 So our next speaker is Dr. Susan Toll, who is a professor of medicine, and she holds the Cornelia Hay Stevens Endowed Chair in Health Care Ethics there. Susan is a graduate of OHSU, and she completed her internal medicine residency and chief residency at University of California, San Diego. She then came home here to University of Chicago to be a fellow in the clinical medical ethics fellowship. And then she then went to OHSU and founded the Center there for Ethics in Health Care in 1989, and really has shepherded into what is now one of the international leaders in this effort, with programs such as the Physician Orders for Life Sustaining Treatment, or Pulse Program that we heard about last year, and more recently the Oregon Pulse Registry. So Dr. Toll is a professional internist in the Division of General Internal Medicine in geriatrics, and she was last year's recipient of the McLean Prize in clinical medical ethics. Today Susan will speak on the topic Demonstrating Mastery to Elevate the Standing of Ethics Education. It's a pleasure to be here. It's a pleasure to be at my 25th McLean Conference out of 27. Not quite all. Mark has more than I do, but it is a pleasure to be back and to see so many old friends. And while I started with this topic and it will be a part of the talk, I really came away with an essence of what happens when you're here at a McLean conference, what happens when you spend a year here, and about a theme of empowerment for all of us. I was born at the Oregon Coast, the northern Oregon Coast, and originally lived in a town of 300, where everyone cared a lot for other people in your community, but there wasn't a lot of sense that you could change the world. Our Center for Ethics in Healthcare does not accept gifts from healthcare industry sources for any of our programs, nor do I personally. In talking about what I'd like to focus on today, there are some areas in education I'd like to talk about, but going beyond that, really focus on a theme of advancing our work. There is so much that is so powerful that we've heard about today, and is it reaching as widely as it could? Are we dreaming as big as we could? So three examples of elevating our work and doing more than we may have originally set out to do, and what would that look like in three different areas? And in thinking about that, the first has to do with raising the bar in curriculum, that so many of us teach, whether it's fellowship, whether it's consult service, whether it's medical students, nursing students, pharmacy students, dental students, but sometimes what we teach isn't given the highest of priority in the curriculum. It's often difficult to measure mastery in ethics and professionalism, and we are just beginning on the path of launching a new initiative, and I'd like to share with you a seven-minute movie that shares some of our dream for where we'd like to go. Technician at the MRI said, okay, you can watch the machine while we do the MRI, and then he said, do you see this portion of the screen here? When you get back over there, you need to immediately get a physician or someone to look at this and know that she probably needs immediate attention. And he said, but do me a favor, don't tell anybody that you were in here with me or I could lose my job. Amy was being wheeled in by the techs. I grabbed the nurse that was there, and I said, I cannot explain this to you, but you have to get those MRIs read right now and see what needs to be done for her. Shortly thereafter, they did a bedside hematoma drain. I really think that had they have not done that, Amy would not have survived. Definitely the odds were against me, and I was saved, and I don't know exactly why. Any story illustrates what the program and compassionate communication will do. We will be partners with patients and their families. They'll be more empowered, will make fewer mistakes, and they'll get the care they want. My dad's diabetic, and when he went to go pick up his medication, he realized it was the wrong medication. My dad grew up in a culture that you respect healthcare, you respect people and authority, and so therefore you don't question them. The pharmacist repeatedly told my dad that this was his name on the bottle, and therefore this was his correct medication. And feeling very frustrated, my dad left the pharmacy. I later spoke to a different pharmacist. The pharmacist was very helpful, took his time and communicated to me, asked the right questions, and later did discover that my dad was given the wrong medication. Our patients are all individuals outside of our clinic. We see them as names, as birth dates, as a list of problems and medications, but they are whole people and having a little extra time in order to understand them as a person and see their journey. That really makes a big difference. It's been like riding a roller coaster in the dark. When I go to a physician, I'm possibly in English or distressed or depressed or whatever, and they can't pick that up. It's a very lonely place for me. It's not just physicians that I want a connection with. I want all the people who are treating me to be able to connect, dealing with me as a person. I may be really sick at some point, but I come out just with a better sense of well-being. I'm not all alone. Our focus as providers has shifted and away from patients and what they really need. And all of these amazing advances that we have, we really need to tilt the needle back. I think we really need to refocus ourselves on the whole person. I'd love to see the medical community, the healthcare community, come from a more loving place. What would that look like? What could that look like? What motivated me to go to medical school was people and really caring about who they are and helping them live better and healthier lives. Empathy is a skill and it's something that you have to practice over and over and over again. I think the benchmark here is not just that a doctor comes into the room and tells me what I have and speaks an eloquent scientific language about the latest and greatest treatments and offers me the very best that money can buy. I think patients here expect that their physicians, their nurses, their healthcare team are going to sit down across