 Good afternoon. On behalf of the McLean Center for Clinical Medical Ethics, I'm pleased to welcome you to today's lecture in our seminar series on ethical issues and end-of-life care. Next Wednesday, here in P117, Dr. Dan Bronner will give a talk entitled, Welcome to the Cardiac Arrest Paradigm. Now it's my absolute pleasure to introduce today's speaker, Dr. Mark Kaczewski. Dr. Kaczewski is the Michael J. English SJ Professor of Medical Ethics, the chair of the Department of Medical Education, and the director of the Niswanger Institute for Bioethics and Health Policy at Loyola University of Chicago. Mark has also served as president of the American Society for Bioethics and Humanities, the ASPH, which is the leading bioethics organization in the world. Dr. Kaczewski's major areas of interest include the just and equitable treatment of immigrant patients, the role of culture and spirituality in decision making, and bioethics education. Dr. Kaczewski is a member of the Hastings Center advisory board on the Undocumented Patients Project. He served as the project manager to help revise the admissions policies of the Loyola University, Chicago Stritch School of Medicine to include dreamers. The dreamers are individuals who meet the requirements of the development relief and education for alien minors, the so-called dream act. It's a complicated set of criteria, but dreamers are undocumented immigrants who came to the US before the age of 16, have been here for at least five continuous years, are under 35 years of age, and have graduated from high school or have earned a GED or served in the military. Loyola Stritch, under Dr. Kaczewski's leadership, is the first medical school in the country to welcome applicants from dreamers. And I'm told by Mark that seven of these applicants are in the current first year class at Loyola. It is work in bioethics education. Mark's experience in providing resources to support ethics committees in community hospitals led him to explore online education. As you know, Loyola has created two of the major online graduate programs in bioethics. Today, Dr. Kaczewski will speak to us on the title you see behind me. I will never let that be okay again. Medical students' reflections on caring for dying patients. Please join me in giving a warm welcome to Mark Kaczewski. Thank you, Mark. Well, thank you for that kind introduction. I'm Mark Kaczewski, and it is an honor to be here speaking at the McLean Center, and a real pleasure to have a chance to talk with you today about a fairly modest study that we did a couple of years ago that's been published in academic medicine. And it was part of a larger project that was organized by the George Washington Institute for Spirituality and Health at Washington. It involved six medical schools, and we came together to try to figure out a little bit about whether there were competencies that one could define for medical students that they would have to achieve in terms of spirituality, in terms of the spiritual care of patients that they attended to during their education. And through a kind of process in which they did focus groups and so on, we came up with some general competencies. And each school came up with its own specific project under that. And we ended up doing a modest study in which we had our medical students writing about their experience of caring for a dying patient and analyzed their reflections on that to really look at what that experience was like, what the clinical setting looks like to them when they care for dying patients, and how they're affected by that. And so we tapped that, we tried to tap into this world of spirituality. And by spirituality, it's defined in the broadest possible terms. It's really about meaning making activity by the patients and by the caregivers. And so really looking at how patients and caregivers understand the processes they're going through, this process of illness, treatment, and in these particular patients' cases, the dying process and death. And how they see that in terms of what's going on around them and the transcendent, ultimately spirituality, suggests that bigger picture. And so when we say spirituality, not necessarily talking about religion, but in those more general terms. Our project at Loyola that we worked on, we called our significant death project. We wanted to ask the medical students, our first idea was to ask them about the first death of a patient that they dealt with. But that didn't necessarily always turn out to be an easy question to ask people because they may have dealt with death prior to their third year clinical rotations. And we are talking about third year medical students here. Or the first death that they dealt with on the clinic form may not have been significant. They may not have been extremely engaged with the patient. So we asked them to write about a significant death that they encountered of a patient on the clinic floor. It was a multi-disciplinary team from our school that engaged in this myself as a bioethicist who's been trained in philosophy prior to being in bioethics. Michael McCarthy who's a theologian and a physician, Dr. Aaron Mickelfelder from Family Medicine. And as you can tell from looking at that lineup, we were probably going to be hopelessly methodologically clueless. So the publication ended up with three additional people who were our methods people that we added partway into this to help us bring this to something that could be explained to the public. And so we simply asked them to the third year medical students during that year they're on their clerkship floors. But during that year they should identify a patient