 So this afternoon's conference is going to be about medical education and medical institutions. And our first speaker is going to be Professor Mary Simmeling, who is an assistant professor of public health in the Division of Medical Ethics at Wild Cornel Medical College. Dr. Simmeling's research focuses on medical and research ethics with an emphasis on issues related to justice in human rights. The main area of interest is in organ transplantation ethics and clinical medical ethics. The privilege of having Mary serve as the chair of the Social Science IRB while she was here, and it's a wonderful opportunity to welcome her back from New York. Mary? And thank you, Mark. Thanks for having me back. It's really an honor to be here. I'm going to be talking about misconduct. Something a little bit different. So misconduct in the profession's ability and responsibility and willingness to self-regulate in this area. One thing that strikes me about this topic is the constrained discourse around the issue of misconduct. What I hope to do in the few minutes that I have this afternoon is to create some space to reflect on what I see as a few of the most serious problems we currently face in this area, and to offer some ideas for how we might move forward in addressing some of the challenges. Oh, I'm sorry. Am I not speaking into it? Oh, thank you. As you might imagine, it's very difficult to get data on this topic, in part because of some of the issues that I'll be talking about in the next few minutes. But I'm working on a project with Joe Finns from Cornell to try to collect some data on this topic, and perhaps Mark will invite me back to share that with you next year. So for now, my comments on this topic come from my experience as the research integrity officer at Cornell. I work with other integrity officers. The interactions I have with my medical ethics students and students in my responsible conductive research course at Cornell. So you might be wondering how this topic misconduct applies, if at all, to clinical medical ethics in the future of medicine, which is the topic of this conference, as you know. Because of the way in which misconduct has traditionally been defined by the federal government as falsification, fabrication, and plagiarism, it has largely been considered to be professional transgression committed by basic scientists and not by clinicians. However, some recent high profile cases, including Nemerov, Biedermann, Spencer, Willens, and too many others, have shown that this behavior that can only be described as misconduct is also in the domain of clinicians who are sometimes in the dual role as researchers as well. Indeed, standing where I am right now at the forefront of medicine, and I am at home on the block where I work that houses Cornell, Sloan Kettering, Rockefeller, and Special Surgeons, I think it's fair to say that it's increasingly difficult to clearly separate and distinguish much of clinical care from research and that the push is to do more and more research in order to improve clinical care and clinical outcomes. In fact, there are a number of clinicians at Cornell who proudly tell me that almost everything they do is research. So I'm going to talk about misconduct broadly, not just as falsification, fabrication, and plagiarism, but also other actions that seriously deviate from the profession standards. And you might want to know this is a clause that was decidedly not included in the 2005 provisions to the misconduct rules. And I think these issues have real implications for the profession as a whole. Importantly, the way that we handle these issues is a profession. It shows the public, and also those coming into and already part of the profession, what we're willing to tolerate. In thinking about these issues, I have benefited a great deal from Troy Brennan's 2003, when the journal paper entitled Do Process in Investigating Research Misconduct. I'm sorry that Troy is not here. I really love this paper and learned so much from it. And the paper, he argues that the then current regulatory framework did not provide adequate protection of due process for those accused of misconduct. And the framework, although the rules were revised in 2005, the framework really hasn't changed substantially with those revisions. So Troy identified the following problems with the framework. Number one, the actual policies and institutions vary substantially across institution, including with regard to procedures, the design of research investigations, and the design is largely left to the discretion of the individual institutions. Number two, institutions have very little experience dealing with allegations of serious misconduct, and the risk of an erroneous finding is fairly high given the complexity of the issues involved. I want to add two points to Troy's, my 1A and 2A. First, the federal rules apply only to certain kinds of research, and that is research that is federally funded. And this means that institutions have complete latitude to establish how they will deal with issues that arise from related to misconduct that are not federally funded projects. And the second point is that institutions often have an interest, be it financial or reputational otherwise, in the outcome of the cases. While Troy focused his arguments on due process for the accused, I want to focus on, I think, a different maybe complementary piece, which is what I have come to think of as a kind of willing institutional blindness and failure to adequately, if at all, sanction the guilty, who are, by the way, often, though not always, outside of the federal domain because of their funding. They're either independently funded or they're funded by the private sector. So I'm going to talk briefly about a few of the problems, the conditions that need to exist for these problems to occur, and then I'll briefly address what I think some of the solutions might be. First, I think there has to be an institutional and individual willing suspension of disbelief and difficulty believing that someone in this profession and of this high level could actually do these things. And what we often see is that there are a number of misdeeds that predate those that people are ultimately caught for. If you look at the misconduct cases that are actually publicized and published, these are not first-time offenders. Number two, the forces needed to prosecute or investigate these people are the same forces that hired them and benefit in some way from their staying. As I said, there are often financial issues that are considered relevant to the cases and institutions do not want the embarrassment or public scandal should the case be made public. The third thing is that loan accusers are vulnerable and are often in a hierarchical or a competitive position and so do not themselves have the power or are thought to lack credibility because of the competitive relationship. However, you have to be close enough to the misconduct to be able to see that it's happening so often these relationships exist. And I've had occasions to call the federal office with different cases and they say to me, oh, well, these are sandbox issues that these are people who used to collaborate and now they're not friends anymore. So that's kind of the federal take on these things. The fourth thing is that institutional responses are not transparent and they tend to focus on resolving situations without resolving underlying problems. I think this is one of the most critical pieces. They are defensive rather than proactive. This often results in getting rid of the problem at that particular institution only and the perpetrators move on to yet another institution and engage in the same or even worse behaviors. As an example, I'd like to quote from an interesting email that Nemeroff sent to pharma neuroboost after he left Emory under a huge scandal to go to Miami where his friend endowed a chair for him. And he basically says in this email, I switched institutions, I want the rest of my money now. So let me quote for you. You will recall that thus far as the chair of the scientific advisory board I have only received $10,000 of the promised $40,000 due to me because of the limitations I had during my affiliation with Emory University. You can, however, now go ahead and send me the remaining $30,000. So the difference in the standards of the institutions and how we handle these things is really important. There are some potential solutions or remedies. First, we need to recognize that this problem exists. There are bad guys in medicine too and Carl Elliott has offered some very persuasive arguments that some of these bad guys are sociopaths. We need to establish a single standard for integrity that is not tied to a funding source and that definitively shows that the profession takes these issues seriously and that we consider serious deviations from the profession's accepted standards to in fact be misconduct. We need to provide education around these issues and real protection for whistleblowers, someone who could act as a senior advocate for junior people. One of the things I have seen is that we're such small communities that there is no protection for whistleblowers. Everybody knows who it is including the person who's been accused which as Troy argues is relevant and appropriate in some cases for due process. We need to have prescriptive procedures and establish committees that can fairly adjudicate these issues, get these cases out of the inner circles and into a place where they can be handled fairly and transparently. We also need to eliminate jurisdictional issues. This is a common responsibility of the profession. I too often hear about and see what