 I am standing in for, as the chair of the next session for Dr. Peter Singer who I told you yesterday, unfortunately is not able to join us. He's somewhat ill in Toronto, but he sends his warm wishes and says he'll be with us next year. The session is ethics training, good preparation for leadership roles in healthcare. And we have three speakers, Dr. Laura Weiss Roberts, who is the chair and the Catherine Dexter McCormick and Stanley McCormick Memorial Professor of the Department of Psychiatry and Behavioral Sciences at Stanford. Laura formerly had been the chair of psychiatry and behavioral medicine at the Medical College of Wisconsin. Laura will be the first speaker on the panel. She'll be followed by Jerry Menikoff, who is the director of the Office for Human Research Protections, the OHRP, which is a component of the Office of Public Health and Science in the Office of the Secretary of HHS. Jerry is also an adjunct faculty in the Department of Bioethics at the NIH. Third speaker will be Lois Nora. Lois was president and dean of the Newcombe, the Northeast in Ohio University's College of Medicine and is now the president emeritus and dean emeritus for Newcombe. She continues to work there as a professor of internal medicine and behavioral and community health sciences. Before that, Dr. Nora had been a professor of law and neurology and the associate dean of academic affairs at the University of Kentucky College of Medicine. So these three speakers will talk to us about their leadership experiences. There is then a lead-in to, at the end of that session, Ken Iserson is going to speak for a few minutes, just lead us into lunch on ethical issues and global health, because Ken has done some extraordinary recent work in that subject. But let me begin by having Laura come up and start. I thought I would take almost a gentle approach to the topic of leadership in our field. Oops, how do I change? How do I make it go forward? Here we go. And this topic came up, because Mark and I were talking one day about how remarkable it is, how many people who've had ethics training in the center have ended up in really very significant roles in healthcare, leadership roles. And so I thought what we could first do is look at the question by first thinking about what are the qualities of leaders. And if I could just ask you, it's before lunch, it's been a dense day already. Just imagine for a minute someone who you consider to be a great leader. I'm not talking about your boss. I'm not talking about people who have ended up being kind of in charge of things and responsible things, but I'm talking about people who you really believe have great attributes as leaders. And we're going to try to explore that just a little bit. And I think probably a great hero for many of us is Helen Keller, who talked about how the world is full of suffering, but full also of the overcoming of it. And I think the leadership attribute that she really possessed is this notion of purpose and of calling, where the individual is subordinated to something far greater, something much more substantial and meaningful. And there's also a quality of leaders that they just don't give up. They're tired of giving in. They kind of tenaciously and fiercely hold on to critical ideals that are greater than the individual person. And they're also action-oriented. If you think about these wonderful words of Florence Nightingale, I think once feelings waste themselves in words, they ought all to be distilled into actions which bring results. And the statement by Shakespeare that action is eloquence. The other attribute I think that's really quite present when you think about many wonderful leaders is this empathic connection to others. Much of the hardness of the world is due to the lack of imagination which prevents realization of the experiences of others. So the capacity to appreciate in a deep sense the experiences of others, that meaning of it, and again the subordination of the self to that larger task and character. People grow through experience if they meet life. Honestly and courageously this is how character is built. Leaders are the people whom we entrust. It's not a careerist thing. In fact many great leaders, they did not in any way intend to have the careers or the tasks that they had taken on. It was because others turned to them. They were the ones who others would prefer to hold the responsibility. It was their judgment, it was their kindness, it was their thoughtfulness. They were the ones turned to. And leaders, I become leaders because they're entrusted with leadership by others. And this notion of your experience informing it in the courage that it takes to really be a great leader. And what many people who are in these amazing leadership roles will say is, I have no choice. I must stand for this. I must do something. Necessity does the work of courage. It is a very fundamental commitment. Now if you look at the literature on leadership everybody talks about vision. What's the clarity? What's the future? What's the thing that the person stands for? And I really value that too. This notion that we must imagine and create a better future. This is the notion of vision and immense clarity as we approach that. And the patience to see it through long as the road from conception to completion. So it is the ability to envision a future, the ability to work your way through it, and to have that capacity and that tenacity and pragmatism. But what I've been struck by in my leadership roles are the givens. The givens of immensely wonderful leaders. It's the absolutes. It's the things you don't have to explain. And I'll give one example from Mark. When I was a medical student and I was a pregnant medical student and no one else was pregnant anywhere around me, it was just an absolute given that he would support a young woman in medical school. Even though at that time it was really quite an act of deviance to have been a mother while also a medical student. And it's just the givens. The other thing that people who are in these positions of immense responsibility will tell you is things come at you. There is no way you could be prepared for every single thing that comes at you. And really it's just your basic set of values. It's the absolute givens, what is permissible and what is not permissible on the basis of your fundamental beliefs as a person. It is the givens of leaders as well as the vision that is fantastic. And I sweat if anything comes easy to me, I mistrust it. Leaders work hard. Now this one says, how come I never hear you say please and thank you? And the notion that leaders are often role models, they have character attributes, they have qualities that get amplified across the groups that they work with, the systems that they support. And the notion that who you are as an individual becomes part of the fabric of your leadership. The other thing that leaders can do is they understand and know how to assign significance. Not every problem that comes at them is of equal weight. You assign priority, you appreciate the meaning of certain situations rather than others. And yet when they find themselves in an ominous situation, great