 Good afternoon. It's officially afternoon, so I can welcome you. Dr. Siegler is not able to be here today. I'm Peter Angelos, one of the associate directors of the McLean Center, and so it's my privilege to be able to introduce our speaker today. So on behalf of the McLean Center for Clinical Medical Ethics, the Center for Health and Social Sciences, and the Bucksbaum Institute for Clinical Excellence, I welcome you to this presentation on the present and future of the doctor-patient relationship, and our speaker today is Dr. Angie Wall, and I'll just introduce Angie very briefly so you'll get a chance to hear her remarks. I've known Angie for many years now. She is an abdominal transplant surgeon at Baylor University Medical Center at Dallas. Her clinical interests are in liver, kidney, and pancreas transplantation, as well as living liver and kidney donation. Angie's medical training began at St. Louis University School of Medicine, where she received her medical degree, and along with that, a PhD in health care ethics. She's completed her general surgery residency then at Vanderbilt University Medical Center, and then went on to do abdominal transplant surgery fellowship at Stanford, and has then moved on to be faculty at Baylor in Dallas. Angie's extensive research focuses on clinical ethical issues and surgical practice in general, and specifically in transplantation. She's particularly interested in how listing decisions are made and how organs are allocated. Angie's current research projects include studies of uterine transplantation and living donor transplantation. She's published widely in academic journals such as the Bulletin of the American College of Surgeons, the AMA Journal of Ethics, and lots of others. Angie also has written an excellent book entitled Ethics for International Medicine, which was published in 2012, and I highly recommend it to you. Angie's talk today is the patient-robot-computer-surgeon-extender-resident team-surgeon relationship, and it really is a pleasure for me to introduce her. I think Angie is one of the most thoughtful and creative people I know in the world of surgery, and so it's a pleasure for me to welcome her, and please join me and welcome me, Angie. Okay. Is this thing on? Can you guys hear me? Okay, great. First off, I want to say thank you to Peter and to Laney, who I see somewhere up here, and to Dr. Siegler, who isn't here today for the invitation to talk to you all and to be part of this McLean lecture series. As one of the few surgeon bioethicists who hasn't had the opportunity to train here at the McLean Center, I feel like it's so cool to actually be invited to talk. What I'm going to talk about today is the patient-robot-computer-surgeon- extender-resident team-surgeon relationship, and what I'm ultimately going to talk about is how surgical practice has changed over the timeframe of the last 30, 40 years since the 1980s when the last McLean lecture series was about the patient-physician relationship. I'm ultimately going to argue that despite the changes to the context of surgery and the insertion of all of these things into the surgeon-patient relationship, that trust remains the central element of what this relationship is about. Now, before I start talking about the changes in the context of surgery, I want to just talk a little bit about how I go about creating a relationship with a patient. So I'm a transplant surgeon when I encounter my patients for the first time, it's usually right before they go to the operating room. My typical practice is that I get an organ offer, I call my coordinator, the coordinator calls a patient, the patient comes to the hospital, the resident or the fellow sees the patient, puts in orders, the nurses prep the patient, they send the patient down to the preoperative holding area, and I usually meet them there about 30 minutes before they're going back to the operating room. I introduce myself, I say, hi, I'm Dr. Wall, I'm going to be doing your liver transplant today, and then I start telling them about what I'm going to do. I'm going to make a big incision on your abdomen, I'm going to take your liver out, I'll put the new liver in, I'm going to make all the connections that the old liver had to the new liver, the blood vessels, the bile ducts, there are a lot of risks to this operation, you can have bleeding requiring blood products, infections, heart attack, blood clots, stroke, you could die in the operating room, you could have a problem with one of the blood vessels in the liver, or the liver may just not work, and we may have to relist you for a transplant. So I go through this whole thing, make sure they don't have any questions, and then we head off to the operating room. And I think that every time I have this conversation, I'm amazed that my patients even want to have an operation after this discussion, they've just met me, I tell them all these crazy things I'm going to do, and then they're like, yeah, let's go for it. And it really is overall, I think that surgery, liver transplant in particular, but surgery in general is an absurd proposal. A surgeon decides that they're going to cut you open in order to make you better. And I often question why this absurd proposal works. I don't think that the absurd proposal works because the informed consent process necessarily provides information to a patient that they can internalize, have control over, and then have so much knowledge about the situation that they're able to make a rational decision. I think that it works because sitting down and having a discussion with a patient develops a relationship and it develops trust. So when you develop this trust, you have to follow through with the trust. And the reason that surgeons continue to be able to be surgeons and continue to develop these trusting relationships is that we hold up our end of the bargain. We hold up our end of the bargain by being competent in what we're doing, by always having the best interests of our patients at the heart of what we do. And we also have open and honest communication when things don't go the way that we expect them to go so that we can keep treating our patients even when things don't go according to plan. Now, while trust is, and I think has always been the center of this relationship, the way that we gain trust and the way that we maintain trust in the surgeon-patient relationship has evolved with the evolution in surgical practice. And so that's what I'm going to talk about today, how has trust or the development of trust evolved through the evolution of surgery? The first thing that's evolved in surgery is the environment. So if we look at Stanford, where I did my fellowship training, in the 1980s, this is a picture of Norm Shumway doing the first combined heart lung transplant. And what you can see about this operating room is that it's very small. There are no screens. There are no machines that you can see in the picture, although I'm pretty sure anesthesia had some sort of machines in order to keep the patient asleep. And everybody has their eyes and their hands on the patient. Compare that to the new Stanford hospital that just opened a few months ago. This is a vascular surgery hybrid room. And what you can see is that there are screens everywhere. There is a big fluoro machine over on this left-hand side. And then in the back, you can see that there's a whole wall of