 So it's my pleasure now to introduce the final speaker of this session, and that is Dr. Karen Devin. Karen is an endocrine surgeon, general surgeon. She has an appointment at the Women's College Hospital and an associate staff appointment at the University Health Network of Toronto. Karen was our very first endocrine surgery fellow here at the University of Chicago, and she also did the ethics fellowship and since being back at the University of Toronto, she's been doing some tremendous work. So Karen, welcome. Thank you so much. It's great to be back. I just want to acknowledge a few people. In particular, Ryan Snellgrove was a fellow who did a lot of this research with me and allowed me to shorten a longer talk that he created for today. And of course Peter Angelos, who has been a tremendous mentor for me over the past five years. And without my experiences here at the McLean Centre, certainly would not be really along this career path at all. Traditionally, matters of technical information and the transmission of technical skills have been thought to light the heart of surgical knowledge and education. And while obviously technical knowledge is essential to surgical training, residency training is also a period of transmitting professional identity and the associated rules and expectations for behaviour. These are not the same types of knowledge. And while we do a relatively great job at technical training, I think we could be doing better making surgeons. So when I got to Toronto, someone gave me the advice to study what pisses you off. And what was pissing me off was that upon my arrival as the new surgeon ethicist, I was being bombarded with emails throughout the entire university programme asking me to do these add-on ethics lectures. And so I really wanted to try something different. And so I said yes to a lot of those things at the beginning to get some credibility. And now I'm saying no and trying to do things a little bit differently. So four years ago in an effort to improve the curriculum in Toronto, I introduced an ethics component into the surgical M&M rounds at five hospitals at the University of Toronto. It was a huge surgical programme with over 200 faculty and several hundred residents. This was actually inspired by rounds here that were started by the department of surgery here at the University of Chicago. So ethics M&Ms consist of 30 minutes per month wherein the ethics issues is the complication being discussed at M&Ms. So these cases would not have otherwise been presented. Residents prepare the case with a simple framework that I created based on the four-box model. And they do a literature search to find some data and knowledge on the topic and come prepared to apply it to the case. So a real case is presented as it occurred and in the same method that any M&M would be presented, and the focus of the discussion is on the ethical dilemma. The scope of the issues has been very wide, includes belief in miracles, surgical innovation, VIP patients, resource allocation in the operating room, residents operating independently, which we've heard a lot about, and disclosure of other physicians' errors. And so we wanted to evaluate the impact of this. We used a constructivist-grounded theory approach. This is a qualitative methodology where we performed semi-structured interviews and all four team members reviewed the transcripts in an iterative approach with constant comparison of data generated until we saturated themes. There were 21 participants in the study, not in the M&Ms. And this included nine residents and 12 faculty. We used an open-ended approach to interviews with purpose of sampling and interviewed a wide range of participants to really represent all experiences. We even tried to identify deviant samples, so people who loved it, people who hated it, people who never attended. And then as the theory was built, additional participants were found to sort of fill in necessary gaps. And so as I present this qualitative research, I'm going to show you some quotes which are representative of these findings. So first we're going to talk about the findings from residents and faculty who had not attended rounds or who were reflecting on previous experience with ethics education. These typically included mandatory workshops or lecture sessions. So the first theme was that ethics education is painful. Ethics was always an add-on, and there was a sense of, oh no, another ethics teaching session I didn't want to be involved with, nor did the faculty. Ethics education is ancillary. So the focus is more, oh, sorry. The focus is more on, oh, the decision-making, communication with the family or the patient. There was less emphasis on the actual medicine. Ethics education is not teachable. So the thought that one's moral character is already established prior to entry into the program and that this could not be reshaped, which is, as you know, quite contrary to adult learning theory where in this time there's actually tremendous opportunity for moral development and attitude change. It's something that maybe can't be taught. People have an opinion. I know what I think is right or wrong, and when I'm a staff one day I'll be making these decisions. So this also ignores the fact that decisions are not made independent of the context and environment in which the decision is made. And finally, ethics education is modeled. You look at faculty for how to behave, how to make decisions, and the knowledge gradient is set up to be in that direction. The expectation is that you follow the example of your staff. I say that in part because there is a paucity of other ways that it seems to be taught. However, there are obvious limitations to this. Residents don't generally know how to deal with those situations. They'll typically be persuaded by the patient's family and sort of get lost on this course of treatment that's not appropriate, or they'll have a difficult encounter, or they'll just abandon it and leave it to staff to come in and resolve it. Then the staff may come do it at a time that the residents aren't around and then there's no learning opportunity. When faculty do intervene, the lesson is far from explicit and often takes the form of humor or an appeal to protection from litigation. And this doesn't even take into account the issue of negative role modeling where residents have a hard time sort of reconciling good technical skill mentors who may role model poor professional traits. So within the traditional model of teaching ethics, learners appear to know the content as marginalized, unimportant, abstract and inapplicable to everyday practice. Expecting any modification