leaders have the ability to kind of find the path that will lead perhaps to a better outcome. It's not just positive framing, it's not just optimism, but given what's out there, given what exists, how will we find our path? And I love that Al Johnson talked a lot about the notion of Stephen Toolman helping chart the course going forward. There are no guarantees, nothing simple, it's always complex. But the ableist navigators can kind of seek a better outcome. Now this one is for my, I hope you understand, the idea is your four aces don't beat my two eighths unless you've got a red king. The world is totally irrational and the rules change all the time. And so this idea that you are able to kind of look at complicated, messy, absolutely unpredictable situations and really work your way through and still play the game. In recent years we are one world. This I quote I think is especially relevant, I suppose at leadership at one time meant muscles, but today it means getting along with people, the capacity to cooperate and collaborate and communicate. I love this. Have you got any others with more spikes? Communication is really a critical skill, the ability not just to hold these values and emulate these values, but to actually get them across to people. Now this one saying no. Great leaders say no sometimes. They're not just affirming of some positive thing that you agree with and wish for. Being a wonderful leader means that you have to make choices, you have to say no and you have to be firm. And if you fail to say no, bad things happen. As a result, you stand alone many times. A leader does not deserve the name unless occasionally he's willing to stand alone. And I think I told you in previous years that my husband several years ago talked about how as a psychiatrist in ethicist it's a wonder you have any friends at all. Then I became a chairman and really you don't have very many friends. It is a lonely task and the courage to kind of stand alone with hard decisions to say no, to be affirming and inspiring at the same time is very, very challenging for many people. And to do it without becoming fearful and without communicating your fear of the uncertainty of the future, the consequences of the decisions, you must hold those feelings very carefully. And the other thing that people I think it's under recognized about leaders is it's not just the action you take, it's the times when you sit still, when you sit on your hands, preventing unwise steps. And I think many of the talks today kind of speak to this. Standing still, listening, not taking premature action. Here's another one, either cheer up or take off the hat. Good leaders will hold steady even when it's not a lot of fun. And so when you put it all together, the kinds of qualities I can ask you to harken back to the imagining of the person you thought of when I asked you to think of a great leader, the sense of calling, the deep sense of purpose, the subordination of self to that sense of purpose, the clarity and envisioning the future of how to get there, tenaciously holding it, courageously holding it as important, collaborating and engaging others so that they are with you in this and entrust you with this, communicating it well, having the capacity to very naturally hold immense responsibility and then at times to be calm while you're doing it. It's big, it's really big. So, okay, that's all very elegant. Does ethics training help prepare leaders? I wish we could take a vote. I would say in certain attributes yes and in certain qualities no. So we'll get to it. The first thing is as you have ethics training, you really do become more explicit, more rigorous, more thoughtful about what Professor Thulman talked about, substantial arguments, what we've been talking through this morning. You know, this idea of intuitive appreciation of human experience and decisions, but really the careful rigorous thorough analysis that precedes that and marrying those. The use of data is I think probably one of the most interesting pieces that is different in this last decade, but is very important in clinical ethics analysis and very important in leadership. But this piece is I think probably the most important contribution of ethics training. It's this notion that the mind can only see what it is prepared to see. In ethics training, you have to pull pieces out, implicit values, psychological issues that are very uncomfortable, societal issues that are almost unbearably painful to look at and pull them out so that you can see them. The process of learning in clinical ethics and in moral philosophy and bioethics, this notion of pulling it from the implicit to the explicit and then being able to see it in the future. And this is a great quote, all the thoughts of a turtle are turtle. You could work on this for a really long time. But this notion that we get very set, we are caught and bound in our own experience and leaders and ethicists, part of what this new modern approach to ethics is, is really trying to appreciate what it's like to be something other than turtle, something other than your own life experience is governing truth. Another one, and Claire asked you a question, dear, are you a pitcher or a catcher? And so it seems very obvious. To us in ethics, when we have learned certain things, it seems so obvious to us. Are you a pitcher or a catcher? Don't you know that rule set? Many of the people that we are working with in healthcare, in the federal government, in working in the front lines of medicine, they don't know the language, the kind of knowledge base, the fundamentals of our field that we just take for granted. And so this notion, first of all, that we do acquire expertise in an area that's fed by many disciplines, but also the ability to make it a little bit more widely held is another issue that I think clinical ethics training and ethics training can help us with. And it says here, sure footed little beast, aren't they? Clinical ethics training makes us tolerate the intolerable. We're able to hold difficult decisions as described by Tullman, probable solutions, what I would say are maybe permissible solutions that then we can work our way through and maybe go back and correct and work along that path. But being able to tolerate uncertainty, you've got to start some time when you operate on this one, do very new skills, new activities. That's always a good one. And then to really emphasize certain values, this has come up throughout the day, to lay emphasis, just the ominous cloud in the distance, but this notion of what you assign value to. Are we going to permit medicine to remain a humanitarian and respected profession or a new and depersonalized science asked throughout the last many modern decades? The cook's coffee breaks so eat your dessert. First, we are pragmatic. Maybe to a fault at times, we become pragmatic. And I think this is another thing that helps with leaders because everyone must row with the ores he has. And this is my new boyfriend. Can he have something to eat? The boyfriend could be the IRB. It could be the CFO of your hospital, the CFO of your medical school. We all have people who come into our lives and we've