screens behind the glass, where they have a control room to manage all of the technology that's needed to do these hybrid vascular operations. Another example of a high-tech operating room is the robot operating room. So here you can see that the surgeon is the person wearing the green scrubs. And he's sitting away from the patient at a console with his head in this box, doing the operation kind of remotely on the patient. And the only thing that's touching the patient here is the robot. Not only do we have high-tech, high-intensity operating rooms now, we also have changed what we can do outside of the operating room. This is a picture of an extra corporeal membrane oxygenation circuit or an ECMO circuit. And back in the 1980s, we did have ECMO circuits, but they were specifically used only for neonates who had reversible respiratory failure. And the success rate of ECMO at that time was around 20%. In 2009, with the H1N1 epidemic, the thoughts about ECMO in adults changed. So there had been a failed trial in 1979 in adult ECMO, so it was no longer used for adults for many, many years. And then in 2009, when teenagers and young adults were having acute respiratory failure that was potentially reversible, physicians revisited the use of ECMO for teenagers and young adults. And it proved promising. And now at centers like mine that are very aggressive with ECMO, we will put, I think, anybody on ECMO. I'm really often surprised by our M&M conferences when the presentation starts with a 79-year-old who comes in with respiratory failure who's placed on ECMO. It is pretty interesting. Now, not only do we have the ability to manage complex problems inside the hospital, we have the ability to manage end-stage organ disease outside of the hospital. So these are pictures of ventricular assist devices. They're tubes with pumps that are hooked up to different chambers of the heart, and they move blood either from the left ventricle into the aorta or the right ventricle into the pulmonary artery. And patients can walk around with these ventricular assist devices in place and can survive heart failure. So the question that I have with all these changes in the environment of surgery is what does the environment mean for surgical practice? Number one, I think it means we can do more things. We can do more things to treat our patients. We can operate on sicker patients who are much more complex. When I was a resident, I remember the first bad patient that I operated on was for a splenectomy. And I learned very quickly that the way that you power the devices through this thing called a drive line that goes right through the abdomen, and you can't make an incision over that because you'll cut off power to the VAD. So this patient would have never been able to have an operation, let alone been alive, before VAD technology. One of my co-residents once commented when we were working together in the ICU that we really can keep anything alive. We can keep a rock alive. And the question is what does this environment mean for trust and for the patient-surgeon relationship going forward? And I think what it means is that our patients trust us when we suggest that we're going to do some high technology, high stakes intervention. That they trust us to push the limits. They trust that we're competent to push the limits. And that we have their best interests in mind when we suggest these procedures. They also trust that we aren't going to push the limits too far. That we're not going to be placing our patients on a metaphorical bridge to nowhere. So what I think this evolution has done is that it has changed us from the mentality of what can we do for our patients to what should we do for our patients. Now another contextual change in surgery is that of demographics. Not only has the environment changed, but the makeup of our surgical workforce has changed. Here's a picture of the Vanderbilt surgery residency in 1988 to 1989. If you all notice here there is one woman in the residency program. And otherwise it's a very homogeneous group. If you compare that to the Vanderbilt surgery residency in 2017, what you can see is there is a much more diverse group of trainees and of faculty. And one of the things that's really cool is in the front row there are the chief residents. And one, two, three, four of them out of the eight are women. So it's a 50-50 split of residents here, at least of chief residents in this Vanderbilt surgery class. The shifting demographic of surgery made a big splash on social media and in mainstream media with this New Yorker cover. I don't know if any of you saw this, but this became the New Yorker cover challenge with a Twitter campaign of I Look Like a Surgeon. And what happened is that minority and women surgeons replicated this cover and took pictures and posted it all over social media to show that there really is a diverse workforce in surgery. There was also a fundraising campaign that my husband made me a part of with these t-shirts that say this is what a surgeon looks like. And this is a picture of me with my brand new baby who has on his shirt that says my mom is the world's greatest surgeon, which I just think was like totally awesome. Not only is the shifting demographic happening in faculty and happening in residency, but now it's actually moving up into the leadership of surgery. So these are five of the 21 female chairs of general surgery departments in the United States. The reason that I chose these five are that I have worked with or presented with all of these women and it's really cool that they have been a part of my training and development in surgery. So Betsy Tuttle here, she's a chair at East Carolina University. She was one of my attendings at St. Louis University and had an elective called Women in Surgery, which is basically the reason why I went into surgery. Carmen Solerzano up in the middle here is the chair at Vanderbilt. She is an endocrine surgeon and she's one of the first attendings that actually let me lead a dissection in a thyroid operation. Mary Han down here is the chair at Stamford University. She became the chair while I was fellow training there and has created a huge change in the culture of that program. Rebecca Mentor is at Wisconsin. She and I and Dr. Angelos and Dr. Langerman gave a presentation a couple years ago at the academic surgical congress on ethical issues in residency training. And then Diana Farmer is the chair at the University of California, Davis, who presented this year at the American College of Surgeons on ethical issues in high technology care where she talked about fetal surgery from an enginomyelaseal. So not only are these women personally inspiring and really involved in ethics and surgery, they're also changing the way that departments of surgery are run and they're changing the culture of surgery. So this is a quote by Julie Sosa who is the chair at the University of California, San Francisco. And what she said was she's building an organism rather than a hierarchical structure in her department. She's creating a culture of transparency and equity around salaries, promotions, career opportunities, and issues of diversity, equity, and inclusion. That's what she's doing with her department. This is from Mary Han. She's enhancing a culture of inclusion. She's prioritizing diversity, inclusion, and wellness. And I truly believe that not only are these