 Hi, my name is Melissa Ruiz. I'm a pediatric resident at UIC. So actually this was for the last talk, Dr. Howell. I went to medical school at Columbia and we did a lot of theater, probably anywhere between 15 to 20 percent of my class probably was involved in some kind of musical theater or theater. And I wonder if you have, because you did a lot of observation of our observation and performance art, if you've thought about incorporating actual like engagement in performance art, just because I think theater and specifically it really gives you that focused in the moment aspect and learning to react to people. Absolutely, actually Columbia is a real leader in this field. Rita Sharon, who runs the narrative medicine program there, has done some path-breaking work and we're pleased she's collaborating with us on this. The short answer to your question is yes. Not only in theater, but in the production of visual art. We have a session coming in January in which students are going to work with an artist to create art and talk about it. One of the problems with theater and performance is some people are very comfortable presenting themselves, others are not. And we're interested in seeing if there's an educational initiative that can reach everybody. But your point is well-taken and it's good one. My question is for Kayla, Ben and Susan. We spent the last 25 years encouraging the better management of pain and one of the metrics that we used was the increased use of prescription opioids. In fact, Oregon is proud that it's a leading state on a per capita basis in prescribing opioids. I just want to hear your comments and Susan's on whether this restriction of the use of opioids is the way to go. We do face some challenges. We have had an extensive statewide educational program to promote more thoughtful care at the end of life. It includes attention to pain management and it includes advanced care planning. The spillover to those with chronic pain was greater than I had anticipated in the sort of overall message of treat pain. And we are working with the Oregon Board of Medical Examiners and others to see if we can further refine the message that there may be substantial distinctions in the final weeks of life versus those with chronic pain. Yeah, thank you. I think it's an excellent point and indeed there were large campaigns. Not only pain is the fifth vital sign, but campaigns by the World Health Organization and others to promulgate measures that would support the improved treatment of pain with prescription opioids among other therapies. And I think there is a lot that we don't know. I mean, it's surprising and I think it's a crucial piece of information how well we've done broadly speaking at a population level with improved diagnosis and identification and treatment of patients with pain. And that's part of the work that we have ongoing is to examine that in nationally representative ambulatory data. I guess the other point that I'd make though is that a lot of the opioid use that I discussed and that my comments were to address is not among people near the end of life. And so I think Susan's comments also allude to that. And so you know, in fact in our, in most of our analyses that we're doing, we will exclude people based on age or based on certain conditions. So we're talking about the chronic use of opioids for non malignant pain is the primary group where where there is substantial concern. Many of these individuals have 20 or you know are far from the end of life and these therapies aren't being used for palliative purposes around the end of life. Okay. I wanted to do a little crossover between the pain issue and the art issue and ask people to think about this. As you know, the Institute of Medicine's report on chronic pain came out with a strong focus on the Neuroplexus being a site that could decrease pain in the same way opiates do if handled properly with alternative therapies. I've been fortunate in working in a Zin hospice for the last seven or so years where therapies such as art therapy, movement therapy have been used to deal with chronic pain. Where laughter from films that have been a part of people's lives at another point in their lives like when they were 25 and 30 have helped to bring people back to an understanding. So I'm wondering if in the arts, have you seen the therapeutic use of arts? Not just with medical students, but for medical students who are in pain of different kinds as well as the therapeutic use of arts for the care of the patients that they're doing and in the pain world that is chronic pain. Have you begun to use art and other music and other forms of therapies as well? So that would be for all of you. The short answer is I agree. Our program is focused on it's a little too close. Our program is focused on the house officers and one of the poems that we have found incredibly powerful for helping them in treating patients with pain is a poem by Emily Dickinson called Pain Has an Element of Blank. Does anybody know that that poem? Some people are nodding their heads. If you're at all interested, I encourage you to Google it. It's called Pain Has an Element of Blank. It cannot recollect when it began or if there was a time when it was not. And I've just quoted half the poem so it's very short. It talks about what it experiences like of being in severe excruciating pain and one way to understand this with neural channels and plexuses and calcium channels and opiates. I would argue that another way of understanding it is by turning to the great artists who have either experienced pain themselves or been around loved ones who are perhaps better at communicating the essence of what it means to be in pain. The other question about that poem, of course, is she talking about physical pain or emotional pain? And the answer is yes, and it doesn't matter. It's applicable to both. I think the point of the Institute of Medicine's compilation is that physical pain is emotional pain. It's a psychological phenomenon and perception in large part. Of course. I mean, is the pain in your head? Well, of course it is. Where else could it be? I mean, the answer, the other point you made is the short answer. That's not what we're looking at, but I think it's potentially very useful and I encourage people to look at