got to feed them. And I think in clinical ethics training, we kind of realize that there are things outside of what we wish for. It's a more pragmatic, more down-to-earth, and there are obligations and precedents, regulators, laws, things that we must take care of. So if I call the right number, why did you answer the phone? We become clear communicators and we do conflict resolution. I don't care who started it. We also learn how to deliver bad news and to do hard things. And that is not a small matter when it comes to leadership tasks. They're very, very difficult things at times that you have to do. And people make mistakes. There's nothing you can tell me that I haven't told myself already. We work with mistakes a lot in clinical ethics and leadership involves working with people who've made mistakes, mistakes intrinsic to a system. So what I would say is yes, I think clinical ethics training, and I hope you'll forgive this rather playful approach to this, but there is a caution and it actually is related to what John Lantos talked about that. Where there are no tigers, a wildcat is very self-important. The issue is narcissism. The issue is what is your motivation? The issue is what leads you to become an ethicist? What leads you to become a leader? If it's really just a self-congratulatory careerist move, I doubt that you'll be effective. There'll certainly be a point beyond which you cannot be effective. But the process of examining your own motivation, and I think there's a very significant issue in ethics which is ethicists become within organizations the turned-to-person-to-resolve complex problems. Our own biases and our own investment in enjoying being the judge and the jury, the person who is able to make these decisions is really something that we all have to be very self-honest about. And more than that, build safeguards outside of ourselves. I think in the sense that a very fine clinician, a clinical ethicist or bioethicist works hard to understand their own motivations and potentially either biases or even pathological motivations for being in the positions they're in, both as an ethicist and as a leader will be very helpful. So it is a problem, though. If you are in a leadership role and you use, for example, a lot of ethics arguments for the reasons behind certain things, you create this moral high ground that actually is a stopper for good dialogue and good shared decision-making. This kind of preachy and righteous kind of perspective can actually be very damaging in leadership roles. So that's the note. That's the question. But it's okay because creative minds have always been able to survive any bad training. That's actually the only Freud I ever quote. So we've talked about vision and clarity of purpose, the givens, the intuition analysis decision-making, the attunement and empathy, the courage and tenacity, the action and at times inaction, voice and silence that work together, the different kinds of roles and structures, the kinds of things that we do, opportunism, pragmatism, the ethical use of power, which I just underscored, the fiduciary responsibility, we're the ones that people turn to, the professionalism, our integrity, our ability to be good role models. So I would say on balance, it won't hurt and often it can help inform very good leadership to have been trained in clinical ethics and in ethics as a whole. Certainly the process of reflecting on your own knowledge, gaining a new knowledge base, being a more careful analyst of issues, these are all good things. The caution would be to be careful, be careful of your motivation, be careful of the tools you use, be careful of the power that you wield by virtue of the overlapping role of being both an ethicist and a leader within a system, which is very important to use it well. But never doubt that a small group of thoughtful committed citizens of the world to date it's the only thing that ever has. And I think that the history of this center and the examples that Stephen Miles gave of the different manuscripts and contributions that the center has made is good proof that we can make a difference. Thank you. Thank you for the invitation. This will be a little different. I don't pretend to have any particular wisdom on this topic, but what I'll try to do, and maybe this is partly a thank you to Mark and the McLean Center and colleagues on almost a more pragmatic approach on how you could use ethics training in terms of trying to effect change and perhaps improve things. And I'll personalize it a large amount just because I have to be plopped into a scenario in which it seemed very helpful to be able to say that you had some training and to use that training. So let me tell you a little bit about the office I run and the history of it and some of you, I'm sure, know a fair amount about this. Going back about three years ago, following up on the baseball metaphor we got earlier on, sort of three strikes against my office. The first of, and these all centered around, a fairly famous study that Peter Pronovost at Hopkins did demonstrated that if you had just implemented a lot of information we already knew about how to prevent, how to insert central lines and reduce the number of infections that result from that. It was a very, very effective demonstration of the ability to really produce better results for patients. Well, I told Gawande and ended up writing a piece in the New York Times, an op-ed, and he actually had a fair amount of misinformation about it, but Gawande's a fairly effective writer and so he starts out discussing this squat ugly building and went on to discuss all the allegedly evil bureaucratic types who were inside this building and one of the alleged things they did was to shut down the study that Dr. Pronovost had been involved in and if you read the piece you would have concluded that these horrible federal bureaucrats were causing all these people to die because you can no longer use all these wonderful methods to prevent the central line infections and a lot of that was not true but nonetheless it got a lot of people barked up. Your second strike was a few weeks after that, Jane Brody, these old New York Times events wrote another piece which she sort of followed up on this and then further encouraged everybody to write their congresspeople, et cetera, and complain about all these horrible bureaucrats and then the third piece was that the New York Times actually wrote a real editorial on this, titled something like Pointy-Headed Bureaucrats and kind of saying, gee, this is a horrible thing to do. People in HHS took notice of this in terms of leaders who often don't like people saying very, very bad things about tiny subunits in your department. Health and Human Services has about 44,000 people and nobody by and large except you were, if you were in the details of IRB work knew anything about OHRP before this and suddenly people all over the place were talking about it. So Tevi Troy, who was the deputy secretary at the time, got involved and kind of wanted things changed. Interesting, Tevi Troy was from a very seriously Jewish family and he was a serious Jew. I'll say this as a non-serious Jew and