from them and treat them like human beings. It's going to take a sea change. Sort of like dads in the delivery room, things are very different now than they once were. Only this is much bigger. It's going to mean that the entire community stands up and pushes back and together we make things change. Moral courage is when you've got the courage to actually do something yourself including that it is more than when you merely suggest that other people do it. It's something the ethics centers prepared for for 25 years. We've made profound changes in end of life care. Now it's about the entire lifespan and every setting of care. It's big and together we can do it. I think that all healthcare providers would appreciate having the opportunity to re-center why they're in medicine. I'd like to begin with a bit of humility. There are so many of you doing so much to improve communication skills. You have an amazing program here. There are many things that are happening and together there can be a lot more synergy. In creating this video and working with my own institution, we have begun to get a little more traction on some opportunities within the curriculum that weren't available before. There are three major themes that we focus on in this particular video that we're pushing toward. One is empowerment, both of patients and families, but also of healthcare professionals throughout the entire system. Another is respect and we've heard a number of different talks including important talks about whether or not patients feel heard and respected. Sometimes they don't. And a sense of whole person care. Our institution has given our Center for Ethics and Healthcare permission to design measures of mastery for the graduating class of 2018. I don't know what that looks like yet. We don't know how to do it, but we've agreed to try. And the mastery will look at professionalism and ethics via communication skills as a graduation requirement. We also believe that by putting some of that focus, we may be able to put some additional pressure on aspects of the hidden curriculum. The modeling of behaviors we're not so proud of that we need the moral courage to extinguish. My hope is that we will be successful enough in developing this program and in partnering with people who are also bringing about these changes across the country. That we will be able to become a stronger program and be back not too long from now recruiting a fourth endowed chair for our Center for Ethics. A next area of empowerment has been our palliative care team. Sometimes palliative care teams struggle for adequate funding, adequate resources, recognition within health systems. Things are changing and certainly the new CMS ruling to pay for conversations that will go into place in January may be helpful to palliative care teams and their financial stability. Our palliative care team has become what I am not directly on the team, but I do a lot to advocate for their success. I'm referred to them as having favored nation status now. They are the most popular consult service in my hospital and they are considered the number one quality initiative for this academic year. And that means more resources for them, resources to make movies, to educate about goals of care conversations, opportunities for retreats for residents to be taught, how to have goals of care conversations or hold family conferences. It's a different way of thinking and a wonderful opportunity for a very hardworking team to get much more recognition than they have historically had. The third is to build a program that links to our Pulse program and design a new innovation since I was here last year. We have created a thing, a program called E-Pulse. You electronically go into our OHSU epic record. From the patient header it says Pulse, yes, no. You click on the button. It opens up whether they have any existing forms and you can view them. It allows you an opportunity to electronically complete a new form. The new form that you complete captures with my cell phone, the patient's signature and my own. It loads to the statewide registry, loads to the header, is available immediately and prints for the patient to take home. Convincing my institution that this opportunity to work with a company out of Stanford bio design called VINCA to create this bond on so you can send and communicate with the registry meant some extra financial outlay in IT to create this. There was a conversation and I can be a little persistent. So there were many conversations and we now have this program operational. It went live April 7th and the process of securing support means that you're really truly showing the impact like Peter Singer talked about. What will this do? What will this mean? What this will mean is that we will not have anyone intubated in our ICU who had a pulse form that said comfort measures only unless someone changes their mind. And we have gone to zero since March. That was our last one when we launched in April. This new program is remarkably effective and in a six month period of time we are able to measure lots of quality measures. One of them is how often that e-pulse button is opened by anyone. Over 11,000 times in one hospital in six months which means lots of different people are looking at a single patient throughout their admission process in the ED and in the ICU and that people are much more aware of what is happening. We've also implemented a few things relative to the trauma program that have helped in the event they're not in our system. Our next step will be to create the ability to do a bi-directional query directly from the patient header and actually query the entire quarter of a million pulse forms in our statewide registries so that if they're in a competing health system they will also show up as pulsed, yes. We expect to implement that in the first quarter of 2016. But the institution to support us in doing that and to provide the IT support behind it really shows a trust and a belief and an investment that this can work because it hasn't been done before and that it will make a difference. I welcome your thoughts. I could not have done any of this from my town of 300 on the northern Oregon coast if I had not come here, Mark. If I had not spent time at