 On behalf of the McLean Center and the Center for Health and Social Sciences and the Bucksbarm Institute, Dr. David Meltzer and I are delighted to welcome you to today's lecture in our 2019-2020 series on the present and future of the doctor-patient relationship. It's a pleasure to introduce our speaker today, Dr. Peter Angelos. Peter is the Linda Kohler Anderson Professor of Surgery, the Vice Chair for Ethics, Professional Development and Wellness in the Department of Surgery, the Chief of Endocrine Surgery and the Associate Director of the McLean Center. Peter is a highly regarded surgeon with extensive experience in surgery of the thyroid, parathyroid and adrenal glands and is also an expert in treating endocrine cancers as well as islet cell tumors of the pancreas. He has a special interest in minimally invasive endocrine surgery. Peter has served as past president of the American Association of Endocrine Surgeons. In addition to being a surgical leader, Peter is a recognized expert and a national leader in the field of surgical ethics. In fact, he's probably one of the creators of the field. Since he completed his McLean fellowship here in 1992, Peter has written widely on ethical issues in surgical practice, how to best teach surgical ethics to residents and since Peter returned to the University of Chicago in 2006, can I say from Northwestern, the McLean Center has trained more than 80 surgeons in the field of surgical ethics. By far, this is the largest number of surgical ethics fellows trained anywhere in the world. A great writer, Peter has published more than 200 articles and book chapters on his research in improving thyroid and parathyroid surgery on minimally invasive endocrine surgery, best practices for thyroid cancer management and of course in surgical ethics itself. Peter's talk today is listed behind me, the ethical dimension of the surgeon-patient relationship and why it is beneficial to patients and surgeons. Please join me in giving a warm welcome to Dr. Peter Angelouce. It's a real pleasure for me to be here with you all and I appreciate you coming and it's great to have the opportunity to speak as part of the series. I have really enjoyed the talks and hopefully the thoughts that I have for you today will be of some benefit as you think about some of these things. I have no financial disclosures with respect to this presentation. I do have some disclaimers though and it is valuable to know what those are up front. First of all, there is not a whole lot of evidence for a lot of the things that I am going to suggest to you that I think are important. Where there is evidence and where I refer to the literature, I cite those folks, but there's not a lot of proof that I can give you and certainly I don't have a lot of graphs and p-values and things like that. That's just the nature of the topic. Second thing that I have to tell you is that I will talk a lot about surgeons because that's what I am and that's what I know. I know the world of surgery and the extent to which what I talk about with respect to surgery, I leave that to you to interpret how well does that track with other medical specialties and similarly how well do those thoughts track with other clinical activities. There's lots of people that care for patients in the hospital and clearly it's not just surgeons and physicians, but I'm going to primarily talk about surgeons or talk about physicians, but again, please don't think of this as excluding other groups, but more just I am reflecting on my own experience and so I certainly hope I don't offend anyone. By way of outline, I'm going to talk a little bit about what I believe is the ethical dimension of the surgeon-patient relationship. I want to talk a little bit about why patients benefit and how patients benefit from having ethical surgeons because we generally say it's good to be ethical, but why? Obviously one could spend a lot of time talking about that, so I won't spend a tremendous amount of time on it, but I do want to touch on it. I'll talk a little bit about surgeon distress and burnout because these are, I think, again, related topics and I'll talk a little bit about what I'll refer to as moral injury in surgeon distress and how might attention to the ethical dimension mitigate some of these issues specifically related to surgeon distress. Now, I have to admit that frequently when I give talks, I've given the talk multiple times and it's very, well, it's fairly well thought out. At least I know what the slides say because I've done it a lot. This is a new talk because the unfortunate thing about being around here so long and there's lots of fellows in the room, I don't have that many original ideas and so after you've heard me talk a few times, it's pretty much gets repetitive and so I've tried to suggest some new ideas and there, again, they're not completely well formed but hopefully it will be at least a source for some discussion. That being said, I think it's valuable to think a little bit about some of the stereotypes in surgery and how surgeons are thought of and primarily the stereotype of a surgeon is that patients come and they have technical problems and the surgeon solves the technical problem and so in the world of endocrine surgery what I do, I don't fix anything actually, I only take it out. So if you have a thyroid problem, I take it out. You have an adrenal problem, I take it out. You have a parathyroid problem, I take that out also. Now, there are some surgeons who fix things but I'm not one of them. So for me, it's fairly, you know, I have a very limited repertoire and that I think feeds into the idea