if you ever met him he would often take you to his conference room where he had this display of yarmulkes that were used for Bush's election. This was still during the Bush administration and apparently at some point he actually donated these to the federal government so they may be on display somewhere. So anyhow, so I end up being at OHRP and there was actually a fair amount of merit to a lot of the complaints that were being made about what was happening. And I want to go through some of these things and one of them was basically that we had this system that was seriously out of whack that was causing people to spend a great deal of time going through huge administrative burdens and trying to allegedly improve the ethics of human subjects protections. But a lot of people were saying too much of this effort was being expended on very, very low risk studies, a lot of social and behavioral studies and even studies like the Pronovost study that a lot of people would have said, gee, this is a study in which pretty much you were doing things and everybody agreed for standard care. It's QI, QA, why do we need all this burdensome review? So this is one of the huge problems with this system and so the question is, is there a way to use ethics in terms of kind of shifting the debate? And so one way to think about it is, well gee, maybe there are ethical arguments for saying that the current system is not functioning correctly and so one way to kind of play with that is to argue that by expending all this time and effort on the very low risk studies, maybe what we are doing is in fact something that is unethical. And so this is one response to the complaint that a lot of the reason why the system was out of whack was not so much all of the rules and regulations, etc. because in fact these rules were fairly flexible but rather that people in certain institutions were over-interpreting these rules. So again you try to change the direction of the discussion by saying, hey, by over-regulating the low risk stuff, by expending too many resources on these low risk studies, maybe you're doing something that is unethical. And I know some of us have sort of found that actually by altering the argument in this way, I mean it's not a huge change, maybe this is misusing following up on Dr. Roberts' point, maybe it's misusing ethics in that way, but nonetheless it actually can be very effective at a policy level. For whatever it's worth, and to be honest I think in many ways ethical thinking isn't all that different than other reasoned ways of thinking, the way lawyers and others think, but nonetheless there is a sense in our society that ethics is somehow, you know, you're looking to some sort of higher source, it has a greater importance to it. And so when you recast something in terms of an ethical argument, you're not really saying anything different than what's said before, you may get greater and greater attraction. So following up on that same theme, in terms of another aspect of the system, not just on the low risk studies, but in general many people would say that even on the high risk studies, even in terms of clinical medicine for example, our system is seriously out of whack because we basically have a gazillion people involved in IRBs, et cetera, reviewing studies left and right to make sure they're ethical and what we have for example are, you know, on your multi-center study virtually having one IRB at every center reviewing the study, the result is a massive amount of time spent on trying to improve the ethics and it's far from obvious, so getting back to the excellent points made earlier on in the pediatric sessions and even more closely to that, that we need actual data to demonstrate are we getting appropriate results. Well there's not a lot of data about how well our system of human subject protection is working. A lot of us would love to see much more data but for the moment given the absence of the data, maybe the one thing we don't have to be doing is basically having hugely duplicative reviews of studies. So again, all you have to do is sort of retweet the argument and say, hey instead of the conclusion most people probably would come to that by having all these IRB reviews we're doing such wonderful, wonderful things we're attaining the highest ethical standards you flip it around and sort of say well hold on a second, by doing this maybe you're actually diffusing responsibility and you're producing studies that lack scientific integrity precisely because you now have a hundred sites doing a hundred different things in terms of how they enroll people and maybe that isn't a good thing and therefore we've actually lowered the level of ethics by doing this sort of thing. So again, it's sort of a way of using your ethical arguments to move in a certain direction. In terms of, let me give you another example one of the biggest areas of attention in terms of human subject protection is that we're doing a lot more research using biospecimens and using data and this is certainly going to be a growth industry and we've already heard discussions of using genetics and genomics and this is incredibly important stuff. One of the ways our current system works is that you could start out having collected some of these materials in a research study and then down the road somebody else wants to use these materials for some different purpose and what they end up doing is stripping the material of the identifiers and under the current rules we concluded you're no longer doing human subjects research and so the notion is it's perfectly fine at that point not to have to re-consent even if the original consent didn't point out to the person that by the way we're going to do this stuff down the road and that's basically the way the system works and so the question is is that a good way to do it and might we want to change the system and to give you the extremes to which people sort of become very oriented in terms of narrow rules regarding this I had gotten questions from certain very high level people who were proposing in certain scenarios you had a consent form that had a fairly standard paragraph in there saying by the way we promise not to use these materials for commercial purposes and so the argument people were coming up with hey let's strip the biospecimens of identifiers and we'll give them to a new researcher and then they'll use them for these huge commercial purposes and this was said with a perfectly straight face and they wanted to actually get the regulatory take on this would this be okay? So this is a scenario in which in your benefited we had Laney's advice and others on SAACARP or advisory committee which reviewed this this way of going about these things and concluded this is unethical now at that point they wanted to say it was unethical but it wasn't regulatory violation but again using ethics in terms of pushing the envelope a little bit you could then go one step further and basically say well it shouldn't just be unethical let's use the ethical thinking to change policy because the bottom line is a lot of us knew it could be unethical but that's not going to prevent everybody lots of people