is, I hate to use this term here Mark, but it's true, the time-limited trial. We have to clock out until we can get rid of this guy from the institution and pass it on to somebody else. We have to do with the related to the time-limited trial, the no-backsees approach we have and establish real sanctions for wrongdoing. So in conclusion, I think it's clear that there's a strong sense by the public and the government that at least in the areas of conflict of interest and human subjects research, institutions have been given too little oversight and too much leeway. This is evidenced by recent changes in the complex of interest regulations, the sunshine rules and in the recently proposed extension of the IRB regulations for human subjects research to extend to all human subjects research, regardless of the funding source. If we want to preserve a role for self-regulation in this area, we need to reflect seriously on these issues and we need to begin to identify ways to address them. Thank you very much. Speaker is going to be Dr. John Nune, who's an assistant professor of medicine at the University of Chicago, as well as on the faculty here at the McLean Center for Clinical Medical Ethics. His research interests lie in the field of virtue ethics, moral psychology, and moral and professional implementation in medical education. He's also interested in the role of burnout and a sense of calling in physicians' work motivation and career retention. Today, John is going to talk to us about virtuous exemplars and the informal curriculum in medicine to role models make a difference. John? Thank you for the opportunity to speak before you today. Medical schools are filled each year with idealistic students motivated by enthusiasm to live up to the noble ideals and values of the medical profession. But somewhere over the course of their medical training, a common experience happens to these idealistic students. They become jaded, cynical, discouraged about the meaning of their work. Why would that be? The research literature and our own experience as educators suggest that students feel this way in part because the professional ideals they are taught in the formal curriculum do not match up with the practices they learn on the words in the informal curriculum. In response to declining morale and concerns about declining standards of behavior among students, prominent medical organizations and medical schools have launched initiatives to develop formal curricula that teach medical professionalism. Medical educator Jack Kulahan has long argued that such efforts to teach medical professionalism will be hindered insofar as they are contradicted by what students learn on the word. He explains, quote, there has been a conflict between what medical educators think we are teaching medical students, i.e., the formal curriculum, and a second set of beliefs and values that they learn from other sources, the informal or hidden curriculum, and that hospital culture often embody a set of professional qualities that are diametrically opposed to virtues that are explicitly taught as constituting the good doctor, end quote. For example, a survey of students from six medical schools found that 62% of students reported that their ethical principles had eroded during the process of their education. A recent study of the faculty in five medical schools found that they tend to find their schools' institutional behaviors are not well aligned with their personal values. So medical students sometimes say we may be taught Hippocratic medicine in the classrooms, but on the wards we learn to practice Hippocratic medicine. As a result of this disparity between what is formally taught and what is informally experienced, many educators are starting to turn their attention to the influence of virtuous exemplars. And in case you do not recognize this figure, this is Sir William Osler, once called the Saint of Johns Hopkins, exploring the medical profession, the paradigmatic good physician. The presumed influence of role models in cultivating professional virtue, however, raised an age-old question, can virtue be taught? In an editorial in 2000, our very own Dr. Dan Somacy draws upon this question and ponders whether medical schools themselves can be transformed into schools for virtue. Dr. Somacy writes, the cynics will contend that virtue cannot be taught, it cannot be packaged and incapable of change. The data shows the data show that students can and, in fact, do change. Unfortunately, this change is in the wrong direction. Thanks for the word of encouragement, Dan. As Dr. Somacy notes, a growing body of research suggests that change often occurs in the wrong direction. Our question is whether moral exemplars, role models, can lead to change in the right direction. There's little empirical data to suggest that role models do, in fact, move students to be good doctors as we intuitively think they might. In medical education, perhaps, virtue is most powerfully taught or more accurately caught when students have a desire to follow in the footsteps of a physician role model they admire. The medical literature involves a variety of anecdotes in which physicians report that they end up practicing among the underserved, role model whom they admire. So, as part of a national survey of third-year medical students, we examine nationally whether having this desire to follow an admirable role model was associated with intention to practice among the underserved, to choose primary care, or to even go into the same clinical specialty as that role model. This year, we conducted a national survey of 960 third-year medical students. We chose a sampling method among schools to ensure that our national sample represented students from 133 allopathic M.D. schools this to ensure a broad representation of school characteristics including public versus private, sampling from all four U.S. census regions and from schools throughout all levels of ranking scores, both from U.S. News and World Report and social mission score rankings. We selected only third-year students because of our interest in sampling students with sufficient clinical experience in working with potential role models in medicine. In our survey, students were asked to identify a role model by asking whether they encountered during their medical training a physician who in their judgment displayed the best characteristics of a good physician. They were also asked about their intended clinical specialty and the specialty of the physician they identified as a role model. Through a combination of mail and online questionnaires, we obtained the adjusted response rate of 61%. Our predictor variable included an item to ask, how much do you think the desire to follow in the footsteps of a physician will influence your specialty choice? Their responses were trichotomized to little to no influence, some influence and a lot or the most possible influence and the frequencies of their responses are displayed here. Then we examined whether reporting this desire was associated with various career outcome variables such as intending to practice among the underserved, choosing primary care or even choosing the same specialty as their role model. In our multivariate model, we also controlled for gender, race, region, medical schools, social mission score and the influence of debt and lifestyle considerations on their specialty choice. Let's begin with students' intentions to practice among the underserved. You can see that among all U.S. third-year students in our sample, 30% of U.S. third-year medical students report intentions to practice among the underserved. But this percentage varied by the extent of influence that the students desired to follow in the footsteps of a physician on their specialty choice. So that those who report that this desire had little to no influence upon their decisions, only 26% say they intend to practice among the underserved. Whereas those who report that this desire had a lot or the most possible influence, a larger percentage, 42% intended to practice among the underserved and this gave an adjusted odds ratio of 2.3 after controlling for all the variables mentioned earlier. I found similar findings regarding students' intentions to choose primary care specialty. Notably 36% of medical students report intentions to choose primary care, at least at this point of their clinical training. And again, this percentage varied according to the extent of influence that a desire to follow in the footsteps of a physician they admired had on their specialty choice. So that those who report that this desire had little to no influence upon their decisions, only 31% intended to choose primary care. Whereas those who report that this desire had a lot or the most possible influence, only 25% intended to choose primary care. And this gave an adjusted odds ratio of 2.1 after controlling for the other variables. Lastly, I found a similar trend for intentions to choose the same specialty as one's role model. Surprising to me, only 14% of students tend to choose the same specialty as one's role model. One limitation of this overall study is the survey only asks about intentions, but we plan to longitudinally follow this national cohort of students over time to determine whether intentions end up getting translated into concrete career decisions and commitments. To summarize our findings, the desire to follow in the footsteps of an admired physician is associated with intentions to practice among the underserved, to choose a primary care specialty, and to choose the same specialty of a role model physician. The emotional experience of admiration during medical education may play an