that I think there are a lot of stereotypes and I just want to share with you. Many of you may be familiar with this YouTube clip. It's kind of funny in some sense. Hi. Hi. Are you the registrar of anesthesia? Yes. I need to book a case. Who are you? I'm the registrar of orthopedia. Sure. What's the story? There is a fracture. I need to fix it. Okay. Tell me more. There is a fracture. I need to fix it. There is a fracture. I need to fix it. Can you tell me more? The fracture is very displaced. I need to fix it. Okay. Let's start from the basics. Where is the fracture? The fracture is in the emergency department. I need to fix it. That's not what I meant. Who does the fracture belong to? The fracture belongs to a bone. The bone is a femur. And who does the femur belong to? The femur belongs to a 97-year-old lady from a nursing home. Okay. Anything? So, you know, clearly this, there's a whole series of these. So if you want to look up on YouTube, you'll find, so there's the general surgeon and the internist, there's the general surgeon and the anesthesiologist. And there's a certain humor associated with them. But what's, of course, what's, I think, interesting and the idea that the surgeon is so focused on fixing a problem that he or she may lose the sense of what else is happening with the patient and is purely a technical discipline. I think there is some reality to that, although, obviously, this is a sketch. Now, it is true, I think, that surgeons have traditionally not been known for their incredible bedside manner. And if you think about how people choose their surgeons and you look, you know, we're all rated online. So if you look online, you can find surgeons' ratings and people, friends, relatives will tell me things like, I don't care if my surgeon is a nice guy, I only care if he or she can cut. And so I've had patients say, yeah, Dr. X, boy, I would not want to spend an evening with that person because there's no way to carry on a conversation with him or her. But they're really good in the operating room and that's all that matters to me. And this idea that there's something in surgery that's purely technical, I think, has sort of pushed the idea that really surgery is purely technical. Now, I've, in multiple occasions, raised the question, is surgery a purely technical discipline? And many of you who have heard me talk have said that, have heard me say that technical mastery is necessary for excellence in surgery, but that it is not sufficient. We need to do more in order to be good surgeons. Now, the question is, why not? Why is technical mastery not enough? Since residents and fellows spend a very long time gaining technical mastery. And so I just want to spend a couple minutes thinking about why. And the reason that I think it is not enough to have technical mastery is that the central question for all of medicine and surgery for centuries has been, what can be done for this patient? And so patients would have problems, they would seek medical attention, and that was always the question, what can we do? And generally, the feeling was, do everything you can. And this is the answer, what can be done is a medical one. There's lots of things medically, surgically that can be done for patients. Of course, today, the question has changed. And today, the question is so much more frequently, what should be done for this patient? And what should be done for this patient is not a purely medical or surgical question. And so when we say what should be done, then that assumes that we realize that there are a lot of things that we could do, but we're going to choose not to do. And part of the question is, why do we make that choice? And how do we make this determination? So how do we currently answer the question of what should be done for this patient? Well, first of all, we have to attend to the patient's values because what is beneficial for a particular patient is going to be dependent on what the patient values. And so if we have a therapy that's going to make the patient live longer, but their quality of life is going to be horrendous, then for many patients, that's not a benefit to have them live longer. Similarly, there may be therapies that we can offer that will improve the quality of life, but that life will be shorter. And whether that's a good thing or a bad thing really is dependent on what the patient's goals and values are. So it requires more than just medical knowledge. We have to increasingly engage in these dialogues with the patient or the surrogate. And so again, it's not enough to say I have a series of five things that I could do in the operating room to help this patient, but I need to, in some fashion, determine whether this is going to be good for this patient. And so that issue of what's beneficial for an individual patient, you really can't answer in purely medical or surgical reasons. And so in this circumstance, again, shared decision making is essential. And so I don't think I'm telling you anything that we all don't know, but that is sort of to emphasize or reiterate that it is a complex thing to make decisions about what's the best thing for a patient to do. It is not a simple thing to make a recommendation to intervene and do an operation for someone. So let me talk for a little bit about this ethical dimension of the surgeon-patient relationship that I mentioned. And in fact, specifically what is the ethical dimension and what am I talking about? So the ethical dimension in surgical care is the attention to the non-technical aspects of surgical care. And so there are a lot of aspects of offering surgery, doing surgery for