 I'm gonna be presenting some new data on a study that has not yet been published. I'd like to begin by acknowledging the Green Wall Foundation for their generous support to Altarum and my co-authors, Miriam Danis, Anita Tarzian and Chris Duke. And I have no conflicts to disclose. As background to the study, let me take you back 20 years. Between 1999 and 2000, I conducted the first and only to date large-scale study of ethics consultation in US hospitals. And when this study was published in the American Journal of Bioethics, it created quite a stir. In various publications, the results were described as troubling, quite dire, deeply distressing and sobering. It was widely seen as a wake-up call for the field. So just what did clinical ethicists find so shocking? Well, here are just a few of the major findings from that study. The median number of ethics consults performed by hospitals during the year prior to the survey was three. An estimated 29,000 individuals performed ethics consultation that year. Very few of the individuals who performed ethics consultation had completed a fellowship or graduate degree program in bioethics. And only 28% of hospitals had a formal process for evaluating their ethics consult service. Almost immediately after this study was published, the American Society for Biotics and Humanities, which is the big national organization for bioethics, embarked on a variety of initiatives designed to address these concerns. And they cited the article as the major motivation for these initiatives in many cases. And over time, a strategy emerged. I'm not gonna go into the details of this, but these are just some of the milestones. The strategy was to establish quality standards for ethics consultation and then develop a method for assessing whether ethics consultants were meeting those standards. Now it took several years, but in 2001, ASBH published new standards in a report called Core Competencies for Health Care Ethics Consultation, and then in 2018, they launched a new program for testing and certifying ethics consultants. And I should disclose that I've been involved in several of these efforts as a member of the Core Competencies Task Force, co-author of The Standards, a member of the Board of ASBH, and most recently as a certified health care ethics consultant under their program. Nonetheless, I've had some concerns over the years that this strategy of professionalizing ethics consultation by credentialing clinical ethics experts was being developed primarily by bioethicists who work in university settings and in large teaching hospitals with high volume consult services. People like many of us in this room. And yet the strategies seem to be designed for the types of hospitals that people like me or like some of us work in. But most hospitals in the U.S. are actually not those hospitals. Most hospitals are very small. More than 50% of the hospitals in the U.S. have less than 100 beds. Only 6% have greater than 500 beds and only 6% have major teaching affiliations. While ASBH's strategy of professionalizing ethics consultation was understandably quite appealing to bioethics professionals, I worried that it might have little impact on the hospitals that need it most. To develop the right strategies, strategies that are effective at addressing quality problems to the extent they exist in the field, I think we as a field need to understand what's going on in the typical hospitals in this country. And that's why I conducted this new study which addresses these research questions. How have ethics consultation services changed in the past almost 20 years? How do consult practices compare with ASBH standards? And what are ethics consultation practitioners views on ethics consultation quality? And what strategies would be most effective at improving quality? The new study replicates many of the methods of the prior study. A random sample of 600 general hospitals was selected from a national database. And because most hospitals, as I mentioned, are quite small, we used a stratified sampling strategy to oversample large hospitals. And then during data analysis, we used waiting to adjust for the sample selection. And we used a validated phone protocol to identify the best informant about ethics consultation at each hospital and then invited them to complete a web-based survey. The survey consisted of 77 questions, including 15 from the prior survey, plus 29 contingent questions. So a lot of new data, wealth of data, and I'm only going to have time to scratch the surface today with a few highlights. So one hospital closed before data collection, 79 hospitals we were unable to reach a best informant usually because the person, we identified somebody that they didn't call us back. An additional 58 hospitals declined to participate so we had 462 hospitals that completed all are part of the study for a response rate of 77%. Now this is a complicated slide and I don't expect you to necessarily be able to read it, but I just want to show that we compared the hospitals in the sample to the hospitals that participated on a variety of demographic variables and there were no significant differences. So from now on, the results I'll present will be estimates for the entire population of U.S. general hospitals. Start with prevalence of ethics consultation services. Of all U.S. general hospitals, 86% had an ethics consult service which was significantly higher than in the previous study when it was 81%. What about the number of case consults that are performed? One of the big shockers, remember it was three last time. Drum roll please, the medium number of case consults was three. Same as in the prior study. And as you can see from this slide, the distribution was strongly skewed to the right as it was before with 62% of hospitals performing five consults or fewer and only 5% of hospitals performing more than 50 consults. The number of consults varied significantly according to hospital bed size as you might predict as it did in the previous study when it was essentially linear. But, and this shows bed size categories on the horizontal axis and the number of consults on the vertical one. And the blue line is the current study and the pink line is the previous study. And as you can see, while the median number of consults was unchanged for hospitals with fewer than 300 beds, it more than doubled for the two largest categories of hospitals. And remember the vast majority of hospitals are small. And that's why the median overall didn't change. When respondents were asked which of three models of ethics consultation best described their consult service, about two thirds responded that consults were generally performed by a small team