it. Yeah, and I would just say that you know, from a clinical, I think it's a great point. You know, no one will come into my office and buy me lunch and talk with me about the latest therapy or how I can access it. And I think that, you know, the opioids have been heavily promoted and marketed and they're also part of the armamentarium that clinicians can easily reach towards. And so I think one of the challenges with increasing the use of adjunctive or alternative treatments, complementary and alternative or otherwise, is that they're harder to access than as the prescription pad to write a script for, you know, 60 oxycontin. But I think you raised a very good point. Dan Brunner, a faculty here. I really enjoyed this group of talks and I'm going to have to try to limit my questions. I think the pendulum in, you know, in treating pain has really swung the other way. And I think Caleb is here on to this and it's really important work. In terms of I really want to applaud Susan for for trying to take that DNR question, making that not the first question the way it was created in the post. And but I think the inherent problem with that is that it's a historical precedent. DNR was the first advanced directive and everything else sort of follows out of that and is based on sort of the same premise. And the premise is we're going to do whatever we think we can do to you, whatever it is, based on this sort of default notion that we can, you know, that these treatments are based on very limited indications that doctors will use these default therapies. And in part these therapies became defaults because they were made into advanced directives. Once we create an advanced directive that says you have to opt out, everybody else is automatically opted in. And so the basic nature of the advanced directive sort of changes the way we practice medicine. I think it's unfortunate that people who still have treatment, still have illnesses or problems that are amenable to medical treatments are being forced to sort of opt out of them by these advanced directives. Because they're really scared of what we're going to do to them once they get to the hospital. I've made the analogy that it's sort of like advanced directives are a little bit like the mob selling you protection. And who is the mob protecting that you from? They're protecting them from themselves. And in some ways we're protecting patients from our default therapies, which we subject them to, whether or not we think they're going to work. And I think what's needed really is a change in how we practice medicine in general. Thank you. Was there a question in there? No, but I'll give an answer anyway. Yeah, please respond. Well, the most important thing about the way people respond to the pulse form is it's certainly about the default, which is full treatment unless marked otherwise, is that the most common response is limited additional intervention. That that's slightly more frequent than any other category, people saying I want some things and not others. And that I do want to go back to the hospital. But the default would be straight to the intensive care unit for people with advanced illness and frailty without that. But it is a difficult conversation and whether we can ever move advanced directives from the very first line on pulse form to any other place is highly controversial and and whether EMS can adapt to that if that's done is not yet known. Thank you to all the panelists. My name is Scott Goldberg. I'm a first year at Pritzker and my question is primarily for Dr. Howell. I'm 29 years old. So I've sort of taken more of a non traditional path to school. I actually feel at Pritzker that that non traditional experiences value. So I feel fortunate to be at a place like this and also to have colleagues who were also have had other experiences before medical school. But I don't think that that's necessarily the trend. I do think medical schools are starting to accept more people who have had different experiences. But I mean, I was clearly told that one medical school interview that I wasn't going to get in because I never mixed two test tubes together. So I just was wondering if medical schools could do a better job and maybe more formally of screening for people or embracing people who have had different experiences and not focusing so much on that person with four years of basic science research and you know, biochemistry background and how medical schools could do a better job of that. Thank you. Former first year Pritzker student. It's good to see you and I congratulate you for coming. I don't know if I would have had the nerve to go ask a question at a conference as the first year student. I think that I think and I hope that you're wrong. I think that medical schools are beginning to realize the value of a broader life experience. We and you and many others of around here. We could fill our class at Michigan with 4.0 biochemistry majors and you could too. We choose not to and you don't and I think that's a good thing and I think the medical school admissions committee is beginning to realize that. Wouldn't it be interesting if our data showed some systematic differences between students who were exposed to the arts and who are interested in the arts and those who are not? I'll just leave it at that. Wouldn't that be an interesting finding if we could show that they're actually doing better? But we don't have the data yet so I can't say it. So I apologize for everyone who's standing up. We have 30 seconds. So if you would like to ask the last question. My work is in chronic pain and has been for my whole career. From an ethical perspective. My sense is that part of the problem is that we that we have reached a point where beneficence has run amok. And I think it's important to realize that in that patient encounter. It's helpful to be mindful of the fact that it's easier to write that prescription than it is to be aware of our obligations to non maleficence which clearly are abdicated when we write prescriptions out of out of the sort of misguided notion that we were being beneficent. Question is should we be educating more about that tension in that environment in medical schools? Short answer. Yes. Okay, let me let me ask you to join me in thanking all of our presenters for wonderful