chairs or these women improving the culture of surgical practice for surgeons, but they're also enhancing patient care with a focus on inclusion and diversity. And if you don't believe me, you can check out these couple of articles that may suggest that having a woman as your surgeon or as your physician might be a better choice. So what does the change in demographics mean for surgeons? Number one, it means that we have the potential to expand research in areas such as healthcare disparities. It means that we have the opportunity to learn from each other and to rely on each other's personal strengths in different situations. Just a few weeks ago, one of our hepatologists asked me to have a conversation with one of our patients' wives about why we were considering listing him for liver transplantation versus not listing him. And the reason that he asked me instead of one of my partners was that he thought I may have a little bit more patience and better communication skills than some of the other folks that I work with. And I don't necessarily think that's true. I think that everybody can sit down, all of my partners can sit down and have a discussion. But being able to sit there and have a little bit more patience and listen, I think, is something that at least I feel like women bring to the practice of surgery. Now what does it mean for patients? So I think that one thing it means is that patients can get better access to surgical care through culturally targeted interventions. This is an example of the Hispanic transplant program at Northwestern University. It is a culturally targeted program where they have their Hispanic patients come to a clinic that is all native Spanish-speaking providers. The discussions about living donation are led by the surgeon and not by a nurse coordinator. And there's an encouragement for the patients to bring family members so that those family members can help advocate for living donation. And they've shown that they can increase the rates of living donation in this population with a culturally targeted set of interventions. Now, the other thing it means for patients is that they may not encounter a surgeon who looks like what they expect a surgeon to look like. So probably once every couple weeks I'll go see a patient and the patient or the family member will say, oh, I didn't know we were going to have a female surgeon. And I usually say something like, well, I have smaller hands so I can make tiny incisions or something along those lines. But it does kind of sting a little bit when somebody sees me not as the person they expected to be their surgeon, because I think anyone can be a surgeon. And a recent New England Journal of Medicine study came out just a couple months ago that found that surgical residents who had experienced gender or racial discrimination had the majority of that discrimination from either patients or patient family members, not from other staff members or from attending physicians. So what I think the evolution of demographics in surgery has done is that it has done for trust in the patient-physician relationship is that it's allowed us to have the best interest of all patients, not just some patients addressed in surgical care. It's also allowing us to foster communication with diverse patients through diverse surgeons. But it forces us to be diligent about recognizing and responding to bias and to fiercely defend the competence of all of our colleagues, particularly of our colleagues that are minorities and women. The next element of evolution in surgical practice is that of knowledge. Our patients today arguably have unlimited knowledge. So let's start with selection. Our patients, before they even come to see us, can figure out who they want to go to based on information that they get online. So this is an example of how you can find out how different transplant centers function. This is called the Scientific Registry of Transplant Recipients. Anybody can go online and look at SRTR. They create all these graphs. I have an example here. This is Baylor University Medical Center and Baylor Scott and White All Saints, which are the two hospitals that I operate at. You can see that there are these little line ratings that patients can look at that tell you how good we are with survival on the wait list for getting a deceased donor transplant faster and for one-year liver survival. And you can even look at a complete report. You can look at summary data. You can find out what happens to patients on the waiting list. I have Chicago here just as a comparator. But you can see what happens to your patient on the wait list who was on the waiting list, what happened to them, how many patients joined the waiting list, how many patients were removed and for what reason. So there's a lot of information that patients can seek prior to selecting where they're going to go to seek operative care. Now when patients decide that they're going to go somewhere or start to decide on what they think might happen to them, they have the opportunity to watch videos about their surgery to see what actually is going to happen in the operating room. They have access to information about their disease process. This is a Medscape article on what a liver transplant is. So they come in with a baseline of knowledge that is more than what the patients in the 1980s would have been able to access. Not only do they have information just in general about programs and about procedures and about their diseases, they can also get their personal health information at their fingertips. We have a patient portal called MyBSW Health. I found another portal called Your Health, Your Health File Portal. I'm sure that you all have a similar thing where patients can get their lab values in real time. So last, or on Monday I was in clinic and my patient's wife had already pulled up all the labs on her phone and had a list of questions for me about the patient's labs before I even got into the room. So there's this knowledge of what's going on with the patients and with their particular labs and so forth that patients can access in the absence of their physician or their surgeon. Another source of knowledge about surgical practice comes from the media. And unfortunately, a lot of these stories are negative. Here is a Boston Globe story about entitled Clashing the Name of Care where it talks about having a concurrent performing concurrent operations. Another story about a children's hospital that suspended complex heart surgeries due to trying to hide mortality data after some complications with their pediatric heart surgery program. Here's one. This is a recent one that just came out. Feds to investigate a hospital alleged to have kept a vegetative patient alive to gain transplant survival rates. And another pro-publica article on a surgeon in Texas, a neurosurgeon in Texas who was completely not competent to perform the operations that he performed and injured a lot of patients. So I can understand why patients would be skeptical about trusting surgeons when they see articles like this. And what I think this means for surgery, for surgeons in particular, is that we're no longer the sole source of information to patients. We are now tasked with being the translators of information, not the source of information. And what it means for trust is kind of twofold. So one, you have patients who may come to