patients to benefit patients that is non-technical. And so things like communication with patients. So many people would say, well, communication, that's not a surgical skill. But I would say that is a skill that's necessary for someone to practice surgery today. Similarly, I think it's a skill that's necessary to practice medicine, pediatrics, neurology, any specialty. It's a skill that's necessary in order to interact with other human beings and to provide them with medical care. I do think that the relationship that surgeons and patients have is really a fundamental one. And the ways in which that relationship may be similar or different from other relationships in medicine I think is certainly worthy of attention. But I'm not going to spend a lot of time on that today other than to suggest that the relationship that surgeons and patients have is generally one that has to develop in a shorter timeframe than for other physicians with their patients. And it is also a relationship in which the necessity for patients to develop trust in a very short period of time is really critical. And so we meet patients in the... So I'll give you myself as an example. I meet someone in the office first time. I've never met them. They've never met me. And within 30, 45, 60 minutes, depending on how far behind I want to get in clinic, the patients can agree or not to lie down and let me cut their throat, take out their thyroid or parathyroid or whatever. And so I'm actually expecting that patients are going to give... They're going to trust me so much. At the end of this short interaction, they're going to say, sure, I'm willing to let you do all these things to me. And I think that that's a really significant thing. And that is part of what I would argue is the ethical dimension of patient care. And I think you can identify this ethical dimension in multiple areas, but again, I'm mostly focusing on surgery. Obviously, shared decision making is central to this. So patients don't come to see me and say simply, tell me what to do. But they frequently or more frequently say, tell me about my disease. Tell me what you recommend. Can I discuss with you the options? Now, occasionally patients will say, well, if it was you, or if I was your mother, father, sister, daughter, what would you do? And I think it's appropriate for me to answer that question, what I would recommend to them. But it is very rare that patients come in and just say, whatever you think... I don't even want to hear about it. You just do whatever you think is best. Occasionally that happens, but very infrequently these days. Because again, I think patients expect and appreciate the shared decision making. So how do patients benefit from attention to the ethical dimension? Well, I think that it's this ethical dimension that gives us the background with which to answer the question, what should be done for this patient for all the reasons that I mentioned a minute ago. We need the ethical dimension in order to provide high quality care for individual patients. So again, throughout medicine and surgery, there are increasingly guidelines. There are guidelines for everything, it seems. And yet guidelines aren't helpful for individual patients because individual patients don't always exactly fit the guidelines. In addition to the fact that individual patients have their own values that may or may not match with living longer. So I would argue, again, just to reiterate, knowledge of anatomy and physiology are not enough to care for people. So we care for people and people who want us to care for them need us to know more than just anatomy, physiology, pathophysiology, etc. So let me turn for a sec to talk about burnout. And as Dr. Siegler mentioned, I have this position in the department of surgery and part of my responsibilities are related to the issue of wellness. And so in that capacity, I've been doing a lot of reading about burnout. And I don't think I've burnt out, but I think I may have been at times in my career. There's no question that burnout is an important issue for surgeons. And whether there's currently an epidemic of burnout or whether it's just greater attention to this issue, I don't think I know the answer to that. But I don't think it matters, because in either case, it demands our attention. It is in fact a big deal. We know that burnout is a tremendous risk factor for depression and suicide. And we also know that approximately 400 physicians per year commit suicide. And so this is really a big deal. This is a very large medical school class every year that commits suicide. And so I think we have to take this seriously and say as a profession, something's wrong, and we need to try to figure out what we can do about it. Now, there are a number of potential factors that have been identified, again, associated with surgeon burnout. These are things like loss of autonomy, that we are increasingly not in charge of so many things in our professional practices. And that may be an issue. Many people have identified a diminished sense of value in clinical activities. And some people have identified the electronic medical record as perhaps adding to that. That in fact it may, it seems as though the interaction with the patient is less important than the documentation of that interaction on the electronic medical record. But again, you know, you've heard some very good talks about this topic, so I won't go into it in a lot of detail. Some people have argued that in fact inclusive language may devalue individual physician contributions. And as an example, to talk about everybody as a provider suggests that we are all