important role in shaping students' career choices. Linda Zajewski and her exemplarist of virtue theory writes, we find the admirable attractive in a way that, given certain conditions, we would imitate or emulate. So the admirable is what we call, we might call it imitably attractive. We do not always have the desire to imitate because imitation is often incompatible with our own situation or abilities or is incompatible with something else we want, but there is an attraction that makes imitation the natural thing to do given the right conditions. The power to move us is present in the emotion of admiration. Our findings may support some elements of our theory in which admiration and the desire to imitate an attractive role model might be serving as a power to move students to be good doctors. Interestingly, current empirical work in the field of moral and positive psychology led by Jonathan Haidt is starting to demonstrate that experiences of moral elevation, like the emotion of admiration, can serve as an impetus for a variety of pro-social behaviors and decisions. If the power to move is facilitated through the emotional experiences of admiration, perhaps this offers hope that virtue can be taught and that change can occur in the right direction. This power to move might be harnessed through thoughtful models of professional formation that integrate the life experiences of virtuous exemplars into the formal curricular experiences of students. These longitudinal apprenticeship models of formation may be effective because students would be working closely with these exemplars and potentially developing emotional experiences of admiration that are sustained over the course of their professional development. Finding creative ways to harness and sustain this emotional power through initiatives like the Bucksbaum Institute may not only start moving medical students in the right direction, but also perhaps start moving the medical professionalism movement in the right direction as well. I will conclude by acknowledging our research team as well as the virtuous exemplars over the course of my own professional formation. Thank you. Thank you, John. Our third speaker today is going to be Dr. Kiki Hinami. Dr. Hinami is an assistant professor in medicine at Northwestern University's Feinberg School of Medicine. He has practiced hospital medicine at both the University of Chicago Medical Center and the Mayo Clinic. His area of interest are ethics of research with human subjects, health communications, health service research, healthcare quality and medical decision-making, among others. Kiki. It's good to be back. Thanks for having me. When I was a fellow at the McLean Center, I found that many of the dilemmas that prompted ethics consultations were similar in one respect. While many were ethical conundrums whose resolution required their careful philosophical deliberation, the majority in my experience were interpersonal conflicts, usually among providers, that arose as a result of failures in communication. By this, I don't mean to imply that mere communication failures do not generate legitimate ethical dilemmas. Far from it, I have come to believe that communication failures are a dominant source of perceived moral distress and their prevalence and impact on professionalism and care quality have motivated my interest in understanding the challenges to protective interactions among care providers and on exploring ways to overcoming these challenges. Deliberating about doctor-patient relationships is a staple of medical ethics, but when it comes to ways doctors and other providers relate to one another, ethicists have yielded a lion's share of the scholarly discussion to regulators and management. But the negative effects of poor teamwork by individuals who contribute to the modern standard of interdisciplinary care have a distinctly moral overtone. It is precisely things like poor communication, social miscues, and misalignment of goals among our colleagues that evoke our sense of threat to our autonomy, injustice through lack of social reciprocity, even maleficence in extreme cases. On the other hand, there are a few things more elevating than a feeling of seamlessly working together with others who share common goals and values. And although I won't go into this, I think these innate feelings underscore healthcare providers as social and moral animals, one of whose frustrations originate from barriers to our ability to work cooperatively with others. To overcome the silo effect of the healthcare workforce structured in disciplines defined by organ systems and rigidly hierarchical professional titles, rather than in systems designed for best patient care, novel organizational changes in inpatient care delivery are currently in vogue. One such rising trend is inpatient co-management between proceduralists and hospitalists. Co-management is team-based care, distinct from the traditional consultant relationship in its overlapping responsibilities, especially around care coordination and decision-making. It's less about lending expertise than about partnering through the entire clinical encounter. A recent paper in the Archives of Internal Medicine illustrated the rising trend of co-management by generalists and specialists among Medicare beneficiaries, such that more than half of all surgical hospitalizations are already co-managed. These generalists are none other than hospitalists, the newest specialty in American medicine, now 15 years old. Hospitalists over 90% of whom report participating in co-management of specialty patients in their current practice. But as widespread as co-management has become, its execution has real problems related to teamwork. We showed in work here at the University of Chicago, for example, that the presence of a single poor coordinator on a co-managed team, a weak link, so to speak, sabotages the effects of the whole team. In the data presented here, after demonstrating minimal negative confounding, we showed that teams with a single poor coordinator, whether they were hospitalists, hepatologists, or fellows on a specialty co-managed service were rather alarmingly associated with worse patient outcomes. But when co-management works, we have evidence to suggest that patients reap the benefits of high functioning team-based care, an ideal to which we still aspire. Under a co-management model built around personal relationship between surgeons and hospitalists, we found a significantly smaller rate of failure to rescue in adjusted analysis. For all of you who are not surgeons, I see just a few. Failure to rescue is death following post-operative complications, and is the dominant mechanism of post-operative disability, whose reduction here is probably attributable to the coordinated surveillance and response by hospitalists to post-operative complications. What the co-management example demonstrates is that ergonomic interventions can have a powerful effect on outcomes. Using the non-median conceptual model of patient safety, we can represent interventions like teamwork training as care process, where evidence to date have shown training to be effective interaction, but their effect on actually improving teamwork and downstream outcomes is mixed. Interventions like co-management, on the other hand, restructure the norms of interactions among interdependent providers by affecting structure, such that resulting team-oriented behavior inevitably emerges as an adaptation. Let me provide another example that further illustrates this point. At Northwestern Memorial Hospital where I rounded this morning with my inpatient team, the two towers of the hospitals is considered the world's fourth tallest hospital, the second in the United States. My house staff team can have a patient on 14 east, and if we're lucky, have another patient on 14 east, but we can have one patient 14 west and four other patients on different units across the hospitals including the emergency department. As a consequence of geographic dispersion, we end up dedicating a significant amount of time and frustration coordinating care with multiple nurses usually through the pager telephone system. Not only do we struggle to reach them to give updates and instructions, we receive far too many disruptive pages from them, from nurses struggling to coordinate care with several physicians themselves, not to mention all the therapists, social workers, consulting physicians and patient families. Other teams under identically dysfunctional conditions yield the chaotic structure of the care environment that serve as a clear obstacle to productive inter-provider interactions that often results in exasperation by the end of a busy day and burnout from persistently exasperating days. To ameliorate this problem, geographic localization of patients was implemented to facilitate enhanced team communication through frequent informal contacts among the care team as well as through daily structured interdisciplinary rounds. Hospitalists were also geographically localized so that they now recognized unit nurses by name. In a paper we published this year, we showed that these structural interventions translated into a significant reduction of mostly preventable errors demonstrating again the promise of care coordination and improving care delivery. Far too often, our entrenched culture of low expectations tolerates poor communication and absence of mutual respect among the people with whom we work. The standards of professionalism ought not be achievable only by the exemplars among us. But by designing our work environment to allow professionalism to flourish do we obtain the full advantages of our natural endowments for