the McLean Center. If many of my colleagues had not partnered with me including some who are here like J. Jacobson and some who aren't like Woody Moss and other colleagues who are running and launching things here in Illinois like Julie Goldstein. It wouldn't have been possible to be to a place that we could convince people to invest because of the impact. You will always be a major leader in communication, Mark. And thanks to Mrs. Bucksbaum, the leader. We will do all we can to follow what you're doing and to enrich it. Thank you very much. Questions? Mrs. Bucksbaum gets to go first. The POST program is designed when done the best possible way in advance of a crisis. So you might have several different visits or you might have a visit in primary care where you received information. Maybe you watched one of our online videos about understanding POST or other kinds of resources and you came back and met with your healthcare professional or maybe there was a family meeting in the hospital before someone was discharged. And then you're ready for the button and the filling out. But obviously a great deal takes place in advance and a thoughtful conversation has occurred before we get to the technology I was talking about and certainly that should never be shortchanged. That's the most important part of all of this is are we hearing, are we listening, are we honoring what you want? And in the process then do we ultimately record it and can we find it? But I shortchanged the part about the important conversation and you're just the perfect person to bring that up. Julie? Susan, mother of all things POST. Thank you. For a brief second I thought you were going to give your, or be at your 25th McLean conference without talking about POST. Well, I almost did. But then some things happened with ePOST that were just irresistible. Yeah, so thank you for that. And so I just wanted to, since you brought it up I want to take the opportunity to pitch the national POST conference that's going to be here in Chicago in February, February 3rd, 4th, and 5th, Wednesday, Thursday, Friday. It's the first national, as you know, national POST conference that's going to be an open conference rather than one or two people per state. And so I'd encourage anybody who's interested the schedule just came out this week and it's going to be a very robust and vibrant conference downtown in the beginning of February. If you want more information you can go to the national POST website which is POST.org and there's a section under news that has, there's a little green button that has the conference information. Thank you very much. Julie's a bit humble. Julie's helping to host the conference here at Illinois as our host for this year's national POST conference and we are expecting hundreds of people and it is very different from what we've done in the past which is just to have two leaders from each state. Yes. Hi, I'm a hospice social worker and I'm here today with my partner who is a hospice physician. And so we'll use the POST, I've used it several times this week and had really meaningful conversations and thank you for that. I just wanted to ask you when you talk about compassionate communication there's a sort of a quandary that comes to my mind when I've attended these conferences which is you're using so much from the field of social work the basic tenants are patient self-determination and meeting the client or patient where they're at and I just wonder, I don't see really any evidence that I'm not an academic, I'm a clinician of those fields merging and using the expertise of people like me who are not necessarily academics but have a lot of skills in that area and using that knowledge that we come from as social workers and therapists and bringing it to bear into the medical profession. Well said. One of the things we're trying to do under the theme of empowerment is to truly empower every voice within healthcare. That's part of why we showed the story of the technician in an MRI scan who didn't feel empowered in the system and you're quite right there is much we can learn from social work there's much we can learn from pharmacy there's much we can learn from nursing and then unless we all work together and support education and knowledge and empowerment across all parts of the lifespan we won't be what we could be in serving patients. Your point is very well articulated and certainly it's a message I had intended if did not deliver. Thank you. September. I'm now humbled. You know how to make movies. Well, you know, it's I learned that here too that it needed doing. Here's my question. As the electronic medical record becomes ubiquitous and there's important reasons why we want that what I am noticing is that the capacity for clinicians particularly students who are very endowed with the ability to use computers but older attendings there is less and less contact with patients in direct interaction. So I'm wondering if you have in this compassionate conversation communication paradigm a way to help people deal with that to not have their backs to their patient while they're talking. It is such an important issue. I will tell you it greatly resonates with the public and anytime someone has been in a visit and felt that primarily their healthcare professional was talking to the computer and not to them there's certainly a real passion for how do you do that? When do you stop? When do you look only at the patient? How do we integrate things? It will be an important part of the teaching which is yet to come and I don't have all the answers but it's a huge challenge in front of us and we're very aware of it. The very basics of turning the computer around so that you are looking at the patient while you're typing gets missed. Well I think that's the whole systems level. That's where everyone goes in and says are they even in the right place? Are the rooms designed correctly? There are different things at all levels when we say see change and it does mean structurally how things happen how does the flow happen how does the teamwork happen and what kinds of communication and in the end did people feel heard and respected? I don't have all the answers I have most of the questions. That's right. Thank you so much.