 To introduce our second speaker on this session, and that's Alex Langerman. I have actually known Alex since before he went to medical school. I think we wrote a paper together before you went to Pritzker. Alex is associate professor in the Department of Otolaryngology at Vanderbilt, and he's also at the Vanderbilt Institute for Surgery and Engineering and a faculty member of the Center for Biomedical Ethics and Society at Vanderbilt University. He's director of surgical analytics and also of the program in surgical ethics. Alex is a practicing head and neck surgeon whose research focuses on the interaction of ethics and data science in the operating room. And today he'll talk about candor and informed consent. So really a pleasure to welcome you back, Alex. Thanks so much, Peter. It's always my favorite time of year to come to this conference, and I think Sarah's presentation reflects what's so exciting and awesome about the world that Mark has created where clinicians will see something in their daily practice and just think, hmm, I wonder what to think about that. I wonder what to do about that. I wonder what other people have written about that, and suddenly a whole research avenue emerges, and I love this conference in large part because you see research as it's emerging out on new topics that haven't been discussed before. So thank you, Mark, for including me and for creating this world. Some disclosures. I started a company on surgical data analysis, which I continue to advise. I'm not going to talk about its products or services. And Vanderbilt has a patent out on one surgical camera that I developed and to a degree that intersects with my research, but it doesn't affect it. So what is surgical transparency? There's a lot to unpack there, but the basic concept is we think about what should we be capturing in the operating room? And then what do we do with that data? And then lastly, if we have that data, how do we interface with patients and what does that data also prompt us to tell patients that we might have previously not bothered to say or kept secret or were unsure how to talk about it? And so that's what I'm going to talk about today is that latter part. Preparing patients to understand the day of the OR and the language of transparency. And if you think about what is surgical transparency, I'd like to begin with the assumption, if you really want to be super transparent, that a patient could know everything that happened in the OR. Now, could is a very intentional word there. I'm not saying that they should necessarily, and I think that is part of the ethical analysis that's still ongoing. And I'm not saying must either, even if you could, you don't necessarily have to push it on a patient. You have to figure out what patients want to know, what they need to know, what they ought to know. And that's a big part of the research that I do. So this is the old joke about no one wants to know how sausage is made. And there are many sausage aspects of... Yeah, it's awesome, right? There are many sausage aspects of the operating room, but I'm going to talk about just one today, which is this idea of training, teaching residents, and residence autonomy. So how do we talk about it now as far as resident participation? Well, this is the most common way, is that little tiny disclosure on the operative consent, which used to just say whoever he or she may designate, and now consents have evolved a little bit to be even more specific. However, the degree to which surgeons actually go through these disclosures with their patients, anecdotal evidence suggests it's very rare and there's not much study on it. So when you think about the language of transparency, what we really need is to create things that are both truthful and reassuring. What you don't want to do is cause a ton of anxiety by airing the dirty laundry of the operating room, the sausage argument, but rather create a language around discussing the realities of the OR and what happens in a way that also can be reassuring to patients. And that's the active research. This was a great study out of 2012 which the authors asked patients if they support the idea of resident training, most did, vast majority, greater than 90%. And then they asked patients to respond to their willingness to consent to various surgical scenarios that they describe, starting with first the resident watches the attending, and then the senior resident assists the attending, junior resident, the attending assists the junior resident and the attending observes the resident, and you see how dramatically the willingness to consent drops off. And so one of the challenges that this article points out is if you're really truthful, are you going to get patients who refuse to have surgery because they are worried about a resident operating on them and what is that worry based on? So in prior research we found that patients really want to have a lot of knowledge and control over who does what in the operating room. So it's about some think that residents should just be observing. Some say, well, if that person is going to operate on me, I want to know them. I want to vet them as I have vetted my attending surgeon. And so that is in part knowledge because knowledge is reassuring. It's not a stranger, even hearkening back to this idea of ghost surgery. You know, this is someone that's known to the patient, they can assess themselves. But it's also an attempt by the patient, a very legitimate attempt, to control the circumstances under which they will be put because they're asleep, they surrender their autonomy to a degree because of the anesthesia and the surgeons can do whatever it is they're going to do and so they want to know and be able to design what's going to happen to them in that setting. So surgeons actually recognize this and respond to it. So here are some examples of what surgeons say they talk to patients about when they talk about the operating room and residents and resident autonomy. Some surgeons talk