cooperative behavior. As humorously captured in this cartoon and despite the hype, I do not believe technology alone offers the necessary solution to the many social problems we face. Harkening back to Chris Casal from yesterday, I think the first step is realizing that we behave as if we are at once Knight's Naves and Ponds. Conceptually anterior to introducing performance incentives, there is still plenty we can do to remove structural dis-incentives that obstructs and also unwanted extrinsic motivations that extinguish internal motivations of nightly behavior. My current research interest examines the effect of familiarity among providers involved in care transition and I believe in the future opportunities for health services research and exploring social solutions to address healthcare's most pressing problems. Thank you. Thank you very much. Our next speaker is going to be Dr. Eric Grossman. Eric is a surgical resident here at the University of Chicago Medical Center and a senior fellow at the McLean Center. He is in the field of violet cell transplantation and beta cell regeneration. He was recently chosen by the Pritzker School of Medicine class of 2011 to receive the Hilger Perry Jenkins Award and we're thrilled to have him back for a talk next year. He'll be heading off to Children's to do his pediatric surgical fellowship. Thank you very much for inviting me. It's a real honor to be able to participate in this conference. My topic is ethics education and surgical residency and what I'd like to do is kind of discuss how the University of Chicago has begun a model a new model of surgical training. So in the next 10 minutes the three things I'd kind of like to highlight is first a brief background on how ethics was taught to surgical residents or residents in general and then how that's changed basically from 1997 to 2010 and then the last couple minutes to talk about what we're doing at the University of Chicago Department of Surgery and specifically the section of general surgery as far as ethics education is concerned. So with the background so as early as the mid 90s the principles of bioethics as well as moral reasoning were taught in a formalized manner at most medical schools in the United States. The American Board of Pediatrics as well as the Board of Internal Medicine required ethics education during residency and actually tested for competency in their respective certifying examinations. And then interestingly the fields of psychopharmacology bioengineering, computer science engineering and all these other fields dentistry, dental hygiene, all published attempts at formalized ethics education in their respective fields. So this kind of led to one of the earlier landmark studies by Downing in 1997 looking at how is ethics taught in general surgery. This is a survey study in which almost 200 programs were surveyed and 71% responded. And what they found was that more than half of residencies did have some type of educational resource for providing ethics instruction. And in 75% of the University affiliated residencies department or medical college program in medical ethics whose mission included education for undergrads as well as post-graduate physicians. However no residency indicated that it had a regular established curriculum in ethics as part of the general education for house staff. So of 198 residencies 48% had at least one teaching event 24% had more than one activity and 28% had no scheduled opportunities. They also looked at the attitudes towards ethics education. And this was a part of their data from their survey. And so what they found was despite the fact that there was not a lot available 85% of respondents did favor some type of a formalized ethics curriculum. But the lack of faculty expertise was cited as a major element for establishing such a program. So it was basically this study over 10 years ago that prompted us to look at where are we now and kind of survey the literature for what exists for other residencies as well as what's changed since 1997. So what this looks at, this is a graph comparing different subspecialties and their published ethics education curriculum or efforts to establish an ethics education curriculum in the various fields. Not necessarily publications as far as an ethical case, but actually looking at how they implement ethics education. And as you can see internal medicine, pediatrics, family, and then you can see general surgery in the middle. And then psychiatry, OB-GYN, family medicine and radiology are quite a bit less. And then we also looked at how are people teaching ethics? What's the modality by which ethics is taught to residents? And it's basically distributed in three ways. Lectures, case and integrative case and lectures. Which I don't think is terribly surprising but what is surprising is the distribution as it relates to different subspecialties. And I think it's pretty evenly distributed between medicine and pediatrics. However in surgery what we found was quite a bit of a lecture based ethics curriculum, which may or may not be the optimal manner to teach ethics. In 1999 Dr. Angelos reported on one of Northwestern's earlier attempts at establishing a formal ethics education. And this was one of his publications and what they found was that surgical residents did welcome the formal instruction in numerous ethics education that were pertinent to surgical practice. And they concluded that a formalized curriculum can be developed that has a measurable impact on a resident's confidence in addressing ethical issues. Additionally in the Journal of Surgical Education surgical residents were exposed to a case-based format five-year curriculum that was found to be both popular with the residents enabled residents to feel more prepared to make absolutely challenging decisions and just solidify the concept that ethics is both a teachable and a desirable topic amongst the surgery residencies. Staying with how ethics education has changed throughout surgical training. In 2010 I had the opportunity to work with Dr. Angelos to institute a formalized ethics curriculum for the American Society of Transplant Surgeons. Their fellowships are required to participate in an online curriculum that spans immunology to surgical technique to surgical practices as well as there's three or four online chapters about how ethics was incorporated in the American Society of Transplant Surgeons fellowship training also solidifying how ethics education has really become to permeate surgical training and also surgical sub-specialty training. Back to our study in 2010 now how is ethics being taught and is it being taught so we basically attempted to redo the 1997 downing study and what we found was that after surveying all of the general surgery programs with a response rate of about 50% every program in America has some type of formalized ethics education with only one exception and the manner by which it's established is listed here part of the core curriculum, part of grand rounds or case-based studies but a vast change since 1997 these are the attitudes and the attitudes have also gotten better as far as surgery is concerned with 94% of our respondents believing that ethics education is adequate in preparing residents to handle ethically challenging situations and 98% of program directors believing that ethics education can improve your ability to handle challenging situations additionally there's now a formalized ethics curriculum that's published through the American College of Surgeons with the resident review committee issuing six core ethical principles and a formalized curriculum that is distributed to participating programs that here at the University of Chicago we have access to and participate in University of Chicago is one of 16 surgical programs that have received the Camananger Ethics Award helping to enable ethics education so more evidence how things are both improving and very impressive as far as ethics education in surgery our what the University of Chicago is now attempting in addition to the American College of Surgeons curriculum and instituting that as we're now instituting a very comprehensive ethics education curriculum at the University of Chicago we have monthly morbidity and mortality devoted just to ethics as well as ethics conferences on a monthly basis the curriculum was decided both by faculty as well as residents polling the residents we have faculty both from the surgical side as well as medicine the Plain Ethics Center and even the humanities residents have the opportunity to provide feedback after each ethics lecture and then we use this feedback to then re-address our curriculums and our lecture you know we've had a year of this and we've had some data that we've been able to quantify and at a year 30 out of 40 of our residents have placed a high or very high value upon the importance of ethics education and 38 out of 40 believe that it was capable of improving their ability to handle ethically challenged situations and here's how satisfied people are with 80% of respondents being satisfied with our program and 71% of our residents believing that the conferences have helped improve their confidence in addressing ethical issues so something we're very proud of at the University of Chicago is both the institution of this curriculum as well as the success it's having so kind of to conclude 10 years ago nearly one third of surgical residency programs offered no formal ethics education half only offered a quarter and less than one quarter offered only two teaching activities presently 99% of surgical residencies include some mode of ethics education with the majority of residency programs are associated with