you as your number one fan. I checked out your center. You guys are the best transplant center in Dallas. And so I came here because I know that I'm going to get the best care. And what we have to do is we have to ensure that we have the best interests of those patients who have a preconceived notion and a positive bias of what's going to happen in their mind and that they don't take on unwanted risk because they're kind of blinded by this bias. It also means that our competence is public knowledge, but that the onus is on us to maintain that competence and or to explain the deficiencies. So when I showed you that, the SRTR data about Baylor All Saints, one of the lines was just a two line, two star or whatever rating. And it's for getting transplanted faster. And the reason that there's a lower rating for that particular institution is that all of our patients are double listed. So a lot of them end up getting transplanted in Dallas rather than getting transplanted in Fort Worth. And so it artificially lowers that particular number, but it doesn't mean anything. Overall our patients still get transplanted faster and we have great outcomes. So it's on us to explain why we have that particular outcome publicly reported. And finally, we have to be able to have these open and honest communications about the knowledge that patients have, what they bring to the table. And we have to make sure that their expectations are really in line with the reality of what we expect to happen so that they don't have either the wrong knowledge or a bias knowledge or something along those lines. So again, we are the translators of this information, not necessarily the sole proprietors. The fourth element of evolution in surgical practice is in surgical training. So some of you, many of you may have heard the war stories of old where surgical trainees were on every other night call, they lived in the hospital, they drew blood on their patients, they went and they had to find all the radiology studies and bring them to rounds in the morning. They operated without the attending surgeons in sight and it was the good old days of surgery. Well, that's just not how we are anymore. One demonstration of this is that in 1988, the American College of Surgeons put out the statement in response to regulatory and legal pressures after the Libby Zion case and it says the college strongly disagrees at specific hours, for example, 84 hours per week can be defined for each surgical specialty. This was a statement from the college. Finally, in 2002, the college said, all right, well, maybe we should change this statement around a little bit. Residency is about the educational experience and direct patient care. So it's inappropriate to rely on residents to perform tasks that are not directly related to either education or patient care and patients have the right to expect a healthy alert responsible and responsive physician. So maybe we should let our residents get a little bit of sleep and not be in the hospital for quite as many hours. And the college has even endorsed study of these duty hour reforms through this national randomized control randomized trial of duty hour flexibility and surgical training. And while what this study showed is that whether you have a very strict duty hour requirement like the ACGME has required or you have a little bit more flexibility, you keep the 80 hours, but you can kind of construct them however you want it. There was no difference in patient outcomes in burnout. And there was actually some preference in surgical residents for having the flexibility in these duty hours so that they could do what they were there to do, which is take care of patients and learn how to be surgeons. So even though surgical training, the hours have been limited, the regulations have skyrocketed. So these are some of the things that surgical residents have to do in order to complete their residency. On top of just being surgical residents, they have to complete the fundamentals of laparoscopic surgery course and testing. They have to do fundamentals of the endoscopic surgery. They have to do advanced trauma life support. They have to be credentialed in advanced cardiovascular life support. They also have to do all of this while working 48 weeks per year. 54 of the months of their residency has to be in clinical surgery. They have to perform at least 850 operations, 200 as chief, 40 critical care cases and 25 teaching assistant cases. And even when they finish and they get their board certification, we still have to continue with the American Board of Surgery regulations to ensure that we have continuing competence and continuous certification. Now, on top of the shorter duty hours and all of these other regulatory things that residents have to do to become surgeons, there is what this article from the bulletin of the American College of Surgeons terms the autonomy crisis. And what they're getting at in this article is that there are a lot of pressures on attending physicians to do things that can impact residency training. So for example, this first legislative policy, attending surgeons have pressure to expedite operative time and increase operative load, meaning they can't let residents sit and struggle in the operating room, even if it's safe for them to do so, because we have to turn over. We have to do more operations because the way that we get paid is through relative value units. There are also a bunch of regulations that require more attending surgeon supervision, more attending involvement in directing the care and the documentation on patients, and requirements that surgeons are present for whatever that presence means for the critical portions of the operative cases that they perform. On top of all of this, there's now a new push, an additional push for residency programs to create balance and to ensure that our residents have some sort of wellness program. This is a picture of the Stanford residents doing one of their wellness things. And you can see the quote at the bottom says, the old school surgeon mentality is that surgery is your life, and the existence of this program shows that the culture is shifting. And I think that rather than reminiscing about how great the old days of surgery were, we have to as surgeons recognize that spending your 20s and 30s inside of the hospital, solely as a surgical provider, isn't great. And we have to embrace this idea of wellness, the idea of balance, so that we can bring more residents, more medical students into surgery, and we can encourage them that this is a great career, and it's not something that's going to take away from your life, but it's something that's going to actually enhance your life. And it's something that we can all do. So what does the evolution of surgical training with these duty hour limitations, with all these knowledge components, time requirements, paperwork, less autonomy, and a focus on balance mean for surgeons? It means that we have to provide smarter, more focused, dedicated, and intentional training for our residents. And we also have to shift our expectations or our perceptions of excellent patient care. So what I mean by this is that in my mind, excellent patient care means that my residents are really good at handoffs. They're really good at communication. What they're able to do is they can anticipate issues that might arise when they leave the