cogs in the wheel rather than essential actors. And so many people say, well, it would be nice if people called me their surgeon or my doctor as opposed to my provider. Now again, whether that really tips the balance or if that's a big deal or not, I leave for you to think about. But these are all factors that have been associated with surgeon burnout. And I think that they're worthwhile for us to at least think about. There's been a lot of attention to personal characteristics and what can we do personally to reduce the likelihood that we will suffer from burnout. And increasing resilience isn't one that's been identified and resilience of course is the ability to bounce back from adversity. And this has been identified as really important and I'm a big fan of resilience. Capacity is also thought to be a good thing. It is the ability to bear the many unavoidable irritants of daily life with relative equanimity. That sounds like a very good thing as well. And I think that efforts to increase resilience and capacity in all of us are probably good things. And we are currently in the midst of resilience week at the University of Chicago. Last year at this time, there was a lot of publicity about resilience week. Of course, just like this year, lots of activities going on. Last year, I thought it was so ironic that it was during the polar vortex. And so it was canceled due to extreme cold. So that somehow seems ironic that we're not quite resilient enough to manage the extreme cold. But that's another story. So all of these things are in fact important. The question is, could there be aspects of surgical practice that increase resistance to burnout? And my suggestion, and I'll come back to this, is that emphasizing the ethical dimension of surgical care may have benefits to surgeons as well as the benefits to patients that I just mentioned. So let me just turn for a second away from burnout and talk about slightly different topic, which is moral injury and surgeon distress. So moral injury occurs when we perpetrate, bear witness to or fail to prevent an act that transgresses our deeply held moral beliefs. So this, I thought, was a very nice paper. It's from a journal, The Federal Practitioner, that I don't subscribe to. But nevertheless, with PubMed, you can find anything. And I think that this idea of moral injury is a valuable one for us to think about. So moral injury, if you think about it, think about what are the things that are important to our sort of moral fiber as physicians? And putting the needs of patients first is central to deeply held moral beliefs of most physicians. Obviously not everyone. We can't, you know, generalize completely. But certainly this is central to many people's view of what it is to be a physician. Every time we are forced to make a decision that contravenes our patient's best interest, we feel a sting of moral injustice. Over time, the repetitive insults amass into moral injury. And so again, if you think about this concept of moral injury, I think that you'll see that there are a number of parallels to the issue of burnout. What's different, and the reason that I think that these are valuable to think about in a complementary fashion, burnout and moral injury, is that they are somewhat different ways of looking at clinician distress. So burnout suggests that the problem lies with the individual, that I need to do a better job, that I perhaps lack resilience or lack capacity. Maybe I need to, you know, be, practice mindfulness. Maybe I need to do yoga. Maybe I need to do something to help me relax more. These are things that would suggest that I have a problem that I should be able to fix. Whereas moral injury describes the challenge of simultaneously knowing what care the patient needs, but being unable to provide it due to constraints. And what's different about it is that the long-term solutions to moral injury demand changes in the business framework of healthcare. And so it's not enough to just say, well, I'm going to do better and therefore I will be able to avoid it. But rather, moral injury would suggest that we need perhaps greater structural changes and perhaps a different focus in what our priorities are as an institution. Now, how might this attention to the ethical dimension mitigate surgeon distress? Well, I would say that regardless of the practice setting, the individual relationship of a surgeon and a patient is an intensely personal one. And so patients don't decide to have an operation by someone at the University of Chicago. They decide to come and have this surgeon operate on them. This is, of course, an elective circumstances. In emergency situations, it's different. You don't get to choose in an emergency what happens. But in elective situations, it's different. So in an elective situation, we're asking our patients to trust us individually. And the responsibility to uphold our patient's trust is, I would say, a central motivator to what many surgeons feel is the drive to do a good job and get better and continue to pursue continuing medical education, keep on top of things, that sort of thing. Now, I think it's helpful to think about why many people choose to be surgeons. It's really the opportunity to use individual skills and talents to aid another person in need of assistance. And in many ways, I would say the joy of surgery is in helping patients. And there is no question that there are times when I am not joyful at getting up at four in the morning. But it is certainly very professionally satisfying to take care of people who trust me to do something good for them. And I do think that regardless of how