that they cared for who died and whose death was in some way significant for them and write a reflection on that. And then we did content analysis together for themes through a multi-step iterative process of outlining the themes and coming to some agreement on this. So it was strictly qualitative. There is not a quantitative dimension to this study. And I should say that the task was given to the med students at the beginning of their third year. So by October they were already well immersed in this process and they didn't turn this in till May. So they had the full array of clerkships under their belt by the time they turned this in. So they could have chosen it from any service that they were on. And I'm gonna give you the literal words that we told the students. So you'll know what the prompt was that we gave them to which they gave these responses. And so we said to them, please tell us about your experience in caring for a patient who died. Your paper should focus on your personal experience of this patient and all the people involved in the process. We also hope that you will tell us about the ways in which you and the other members of the healthcare team took care of the patient and his or her family's spiritual needs. And we went on to say, consider telling us about issues that were important from your perspective. This might include matters of communication. The underlines in bold were not in the directions we gave them, just putting that for our emphasis. So you could see some of the competencies that came out of the George Washington study. The ways in which the particular caregivers did or did not demonstrate compassionate presence. The extent to which the patient and patient's family's spiritual needs were evident to, assessed, or addressed by the caregivers. Share any insights regarding the spiritual needs or resources of the members of the healthcare team, including yourself. Please close your paper with a discussion of how this experience has impacted how you care for yourself today and or how this has influenced your care of patients, if at all, okay. And again, the underlining and boldening were not in the original directions. But what I was, why we put that in was to show you that we were really asking them. The prompt was designed to get at four of the six competencies that were outlined by the six G-WISH schools in the initial project. And the six competencies that G-WISH put out and they published in an accompanying piece in academic medicine include patient care, communication, compassionate presence, personal professional development. And then the ones we did not try to prompt for were healthcare systems and knowledge things, knowledge, things like the difference between religion and spirituality, the difference between a spiritual assessment and a spiritual history. None of those knowledge kinds of things were prompted. We were really looking at the experiential dimensions of their caring for the dying patient. And so, because I know in medical center people often have to leave very early in this. I'll give away the punch line. Here's what we ended up finding as the salient findings from this qualitative study. Basically, it is a mixed report on how well we're doing in caring for dying patients out there. Sometimes when we're in conversation, you hear people in frustration say, oh, nothing's changed. Everything's just as bad as it always was. We're not doing a great job at the end of life caring for patients and certainly not good caring for the whole person, just the medical stuff. Other times you'll hear people really coming from the other end of the spectrum saying, things are completely different than they were 30 years ago. It's night and day, right? And the answer according to what our students were telling us is that actually it's somewhere in the middle. That it's not that we're not doing well at all. Some people are doing very well. They reported on some role models who were just fantastic at knowing how to modulate their approach to patients, how to deliver difficult news without beating them over the head with it, but yet how to be truthful and supportive all the time. And they told us about these kinds of role models. On the other hand, they also told us that sometimes it is like it was 30 or 40 years ago where nobody actually brings up the subject of dying and that there is a kind of spiritual distress going on in that situation, which nobody's really talking about. And in particular, they did tell us that there were problems that are really still caused by the fragmentation of our system. That in fact, care is still delivered in episodes by specialized teams. And so because patients are moved from service to service because teams rotate on and off, it's very easy and there's multiple teams sometimes caring for a patient at the same time. It's very easy for Buck to be passed, for everybody to think the other person is addressing the personal and spiritual dimensions, or to just say, well, what can I do? I'm rotating off tomorrow anyway, and to let things go. So that kind of fragmentation came up again and again as a systemic problem. But they also told us that there were times people show us some continuity across that fragmentation. There are ways people reach across it. One student telling us about an attending who when the patients rotated off their floor and to say a rehab unit would still send the medical student to go check on the patient for several days afterward and report back to the team. And so there were some good stories to go with that, but that they did tell us that there is in fact competency at this stuff, that they did tell, when