about the idea of everything's under my control. They kept on the ship. Some other surgeons will diminish the resident's role and say, well, you know, I mean the resident is sort of like my secretary typing my letter, you know, and I'm the CEO of a company or, you know, they're going to do, you know, the surgeon isn't doing the fly in the plane the whole time, but the routine parts the resident will do. Well, it's actually not 100% true, you know. I mean, residents actually are supposed to do complex parts because they need to learn how to be a surgeon. And so this sort of is, this is Denton Cooley with, you know, implanting the first artificial heart in the United States. And it's this idea of surgeon as God, you know, and all these other assistants and what are they doing? They're just watching them. And that's the concept that many patients have is that there's the surgeon and then everyone else there is to learn by just watching. You know, avoiding the obvious that the only way to actually learn how to do surgery is to do surgery. This is a great article from 1981, sort of a classic article and the idea of, thank you, a classic article and the idea of resident autonomy and resident training. The myth of the omnitid surgeon needs to be laid aside. And the reality is that it's a team, you know. We're all kind of doing the operation. So, here's a video. All right, so we have a surgeon with blue gloves on, a surgeon with white gloves on. Who's the attending surgeon? The white gloves? Show of hands? White gloves? Wow. Smart audience. And the attending surgeon, blue gloves? Yeah, yeah, so it's the blue gloves. Many patients, when you show them this video, think that the surgeon is the one holding the cutting tool, that that's the concept in there. Whereas, in fact, if you, you know, as anyone who's been in the operating room would know, the, you know, the surgeon is clearly sort of controlling that situation. So, surgeons actually address this. Other surgeons, and the ones I showed examples of, actually address this directly with patients. They talk about the idea of taking two to Tego. They talk about a team sport and that they're actually seeing the resident through the operation and that sometimes, you know, one pilot's flying, if he gets really complicated, another pilot takes over if there's some danger or some difficulties. And that does actually represent the reality of what happens in a training institution. Other surgeons also elevate the team. They talk about the benefits of residents being in the operating room. I'm better with my team than I would be without. And there's more eyes on you. There's more chances to catch errors. So, we need to think about the whole surgical team as we represent ourselves to patients rather than representing only ourselves as the omnipotent surgeon. So, we got really curious how patients would respond to actual videos in the operating room. And that's one of the videos that I showed you earlier. I'm going to show you this video again now with audio. It's going to be a little loud. I apologize. All right. If you can cut along the trachea. Great. Keep going. All right. You get the idea. When we show patients that video with audio, they began to realize, oh, in fact, it's not the person with the cutting tool. It is the person who's instructing, the person with the blue hands. And this is preliminary data. We're still actually doing this study. But I got an opportunity to collect just what we had so far. Interestingly, when you think about who does the operation of the patients who figured out that it was, in fact, white gloves that was the trainee, 72% felt that the trainee indeed was doing the operation because they were the one cutting. And so that gets into the heads of what patients think about what it means to do an operation. So here are some quotes from the white gloves tweezers and knife. Other patients, and again, this was second patient, felt that it was the white gloves that really did the operation. But really they both looked like they're doing something and they're participating. And then we had a patient who felt like blue gloves really did the operation and described the resident as sort of a tool that the surgeon was wielding in the operating room. So that was a very interesting concept. There's more to come here. So we asked the patients, okay, well, you've seen the video. Now you kind of know what might happen. How would you talk about this to patients? How would you tell your colleagues, your fellow patients about this? And they talk a lot about this control idea. But also they're blatantly amiss about it. This resident may be doing some of the cutting and sewing. I'll be assisting. I'm guiding. I'm very much in charge. And I'm closely watching the park, Sydney and advising. This is actually kind of what happens in the operating room. And they may be helping me or they may actually be doing some of that. And this begins to give us some clues about how we might talk about it in a way that theoretically could be reassuring to patients. And I should say when we asked certain patients to explain how they would, you know, say how they would explain it, we said in a way that would be reassuring to you or someone you know. And this is what they came up with. So, still patients want to meet their surgeon. And I think that there's that aspect of it that we're following short on. They actually want to vet their surgeon to a degree. How much this is practical is a different question. But patients say, well, if someone's going to be operating on me or doing a substantial part of my operation, I want to know a little bit about them. I want to be able to assess them, really, you know, see if they care about me enough to actually I can trust them to operate on me. So this is a work in progress as I said. And of course this video that I showed just shows team surgery. It doesn't actually show the resident operating with the attending standing off to the side or just holding the retractors. Both are kind