from going ahead and following this approach so let's use that argument and then change the rules and then say look if you've sort of promised something if you've collect something under certain conditions it's a no brainer that it's not good for the system to then turn around and use it a different way and the bottom line is that people are going to disrespect the system if they learn about this why not they do the right thing if you wanted to do that in the first place then rewrite your initial consent form so another example of sort of how you could again use ethical thinking to sort of make policy decisions and let me just close with some comments about informed consent I often find it hard certainly in the human subjects area to sort of figure out going back to the earlier point about what works and what doesn't work we often don't have a lot of data on things that are not effective but the theme of autonomy and letting people make their own decisions is a clearer theme I think than the other sorts of things IRBs do in terms of balancing risk and benefit and that sort of stuff we don't really have very, very good answers on that but autonomy is huge and it's something that people in general you don't have to be a philosopher you don't have to be a bioethicist to understand the strength of that theme and it is certainly one area in terms of human social protections that we have a long way to go there's no shortage of articles out there saying that we're probably not doing the best job we can be doing in terms of obtaining consent and similar things and you see this all the time a recent example is probably the most debated recent drug or one of the most debated is Evandia and huge scenarios about whether the drug should or should not be on the market but the sub-scenario into all that was that there was a research study taking place recently and there was actually a consent form in that study and thousands of people had been enrolled in this study for over a year and it's interesting to look at the consent form for that and then ask ourselves how good a job were we doing in terms of that study to give you one final vignette people often think regulators have incredible amount of power in terms of punishing people it's sort of surprising I have this little office that allegedly people quake are doing something and we actually don't do a lot in terms of punishing entities I mean if you look on our website 10-15 times a year we send a letter out to some institution saying oh it looks like you did a few bad things but they're not that horrible please change your ways please change your policies etc etc but so getting back to informed consent and bad scenarios in which bad things actually happen to people we actually don't have the power to when something bad happens to somebody actually resolve that in a way that helps out the person who's been harmed and in the past the agency didn't take advantage of what is again a no-brainer in terms of just following ethical principles you go back to autonomy if something bad happens to somebody something seriously bad and this falls up with a theme in terms of clinical ethics one thing you actually can do about it there's actually an interesting example and this is all on the web so I'm not telling anything inappropriate here Columbia University did a study took place about 1999-2000 and there were seriously huge problems with informed consent in that study and Columbia has owned up to that it owned up to that over 10 years ago but one thing that didn't happen and this was big stuff there was people undergoing open-heart surgery and you're randomizing them to different types of volume expanders and for 10 years Columbia, the one thing it didn't want to do was to actually let the subjects know what happened to them and I mean it sounds like a pretty benign thing and it's fascinating if you ever want to look it up on the web somewhere because this was written up in Huffington Post and then some other blogs there were efforts that Columbia went to with very very distinguished people on panels to come up with arguments how nobody was harmed in this study and this was after to give credit to one of the anesthesiologists at Columbia who kept pushing this and got multiple reports written and ultimately Columbia concluded there were statistically significant differences in the arms with people in two of the arms ending up having to get increased transfusions with a tendency to having to go back and get re-operator on and the face of this they came up with arguments saying well but nobody was harmed in the study and it's fascinating to read but the bottom line is just following up a very straight forward simple ethical argument namely autonomy is actually a good thing and in the face of nothing else just letting people know what happened to them can be incredibly powerful probably far more powerful than all these letters you send out to institutions saying well we spent three days reviewing your records and you have 14 points in which you do bad things but on the other hand letting 200 subjects know that hey they were in the study and now they could you know exercise their autonomy to figure out what else should happen in terms of other things just another example of ways in which again I think ethics can indeed in appropriate ways be a powerful force that can affect rate change at high levels I'll leave it there morning for two more minutes I get that I'm kind of between now and lunch so the McLean conference usually overlaps with the association of American Medical Colleges meeting which in my business is a mandatory meeting so it is very rare that I am able to be here I am so delighted to be here this year in part to listen to the dialogue the studies of the past couple of days which remind me of I do not know who said it but talked about being in an environment of the greatest brain power an intellectual excitement that they had known ever since Thomas Jefferson had dined alone for dinner it really has been great fun I'm also delighted to be here to be able to say publicly something that I say privately fairly often which is how fortunate I was to have been a fellow in the center and my enduring gratitude to those faculty and staff who taught me who built the center to the McLean family for their vision and support of the center and the others who were mentioned in our program for their ongoing support and most particularly to Mark Siegler Mark asked me to answer this question of whether ethics training is good preparation for leadership roles in health care and I am coming at it from my perspective as a medical educator working at three academic health center institutions most recently the northeastern Ohio universities colleges of medicine and pharmacy the public community based now health sciences university of our region and also with work that I have done with the double AMC the liaison committee on medical education which is our accrediting body of education programs and the AMA now when asked the question I had the reflexive answer of yes and then I realized that I would have 12 more minutes to fill and so while that was reflexive my more reflective