hospital that the next team is going to have to address. And they communicate what they think those issues are going to be. It's not anymore that the Rockstar resident is the one who stays in the hospital all the time, who goes without sleep, and who operates nonstop, demonstrating some sort of strength or stamina that is better than the other surgical residents. And what training means for the trust in the patient-surgeon relationship is that we have to have open and honest communication with our patients about the role of our residents and the importance of their training. We have to pass the baton of surgical skills off in a safe manner, ensuring that future patients continue to benefit from the care of competent surgeons and that our patients now are also benefiting from the care of competent surgeons. And we have to have that balance of training our residents with other factors, obviously with patient safety, but also with our regulatory and time pressures. And we always have to keep the best interests of our patients in the center of the practice of surgery and in the way that we train our residents and our fellows. Another evolution within surgical practice is that of the shift from the individual surgeon to the team. This picture is of Dr. Tom Starzel, who is the father of liver transplantation. This is from the 1980s when he was doing liver transplants at Pittsburgh. And I think that one thing this picture says to me is that he is the head of the team. He's got all these sort of nameless kind of blurry faces in behind him, but he's the face of liver transplantation. And it demonstrates that he's the guy who did the transplant. He's the guy who took care of the patients. It's all about this individual surgeon. But if you compare that to what our uterus transplant team looks like at Baylor, this is just a few of the members of the team. One, everybody is standing looking at the camera, right? And instead of having the surgeon in the middle of the picture, we have our nurse coordinator in the middle of the picture because she's the glue that holds this whole program together. And our surgeons are actually standing on either side of the photo, not in the center of the photo. So this is about, this shift is that every team member has a face, has a job, and has value in patient care. And not only has this hierarchical structure of surgery changed, but we've also changed the idea of individual surgeon responsibility. And what I mean by that is that we've changed the way that we take calls about the way that we take call on patients. So here's an example of a hospital in Texas that has changed from 24-hour to 12-hour emergency general surgery call. So they hand off every 12 hours on this emergency call. And what they found is that patients who need an appendectomy have quicker time to the operating room, they leave the hospital sooner, and they have lower rupture rates. And they have better surgeon satisfaction. The reason why is that the surgeons aren't tired out after a 24-hour shift, they're able to do the operations that they need to do in that 12 hours, and then they hand off to the next surgeon. Here's another example of a night float call system in a vascular surgery practice, where this group decided that they would have an on-call attending at night. And then in the morning, whatever cases needed to be done would be handed off to the surgeon who was fresh, who had had a night of sleep. And interestingly, they point out that the group adheres to the philosophy of the equivalent actor, which I cannot believe that you actually have to have that philosophy. But what they mean is that all surgeons are interchangeable in their group. They trust every surgeon to do every operation that they need to do. They have to be interchangeable in order for this to work. We actually have a similar thing in our practice. So we do call by jobs. And what that means is that one person does donors, one person operates or does first call, does the organ operations, one person rounds, one person's in clinic. At the other hospital, we have another person who does the operating, another person who does rounds in clinic, and then one person's always on research. And what it means for me is that if I do a liver transplant, I leave the hospital and I hand that patient off to my partner who takes care of them post-operatively. If I do a donor, I bring that organ back and one of my partners puts it in. So what this shift, what the shift to team means for surgeons, I think first and foremost, it means a better quality of life. It means that I get to sleep sometimes. After I operate on a patient, I trust that my partner is going to take care of that patient. It means that we can't have fake trust. We actually have to have real trust. It's not about a group of people doing what I say, but it's about a group of us doing what we think is right for our patients. And what I think it means for the patient physician or patient surgeon relationship is that we have to have open and honest communication about how the team works. So when I operate on a patient, I say, I'm going to be doing your operation, but tomorrow on rounds, one of my partners is going to be seeing you. And if I come by to see you, I'm coming by to say, hello, but I am not directing your care after your operation. And if we have that communication, then patients understand why their surgeon isn't coming to see them every day. We also have to have deep trust in our partners to confidently care for patients. And we have to keep the best interests of our patients in the front and center of the way that our team functions. The final element of evolution and surgical practice is that of regulation. And we talked a little bit about regulation in training, but there is so much more that comes with regulation. So one thing that's not specific to surgery, but just to general hospital practice is these site visits. I'm sure any of you who are practicing in the hospital have undergone one of these JCO site visits. I found this interesting checklist on how to prepare for a successful visit. Some of it is talking about how you need to have a year's track record. And maybe you should even do a mock site visit or a mock survey to make sure that you're within standards. So you're doing a pre-visit or a pre-site visit to get ready for the site visit. It just seems like a lot of time and a lot of energy that we put into dealing with these regulatory things that come up. The alternative plan is to do this, but probably not the best strategy for dealing with the regulatory site visits for our hospitals. Now another thing that we have is outcomes tracking. So in transplantation we actually have two different entities that look at transplant outcomes. We have the Centers for Medicare and Medicaid, and then we also have the UNOS, the United Network of Organ Sharing, which looks at outcomes through the SRTR database and through this thing called a cumulative summary of outcomes. And if your rolling cumulative summary of outcomes drops below an expected level, then you will get a site visit either from CMS or from UNOS or from both. So in my practice we actually have to review our Q-Sum every three months and make sure that we don't need to adjust the way that we're accepting organs or the people who we're operating on in order to prevent ourselves from getting into the into a problem of having to have