of doing it. And so I think you need to take this all the grain of salt. So, thinking about challenges to transparency. One, it's potentially anxiety provoking and I think we really need to address that and focus on that. Second, surgeons may be worried that if they're honest about what happens and the realities of the operating room, the patients will say, well, I'm going to go somewhere else. I'll go to a private hospital or go somewhere where someone will reassure me that they're going to do the whole operation, which may or may not be true. I think that additionally, we, you know, anytime you think about trusting, patients trusting healthcare practitioners, we can avoid the potential effects of gender and racial bias. And so any study that would look at how to use language in transparency has to be testing this language with various combinations of providers and patients. Finally, if you're going to talk about this unless it's easy to talk about, it may generate a lot of questions and if you're going to introduce your residents to patients, there's challenging logistics there. The resident might not be with you in clinic that day. He might be meeting them on the day of surgery. And so working through that is one of the barriers here. And then lastly, I want to talk a little bit about what a barrier which is when you're an academic surgeon and you're training residents to a degree you have a dual commitment. You're committing yourself to the patient and giving them the most excellent care of your residents an opportunity to become the best surgeon possible. This was an article that began to address this in 2012. As a pro, they talk about this idea of our duty to pass on knowledge to the next generation physicians. And as a con, they say, well, patients don't see that dual commitment. What they see is they want to get the best possible care of surgery that they can get. Whether the resident trains or not is sort of irrelevant to their goals. And I think you can go both ways on this and this is an interesting area for further debate. I want to present you with one example from interviews that I did that I thought the audience might find thought provoking. So we have an attending neurosurgeon who's talking to me and explaining this anecdote. He's in the room. He's not scrubbed in. He hears the shh sound. He hears some suction going on. You know, and the resident's operating on the brain. I've got some bleeding. He says, oh, you know, I go over there. I look down the scope. That's arterial bleeding. The resident sort of explains what happened. And he asked the attending, are you going to scrub in? The attending says, no, I'm not going to scrub in. You're going to fix this because you're going to be a vascular fellow in about three months. They'll expect you to handle this. I need you to know that you're going to be capable of handling this kind of thing in the future. So I'll be here. I'm your resource, but you're actually going to do this operation in a time when there was beginning to be a potential complication. I think you'd be able to get yourselves out of it. And he talks about how the resident came into his office. Very emotional. The biggest event of a surgical training, he finally felt like, wow, I can go out and be an independent surgeon. And if you are an academic surgeon or an academician thinking about giving residents autonomy and teaching them how to be independent surgeons, it seems like a really pretty amazing example of that. And if you're the patients on the table, this sounds horrifying. You know, my brain is bleeding. And the person that I, you know, who knows if the patient met the resident? The person that I was expecting was doing my surgery is standing there, you know, giving them their opportunity to win or fail at the expense of this patient's brain, which is something that makes transparency that much more difficult because these are real things that happen in the operating room. And how are we going to talk about them? I'm not sure. And that's a big part of the research that we're doing. So surgeons actually recognize this tool commitment and, you know, try to find ways to describe to patients. But we're not sure how this is going to resonate. And that's all I have. Thanks very much. Well, people are coming to the mic. Can I take the frog out of this moderator and ask you a question? So it seems to me that there is somewhat of a metaphysical question about who is doing the operation. Because as an intern, when my attendee took me through a lymph node biopsy, I felt I did the operation. Right, right. But I'm sure if you asked the attending, you would say you didn't do anything. Yeah. Because where I said I didn't do what I said to do. And so I'm not even sure what it means to say someone is doing the operation. Well, I think you're right. And so we can answer that from different perspectives. But we can also think about it in a philosophical sense, philosophical sense of what it means to do it. I think where that question gets interesting is as you go from being the dumb, the dumb assistant who just cuts where you're told. And as an attending surgeon, we have to watch ourselves because it can be very easy to provide no learning opportunity whatsoever to a resident other than how to hold the cutting tool. And they'll leave the operation, they'll think that they did it. And in fact, they have no idea how to do it themselves. And so that graduated progression of responsibility. So what does it mean to do an operation? Well, part of it is the individual components of judgment and decision making and technical skill. But part of it is the responsibility that you're taking over for that surgery and its outcome. And lastly, who does the operation? Well, it's really the team that does the operation. And I think that's the other thing that we need to talk about. Instead of saying, you know, I'm going to do your surgery, we're going to do your surgery. And I think that is something like all the philosophy fits into that one change