multiple resources and I think the University of Chicago is doing an outstanding job leading the way we conclude that an ethics curriculum can definitely be implemented within a surgery program that can effectively meet residents needs and that it can be a viable component of surgical residency training and the implementation of a multi-institution is justified I think it would be remiss not to thank Dr. Siegler for really helping as well as Dr. Angelo's Institute wonderful changes through the University of Chicago Department of Surgery in our ethics curriculum and I know this this New York Times article isn't completely relevant to our University of Chicago Surgery Department but it's definitely indicative of his support and the McLean Center support so thank you Thank you Eric unfortunately pole health was unable to come back today so we're going to continue the program by hearing from Dr. David brush although he's listed as the University of Chicago we're sad to say that he left and he's now a pulmonary and critical care doctor at Walnut Creek Medical Center in Walnut Creek, California he completed his fellowship in the Department of Pulmonary and Critical Care Medicine at the University of Chicago and a two-year fellowship with us at the McLean Center last spring his clinical interests include helping patients manage chronic lung disease improving physician-patient communication and medical ethics and today David will talk about ICU physicians and life support recommendations results from a national survey welcome back David thanks so much, thank you Lainey and thank you Mark and to the McLean Center for inviting me it's a huge honor so I wanted to talk today and I actually may step down and just speak loud so that I can actually see the screen as well because I wanted to point out I wanted to talk today about ICU physicians and life support recommendations I talked about the results from a national survey that I worked on with about Xander and Ken Brzezinski during my time at the center some disclosures so my salary at that time came from a T32 training grant from the NIH and we also received generous support from the cornfield program and bioelectric I am now employed by the permanent medical group in the northern California Kaiser Permanente the work I'm showing you is independent of them and thus it doesn't necessarily look like Lainey says I have to talk to you about it okay sorry about that so critical care society guidelines currently endorse making specific recommendations about life support to surrogates and that comes that's important because one in five Americans right now dies using ICU services now despite that the majority and there's considerable variation in practice but I think it's safe to say that many Americans who die in ICUs die with some limitation in their care either through the use of DNR or in many cases withdrawal of life support and so critical care physicians sort of on the front lines in shared decision making with patients but a recent study by Doug Widenall asked 169 ICU surrogates in the ICU about whether they would prefer physicians make or not make recommendations about life support decisions they actually had a very sophisticated video whose only difference was a slight bit at the end where the physician either said you know let me know what you think or based on what you've told me I think that you know it sounds like we should withdraw life support and then they they actually randomized the ending people saw both of them and then they asked surrogates you know of these two interactions which one did you prefer and did some qualitative work from that so surprising to most people do critical care medicine 46% of the surrogates preferred the MD to avoid making recommendations many of them in the qualitative works that they felt it overstepped the bounds of the clinician caring for the patient that the physician may not have known the patient well enough to be making those recommendations and there was concerns also about how physicians recommendation might overwhelm or over influence the surrogate and so it's unclear to what degree US physicians are offering recommendations just in the first place certainly you know how much are they considering surrogate preferences for those recommendations and so we did a thousand a mailed survey of a thousand critical care physicians about their approaches to disagreements with surrogates and in that we also asked about recommendations and really three big areas so one reported practice so what do they say they do second what are their attitudes and beliefs about recommendations and then third we used experimental data which I'll go over later to see how certain scenarios might actually change whether or not they provide a recommendation I should say that our response rate was 62% for our mailed survey and that there was some response bias respondents were one year older than non respondents and additionally there was about a 10% difference in response rate as to whether they went to a US medical school or not so I'll just briefly go over the characteristics and show that you know they came from a variety of centers this is reflective of the critical care population at large the male gender we need more women in critical care 82% is unfortunately reflective of the difference in critical care we see that interestingly so many of them many of them come from an open unit that is that they are a consultant they're not the primary decision maker for the patient and yet when it comes to leading the discussion for the medical team about whether to withdraw care or not we find very high levels of involvement now we ask them how often do you make a specific recommendation as to whether to continue or limit life support we see that there is some considerable variation and about 1 in 10 physicians rarely or never provides a recommendation we also ask how comfortable are you and there is a considerable degree of comfort and then we ask how often you ever ask a surrogate whether they want your recommendation or not then we ask them more well what do you think about recommendations interestingly a large percentage of them view it as a critical care physician's duty and importantly most of them thought that it actually makes it easier for surrogates to make a decision when they provide a recommendation similarly there were fewer concerns that it was unduly influencing surrogates burden the surrogates or placed too great of a burden on the physician and finally we ask do you think it's only appropriate if the surrogate wants the recommendation and we see again this discrepancy so then we ask that we use an experimental vignette and we actually divided the sample of our thousand physicians into four groups and each one of them got one of these questions right and we vary the question is imagine a surrogate says they do or do not want to hear your recommendation and it turns out the way they're leaning you sort of think they're going to make a decision that you either agree or disagree with and so physicians might see the surrogate asks for your recommendation and you agree with them would you provide a recommendation or they could get a scenario where the surrogate says I don't want your recommendation discreetly and the physician actually says gosh I think they're going to make a decision we disagree with and so I can it looks like this is a four by four table and so of the physicians who got to agree with the surrogate and the surrogate specifically said they wanted a recommendation we see that 91% of them said they'd be likely to provide that surrogate a recommendation again interestingly too even when the surrogate discreetly asks for a recommendation we see that if there's disagreement some physicians are less willing to provide a recommendation even when it's asked for by the surrogate and then if the surrogate says they don't want a recommendation and the physician agrees with the decision it's probably going to be made we see a huge amount of recommendations but a third of them even when they think gosh I think this person is going to make the decision that I think is right for the patient and the surrogate says I don't want to hear your recommendation a third of them still give it and then finally when there's disagreement and the surrogate doesn't want the recommendation a higher proportion of them just you know sort of feel obligated and provide a recommendation and these were all all the interactions were statistically significant and so what are we to take from this so I think there is considerable variability in critical care physicians provision of life support recommendations surrogates and critical care physicians though generally support providing recommendations we did do some multivariate analysis with our background characteristics and the background of critical care training makes a slight difference whether or not you were born in the US makes a slight difference and the rest of it made no difference at all so what's to explain the discrepancy I think we can't say from this data interestingly you know the degree of physician agreement may have an important influence on whether recommendations are provided and finally many physicians while they seem at least hypothetically sensitive to surrogate preference for recommendations we don't know whether that holds up in the real world and you know although they seem sensitive to it they're not asking you know and I think further research needs to go into why if physicians are willing to decide to give a recommendation based on surrogate preference what is their reluctance what is their reluctance to asking obviously there's limitations we had some response