side like the abuse narrative you know it's important for us that someone even commented about could it just have been uh bruising from warfarin use you know so I think it's important um to have those multiple perspectives and sometimes we can get a little trapped into what everyone just views it this this is is hearing this one particular thing so I have um since we began this this developing this this work uh some time ago um I've had the chance and using this in a couple of non-dental classes uh in in a medical um informatics group and I tend to write cases in the first person so it does sound a bit like narrative um but I used it with a group of medical informatics people and and used to zoom and put them in rooms and uh I was actually quite impressed with what came from their independent effort without my without my prompting without with me giving some background and uh uh some standards and codes and so on so it's actually really effective and engaging conversation um I think for the teacher uh or for the facilitator you need to be fairly facile and being able to move through the nuances that emerge as you have this conversation why do we involve or innovate in anything that we do um why are we in this era of digital dentistry with 3d printing and digital dentures and all these kinds of things I think it's important for us to evolve just because something works doesn't mean that we have to stop using that model I don't think this means the um the principled model uh must cease we we obviously still have to talk about those core values and core ethics principles and so we're just talking about it perhaps in a new way or we're reaching some folks and um enlargening perspectives um in ways that perhaps weren't reached or enlarged otherwise so I I'm I'm I'm an eternal optimist and I am a both and person all my days so I I don't like to be cornered into either or in most things in life and I would think uh this extends to this arena as well so I would say both um modalities are useful I just was uh have any of my colleagues picked up a question uh from the chat that we should address common handy at different times we have time for like one more question this is so much more fun it really is and um I think it it as you could see here um it just really encourages much more rich conversation so let's do this one um I like teaching ethics using a case-based format I evolved using the case-based format I've always used it is successful I get good feedback and I'm comfortable using it why should I consider switching to something different a much more pleasant experience for everyone in my opinion I was do you want to start this one so we're near the end of our time do you uh Tony or Odette do you want to add anything uh first of all to the panel I would like to thank Dr. Zagiri, Moore, Ruka and Smith for your valuable contribution to this program I've always believed that success in education is never in the finality of the answer but in the fertility of the question and if that is any indication of how successful your effort was then you should be very very thankful for having you present and you should be very pleased with the outcome I've also monitored the chat I am very very much appreciate all of our new fellas and our older fellas who have engaged this morning the one thing I was rather sorry to learn was that people did not recognize who Alan Alda was although to be fair most of our contemporary graduates were haploid cells when the premiere series mash aired so it is what it is I'll be grateful American College of Dentist and our fellows and friends thank you for your participation today it was deeply rewarding