they told us about those role models, there were consistent things about how people engaged when they're doing a good job. The other thing which I came across very clearly and repeatedly in paper after paper was how aware the medical students are of their own personal and professional development in going through this process in their third year. They're acutely aware that they are changing as they go through this, that they are becoming more desensitized, that they see so many things every day in their daily lives and their work life, that they no longer can react quite the way average people do to such tragic situations. And at the same time, and they realize that some degree that's functional, that they need to do that, but they're also very worried of becoming too insensitive so that they become like some of the lesser role models that they see who pass the buck, who don't address any of these needs. And the fact that that came up over and over against Juckus is a bit of a surprise in this, that while educators often talk about this stuff, we weren't aware that students were that acutely self-aware of that process. And so under each of the four competencies that we prompted for, I'm going to tell you a few of the themes that came up for each of those. And very often, and when I say very often, I mean again, we're not doing quantitative stuff, but at least significantly often came up this idea that sometimes we still just don't address the fact that the patient's dying and therefore fail to meet their needs. And you could see this quote from this student that telling us that the team stayed immersed in the immediate treatment issues. Not once did my team mention or consider that Ms. W was in the process of dying. I did not hear any talk about end of life care so I didn't think it was necessary to talk about this with the family. I spent a lot of time with them answering questions. The patient's sister was very suspicious and felt like she was not getting the whole story. I don't think she did get the whole story either. And so sometimes medical students believe that the patient is dying, but because nobody's talking about it, actually doubt their own perception of that until the patient actually dies and then realizes nobody was addressing it. Under the, we asked them to tell us about the resources the team brought to this situation and what kind of experience that provided for them. And there were a couple of things that came up, sometimes just the shock and suddenness of death for medical students. Seasoned caregivers, like yourselves, often expect a patient to die. For a medical student, sometimes it's quite surprising. And so a few of them talked about things like walking into their patient's room in the morning, ready to greet the patient and seeing a stripped bed or something like that that suddenly starkly tells them, lets them know that the patient has passed away. The other theme that came up under this header was that quite often there is no processing of the fact that this death has suddenly occurred. That the team simply doesn't mention it. We did hear some stories where teams did take a timeout and talked at the nursing station for a moment, but more often than not, the norm was simply going on. I didn't even get a chance to say goodbye to the family. Before I even realized what had happened, the family was gone. The patient removed from the list and my next patient was waiting for me to take care of them. The team didn't make any comments about her death that morning and everything seemed to continue and move on as if nothing had happened. I initially did not know what I wish had happened, but the way this situation ended lacked any closure for me. And again, this battle against desensitization, the students awareness of this. This is a student who was working in the ER that day and a patient is brought in in an emergent situation with a large gunshot wound to the chest. The team is working furiously, the trauma surgeon comes in, a whole full court press being done, the patient dies and the team moves out of the room, the med student standing in the back, the nurse goes up to the body to begin prepping the body to move and send it to the coroner and she turns to the medical student, says, come here, it's time for an anatomy lesson. Let me show you what's going on here. And so the student is glad that he has this teacher who's taken him under her wing, but he reflects on that experience and he says, I kept seeing that scene over and over again in my mind and I struggled to define my feelings toward the situation. Medical student side of me kept thinking, I'm so glad I got to see that, that was awesome to see everything I'm learning come together so quickly. But then the other half of my mind kept thinking, but that was a really human being that died in there. It was not awesome, it was horrible. And I kind of, I think that just very poignantly describes that struggle of which the medical student is aware. And similarly, another student tells us, when I left the SICU, Ms. W was still alive. I hoped that she would make it. In my head, I pretended that as what would happen because I knew that once I started my next rotation, I was likely that I would never see Ms. W again. I was more or less able to wash my hands of the situation. I think that as residents and students, we have the ability to do this because of our ever-changing schedule. I know that it's necessary to be able to move on, but there's something so superficial about this that makes me sick. And so the, again, you could see in the desensitization how it works with that fragmentation of the system we talked about