of individuals as opposed to a full ethics committee or an individual consultant. And compared to the prior study, the frequency of the small team model was unchanged. But the individual consultant model increased significantly and the full committee model decreased significantly. The total number of individuals in a hospital who had performed case consults in the past year was seven. In the prior study, this number was slightly higher at eight. We estimate that in a one year period, approximately 27,000 individuals performed over 67,000 consults. Compared with the prior study, the number of individuals decreased by seven percent and the number of consults increased by 91 percent. So let's look at who's performing consults now. Average across hospitals, there were 24 percent physicians, 23 percent nurses, 11 percent social workers, 10 percent chaplains, and nine percent administrators. And compared with the prior study, the percentage of physicians and nurses decreased significantly, but these still remain the top two categories. And this is continuing on the next slide. Other healthcare providers increased significantly from the prior study, and fewer than 4 percent were attorneys, philosophers, or ethicists or bioethicists, and that was the same as in the prior study. Now let's look at training, another shocker from the prior study. Average across all hospitals, eight percent of the population of individuals performing consults had completed a fellowship or graduate degree program in bioethics. 40 percent had learned to perform ethics consultation with formal direct supervision by an experienced member of a consult service, and 41 percent had learned independently without this sort of formal direct supervision. None of these percentages were significantly different from the prior study. Let's look at a couple of examples of how practices compare with ASBH standards. 55 percent of services required notification of the attending physician before an ethics consultation, but only 25 percent required notification of the patient or surrogate, and ASBH standards suggest that the attending physician should always be notified, and that the patient or surrogate should be notified with rare exceptions. And note that the percentage of hospitals following the standard is actually much lower now than it was before the standards were published. Average across all hospitals, consults were documented in the medical record in 82 percent of cases. Documentation consisted of a brief notation in 30 percent and a detailed case description or analysis in 52 percent of cases. Compared with the prior study, documentation in the medical record was both more common and more detailed. And ASBH standards suggest that consults should be documented with a detailed case description except in rare circumstances. So conformance with this standard has increased, but it's still fairly low. Turning now to the question of evaluation. Only 19 percent of consult services said they had a formal process for evaluating the consult service that involved the collection analysis data on consults performed. And compared with the same question on the prior study, the percent that had a formal process was significantly lower. Regarding evaluation, ASBH standards suggest that ethics consultation must be subject to an evaluation process that is continuous, comprehensive, transparent, and accountable to the institution. So let's look now at some questions relating to respondents' opinions about ethics consultation and quality. When respondents were asked to rate their satisfaction with the performance of their consult service in a variety of different areas on a scale of one to five, the highest ratings were for understanding the practical realities of a hospital, modeling respect for different values, and providing good customer service. And you can read the others. These are in descending order, and this list is going to continue on the next slide. And as you can see here, the lowest ratings were for having clear quality standards for ethics consultation and meeting those quality standards. But note that the ratings for all of these were well above the midpoint on the rating scale. So on average, hospitals were at least moderately satisfied with their performance in all of these areas. When respondents were asked to indicate the extent to which specific words describe their consult service, the highest ratings were for approachable, compassionate, open-minded, and humble. The lowest ratings were for expert, well-resourced, and well-trained. When respondents were asked to rate on a scale from one to five, the extent to which various conditions were a problem at their hospital, the highest rated problems were lack of consult requests, lack of personnel time to perform ethics consultation, and lack of personnel who have the expertise required to perform ethics consultation. And these, note that these means are fairly low. These means, continuing the same question, were not to perceive to be much of a problem at all, including lack of clear standards for ethics consultation, lack of quality control for ethics consultation, and lack of access to outside ethics experts. When respondents were asked to rate the extent to which a variety of strategies would be useful to promote high-quality ethics consultation, the most useful strategies were validated tools, assessment tools, detailed practice guidelines, and education and training programs, not including graduate programs. This list continues on the next slide. And we'll see the less useful strategies. So these were all rated below the midpoint of three, so not very useful, credentialing and privileging, specialized software, graduate degree program, and expert review and feedback. The strategy rated least useful was an external certification process for individuals who perform ethics consultation, such as the one that ASBH has recently launched. 