of one's ethical posture to be adequately accomplished through informal processes such as peer interaction and role models rather than a more formal approach or mentoring might be expecting a lot of a largely unobserved, unmonitored and highly idiosyncratic hidden curriculum. Let's compare these themes to the perspectives from participants who attended the ethics M&M's rounds. So rather than being painful, now ethics education is becoming engaging and interesting. People walk away from them still talking about the issue which you don't see with the regular surgical M&M's. I could be on a subway or on a streetcar just thinking about the presentation or how things happened or the discussion that happens, especially if it's something that you hadn't thought of. Instead of being separate from clinical practice, ethics becomes seen as integral to all clinical decisions. There's ethics involved in everything that we do every day but residents and faculty may not have recognized them as such. They may have just recognized them as part of practice. I think what's involved in an ethics M&M is just bringing that ethical component to the front for direct observation. Instead of being unchangeable, actual learning does occur. Before it was going off of experience in what I've done in the past, a sort of patchwork approach, whereas now I have a more streamlined framework on the things I need to consider to resolve an issue or resolve a conflict. That's the big difference. I now have more of that background to be able to defend my decisions a lot more. How did a simple intervention lead to the emergence of a new perspective amongst residents and faculty? Instead of ethics education being role modeled, we found a more formalized method of learning began to emerge. First, people were developing a language, a language that gave this knowledge form and structure, allowing them to become aware of it. A faculty said, you gradually build up all these experiences and it influences the way you act the next time. I guess one of the difficulties is that they're so ingrained in many ways that you can't consciously dissect it out yourself. Now they have a language to describe what they're doing that they may not have been aware of. They're better equipped to apply it in real practice and better equipped to recognize it because of that. Ultimately what this leads to is an honest, open dialogue about values and expectations. It's been very helpful for both, meaning faculty and residents. You know, there's mentoring from the staff on how to deal with some of these problems where the residents may not have experienced, but I think there's also some newer knowledge and perspectives and standards that help to address these concerns. And many participants found value in debriefing of these cases. We don't do a good enough job debriefing about an emotionally or morally vexing or trying situation while we are trainees and while we are staff. So being able to say that it was really hard to see this guy die, being able to just say that I think is helpful for the residents, you can see they were getting teary-eyed while we were discussing the case. Discussing these cases after the heat of the moment allowed hindsight for critical reflection and it is that critical reflection on one's own actions and motivations that is a way that led to this sort of transformative learning. I think that's one of the good reasons, one of the best reasons for doing this, is that sometimes it does highlight areas where we could be doing better. So what were the critical features that allowed this to occur? The first was this creation of space. It's something that we really don't focus on elsewhere in our surgical training. It forces you to think about these cases that you've been thinking about anyways, but gives you a venue to formally process the situation and to get opinions from others about how they would deal with it. We also sort of identified this rising tide due to scheduling. So at the beginning it was people were sort of struggling to figure out what cases they would present. And now it's the opposite. We're struggling to decide which cases not to present because it just seems that all of a sudden there's all these ethics cases happening all the time. And so interestingly the learning of ethics and culture was happening whether the participants bought in or not. So they didn't need to like these rounds in order to be learning. The other factor was that the cases were relevant. In medical school the cases were a bit of a mystery to you because you hadn't been in any of those situations or truly understood what it was like to take care of patients. Versus the ethics M&M's it's driven by choices you make about cases, challenges that you've come across that you would not otherwise spend the time looking up these problems. Another factor was having a good moderator. There's never a lull in the conversation. It's more like sometimes refocusing people. Like let's talk more about this aspect of a case and let go of this because that's not really what the ethical M&M is about. And finally there absolutely needs to be a safe environment in order to engage in a meaningful dialogue without fear of judgment or repercussions. The topics that are discussed at them are things that we don't normally talk about and you hear opinions that you don't normally hear. People bring up the things that they're afraid to talk about in other settings and it seems like a safe environment to do that. So discussion of ethics really seems to have flattened some of the hierarchy in these surgical rounds and in the interest of time I've admitted a whole portion where we identified barriers in the one center where actually this intervention actually failed. But those barriers really mirror sort of the enablers that we have here. So in a place where the hierarchy just was so prominent it just didn't work. So the problem is not that surgeons are immoral and ethics M&M's increases their morality. The problem is that the values within surgical culture are not transparent and without a guided discussion of these values residents will struggle to assimilate the message. And so teaching and understanding ethics is a technical skill that may lead it to being understood as a tool and the use of this tool becomes abstract and really ignores the contextual features that are essential to practical application. In the ethics M&M model, knowledge is created through a language that allows dialogue, debriefing and critical reflection. And that ethics knowledge now has the opportunity to become a personal and professional identity and hopefully the making of better surgeons. Thank you.