devalued we may feel in our jobs for each individual patient who trusts us to lie down in the OR, we are very highly valued. And whether we think that other people value us that way, our patients do. And I think that that's significant. So how could we emphasize greater, the ethical dimension in surgical care? Well, I think that we should take seriously how well or poorly we communicate with our patients. I do think that we need to emphasize the development of communication skills in optimal surgical education and practice. Because I think there can be such an emphasis on anatomy, physiology, and technical aspects of surgery that we sometimes forget how critical communication is. And I think we need to do a better job at acknowledging the central role of trust in the surgeon-patient relationship. Now, there are certainly lots of things that we cannot control. And it's often this lack of autonomy that makes us feel bad, maybe adds to burnout. The loss of control is a major source of frustration in many large institutional practices. Loss of control increases the risk of burnout without question, and lots of people have pointed that out. But I would argue that in the privacy of the exam room, the interactions that I have with a patient are, in fact, under my control. And despite time pressures, no administrator can affect how well or how poorly I engender my patient's trust. And so I think that for surgeons, the extent to which we can focus on these things that we can control, and the huge impact that these have on our patients, I think will go a long way towards mitigating the effects of burnout and distress. I do think that how surgeons view responsibility is important, and many people are familiar with Charles Bosk's book. And it was a sociological analysis of surgical residency fieldwork done here at the University of Chicago. Bosk spent a lot of time at morbidity and mortality conferences. And he said very nicely when the patient of an internist dies, the natural question his colleagues ask is what happened. When the patient of a surgeon dies, his colleagues ask, what did you do? By the nature of his craft and his beliefs about it, the surgeon is more accountable than other physicians. And he also has much more to account for. And I think that this is really central in how many surgeons think about the things that we do to and for patients. And it is this view of responsibility that influences, I think, the major negative impact that complications have on surgeons. And so there's no surgeon that I know that is not tremendously bothered when there's a bad unexpected complication. And many people have suggested that the impact of complications, patient complications on surgeon well-being is quite significant. And some people have gone as far as to describe the surgeon as the second victim of a complication. Now, you may or may not like that terminology because certainly they're not a victim in the same way the patient may be. But nevertheless, I think it's valuable to consider. Lots of institutions have sought to reduce this impact by pure counseling programs. And I think that these are good interventions. And I think that this is the sort of thing that I'm working towards developing here at the University of Chicago. I do think, however, that focusing on the ethical dimension of surgical care can also help. And by ensuring the adequacy of informed consent from our patients, we engage them in the decision-making process in a way that's perhaps more robust. And shared decision-making knowledge is that the surgeon does not always know what is best and that complications can in fact occur. And having had these conversations does not diminish the physical impact of a complication on a patient, but it may reduce the psychological implications on both the patient and the surgeon. And so I think that these are things that can be good for our patients but also have value for surgeons. So the value of acting ethically is that I think patients benefit from having ethical surgeons. But also, surgeons may benefit from greater attention to this ethical dimension of surgical care. And attention to the ethical dimension requires physicians to attend to expertise outside of medical and surgical science. It requires an attention to things like values and ethics. I think that we are increasingly in medicine today faced with a dilemma. And the dilemma is that we are increasingly pushed to measure outcomes and quantify results. In surgery, we have NISQIP, which measures all sorts of outcomes. And we can do a NISQIP calculator for each patient and figure out what their estimated risks are. And this is good. Lord Kelvin said it nicely. If you can't measure it, you can't improve it. And so there's a tremendous emphasis on measurement and data. And I think that that's a good thing. Unfortunately, it's difficult to quantify ethical behavior, but we still have to encourage it because Einstein said nicely, not everything that counts can be counted and not everything that can be counted counts. And so there are things that we really do need to emphasize and are important, but it's very hard to quantify them. So I'll leave you with then with a few conclusions. I'd love to hear your thoughts and engage in some conversation. I think it's good to be ethical. I'm not sure I've proven that to you, but I think hopefully I don't need to twist your arm to have you believe that. I think that attention to the ethical dimension of surgical care reduces the likelihood of surgeons being considered mere technicians. And I do think that emphasis on the relationship surgeons have with their patients can reduce