a little bit. The fact that one rotates on and off and rotates to different units enables one to simply go into denial if one chooses. And again, she realizes that can be healthy, but there's also something missing in that kind of thing if one simply moves on without talking about or processing any of these feelings. And of course, again, that counter balancing side that they realize that they do need to become somewhat less sensitive to these situations. This is a student who was on his OB rotation. The baby's being delivered. He's with the team through the whole delivery. The baby is stillborn and dead. And of course, the family begins to react emotionally to it. And the medical student also begins to react emotionally to it. And he says, I just couldn't hold my emotions anymore and began bawling. I've never felt so helpless in holding my emotions. The hospitalist that was in charge of us immediately grabbed me and took me to a quiet room so I could sit down. I was so thankful for him to listen to me cry uncontrollably and attempting to get a handle on what just happened. He told me to let it out that it was okay. I'll never forget that day. Now, again, we see here as we want the students to remain sensitive and remain compassionate human beings, the medical students realize, and this doesn't work. If I do this, it takes all the attention off the patient and the family where it belongs. And so I've also got at the same time to get this under control. But nevertheless, and also a very poignant experience in which the attending on is very compassionate and how he deals with the medical student at that time. And of course, ultimately, both have to be true, right? One has to become less sensitive, but one wants to not become too insensate. And so this, the medical student who was looking at the gunshot wound at the top of the, we looked at it a little while ago where it was saying it's awesome, but no, it's not awesome, it's horrible. Continued to wrestle with that problem, said at the end of the night, I had not found any sort of peace with the events I witnessed that day. I was still torn between siding with the medical student in me or the emotions of a human being. Finally, I realized that I did not have to pick sides. I could be and should be both. So at the end of the night, I simply ended my internal argument by praying. I prayed for Ms. P and Mr. P and his loved ones. I prayed for medical staff who care for these patients on a daily basis. And lastly, I prayed that throughout my career, no matter how many patients I see or deaths I encounter, I hope that I continue to face these questions and emotions so that I could help my own patients to die with the great deal of dignity and respect which we all deserve. And so it's interesting in that the reconciliation tries to hold both elements without letting go of either. And also that the student themselves used a spiritual format in order to help achieve that reconciliation, that the student's own spirituality was helpful in pulling that together by doing it in an act of prayer. When we asked the students how will this experience impact your future care of patients, we expected fairly modest observations from them. However, we came to call their response to that, the pledge, because they seemed to be taking a pledge to say I will never do this or I will never do that or I will always do this or always do that. In fact, the title of our talk here, I will never let that be okay again, is a response to a situation that the student didn't think went well and she would never let that be okay again. And so they made commitments essentially and they seem to be strong kinds of things which speaks well for the idea of why we should continue to do reflection in medical school, that when one draws a lesson from something, if one actually makes a performative act of will, it has some potential for affecting one's future development and of course that requires some support and reinforcement but nevertheless it seems like an excellent first step in doing this. The most common pledge or commitment that we heard students make was simply to remain aware and sensitive to those needs of families. Again, holding onto that sensitivity and to not let those needs go unaddressed. And so the student told us all I can do is take this experience and move forward by being there for others when the time comes. I will never let that be okay again. Namely, never let it be okay so that the family is going on thinking they're not getting the whole story because nobody's talking about death but she will go forward to address that. And so that timidity is something that the student takes a pledge to overcome. One of the other kinds of commitments we heard students make all the time was to be present that they felt that if nothing else they could give the gift of some of their time to dying patients and their families. And so one student tells us in a few situations since the time described above, I've turned to the family and asked them if they'd like me to be present throughout the whole situation and if it would offer them any comfort if they had my number and knew I would be there when the time came for the death of their loved ones. I've also turned to my residents and asked them to please let me know to call me when this time arises. So in some ways, compassionate presence becomes a literal physical presence for the students. The other pledge that became very common was referral to pastoral care. And so one student told us if I'm not available to be present with those grieving I will make sure that other qualified people are so these people are not alone. And so