bias in age in US training status other unmeasured characteristics of course may contribute to response bias recall and social desirability biases may have skewed results but we did some pilot testing and some wonderful help from the survey lab helped us at least try to minimize that and finally it's you know it's unclear how physician responses correlate with actual practices or beliefs but this we thought was a reasonable attempt to at least see what's going on and to try to better understand what physicians are doing because we think it's an important topic future dissections could examine in more detail how physicians make their recommendations I would say that not all recommendations are equal and we didn't explore that is the recommendation come from the physician's own preference based on the physician's knowledge of the patient exploration of the surrogate and the patient's preferences we can't say I think you can confirm the effects of disagreement on physician recommendation and I think it's important to better understand surrogate preference for or against physician recommendations because you know that data was very qualitative was based on hypothetical vignette and I think before we start to maybe provide fewer recommendations patients I think we should confirm those findings with surrogates and then thank you so much in the CLAIN Center my mentor is Caleb Alexander-Kinrozinski Jesse Holland and Mark thank you very much our last speaker for the afternoon session and then don't leave because we're going to have a panel discussion but our last speaker is Dr. Sarah Ann Schuman like David Brush he is talking at 405 and like David Brush it says that she's at the University of Chicago in actuality we have to say we already miss her because she left this summer to become the assistant dean for community medicine at the University of Oklahoma Tulsa School of Community Medicine she's an associate professor of family medicine and an associate chief medical officer at Morton a federally qualified health center in North Tulsa she completed the medical McLean Center fellowship with us last spring and she and her husband and whole family have moved to Tulsa and we'll hear about that at the party but for right now we'll hear about an ethical approach to service learning and medical education welcome back Sarah so thank you Laney thank you Mark and it's great to see so many people have stayed for the final presentation so I'm going to talk more about what I did here at University of Chicago I was lucky enough to have a position created for me based on my interest when I was here I was director of community health and service learning for Pritzker Medical School and I was really impressed by the students commitment to service Pritzker is involved in some kind of community activities and some of them spend a good part of their hours outside of class out in the community but at the same time when I saw some of the community service they were involved with about 5 years ago when I started here I also thought that they could be more thoughtful in their approach to the community and that's what sort of inspired me to spend my time during my McLean fellowship thinking about the ethics of service learning so the LCME does have a standard it's not a requirement for medical schools to include service learning but they certainly encourage medical schools to offer service learning experiences for their students and most medical schools are thinking about this and I think it's important to define service learning so it is different from community service this is sort of the working definition from Serena Seifer and the community campus partnerships for health the parts of the definition I really want to highlight include preparation and reflection and community identified concerns they're really good service learning includes community partners having a large role in that and then also a connection between service and academic coursework so there are lots of different ways medical students are involved in service it's beyond this list but a couple of examples of things that I had seen when I first started here lots of medical students do these one-time health fairs sometimes they're just simple screening events there's really elaborate health fair that all the medical schools in Chicago get together and they do a health fair in Chinatown and I had precepted in that about five years ago and it's really it's a wonderful opportunity they do they do diabetes screening hypertension screening they screen for hepatitis they also do they have like four floors of a community center and the patients would rotate through different stations and get full physical exams including neurological exams and one of my concerns was I started to hear from the patients that a lot of them would just come to this health fair once a year and that was the only medical care that they were getting and that was pretty concerning to me there weren't necessarily primary care referrals happening as much as they should and I was starting to be concerned that maybe community service was perhaps doing some harm another example we have a really incredible clinic at Englewood at a shelter for women and children the students do great work there it's and on a positive side it really fills a need for that shelter it prevents unnecessary emergency room visits where residents of the shelter can come in the evening and if they have a rash or allergies or you know a cold they can get they can get taken care of but one of the things I've seen there as well is that again with the primary care I'm a family doctor so I think a lot about that but they would get their blood pressure checked in that clinic as in attending I would always be hesitant to just medicines if they had an outside primary care doctor and then they might not follow through with their routine visits so that they're not being cared for as well as they would be perhaps without the clinic and another thing that I noticed there and this has changed tremendously because we've actually instituted some curriculum around service learning at Pritzker but at that time when I asked the medical students what do you know about Englewood what do you know about homeless healthcare what do you know about this particular shelter I was really surprised that in fact many of them had never been on a tour of the shelter they knew nothing about the neighborhood or its resources and really didn't know much about homeless healthcare again that has changed so just some of this is repetitive but there are lots of potential benefits for having service learning and for patients it can increase access to care health education in the schools is great for kids for the students they develop clinical skills learn about health disparities and often they'll consider careers in underserved settings for the faculty the faculty who actually do go and precept in these settings it's really rewarding and can help prevent burnout and it's a great way to get to know the students outside of the campus and for the institution if it's done well it can improve the reputation of the institution and the community but there are potential harms that I think we don't think enough about for patients as I've said there's a risk of providing substandard care and then using a term that's usually the therapeutic misconception which we usually use in clinical trials but I do think some of these health fairs people think they're getting medical care when in fact they're just being screened for a disease and for students if they go out into the community without the preparation and reflection they may just reinforce stereotypes they already have about certain populations and if they feel like they're not making a difference they may become hopeless there's also it's pretty common that they'll overestimate the impact that they're having on community members and for faculty most institutions do not support time for faculty to participate in these activities and often it doesn't count towards promotion and then for the institution students promise something and then they don't show up or if they're not doing a good job or there isn't continuity it can reflect poorly on the institution I'm going to skip the next couple of slides but given that the topic was professionalism for this conference I mean clearly service learning is a great way for students to enhance their professionalism in their training so interestingly there's not a lot of literature of service learning in this country there are some articles about the ethics of medical students doing service projects abroad and because that's another interest of mine Pinto came up with a framework for the ethics of global health experiences and in addition to the standard ethical principles of justice, beneficence and non-maleficence and autonomy adds humility which is really important for students to recognize their own limitations and seek direction from the communities that they're serving introspection so examining their motives and that's where the reflection part of these courses can really help solidarity so aligning goals and values with the communities being served and social justice so a goal of decreasing health disparities and also it's great for students to get involved in advocacy as well to try to change you know change policies to actually improve the health of these communities is all very relevant to service learning in this country as well so I'm sorry for the busy slides but so what I've tried to do is come up with categories of questions that students should be asking themselves and faculty who are designing curriculum and service learning and then institutions