56% of hospitals thought that financial support devoted to ethics consultation at their hospital was sufficient, and this percentage was significantly lower than in the prior study, when 83% thought it was sufficient. Interestingly, the hospitals that were most likely to think that resources were insufficient tended to be those with the most resources. That is, larger hospitals, hospitals with major academic affiliations, and these differences were really dramatic. In hospitals with under 100 beds, for example, 71% thought that resources were sufficient, while in hospitals with 500 beds or more, 32% thought resources were sufficient. I have a lot more data, but not in a lot more time. In summary, the volume of ethics consultations increased significantly between 2000 and 2018, but only in large hospitals. Ethics consultation practices have changed significantly since 2000 in a variety of respects, but in other respects, such as the median number of consults, they've remained markedly stable. Conformance with ASBH standards has increased in some areas, but decreased in others. Most large hospitals, but not small hospitals, perceive ethics consultation resources as insufficient. And in all categories of hospitals, respondents were generally satisfied with the performance of their ethics consult services and did not perceive quality to be much of a problem. I wish I had time to share more data from this study. There will be a lot of papers forthcoming, but let me just close by telling you what I see as the most important insight that we should take away. Once all the papers have been published, and I've had the benefit of seeing a lot of this data, I think it will become very clear that the typical hospital in the U.S., and in fact, the vast majority of hospitals in the U.S. are very, very different from the academic medical centers that many of us are familiar with, and that they, in fact, have very different perceived needs. In my work as a consultant for healthcare systems over the past five years, I've gotten to know the ethics folks in a lot of these very small or medium-sized hospitals. And these data, I think, will confirm what my lived experience has been which is that a one-size-fits-all approach to these different sorts of hospitals will not work. And so if our strategy is to get these other hospitals to adopt wholesale models that were developed by and for the most elite and well-resourced hospitals in the country, I think we are doomed to fail. I hope that, ultimately, this study will help bioethics leaders like us and others to develop new strategies to better meet the needs of hospitals in this country and the patients that they serve. Thank you. And I'd love to take some questions. Ellen? Ellen? I can't take this. Is somebody else there? It's September, all right. Hi, sister of the Kogelschall Fellowship. A couple of quick questions. One of them is, do you have breakout data in your data about how many hospitals primarily serve Black people or Spanish people out of the grouping? No, I used the American Hospital Association database and we only pulled a few data fields for the demographics and that's not one of the things that we have data on. Okay, I'll leave it there. Thanks. Two questions. I'm not an ethicist, but I have difficulty even understanding that you had a category called expert when it comes to bioethics. Can you help me understand that? And then secondly, the last person I'd call for an ethics consult in any place would be an administrator. But you said 10% would do, I mean, you got to help me out on both of those. Well, to the first question about expertise in bioethics or ethics consultation, I mean, I think it's an excellent question and I think you're really getting to the heart of something that the field needs to come to terms with, which is that it's almost like there's a tale of two cities out there, tale of two hospitals where we have this whole world of academic bioethics where ethics consultation is really seen as an expert enterprise where you have advanced training and you get certified as someone who can perform the skill in ways that the majority of the population cannot do. And that's the sense in which I mean expert. But the other hospitals don't necessarily see ethics that way. And they see, they are using models that rely more on the idea that two heads are better than one and maybe five heads are better than two. And so they believe if you put well-intentioned, good-hearted, reasonable people together, you'll come out with better decisions about these difficult issues than you would with one person making that decision. And if that is your understanding of the best way to make decisions, then having people with a bunch of degrees after their name come in and say, we're here to help you, we're the experts, it doesn't, they may not want what you're selling. So, and then the administrator question, I think the, that's a broad term and it may include a variety of different people that are leading different parts of the hospital. So it may be the risk manager or the compliance officer. There may be a variety of different people that have administrative roles in the hospital. Because you're aware, I'm sure that in a lot of circles that administrators are referred to as bean counters. Yes, thank you. Helen, I can't congratulate you enough on this extraordinary study as a follow-up to that earlier study, which was a number of years ago. And I also can't wait to see the data published. I thought I heard you say, and correct me if I'm wrong, early on in your talk, with reference to the 2018 decisions by the ASBH to do this accreditation process, that you're concerned about professionalizing bioethics consultations. I'm not sure those are your exact words, but could you just say a little bit more about that? Sure, so that is a certification process. I was involved in some of the work when these decisions were being contemplated about whether to go with certification, credentialing, accreditation. There are different ways you can try to control standards and practice. And I think that a lot of these are being referred to as professionalizing the endeavor of ethics consultation. That's the way they're sort of lumped together. These are the things that fields do when they professionalize. It's related to that question of becoming an expert, I think. Does that answer you? Is that what you want? It begins to, yes. Because that decision by the ASBH to do this kind of accreditation process has struck me as premature in the light of the limited data that we have, much of which I think you have now gathered. There's a great deal of debate that went into that, and it ended up being the decision of the organization. Interestingly, when it, and I'm sure Rick Kodish is probably here, but there was an earlier process that was on my slide called Quality Attestation, which had involved a portfolio review that Rick was one of the main investigators on. And that was targeted at kind of a high level of expertise, someone, for example, who might be a leader of a consult service. And this new test, and it is a test with a requirement for a large number of hours of practice, the test is definitely not at a high level. And so it's interesting because I think we're going to see a lot of people now with a certification and letters after their name for certified healthcare ethics consultant who do not have a high level of training or skills in ethics. Thank you so much. Big hand for Ellen Fox for a great talk.