a site visit. There are also positives to having these outcomes tracking. This is an article about how having publicly reported outcomes in cardiac surgery achieved and sustained improved quality in New York State. We also have all these forms that have to be filled out in transplant. There is a seven-point policy on how to verify an organ upon the receipt of the organ, and the policy says how you can identify these seven things and who has to identify them. And you can see that it has to be done at a particular time period. So one of the hardest things about the operations that I do is getting this paperwork right. There are also some absurd regulations. This is a no-holds-barred cage match between the American College of Surgeons and the Association of Operating Room Nurses about whether or not we should be allowed to wear skull caps versus have to wear bouffant caps. In my hospital the surgeons went out, so now we are allowed to wear whatever we want on our head. But there are many hospitals that I operate in where there is still a requirement for the bouffant caps. And it's been a really interesting regulatory battle between the surgeons and between the college and the nursing organizations. Now the question again is what does regulation mean to surgeons? I think it's often perceived as a road block. We have to do all this paperwork, we have to do all these things, we have to have these site visits, we have to put all the water away from the nursing station and it's really getting in the way of patient care. But we have to recognize that it does have a purpose. None of us want to be the physician in this article who has to explain how a patient got the wrong blood type organ. So while I think that it's annoying to fill out the ABO blood type paperwork it also makes sure that I don't end up in the news. And what it means for trust in the patient-physician relationship is that we do have to communicate with our patients about the regulatory environment, especially when it comes to affecting patient care. So a couple of months ago I had a patient that had kind of a very frustrating situation. He had had a liver transplant and then developed respiratory failure from a viral infection, ended up in the ICU on a ventilator, but he was getting better. And as he was getting better his family decided that they wanted to withdraw care because he wouldn't have wanted to be on a ventilator. And I tried to talk with them multiple times about how it really, he's really getting better at like why are we going to give up now. And one of the comments that one of his family members made was well you just want you just want to have good outcomes. And so it really kind of took me back to say it's not about outcomes, it's about this patient and if this is what you really want you really think needs to happen then we can proceed with whatever you think the wishes are of your patient or of your family member. Now we also have to demonstrate competence when it comes to regulatory requirements. Like I said the blood type verification is often harder than the transplant but if I don't do it right then I'm not going to be able to transplant my patients. And finally we need to accept that some regulations really do ensure that we're working for the best interests of our patients and we need to adhere to them because it is really important for patient care. So that brings me to the end of what I think are the main evolutionary changes in surgery. And I hope that I've convinced you that trust remains at the center of the surgeon-patient relationship. What I see for the future of this relationship is really more of the same. I see the practice of surgery evolving and I think that trust still is going to be and going to have to be the central element of the surgeon-patient relationship. And the way that we're going to keep up our end of the bargain is that we're going to maintain competence. We're going to keep the best interests of our patients in the center of what we do and we have to keep having open and honest communication with our patients. So with that I'd like to say thank you and see if y'all have any questions. What are questions? One is the notion that all surgeons are fungible and why do you think they can be trusty? So it's not necessarily that all surgeons are fungible, that all surgeons within your particular practice are interchangeable. So in certain situations it's not the case. So for example in living donors for us we have two surgeons who do the living donor kidneys and we have four surgeons who do the living donor livers. So it's not the case that we're all interchangeable with everything but we are interchangeable with most things. And what I think we have to do is we have to say that there's we have to create consistency in our practice and that's what creates trust and creates a way that we are able to all manage the patients and operate on the patients the same way. So an example of what I think the way that we we make it work in our practice is that we have a meeting every Tuesday where the surgeons and the hepatologists sit down around a table and talk about any of our complicated patients. We talk about the inpatients, the outpatients, etc. And so we really do have a team focused design. So if I'm the clinic person and I have a couple of patients who are difficult then I'll talk with the whole group about it and say these are my thoughts is what I think I'm going to do and we really don't have like rogue surgeons going off and like doing random things to our patients. We have more of a team mentality about how to manage the patients and that may be because it's transplant surgery and transplant surgery has always been more of a team mentality because you can't do it by yourself. But I think that that's where trust comes in. I think it is that we trust each other to operate on pretty much any patient other than the really complicated ones and that we trust that we will call each other if there's an issue. So I know that if I have to do a redo transplant, if I have to do something with a vascular reconstruction that I don't have enough experience to do, I will call one of my senior partners and say hey I can get to this point but I need you to come in and do it. And I'll talk to the patient about it and say I'll be doing your transplant but if I get into trouble I'm having this other surgeon come in. So it's a trust that we're going to do the right thing for the patient that will go to the limits of our abilities but that we have that we'll call people in if we need help. So can I push you? Of course. Okay so what you just described to me is trust in your proof. Correct. Do you have to convince me that me as the future patient trusts all of you equally or why do you think that you're telling me that we all do the same thing in general? So you're saying like surgeons in general like me and Peter? As a patient you come in and you tell me I'm going to be doing this part, this person's going to be doing that part and you're saying and we're all interchangeable in this part of the surgery so it doesn't happen. Maybe it doesn't matter but do we have any data that the patients agree with you or believe you? We don't have any data so I think that this is a very interesting question and something that so I've started doing a study on our uterus transplant patients looking at why what they think about the informed consent