should be considering before students actually go out into communities so for preparation people should be examining their motives why are they going out into the community choosing sites is an interesting question because students a few years ago at Pritzker when students were doing education programs in the schools I asked them I said well how do you pick which schools you know we have 34 communities in our south side service area and they said well it was the principal that called me back which is in that they don't have time necessarily to be thoughtful about their approach you know we couldn't go out into every school on the south side and so we have had different ways of figuring out sites but that's something people should at least put some thought into you know building on what Stacy talked about clearly we want to know the assets of the community and then also their needs and more but the preparation is really key and I think that's something that we don't do so well think about risks and benefits to the population served as well as to the students faculty and institution and then inform consent do patients know that they're seeing students often I think they don't I think we could do a better job of letting them know who's providing the care and then community involvement again something that we can all work on better ideally we would involve our community partners in planning, implementation evaluation deciding whether the project should continue and that's it's hard work to do that but it's something we should be considering also reflection component is really key whether that's an informal discussion at the end of a clinic session or a written assignment I think when people have an opportunity to reflect on the work that they're doing it's more likely going to have a positive impact and perhaps affect their career choice evaluation and quality improvement is really important as well continuity you know we have students we select for leaders and people with innovative ideas at Pritzker so often every single student will want to start a new student group that's going out to the community but we need to think about how do we continue these can we pass them off to the community to continue can we work with the University of Chicago we tried to work with undergrads and high school students to try to figure out how we can not just have a cool idea that we are participating for two years and then it disappears and then the institutional commitment is huge are we creating a culture of service are faculty and deans involved in service I'm going to give the example of University of Oklahoma where there actually there is a real institutional commitment that is part of why we made the drastic move from Chicago to Tulsa and then advocacy is so important if we can motivate them motivate the students to see that they can actually affect change they're they're going to get a lot more out of the experience and they're going to have a much bigger impact so I just want to give the example of the University of Oklahoma in Tulsa the medical school there is now called the School of Community Medicine it isn't fully a realized dream yet but we're still working on it there one of the things that they're doing is that they have these clinics called the Bedlam clinics and there are two nights a week there's a free clinic for uninsured patients from Tulsa and it's really well known in the community but they can come and it's really an urgent care walk-in clinic but it's staffed by every single medical student nursing student pharmacy PA they're all involved in it and it's an expectation that all faculty are involved in it as well so it's a really they're providing really high quality care and then they have continuity clinics as well so if they have if the patients have chronic problems they're referred into the Bedlam longitudinal clinics which every medical student goes two afternoons a week during their time in Tulsa and they have their own panel of patients and the attendings in those clinics are the dean the associate deans and the department chair so it's really the students have a chance to work with these you know high-level administrators and we also have a pretty good electronic medical record outcomes are tracked we do quality improvement projects and the students are learning about that and it really does create a culture of service there's certainly things that we could do better we could have more community involvement we need to build in more of a reflection component but I've been really inspired by seeing this institution that's really committed to service at such a high level thank you so much for staying for the final talk and I look forward to answering any questions so if I can invite all the speakers back up and opening the floor for questions Bob Taylor a quick question perhaps to the last speaker Sarah Ann Bob Taylor at the Ohio State University I couldn't help but think as you were describing what's happening in Tulsa as one sounds wonderful but I vaguely remember the old days when Cook County was a hospital that served a community value I mean so the old model of sort of county community education for medical students was the idea you provide service to the community and we sort of abandoned that in a variety of ways I think by trying to in a sense trying to incorporate those people into the standard care and eliminated we still have Cook County but it isn't the same kind of thing where you know indigents come and get substandard care etc etc so I mean in a way what you're describing is not trying to do substandard care and arguably Cook County never was that but the idea that there's a sort of that medical schools should be providing care to the community that's our solution to the fact that these people have no access to health care so I wonder how you if you could comment on that Well that's why I add the advocacy the advocacy part because I think we should be thinking about policy change and how everybody could be providing care to you know to all the patients who need it and certainly with what we're doing in Tulsa there's you know there's still a problem of lack of access to specialty care and diagnostic testing and you know Tulsa has a very strong generous philanthropic community but in general they like to give money to things that will become self-sustaining over time and just paying for specialty care for uninsured patients is not something that they're really excited about doing long term but I but that's where I think that you know working teaching about health policy and you know working with local and state government to try to make some changes is is really important Dan Salmacy here at Chicago this will be more of a comment I guess for David and you've heard this from me before it concerns the interpretation of the 2009 study by Doug White and I want to make sure that other people hear a different interpretation than the authors themselves and the press gave to that study the interpretation was that surrogates don't want to hear a recommendation but the design of the study was one in which people were given these two vignettes and videos and then chose which one they preferred they weren't asked the question do you want to have a recommendation the inference was made on the basis of these two videos and the script of the video actually has the physician who is supposedly making a recommendation in my view not making a recommendation but actually providing a substituted judgment because the script actually says on the basis of what you've told me about your loved one here's what I think your loved one would want now if I were the loved one I would be offended by that because I don't think that's actually a recommendation it's actually the physician saying that he or she thinks that they can make this sort of substituted judgment it's also important to know that subsequently a year later by Doug White also published a paper using something called the Decision Control Preferences Scale in which only 10% of patients of surrogates said that they wanted to make a decision totally independent of the physician that coupled with lots of qualitative work which suggests that surrogates do actually want the majority of them want an opinion from physicians means that in some ways your data of the practice of intensivists is not really out of step with what I think most of the best data would suggest that surrogates actually want there will be a small number perhaps who don't want a recommendation but I think that we ought to be careful not to say that interpret your data thinking that intensivists are doing what surrogates don't want Dan may have really given the crucial answer to my concern I was astounded Dr. Brush that the few number of surrogates who wished recommendations absolutely astounded and so I wonder if you can analyze your data to compare open with closed units on the basis of the assumption that in the closed unit the physician ICU physician is new to the patient whereas in the open unit the physician has a long standing relationship to the patient and I would hope trust of the patient and thus desire for recommendation well so I'm unable to do that and the reason that I'm unable to do that is we surveyed critical care physicians and so I can only talk to you about what a critical care physician does in an ICU and some of the reason for that I agree with you it may be very different physicians who have long standing relationships with their patients may have very different shared decision making and recommendations for those patients but because of sampling so a database from the AMA that says these people do critical care they safely assume these people