 Great, thank you very much, Dr. Singh, for that exciting update. Next I have the pleasure of introducing Dr. Monica Doe. She's an assistant professor and doctor of nursing practice at Vanderbilt University, Department of Veterans and the Department of Veterans Affairs, and she'll speak to us about shared decision making for patients with amyloidosis. So I think I'm our last talk for this portion of the day, so I'm really going to completely change directions for you from everything we've heard all day. Objectives, we're going to talk about cardiac amyloidosis and how it fits into shared decision-making. I don't have any disclosures, and we'll start with a case study. So in clinic you have an 82-year-old black gentleman who has heart failure with preserved DF. He has LVH. He has Tachy Brady syndrome with a dual chamber permanent pacemaker. His functional status is moderate, meaning he can complete most of his daily activities, but he does use an assistive aid. He has type 2 diabetes. He has chronic kidney disease. He's had one hospitalization this year, but it was planned for a hip replacement. And we know about our patient that he has limited income, and currently where he lives, he does not have much social support. He does have family that he's in contact with, that he enjoys spending time with, but they're not readily available to help him where he is. So we start thinking about our next steps. A little bit of review. We know the incidence and prevalence. It's predominantly age greater than 65, men greater than women. The highest incidence and prevalence is in black men. The highest geographic incidence and prevalence is in the northeast, then followed by the Midwest. And we know that the incidence and prevalence is increasing substantially among men, the elderly and in black patients. So we think about this in the context of our case that we just presented. And all morning, we've had these highly technical talks about diagnostic testing and treatment options, but we haven't really talked much about patient considerations and how we have conversations with our patients about diagnostic testing and treatment options that might be available to them. We haven't talked much about how certain modalities of diagnostic testing are not always readily available. False positives can be common. The system of ordering all of the diagnostic testing, it's time intensive sometimes depending on your institution. It could require multiple patient visits. It can become a significant expense if your patient doesn't have transportation to the visits. If they rely on someone to take them to or from or transportation services. If they have to ask a family member to leave work to take them to their appointments. These are significant expenses to the patient. Certain procedures that we talked about like endomyocardial biopsy, they do have tangible risks associated with them. And we might need to send the patient to multiple specialties with multiple visits given the broad spectrum of organ systems which may be involved in symptomatology. So this is where shared decision making begins. We have this model here. This is from my colleagues at the Rochester Mayo Clinic, a unit called the CARE unit. And they revised shared decision making into this contemporary model where if we're looking at the far left, we have a very straightforward scenario. It's called alternatives based shared decision making. This is where we have multiple guideline based therapies available to the patient. It's very preference sensitive. We have decision aids that we can use. We're able to communicate treatment pros and cons and there's a steep authority gradient meaning you as the patient are reliant on me as the clinician to give you all of the information you need and the approach is very steep in terms of you're relying on me. On the very far right, we have a humanity based approach. These are for patients who are in hospice situations. You're still going to deploy shared decision making because they're facing an existential crisis. We are looking at someone who their humanity or their identity is compromised and we're using dialogue with the patient to promote togetherness, love and purpose in the decision that we're making. For most of us when we're thinking about patients with cardiac amyloid in our either primary care clinics or in the cardiology clinic, they're fitting somewhere in the middle two sections. This is desired based and problematic situation based meaning the options are not necessarily well defined or there are very few. There is a potential conflict between our competing agendas meaning I think you need the treatment and you're not so sure you need the treatment or want the treatment and this is where we have to deploy interpersonal negotiation so that we can achieve agreement. This authority gradient is much flatter. We are co-collaborators in trying to figure out how we want to proceed. When we think about the behavioral underpinning of shared decision making, there's really two predominant models. The first is self-determination theory and this says that when decisions are aligned with patient values and consistent with patient perceived competence, they're more positively appraised by the patient and the patient is more steadfast than if they were behaviors that arrived from paternalism meaning if I make the decision for you. The second piece is difficulty times motivation matrix and this basically says that we need to have a dynamic assessment of our patient over time. Their decision making is not a one-time conversation. It's dynamic. It's each time you see the patient you need to revisit this with them and it also looks at their level of coping, their resources for coping, their resilience, their anxiety. All of that dictates at any given time more or less of a clinician driven approach. So we're always going to keep that in the back of their mind that this is dynamic and it changes over time. If we need to figure out where the rubber meets the road, so we understand shared decision making, most of us deploy it anyway in our practice. We understand the behavioral underpinning. How do we use it in a framework? Well, our colleagues in geriatrics have a framework called patient priorities care and this is a framework that they designed for delivery of shared decision making. When they designed this framework, they used input from patients, caregivers, clinicians, health systems leaders, payers and healthcare design experts and they really had a goal of identifying, communicating and providing care consistent with patients health priorities. They did a non-randomized clinical trial and they found that patients in the patient priorities care group reported a five point greater decrease in treatment burden. And this circles back to our earlier slide about self-determination theory and these two things align and that when the patient is involved in their decision making, their perception of treatment burden is that it's lower. When we