process and so forth and one of the things that comes up over and over again is that after having discussions with the team not with any particular person because everybody on the team sort of has different discussions with the patients that they feel like the team is knowledgeable and they trust the team and they don't talk about trusting the individual surgeon and I found that really interesting that that that's their perception of what's going on so I think it does again depend on the practice but at least in transplantation I think that patients really do have a more of a sense that this is a team sport and it's not an individual surgeon that makes all these outcomes happen. You want to keep going? Well, somebody else wants to ask who are we to go? I'm just not, what I've heard is they trust us and that's why they go to the OR. No, when you come in 30 minutes before the liver and I go and I'm driven in and I kissed my spouse and said if I die I still love you and none of that and then in 25 minutes you give me this whole list of information that I could die in every, right? You've already made the decision, I mean you've already made the decision to undergo liver transplantation at that center. So you're, right, because you've already seen the hepatologists at our center you've seen some surgeon, it might be me, it might be somebody else and that's another thing where when I'm in clinic and I see a patient and they say are you going to be my transplant surgeon I say I don't know, probably not. There's a one in nine chance that I will be your transplant surgeon but every one of us can do a liver transplant and I trust every one of my partners to do it and I think that's where I start building trust with the patients is that I talk about us as a team and as a program and not as me as the best transplant surgeon at Baylor. Oh yeah well I mean my son still thinks I'm the best the world's best surgeon, yes. They'll come for what? And now if I can look that they are not here they will say okay we'll come back when you're here in the situation that you describe do you have a boss or you are only equal? Do I have a boss? Do you have somebody who's in charge of the group? Yeah I mean we have a division chief so he has money. It sort of depends on the situation so in some ways it in many ways we are all equal right but if I have like let's say this I had a patient who had a living donor transplant this was a couple months ago um his transplant failed and we had to emergently take him back and take out the liver and he was antibiotic we did a redo transplant and then I was the rounding call person and at like 2 a.m. I got called by the ICU that like he was getting he was getting unstable and so I came in and put a bunch of lines into him and did you know did a couple procedures and you know after I did that I immediately called my boss and I said hey this is what I want I want to update you because this is what this is what I did with a patient so I do think that in some ways he's still he still has to be the person who's the go to for information and the go to for patient care in that he he has some a fair amount of the responsibility for keeping our program solvent because we have to make sure that our outcomes are good and he's the one who gets all those reports and so forth so there there is a quality in the sense that we all take the same kind of call and everything else but if there's a if there is some decision that has to be made that really can have an effect on our program he's always a go to and that's just the way that it is yeah yeah they can all do the same thing but then ultimately they have to talk to somebody so there still has to be a quote unquote captain in the ship right in the operating room it's the same way like you know I I appreciate having all of this input from different people but when it comes down to having to make a decision if I'm the surgeon of record and there are different ways we could go then I have to make that ultimate decision so at some points you do have to have somebody who makes this is this is you know it's not philosophy we can't go back and back and forth and argue over things forever we have to make decisions and those decisions sometimes have to be made by either the surgeon or by the division chief we talk so much about the doctor-patient relationship but I like the the shift that you're proposing which is to talk more about the the team patient relationship and and partly they're they're willing to trust you 25 minutes before the operation because they've already established trust in the team or even in the larger institution yeah I mean I think that really I think that and again this is coming from transplant and I think transplant is different than other surgical practices particularly from elective surgical practices but I but it really is a trust in the institution it's a trust in the hepatologists who are the people who refer our patients are trust in the nephrologists who refer the patients and say these guys know what they're doing and it's trust that oh I met your partner and they seemed great and they already talked to me when I come in honestly when I come in to talk to them about the liver transplant they've already watched a video on the liver transplant they've talked to coordinators they've talked to surgeons and hepatologists so oftentimes they're like I've already heard this I know I I know the risks so it really is a trust in the team and there's a chain of trust idea it's like I trust my hepatologist he trusts you therefore I trust you yeah yeah and then there are times I mean to go back to having somebody have to make you know a decision or a phone call if I have a patient who is on the fence about taking a particular liver offer like they don't know if they want to take a hepatitis C positive organ or they may not want to they they're trying to figure out whether or not they want to take one of these increased risk organ offers a lot of times they'll tell the coordinator that they want to talk to their hepatologist not to the surgeon even though I'm the one doing the operation they they have more trust in the person who they've seen more frequently and what we do is we'll I'll call the hepatologist and say hey can you call this patient and talk to them for me and tell them that you know that this is why we've accepted this particular offer and so again it's it's a it's about trust in the team and trust in individual people but but overall it's the whole enterprise Peter so really enjoyed your your presentation it does strike me and again this is perhaps tying into some of what Laney pointed out but it does seem to be that there's a bit of a tension between the well-being of the surgeon and what patients may like and so a patient may really like that you know I met this person this person said I'm gonna operate on you and I came to the hospital and they operated on me and then they saw me they were there all night and then the next morning they rounded early and they made all the decisions and to some extent it seems like that's the you know if you came in and you had one person that you were interacting with all the time that would be really great for patients feeling really good about what this is my person they're making all the decisions and yet in reality it can't work that way and so I guess what I wonder is is it so much that are you making