answer is going to be based on my experience in the center my understanding of how ongoing clinical medical ethics training is done and it is informed by the leadership center but it is not particularly data driven I'm going to quickly focus on yes because of certain content issues and then the process of leadership and the character of the leader and I'm going to conclude by tying this concept of leadership in medical education back to some of the broader questions of this conference by highlighting what I think are a few of the leadership issues which are also ethical issues in medical education right now related to health disparities and health care reform so to touch upon the content of what we learn during substantial ethics training and I do think it is important to distinguish between ethics light the four hours which I think can be more dangerous than many people know but an earlier speaker alluded to and substantive ethics training certainly personally from the content that I learned I think it has helped me in leadership roles because I am better able to recognize first of all to ask whether or not there are ethical issues in a situation that arises to recognize that they exist and to identify them to think about the answers but as importantly to recognize that I need to get other people who know better than I do and spend substantial amounts of time thinking through and processing ethical issues and help them help me understand the more appropriate answers and so I think content expertise can be very helpful to a leader who has had ethics training but it is extremely important to recognize that one is not an ethicist and a couple of speakers previously have touched upon this I think the very fact that somehow that sometimes we are introduced and mentioned as having had this substantial ethics training it runs the risk that people believe that business decisions that we have made are somehow ethics decisions and of that higher level and we have to be careful to distinguish between what are business decisions informed by ethics and not necessarily ethics decisions and I also think it could be a danger for an unethical leader to use ethics training or this in a power situation that would be inappropriate so those are the comments on content but leadership is a series of acts a way of behaving and ongoing activity that an individual does and it's not the CEO or the person in the identified leadership spot I would suggest to you that if there's a leadership point to take away from my session it is that we all lead from the middle and medical students in medical schools have enormous power if they choose to wield it and so have responsibilities to wield that responsibly faculty, deans presidents of institutions and the like all have power but ultimately we all lead from the middle in terms of process I would suggest that the single most important tool that any leader has at her disposal is the process that she uses in her leadership and I would also suggest that a critical element that can make or break success for any organization is the character of the leader and that is where I would suggest that in both of these areas process and character I believe that substantive ethics training that I received has impacted my leadership and I believe could make a difference to others when I think about how clinical ethics training in particular is done the case-based approach the emphasis on certain skills that I would suggest are leadership skills and have been mentioned earlier by Dr. Roberts empathic listening Jim Collins in his work good degrade and the rest talk about the importance of good questions well how much time do clinical ethics fellows spend thinking about what are the good questions to be asked the analyzing problems the recognition that oftentimes the stated issue is not the issue at all how many times is ethics consulted because it's really a communication issue the recognition that I think is inherent in clinical ethics training that in many ways it is all about relationships and building relationships considering interdisciplinary perspectives considering all perspectives evaluating and understanding power differentials these are things that are part and parcel of clinical ethics training and they are also part and parcel of excellent leadership problem solving via the application of principles but as others have suggested also looking at the relationship issues and then advocating for positions oftentimes not always the most popular or necessarily cost effective something that ethics fellows certainly have had experience doing I note that medicine and higher education both are noted for taking leadership and identifying leadership be they department chairs, deans and the like oftentimes out of the content strengths are truly outstanding researchers are promoted to leadership as chairs or as deans and yet oftentimes leadership demands a skill set more of what I have just talked about that is not necessarily inherent in becoming the most talented researcher and so a skill set and in fact sometimes becoming the best at one's discipline is at odds with the skill set that is necessary for leadership we know that leadership is enhanced by emotional intelligence Daniel Pink in his recent book Whole New Mind presents six essential right brain skills that he considers important for success in the coming age three of these story and the importance of narrative empathy and finding and creating meaning in one's life and the integration of all three of those aspects are fundamental leadership aspects that I would suggest are handled better in some clinical ethics training program than in many other sorts of education that we do in medicine and finally a few comments on character there are few places where character values, virtue are talked about as robustly as they are within clinical ethics programs the importance of virtuous behavior of prudence, courage, humility honesty, self-discipline habits of self-reflection as to whether those values are present or characteristics are present in ourselves are something that are fostered in many ethics programs and I would suggest that that is also an extraordinarily important part of the development of good leadership not only the recognition of the importance of those attributes but the discipline of the self-reflection and always trying to get better and so I would suggest that the content can be a positive or a negative but in terms of leadership roles be they in ethics or be they elsewhere there is much about the process and how ethics is done and about the character driven aspects of our training that can be very, very helpful I want to finish with just a couple of minutes on a few issues that I think are of critical import in medical education right now and relate to health disparities or health reform. Relative to disparities I just want to remind all of us in this year in which we appropriately celebrate Abraham Flexner for his the hundredth anniversary of his important work is important to recognize that health professions in general and medicine in particular do not reflect the world that we live in one of the outcomes of Flexner's report