do critical care but you can't make that same assumption for internal medicine many physicians do not follow their patients into the hospital anymore many physicians are no longer involved in ICU care and so we were very reluctant to spend some of the limited funding we had trying to capture those sorts of physicians who are still doing that practice because I do think it's a minority but I agree with you I think that sort of shared decision making may be very different and critical care physicians are particularly at risk because they don't have pre established relationships with patients indeed for the two of you who are hospitalists I would recommend a similar study knowing whether patients wish your advice or would wish the advice to their long standing physician Lynn Janssen from OHSU this question is for Kiki so I thought I thought that the story you told about the importance of collaboration and communication and then the data the whole thing was very very interesting and I just wondered whether you have in your research come across anything that indicates that not only changing up how we practice ergonomically as you put it in terms of the structure of the institution changing that up to encourage more collaboration improves patient outcomes and patient care but also changing up the way we educate health care professionals might also contribute to that so for example I know there's been a movement going on for quite some time that's really very barely gotten off of the ground sort of bumps over the last 10 years interprofessional education and in particular more specifically interprofessional ethics education so I wonder if you have any thoughts on that movement as it relates to your own interests I did mention a little bit about teamwork training it is in BOG Agency for Healthcare Research and Quality really is bringing a lot of money into a program that's called TeamSTEPPS it's been led by Eduardo Salas who's been founded by the Department of Defense a lot of teamwork healthcare has its origins in the military and so studies that inform the effectiveness of teamwork training on clinical outcomes are out there but none of them are very convincing what we have is a wealth of data that suggests that teamwork training is well received by those who receive it they like it they're satisfied they feel like they understand teamwork better but whether that translates into actually better teamwork and better patient outcomes we still don't know Nathan Allen from Baylor College of Medicine my question is for John Yoon John I was just wondering if you tried to have the medical students in your survey identify the characteristics of what they thought made a virtuous physician or what were the characteristics of the person who they admired and then maybe to try to reference that what their likely influence was to them that's a very good question well there's actually been a lot of research already on that like what qualities that they what students have tended to identify that they admire in their physicians in our particular survey we did basically we actually ask questions that sort of assess their the students level of generosity and empathy and then we also ask them to identify a role model and also rate their role models level of generosity and empathy and we're sort of going to be comparing the two so thanks I have a comment for Eric and then a question for John I congratulate you and Mitch Posner and Peter Angelos for putting together really quite a remarkable teaching program in surgery the comment would be just to add to everything that you showed us that since Dr. Angelos arrived in Chicago before he arrived in the 20 years or so that we had been doing ethics training we had trained perhaps a half dozen or seven surgeons in the program and in the past five years since Dr. Angelos arrived we've now trained more than 20 more many of whom were inside our program that is attendings and residents and fellows which I think creates a kind of a critical mass within the department that helps with all these other programs that you've described that's the comment I think that's very accurate it's a credit to the program to the McLean Center as well as Dr. Angelos as well as to yourself and how both easy it is to with ethics faculty and how accepting the department has been I agree John my question for you is you pick three outcome measures to see if I'm not sure you help me on this to see if virtue can be taught to see if people follow role models whom they admire and the three outcome measures that you showed us whether the the junior person the trainee went into the same specialty second whether they went into primary care which is so closely related to that first outcome measure and then third whether they provided the kind of service to the underserved that Sarah and captured in her discussion while I see the last one as being not an unreasonable measure I'm just wondering whether specialty choice is so complex and is generated by so many things antecedents before ever encountering one's model or exemplar if those were the two right measures to be looking at to find out whether this role modeling is working well specialty choice is a complex area of study what I didn't mention in our studies we did ask various other factors like financial debt whether lifestyle considerations played a role in their specialty family expectations and considerations of issues of burnout so we asked a whole bunch of things too I sort of limited to in our studies those areas that I thought were particularly important in primary care special in the primary care field but you're right one outcome measure that I haven't mentioned that I want to show is whether the virtues of the students are associated with the virtues of the role models that they say are their role models do they change over the time do they start to match up that's something where we just sent out the virtues of their role models and so that would be a more interesting outcome measure I think I have a comment and then a question for Mary back to the future when I was an Osler resident at Hopkins our patients were admitted onto a firm with a primary nurse that had followed that patient every single admission onto the same floor with the same team of residents and attending so when I picked up my panel of patients the nurses had often cared for that panel of patients for years knew more about them than I did were part of a firm of faculty and residents who had cared for them for many years and so it was a virtuous learning environment where everyone was committed to compassionate, longitudinal and quality care and it made for a much more enjoyable and less stressful experience because you weren't there ever alone even though you might be there in the middle of the night by yourself so that's kind of back to the future future back to the back but Mary my question to you about misconduct do you think industry funding of research prevents a huge barrier because they don't want the institution to really do rigorous research that's question number one and question number two if everything has to go through grants and contracts could the requirements in an office of grants and contracts and essentially adopt NIH standards and apply them across every single grant or contract that gets funded by that institution or accepted for funding by that institution such easy questions Preston the second one first I think a lot of what is kind of off the books is off the books so grants and contracts won't necessarily capture that there's a lot that goes on that's either from the institution there are things that don't go through grants and contracts and we're seeing more interesting ways of compensating doing consulting arrangements that actually come through as want to come through a salary there are all kinds of new things that are coming through that I've never seen before and I don't know that it's the case that industry wants to have less rigorous research or anything like that I don't know that that's true we can look at some of the recent lawsuits against different industry and it may be true but I'm not sure that that's the root problem that we're seeing I think there are the combination of conflicts of interest of pressure to produce of superstar people thinking that they can do anything and it's the right thing to do I think there are a combination of problems but the real issue I see is that so much happens under the radar and is handled at the discretion of whoever it is who happens to be named to be for example in my position the only requirement is that someone has to be an integrity officer there's no training there's no here's what you have to do just name someone to be in that role and it's very subjective depending on who's involved in the evaluation there's no systemization I think that as I said Troy Brennan identified a major issue that is there's no standardization at all and you can really do whatever you want if there's no federal funding it's completely up to the institution and nothing ever gets reported so we don't capture any of it yes if there are no more questions we will adjourn I want to remind everybody that we have a party tonight I think that Mark wants to remind you so I'm going to let Mark have the last word it'll be a very short word I think the party is due to start at 6 but my guess is that if people get there at 5.20 or 5.30 people they'll be set up and ready to begin we look forward to seeing everybody there I want to thank the audience for staying so late and being so attentive it's really been a fabulous day I want to thank this last panel thank Laney for moderating the last two panels and thank you all very much