that referral became a common theme. They made a number of other commitments improving that their skills at delivering bad news, making hospice referrals to connect with the patients on an interpersonal level. One student told us about an attending that he followed who, when the patient was dying he did address frankly the choices for the patient but also spent time realizing that the patient what we're asking the patient what his interests were in life and the patient was interested in the Civil War and stuff. And so he would come with daily with sort of tidbits or common books that they read and discuss those kind of things. So making an interpersonal connection became a common theme as well. And they also offered commitments to ongoing reflection as a method to avoid that over desensitization. And of course to remembering the uniqueness of patients. One student said to us, looking back on this experience many months later, I see how much that first experience of patient death has shaped my third year. Unfortunately, but predictably, I've had other patients this year who have passed away. Even in the moments when I've been really tired and just overwhelmed, I remember that Mr. A, that to someone, this is the loss of someone immensely important. And so holding on to that uniqueness and remembering that even though patients do come and go in the lives of caregivers. And so that's pretty much the themes we saw illustrated in the students own words. And I'd be happy to hear your thoughts or experiences or to answer any questions as I can. Thank you. Thank you very much. It's very helpful. Can you tell us about any of the striking differences between the different responses? There's a lot of this worth thematic similarities, but were there any outliers or real different responses? Yeah, that's a great question. And we did, this was a randomized study so that we had two thirds of the students randomized into doing this and one third did a different kind of ethics paper. And so we wanted to make sure we had a representative group. And truthfully, we did think that when we went into it that there would be outliers, that there would be some students just don't quite get it. And that their reflections remained on a very shallow level. There was nothing that seemed personally to touch them. But truthfully, out of 80 some papers we didn't find anything like that. It was striking that way. That in some way, given this opportunity, every single paper gave us something that was kind of in line with these themes. Yeah, I believe it was 88 reflection papers that we ended up coding through the themes. Yeah, and that's a great question. And as you know, medical education and residency education are complex systems that are fairly hard to intervene in effectively. And so we don't have any particularly easy answers in terms of low hanging fruit that we think we can, if we just do this, it'll really be helpful to them. Two thoughts we have had that we're trying to push in the direction of, one is some kind of a timeout at the death of a patient. Because that was a common thing that came up that students who said that somebody acknowledged the patient's death seemed to have far more closure on it than students who said, we just moved on. Nobody said a thing about it, we're on to the next patient. So our dean has become very interested in the idea of there being some kind of timeout around the death of a patient. Even if it's just for five minutes, the team stops. Anybody have anything to say kind of thing? So that's one thing we're interested in piloting. The other thing that we're starting to head down the direction of is making better use of pastoral care in the support of our medical students and residents. We've been fortunate now in that our pastoral care staff is fairly large at Loyola and they are charting in Epic and they have a pretty intricate system in which they're able to chart. And through which other caregivers such as nurses, and now we're starting to look at opening up to medical students, can actually enter something into the notes for pastoral care that alerts them that an intervention is needed for the patient or family members. And so if they detect spiritual distress, we can make that referral much more effective and simple for them to do. And the thought is that pastoral care would close the loop then with the student or resident so to thank them for having given them the referral and to just explain how they saw what happened and what they were doing to provide because we think that may help the students rather than just going on to know that in fact they were somewhat effective. But if you have any thoughts, we would love to hear them. I mean, as you were listening to this, were there thoughts you had on how we might do better? And during that time students were also going on their chaplain mentor rotations at Loyola. So there's a, we integrate that experience in a lot of ways but you're right that that's, so there's a lot of formation going on there as per contrast prior to the third year rotations. And you're right, it would be interesting to see how that experience contrasts with it. Yeah, and you know, we didn't collect anything like that. You know, and there is, it's interesting as you're saying that because one of the things every time we look at this, it feels almost like there's so much here we want to harvest more from it. And it feels almost like dropping the ball not to get more from it. But we have not yet gone down any further road that we didn't get any further feedback from them. Yeah, and thank you for sharing that experience. You know, I mean, clearly one of the