was that the schools most engaged in educating women and in educating black physicians closed and they were oftentimes as good as schools that stayed that were made it through and stayed open proportionally Steinke and others demonstrated this in an academic medicine article recently proportionally there are fewer African American physicians today than there were at the time of Flexner so the admission to medical schools and to our profession of people from groups underrepresented in medicine is a leadership issue it is an ethical issue and yesterday several times I heard us talk about how important this is in terms of addressing health disparities and it absolutely is but I would suggest to you that we have an equal responsibility any time that we mention health disparities to recognize and to state that our African American students are Mexican American students other students who are underrepresented in medicine have as much right as anyone else to become a highly paid Gold Coast specialist as well and that somehow we have to be careful that the discussion of health disparities does not turn into a discussion of people taking care of their own and similarly I would suggest that it is inadequate when the numbers finally do reach parity to suggest that majority physicians do not have the responsibilities for providing care for all people regardless of race or socioeconomic status I know I'm speaking to the choir but I need to make sure that we explicitly say this and so leadership right now in terms of access to medical schools include leadership decisions oftentimes fall around measurement what we fund and what we talk about I will tell you that at the double AMC meeting Alvin Poussaint the Harvard psychiatrist who has been very engaged in successfully increasing representation in medicine talked about the fact that now that we measure the numbers of black students in medical schools is actually resulting he is concerned about us recruiting more African black students and Caribbean black students and yet he is concerned that the number of students that he calls native African-Americans are dropping dramatically and we are not taking care of that group of citizens in our midst we also talked about funding offices, offices that used to be responsible for minority affairs in terms of recruiting underrepresented minority students and supporting them are now also doing cross cultural competence training our assisting and supporting our LGBT students are doing a great deal of things in terms of women programs all very important but with the same number of people who are inadequately funded and finally what do we talk about at the 100th anniversary of Flexner's paper I was invited by the AMA and double AMC to say a few I was told to be contentious and talk about faculty I said a number and I guess I was contentious from what I heard back but I will tell you what surprised me the most in what I said because I thought it was a no brainer I said to my audience that K through 12 education is the business of American medicine and the business of academic medicine because we are not going to reach parity in numbers and we are not going to change the health of the country if we do not attend to K through 12 education that is the single biggest comment that I had from my audience out loud we have got enough to do don't make us do that as well so the questions we address the leadership we do what we fund, thank you so much Mark and Dr. Roberts for asking the question for letting me be here I am Ken Iserson from the University of Arizona now international disaster medicine physician you never heard of one of those probably I start by thanking Mark for not only his leadership in ethics and letting me do this program before some of you were born but also fitting me in when we found out at the last minute that I would be between coming back from Bhutan working and going off to Ghana next week so thank you very much transitioning to this talk took a little thought it is kind of a non sequitur except that this is taking us from yesterday's talks on global health to global medicine what we may actually do or our colleagues may do it goes to the amazing panel that we had on Steven Tullman we are going to talk on a case based approach we are going to talk about three cases and it is going to take somebody's leadership to help remedy some of these problems we are going to talk about global medicine international medicine clinical practice research and system development but we don't have time to talk about all of them so I will highlight two areas of clinical practice and one in system development and there are unique bioethical dilemmas in all of these areas both US physicians as well as other physicians from the most developed countries now my bona fides I have actually taught or practiced on all seven continents yes including Antarctica six months so yes okay hey the weather here is great I don't know what you guys are complaining about one of the big problems we have is we are sending a lot of people out both trainees and experienced clinicians to do international medicine and they are just not prepared to deal with the ethical issues they know about the strange clinical issues in some cases but they can't deal with the ethical issues and I have seen this over and over again so the question is whose responsibility is it to orient ethically these clinicians were sending out and I suggest to you that it is the international medicine programs that exist in lots of specialties non-governmental organizations the NGOs and they proliferate government programs and others who send trainees into the field the overarching principle if you are doing global medicine is to teach them to fish and we forget that and if you look at your paper here in Chicago or wherever you live there is always the headlines for the physicians who did great work they did 12 surgeries they went to blah blah blah country and you know great and then they leave and they leave behind what a few people who got better and who may have gotten better with local resources anyway so we want to leave sustainable changes and that is very difficult to do unless you really are able to involve the local healthcare establishment and it avoids medical adventurism and that is how I see many many of the physicians and other healthcare workers who go internationally it is just adventurism they are going to be able to tell people what they did and get some publicity feel a little better about themselves but they are not helping a common ethical problem is that the ethics that we learn here and the solutions we have here will work elsewhere and they won't because there is cultural uniqueness I hate the term cultural competency because nobody is culturally competent I was in Zambia and I tried to learn a few words I was the pediatrician and those of you who know me I am not a pediatrician but I was the pediatrician for the time I was there for a huge open bay of critically ill kids about 50 of them and the parents were there because that is part of international culture you have a parent and I tried to say some words to the kids and I got laughter from it turned out it