the risks of clinician distress. And by emphasizing the importance of patients' trust in surgeons, we may be less likely to be negatively affected by complications when they occur. And both patients and surgeons, I believe, will benefit from high levels of ethical care that surgeons can provide. So with that, I'd be very happy to answer any questions. And I thank you for your attention. I'll start with the first question. I really enjoyed your talk. Thank you. But I want to explore kind of the edges of it. And I'm positively inclined towards the idea that surgeons talk to their patients and have relationships. But let's go to the other extreme of, for example, a variety of interventions. So start with transfusing blood. On the other end of that unit of blood is a physician who knows a lot about transfusion. We never talk to them. They don't make any judgment about whether this patient should or should not get blood. They just answer a technical question, do I have a unit of blood? I can give this patient. Then step back a little more. Putting in a G-tube, you know, an interventional radiologist or surgeon does it a central line. There's really never any question as to whether it's the right thing or not. It's been put on us as internists to make that decision, and you guys just do it. The type of surgery you do, it's bigger operation. There are more physiological and technical questions. There's more potential for complications. I guess what I'm wondering is at the core of this, is it really about knowing the patient? Or is it really about the interface between complications and knowing the patient? And if it weren't for surgical complications or technical aspects of surgery that were harder for somehow an internist to appreciate, would we really be having this conversation or would we just be writing an order? Yeah, so that's a great question. I guess I can tell you what I would hope. I'm not sure, but I think that even though it may be that the medical team taking care of a patient makes the decision that the patient really would benefit from a gastrostomy, I do think that it's a little bit different. Again, I can only speak to how I look at things, and I can't speak to my colleagues in radiology or gastroenterology. But I think that most people would say, even if you really think that your patient should have it, if I think that there's really no value in doing it because the patient's life expectancy is essentially zero, for whatever reason, that whoever's on the receiving end of that request would say, yeah, I don't really think that this is the right thing. And so I do think that there is some degree to which there is a value associated with it. And so in that sense, I think that if there's a difference between having a G2 placed by radiology or having a G2 placed by a surgeon, I would hope that it is that the surgeons do feel the need to talk to the patients preoperatively and see them postoperatively. And in that sense, I think that you're right, understanding what the complications are and being able to have a conversation about them, I think is important. But I think it's even a little bit more than that. I mean, it's interesting, there's kind of the Swiss cheese model of another set of eyes. Then there's another model, I don't know what to call it of, you guys understand it better. And then there's the kind of moral distress story of don't make someone do something that really feel good about it. Yeah, right. Yeah, good point. Right. Sure. Yeah, I think the issue, so with robotic surgery, it's interesting because because I think that there is a sense and I think a lot of people sort of feel like, if it's a robotic operation, then the surgeon's not really doing the operation. I think that the way most surgeons think about it is that it's sort of like if I'm making an incision, I use a scalpel to do it because my finger just doesn't work that well to make an incision. But and similarly, the robot is a tool to allow it, but it's completely under the control of the surgeon. And I do think that the bigger the risk of the operation, the greater the impact that it may have on someone's outcome, I think the more important it is to engage in a conversation about goals and values. Now, I certainly would welcome everyone else doing that in addition to the surgeon. I would feel badly if all of my medicine colleagues were so good at knowing all the risks that they actually send patients to me just with a note, this patient needs a thyroid ectomy. So I prefer to see a patient and sort of make an assessment. Do they need a thyroid ectomy? And if so, how much of their thyroid should come out rather than sort of being, occasionally patient will come with a prescription needs thyroid ectomy. And that's helpful. But I do think that it ultimately I think gets to how I would like to believe surgeons should continue to be. So I think surgeons should continue to be doctors in a greater sense. And in that way, I think that they have to have this relationship. But you know, it may be just what I like rather than what's reality. Larry, right? Rather than say, oh, the fact that we're making the wrong test, it may be the right or wrong procedure. And it's the, I think respect is the communication that you mentioned is that it has to be there to discuss it. I mean, I get close to the center, so I get a clap over here. Right, right. Yeah, no, excellent points. And you know, I think it has been pointed out frequently, I think especially in big institutions, we frequently use our patients as means of communicating between doctors. And, you know, clearly, that's not a great way to