the argument that this is actually better or that this is just the way it has to be and so we make the best of a not perfect situation well it's different right it's different and one thing one thing I'll say about that is that I have the bandwidth to do only a few things right if I'm in the operating room doing a liver transplant I am not taking care of any of my patients on the floor for a good eight to ten hours so I just physically have to have somebody taking care of the patients I can't walk out of the operating room and what what I have found is that in my practice we have we have a lot of physician's extenders we have we have three nurse practitioners who are both inpatient and outpatient at at Baylor in Dallas and then in Fort Worth we have three physician assistants who do the same thing and what happens is that the patients see the physician extenders who are there every day rounding on them as the primary point of contact and they're the ones that they end up trusting more than any of the surgeons and the reason why is because our physician extenders are not pulled in all these directions they know they are phenomenal providers they've been all all of them have had some sort of transplant experience even prior to being on our team and they are they're able to sit down and talk to the patients they're on the floor all day they're in the clinic all day and they are the familiar face and the point of contact and I would argue that it's better it's better to have people who are available in house and have the time to communicate whereas when I'm even when I'm the rounder I spend an hour seeing all of my patients and then I have to go off and do a thousand different things and so I have to trust my team but I also think that my patients see my team as an extension of me and that they get a lot of value out of having these additional having these physician extenders and to some extent the residents and the fellows as their primary point of contact anything else I'm sorry to keep arguing I understand that you're presenting maybe in the future when when we are all team and the patient come to the team doesn't specify but the reality in life patients come to see is a name of a doctor unless they are for some reason insurance or otherwise they cannot choose they just you go there and whatever they give you be happy and go home unhappy something like that it's if this is the future of medicine then that's the future of medicine I then I my generation is gone we cannot argue but that that but that's the trend I'm seeing that the patients exactly let me just just finish yeah patients trust more the PAs and the physician assistant because they talk to them they have time to talk to them they call them at night and they do and we don't mm-hmm and we trust these people who work with us and they can make us or break us make it basically they can yeah and that's where the weakness in this team business you trust people who are not doctors but they are health workers and they can they can make you or they can just break you if they want and make your partner or somebody like that well I think that's where that's where building a team that you trust is important so it's not just about having the patients trust the team it starts with you trusting the team so we built like our nurse practitioner team is built from its three nurse practitioners who were ICU nurses who took an interest in transplant patients so we knew them for a long time and we knew that we knew that they were excellent providers at the bedside and and then encourage them to become a part of our team when they got their nurse practitioner license and so it and so yes you can have a you can have somebody on your team who is not taking care of patients the way that you want them to take care of patients and we we also had one of those situations where we had one of our PAs we just we really I couldn't trust her on call and we had to we had to ask her to leave because we we felt that that was compromising our team and it was compromising patient care and so if we are going to have a team model for care we have to trust everybody on the team we have to choose the people on our team wisely and and we have to have really open lines of communication so that's the other thing is like if even if one of my PAs is on call if there is let's say one of the patients gets imaging one of the patients ends up in the emergency room like they might go and see the patient and do a couple of things but they will give me a call and say hey this is what I think is going on will you you know what do you want to do with this or with that so even though I'm not physically standing at the bedside I can still help help them with directing the care that that I want to happen with the patient thank you Lainey So what happens so you have your team? Yep. I have a great team. He's been 10 years from now and you're all still there but one has aged significantly and you notice you know a little tremor and he's not ready to or she's not ready to retire. There's this notion that I'm still I'm still having troubles with the fungibility. Yep. Because people change. Yes. Some people are more junior some people are older and some people are going to lose skills and while you talked about firing your PA it's a lot harder to fire that senior attending surgeon. Yeah. I just I still just want to understand why as a patient I should view you all as the same the fact is if I went and did you know data and got individual data you actually all wouldn't be the same. We would not. Well it would be hard it would be hard it'd be hard to tell it. Yeah. But right. Right. I mean so let's the older surgeon question I think is really hard like the question of when to retire when to push somebody to retire is really challenging. I have not been put in that situation yet. My boss has told me if he if I you know if he if he's operating after a certain age that I just need to kick him out but but I yeah much easier said than done. We right before I started we actually had a transition and that transition was asking one of our senior surgeons to stop operating and I don't it was probably not the easiest discussion but they did have it and they they phased him out of operating and now he he's still around he does research but but for again for the good of the team they asked him they asked him to stop operating. So I think that one thing is is that you do have to keep patient safety and and your outcomes in mind and if you feel like somebody is losing their ability to operate then then you have to talk to them and again in transplant it's different than in in sort of a more elective practice because I operate with my partners all the time so actually see how different people operate. We all we do two attending liver transplants so it's actually really it's it's probably more directly easy for us to talk to each other like you know anytime I do a transplant with one of my senior partners I get a discussion in the office afterward about what went well what went poorly what I can do to change to change the way that I'm operating and we'll also reflect on what they did and so I think that I think that those are tough discussions but they have to be centered around patient safety and patient care for for what it's worth but it's difficult I mean I just haven't been in that situation. All right great thank you guys so much