apply this into a framework, we have a team here that developed out of a debate earlier this year. We've decided to pursue a framework applying patient priorities care. We set it up where we look at an older adult who we have a high suspicion of cardiac amyloid and we break it down into three categories. In the first category on the far left, this patient has no functional limitations. Their life expectancy outside of the diagnosis is greater than 10 years and they have very few comorbid chronic conditions. This aligns with the left side of the earlier graphic where things are more straightforward and the authority gradient is pretty steep. We have guideline directed treatment. We can talk to them and put them right into that if that's what they're open to. On the right side, we have someone who has significant functional limitation. Outside of a diagnosis, their life expectancy is less than one year and they have advanced illness. Again, this aligns with our earlier graphic where they're on the far right and you're really going to consider for this patient population palliative support and potentially hospice support. Right here in the center is where we find ourselves most of the time and that's where you have a patient with some functional limitation. Their life expectancy outside of the diagnosis is around two to 10 years and they have multiple chronic comorbid conditions. This is where we're going to deploy the patient priority care shared decision making tool. It really is in three steps. The first step is that we're going to share our knowledge with the patient in their words on their level. We're going to give the patient information about diagnostic testing and treatment options along with the connection to symptom improvement with their prognosis and treatment burden. We're going to be very clear, again, this authority gradient is steep. We're really sharing information with them. The second piece, we're going to identify and prioritize the patient's goals and values. So we're going to use motivational interviewing techniques, Socratic Dialogue, to really explore the patient's values and identify a tangible, realistic, specific goal that they want to achieve, what is most important to them at this time in their health care. And then we're going to talk with them about any apprehensions they have with respect to both undergoing treatment or foregoing treatment. And then finally, we're going to see how those things align. We're going to take the information from step two and we're going to determine if this is reasonable for the patient. If we're thinking back about our patient in the earlier slide, there were a million red flags intentionally, right? So if we were to deploy this framework for them, I'll walk you through in a second, but I will give you a sneak preview. We are publishing later this year a document that if you're not familiar with Socratic Dialogue, if you're not familiar with motivational interviewing, if it's something that you are not comfortable with, we have a document that will walk you through the language for each piece of the process. So it'll take you through each piece of diagnostic testing, it'll take you through the treatment based on clinical trial data, and it'll help you put it in the patient's words so that you can utilize it as a patient decision aid in your clinic. So flipping back to our patient, if we were to deploy the steps, we talked to our patient about his risk factors, we told him we're concerned, you have a lot of red flags that make us concerned that you have the disease. We explained to the patient that it's a disease that gets worse over time and treatment options may slow it down and may slow down symptom progression, but certainly not curative. And we explained that there are some trade-offs for testing for the disease. We engage in dialogue with our patient and he lets us know that his goal is just to get around in day-to-day life. He wants to make it to church. When it's his time, it's his time. He's not really concerned about treatment options necessarily. He's worried, though, that if he does have cardiac amyloid, he's not going to be able to afford the treatment and the money that he has set aside for when his disease progresses, he's not going to have anymore, and he's worried about his family. So this step, too, is also a part where if your perception of your patient's functional status is different than their perception, this is where you deploy language that helps them assess where they are. You're not going to tell them, you know, your functional status is a lot worse than you think. You ask them questions, okay, you told me that your functional status is pretty good. If you were to think about your functional status five years ago, is it the same or different? And have them explain for you if they feel that their status has declined. That will help them come to the conclusion themselves that they are maybe not as functional as they feel that they are. So for this particular patient, we went through the knowledge in the patient's words. We asked him to prioritize his goals of care, and we now are at the point where we're determining if treatment is feasible. So I would ask the audience, do you think it's reasonable for the patient to undergo diagnosis and treatment, and what would you offer to the patient? So I'll let you think about that, and I'll tell you that this patient decided, yes, he would like diagnostic testing only because he wanted a definitive diagnosis and he wanted to be sure that he didn't need any genetic screening to pass on to his family members. But GASP, he did not want treatment. He did not want treatment at all. But this flips us back to our slide where we talked about difficulty and motivational matrix. This is this moment in time. It does not mean in the future when we have a shared decision-making conversation with the patient that his preferences will not change. They are going through, and we all go through, a dynamic process of internal and external stimuli that we filter against our coping responses and turn into behavioral responses. Just as easily as this patient did not want treatment, we could have a patient who says, I want everything possible. I want to do everything that's possibly available to me, and then in three months' time when we revisit, they no longer want the treatment. They do not like the treatment. It's detrimental in some way, or maybe they're having a great impact. You have to go back and reassess, and reassess, and reassess your patient. So if there are two takeaways from this presentation, it's that one, shared decision-making is a dynamic process that occurs over time, and two, you want to make sure that you're always having the conversation with your patient at every visit, and that's not just the cardiologist or the primary care, it's the whole spectrum of the multidisciplinary team. Any questions? So we're now scheduled for the panel discussion. I'm going to have Dr. Nimit Agrawal to-