communicate. Can I rephrase that? Yes. Typically in big institutions, we don't do that. So we tell ourselves that our patients are not doing it. Sure, sure, sure. I mean, I think that's your communication. I think it's more of us. Yeah, yeah. No, we'll state it. Agreed. Yes. All new knowledge out of this airway is my example. Another example is for stomach cancer or colon cancer. Some of them, because if you want to cut all in plain, you have to dive into those areas, which is close to the artery, which is dangerous. But some of those young surgeons, they need to be aware of this communication. And they're not cutting enough range of the tumor or even some healthy tissues. So this is something that patients do not know. But as young surgeons will face, so what's your thinking process or what do you feel? Sure. Yeah. Well, I think that, you know, the point that you make, if I can, you know, paraphrase it slightly, is that there is no question that as with experience and ability that not every surgeon is the same and that, you know, we have different skill sets and we have different levels of experience. I think that that's all true. I think that it seems to me that one of the challenges is to be able to say that I can provide a level of care that is above the threshold that is good quality, right? So everybody should be able to get good quality care. Now, there may be people who are at a much higher level than others, but there's nobody who doesn't have any complications. And so in that sense, I think that being upfront about what our individual complication rates in our conversations with patients is important, but then also ensuring that if our rates of complications are higher than our colleagues in the surgery that we got to figure out why and make a change. And I do think that it's especially challenging early in one's experience early in one's career to disclose these things to patients in a way that doesn't scare everybody off. Because if everybody always gets the operation from the most experienced surgeon, then there's only one most experienced surgeon. And then when that person retires or dies, we're done. So, you know, we have to be able to kind of teach the next generation. So I think I'm particularly ill-equipped to speak about work-life balance. And if you ask my wife, she would second that. But I think that I mean, I guess my advice is that, when you are in the hospital taking care of patients, that for every patient that I operate on, that's a really big deal. And even though it may be, yeah, I've done 10 of these this week, it's no big deal. But for that patient, it's a big deal. And I would say most patients remember the operations that they've had, and they remember the surgeon who did it. And so I think that the, I think it's really important for us to keep that front and center, that for each patient, it is a really big deal. And we can have a lasting impact positively or negatively on them. I think that, you know, sort of saying, well, I'm not going to be in the hospital all the time, I'm not going to be, I just can't do every case, you know, there are going to be times when I'm going to say, you know, I am just not able to do this. I can't add on another case. I can't, you know, there, I think that we have to in some sense be honest with ourselves. And also, I think it's to, my way of looking at it is we can do a lot of good by taking care of a lot of patients. But there is a breaking point at which we are too busy, too overstressed. And then I don't think that we're doing our best work. And then I think that's harmful to patients. So, you know, figuring out the middle road, I don't think it's necessarily easy, but I think it's a little different for everyone. But certainly I would not dis, I would not argue against going into surgery. I think it's great. I'm, I'm still happy I did. But now I became famous and I am Mr. Einstein. And in a very good language, explain to an old lady what it was. So suppose I am an old lady. I don't want to say, what is ethical. I know this standard of ethical autonomy and all this thing. But when it comes to the individual situation, like last week we had a discussion of a child that is disabled and life is difficult. Is it ethical to continue support for that person through years of misery and suffering? Or is it ethical to let it go and let the person die? And one person may say ethical, the other one says ethical, and when it comes to decision making, it becomes difficult. So who's ethical is ethical? Sure. Yeah. So, you know, that's the, you know, that's a question that has that philosophers have pondered for centuries. So I don't think I have the answer because otherwise, you know, I'd be a famous philosopher and not a thyroid and parathyroid surgeon. But I think that it's important that we not overstep. I think it's important that we not assume that everyone else shares the same values that we have. I think that largely what we can do in medicine is to try to ensure that to the best of our abilities that we're doing what's in the patient's best interest. Now, in the case that you described with, you know, a child with potentially devastating neurologic injury, what's in their best interest has much to do with what their parents say and how they may be incorporated into a family or cared for or loved or that sort of thing. And so I do think that it's not that it's all relative, but I do think that it is very contextual. And I think it is very much dependent on the family and social setting in which one is. So I don't have a great answer, but you know, you have hit upon the central question of ethics for sure.