was cow never mind let's talk about clinical practice two cases in clinical practice clinical practice triggers the most obvious and wide ranging ethical problems and these are the types of clinical practice in global medicine you can do it for pay or with an NGO you can volunteer with government entities individual providers and there is a lot of consultants now in person and electronic so here is a real case major earthquake and subsequent tsunami that sounds familiar occur in a remote but heavily populated area of the world you go and organize in your medical center a healthcare team they are pretty competent and you decide you are going to pay for it you carry some basic equipment and you get on a plane and you go there and it's really beneficent yeah she thinks so doing that responding to disasters and I do respond to disasters with our disaster medical assistance team is the most high profile global medicine activity it's real goal should be to supplement the available healthcare resources to save lives immediately and then to get out this is not the training situation generally and the underlying ethical principle is utilitarian you have to do the most that you can for the most people not individual intensive care which is what we do and that's a very very difficult thing but what we know is actually counterproductive and it's unethical to send this little team over and actually Sherwin Newland who many of you have read he's a great writer he wrote an article if you can't read it from the new republic April 11th 2005 and you can get it online and he talks about his experience doing exactly what I just described and what we know is that these kind of little ad hoc teams use resources do not know how to get involved are a drain on the local society and the local system and are basically a disaster in themselves and the only way he describes that his team actually got to do anything they were ready to do surgery because Sherwin Newland is a surgeon the only reason they could do anything was because one of their team members happened and someone big in the local government but they were basically useless and he says that which is good so also sending unrequested supplies and the United States has graded that we send all these the churches send us your used cook oh come on they have piles real picture of just one warehouse filled with piles of junk sent from the United States to a disaster area and so they're supposed to use their resource to sort it and distribute it and they don't they can't do that and finally an exit plan when we do respond even with teams we need an exit plan we need to get out when are we going to get out where is to get out Haiti is crazy in terms of what the exit plan was but they had an exit plan right away they pulled the American organized teams out quickly after they did their acute response and that was good they probably have to send them back in now that there's color in Port-au-Prince but one of the questions is how do you know the contentious that's how do you know when you've rebuilt a slum enough and Haiti cannot support anything and you'll see more of that in the coming weeks I'm afraid okay here's another case a case I was involved in also an apparently normal full term delivery mother is healthy and vaginal delivery boom boom boom two western doctors happen to be making rounds they walk in on this this is in a remote hospital and the nurse midwife is staring actually just staring at the kid and they take the kid to the corner and start resuscitating the kid kid has sputtering signs of life comes up heart rate comes up goes down it comes up goes down everything gas and you know over 20 minutes and during that time what do they do they're talking about ethics because they can do the resuscitation automatically and they're saying what do we do next the nearest nobody has ever ventilated a kid in that hospital the nearest ventilator for the neonate if it's available it's a minimum of four hours away and there's only two in the country and they may not both be working we thought okay so they and so the question is what standard of care do they use do they use the opportunity standard that hey we're western doctors and we can do this they had the equipment to intubate and to manually ventilate or not and that's a question that comes up over and over again in both global medicine and in wilderness or other resource poor medicine what standard of care do you use and I don't have an answer to that but in general what we go towards is the local standard of care because there's nothing else this is actually and this case will actually be published in January and Cambridge Quarterly and the outcome was that after 25 minutes or so the kid just started I mean his motor motor kicked in and he just started being completely normal so what was the standard of care at that point you pick up the kid you hand it to the mother who was just watching us do the whole thing wrap the kid up mother puts on her clothes hops off the table walks out the door turns around to us and in BEMBA says thank you very much and walks over to the post part that was what can I say medical system the last thing and I was involved in this too you're involved in this too taxpayers a large U.S. sponsored medicine assistance program goes to different parts of the world on a relatively routine basis for long periods of time spends huge amounts of money provides hundreds of healthcare workers for indigent populations in resource poor settings they don't have enough medicines they don't really deliver much care people are cascaded for spending more than three minutes per patient you have 15 minutes in turnists fuel and this is with most of them we're using interpreters so you got to cut that in half and they're basically there to generate PR and you're paying for this and they're not teaching anybody anything and this is a recurring basis and it's millions and millions of dollars being spent all the time so some of the problems with that are that it superficially seems very good and they get a lot of PR for it but it undermines local healthcare providers who hated seeing them show up it disregarded the basic principle of preventive medicine and they could have done that on the cheap and really been effective and actually most of the providers, the primary providers recognize the problem and were disillusioned so conclusions bioethical dilemmas do exist in all areas of global medicine and we just, I just pointed out a few preparation and reading, discussions listening to people who've been there and done that will help somewhat in dealing with ethical problems but people have to be aware of that ethical training has to be part of preparation for people doing ethical international medicine, global medicine and it's up to us as leaders in ethics and in many cases leaders in medicine to make sure that that is happening by the way the top pictures the top right and top left are from Antarctica where I spent 6 months as the chief physician for the US Antarctic program and the one over here on the top is actually the South Pole that's my picture of the South Pole well thank you very much and we'll enjoy our lunch