in word as to how you represent the patients. But it's an interesting question. So there's a lot of people with the mic, so I got to ask you all to ask surgical, succinct questions and surgical, succinct answers. Yes, you go. No. No, that's fine. Emily Landon, University of Chicago. Along the same lines of what Dr. Angelos is saying, I get that it's definitely different for patients for them to be asleep, like physically asleep. But I think in many cases, there are similar issues along with consulting, like when your doctor in the hospital consults another team and you just get whoever's on that day. And I think there can be some crossover between a lot of these things that patients may not be physically asleep, but I think their involvement is about the same level. I think that's a great point. And consultation is an important aspect. Yes. What a great presentation. Thank you. I have one question. The transparency I love, but an element that I tend to emphasize, the tradition of medicine is from generation to generation teaching and advancing knowledge. And like I said yesterday in a context, patients, in my view, cannot selectively take one element of all that if they want it, they get a full package including that tradition of education. Yeah, it's a good point. And certainly if you say, as someone says, I don't want a resident involved in my care. One, it's probably not good for them because, in fact, that breaks up your usual routine. But secondly, one could make the argument that this is going to disproportionately favor patients who are empowered, patients who are knowledgeable about the health care system, or disadvantaged patients who perhaps they're the ones that will only be trained on are the people who don't know to speak up and complain about it. And so I think in that sense we really do have a commitment to treat every patient the same way regarding the inclusion of trainees. Terrific talk. Thank you. Kodesh from Cleveland. I see an opportunity here for moving this earlier in the educational process. I spend every Tuesday morning now with first and second year med students, and they worry about this. And as we do our ethics and humanities education, I would just make the point we should start having these conversations with students early on so they can get comfortable being uncomfortable. Hi. David Keefe from Boston. Excellent talk. Raised a lot of questions. One of which in my mind is what is the public's perception of what is right and what is wrong here in terms of involvement of residents in their procedures? You touched on that a little bit, but I was wondering if there's more data on that. I don't have much more data about that, but the thing that you raise, I mean, there's plenty of papers that show that patients think they watch, but as far as the exact numbers of that, that I don't know that exists. But you talk about public perception and a lot of public's perception is from things like TV shows and this is talking back to research on CPR where people felt like CPR was always successful because it was always successful in shows, and actually there was lobby to have more truth in the depiction of CPR. There may be an opportunity here to lobby for more truthful depictions of training that may help patients understand or addressing the transparency issue in a way that shows OR scenes that might be depicted on a TV show to help patients understand the realities of it. Thank you. As the number of surgical patients who are awake increases, I know that you and former student here, Clara Smith, had written a series of papers. Could you just say a word about the awake patients attitude towards these encounters with surgeons? Thanks, Mark. So the study, the research that we did asked surgeons how they behaved around awake patients who could hear what was going on. And very clearly, they said, oh, I teach less or I whisper when I'm teaching. I try to obfuscate the fact that there's some training going on which shows that surgeons are uncomfortable with this idea and are fearful that patients are going to be uncomfortable with this idea. When we talk to patients about it, when they hear whispering, they get more worried. And so, in fact, many patients said, well, I expect that there's going to be teamwork going on. I just wish the surgeon would have explained it to me ahead of time. And that data is still coming out. But I think it's an important population. If you want to think about cameras in the operating room, start with something that happens already, which is awake patients and how it changes team behavior. Deborah Leff from Chicago. The days of C1, D1, teach one are over. And we now have many other tools in terms of surgical education, including simulation, simulators which aid the technical aspects of learning and milestones so that in the olden days, we weren't really graded or assessed in a more intentional way as we are now. And I think that even the graduating surgical trainees still feel uncomfortable in many cases and need a lot of mentoring. And that's sort of the job of the senior surgeons as these youngsters get out into practice to really watch and mentor and guide them. That's right. Absolutely. And there's a lot of data about residents coming out feeling unprepared. But there's also something completely amazing about getting mentored by your colleagues. And I still get that. As a surgical resident, I'm often tasked with obtaining some or all of informed consent from patients. And I'm curious in how trainees themselves discuss their own autonomy with patients and what those conversations look like if you have any information. Let's write a paper. I'd be curious about that. Yeah. I mean, I think you're right. And the only thing I would say about that right now is it's really important for the attending surgeon to address this early because that actually makes the difference. And I say that more anecdotally, but I think this would be a really interesting study to do is how residents perceive that. So thank you.