interesting things about this is it is a lifelong process right for caregivers like yourselves but you go through it. But then I was almost speaking a lot of times like it's finished at some point, but it's not. At certain moments it comes back, you have an epiphany, there's a recommitment or renewal, all kinds of things that happen. And I suspect that part of what many of you like about medical education is it gives you a chance to remember and look through the student's eyes and see things fresh again and it brings you back to that, but it raises the question how do we support you through that lifelong process? And yeah, and I haven't specifically in reference to this study, but you raise a good point that as you distinguish there between modeling and mentoring, right? Modeling being something that the student sees that doesn't have to necessarily be a direct engagement, mentoring being where there is a direct relationship between the two. And it did seem that models are all over the place right in that third year. Whereas mentors may be few. And I don't have any particular answers as to how we make sure work that the students are all exposed to particularly good models, role models. It does seem to happen somewhat naturally through the system, right? That some people become recognized as really good clinical teachers and we try to put them in those roles, make them clerkship directors, reinforce them in that. But it doesn't seem to be particularly systematic in these kinds of terms. And so yeah, I'm open to good suggestions on that. Say more. What do you think about it? Thank you for sharing such a powerful story. In one of your earliest slides, she mentioned six objectives of the overall project of which two were excluded from this particular project. Number five was health system factors. And I had this thought during your talk about the whole patient safety field where the old analogy was well, if you just trained the person better, well, we're gonna avoid a mistake and that's the way to do it. In some ways, I thought that was sort of the nature of your findings that students were aware that different issues had come up or from a teacher standpoint, issues that we would want to talk to students about and say in a trust and a teaching way. So clearly there's a role for that. But you also sort of raised how this whole set of system factors in terms of transitions, for example, or a culture that makes it so it's kind of automatic these issues are dealt with. So I'm wondering if in retrospect, it would have been better to also somehow incorporate that 15 in the projects, because for lasting change, I think by end of life here, I mean, not a lot really has changed in the past 20 years of the actual implementation of the institutions that maybe we'll talk about it more, these systemic problems and the lack of the cultural imperative and made it difficult for change. So I'm wondering if both from a learning perspective as well as for implementation and change, starting to incorporate more of the system discussion explicitly would give us big gains. Yeah, and that's an excellent point and you're right that we meant to exclude it in the prompt, but in the end, that theme of fragmentation that came back is a system issue, right? And that came back very strongly. And so yeah, asking it explicitly so that students might offer us some insight into what they think can help. Because it did come up anecdotally, as I say, some students talked about attending, sending them to check on patients that had rotated onto other services that they've moved along the continuum of care. But we didn't hear particularly systematic answers to how to deal with some of that fragmentation. And as you said, partly it's because we didn't prompt for it. And so it is something that is worth asking their insights on in future iterations. But I took your point to be beyond that. Your point was that if this is a problem, part of the approach to finding a solution should not just be the personal mentoring or modeling, but should also involve more general system changes. So I have to vote, I mean, if it's still given partly the example of, so why don't all the investors hand in? Yeah, excellent questions. And I'm probably gonna disappoint you a little bit in the answers to them. Other than knowing that the pledge came at the end of their reflection, just where it came chronologically in it is if everything they reflected on led to it creates the impression that they may not have known what it was until they started writing. But there's no way to really know that, right? A good writer can know where they're going before they get there. And I don't know the literature on this kind of thing. Because again, we didn't study up on expecting it. It came as a surprise. So now we have a chance post-hoc to go back and look at it and look at this literature. So yeah, if people do know of literature on this kind of thing, I'd be interested to hear your take on it. We'd love to look at it. And also one of the thoughts is whether we should seek to get their impression of those pledges at some point down the road. Perhaps sometime after, when they say just finished residency or something like that to send them their reflection and ask them about it, perhaps either through an interview process or some kind of survey thing. And just see how that is held up or if it's meaningful to them, if it's been reinterpreted, people can integrate or reject these in a whole variety of ways. And it would be fascinating to kind of know more about that. What's your suspicions on that? Yes, it is to be able to be able to show my love to the rest of you, but that may not be the thing that probably has to be some kind of literature on this other kind of setting on this play, like the title. I would never let that feel again to see that we had a lasting impact in the way we practice medicine. Right. It's a very long way to be very powerful at literature. Right, yeah. And I do say that as we've read these things, we didn't set out to feel like a tremendous sense of responsibility towards these students for having asked them to write this, but that we ended up feeling that. And it does feel like there's these intense things being shared and potentially, as I say, game changers in their life happening. And we do feel a little bit short on, I'm not exactly sure what we should do for you at this point to help you with that. And so we are really open-minded towards additional possibilities here. Yes, please. A number of years ago, this was a proof of a loss where the book on death and dying defied stages of the patients, those who were in death, and these customers, is that still being used in two minutes so that I have an idea of how the patients with the stages are going 2000 to the next? Well, we certainly aren't using it in any kind of formal way. We are thinking about it in terms of stages. And my understanding of the literature on it is that they're still relevant, but people don't necessarily progress in a linear kind of fashion through these things. But clearly, the same kinds of dynamics that she outlined where people do, try to negotiate with death, try to deny it, try to do all sorts of things and eventually come into some kind of resolution, you know, is a process that works with death and also with most kinds of formation where people go through various things on their way to resolution. You know, and that one student who comes to that moment of peace and prayer about those two aspects of their future, that the medical student scientist and the human being side, you know, kind of plays out a process. I'm hearing acceptance in that, you know, in a way. And so the kinds of dynamics that Kubler-Ross-Allens are certainly relevant, but we're not making formal use of them in any way. You know, well, that's a great question. You know, one in reading these essays is much more confident about their competence, about their self and professional development than we had thought, right? That seemed to be the part that was coming across very clearly, that they knew where they were at, they knew where they wanted to go and they were taking some responsibility for that. So that personal and professional development thing came across well. It's much harder to know how their experiences of, say, referring to chaplain, you know, a simple patient care competence make the referral when the patient needs the referral. Whether, in fact, that was as well-developed in students or not. And so this kind of reflective exercise doesn't necessarily give you that. And that is where there is a role for things like simulations or role plays or things. As I was mentioning earlier, that introducing the med students in the future to have the chaplains do a spiritual assessment in the chart and has some signs that chaplains look for when they would like a referral to them and becoming part of that kind of system would go along towards developing basic competencies that would give us more confidence that from the patient's perspective, they're getting what they need than we're able to attain from a reflective exercise. When you hear these moving stories, the quotations that you gave us from medically naive clinical students, it gives me pause to wonder whether we're moving in the right direction. The direction we've been moving in for at least a hundred years to train these students for desensitization. That is whether that is an appropriate or legitimate goal. That is that famous essay by Renee Fox about 40 years ago called Detached Concern, which looked at five or 10 different critical encounters beginning in the anatomy lab that medical students go through. And at each stage, the effort to sort of encourage the student to be concerned but detached or desensitized to the experience. I wonder if we wouldn't do better by acknowledging human emotions and recognizing that feeling and empathy and compassion, sadness, are legitimate things to have when faced with death and not moving in that other direction. And have you had experience like this in your teaching? Yeah, I mean, I've tried. I've tried to say that medicine is part of my interest and that doctors are part of the community in which they practice, the community they serve, and that feeling with your patients and their families is perfectly human and understandable and reasonable. I mean, I'm sure you can go too far on that. But yeah, that's the way I tried to. There is a difference being desensitized than to become insensitive. Nice. The physician becomes desensitized after we see some of the things. But then, in general, one does not lose this, it's sensitive, it doesn't become insensitive. And also, it is situational, like I read in a journal that somebody did MRI and showing it to people, surgeons of MRI and showing blood. And the surgeons showed less on their brain light up that other people did and a conclusion as insensitivity, which I think it's not true. If I were to give you an example where I operated for 40 years and I have built a, you know, dealt with blood a lot in the operating room, but if someone's hand scratches here and it's the drop of blood, I become very uncomfortable because the situation is different. I become uncomfortable if you fall and then I see some blood coming, I become just as uncomfortable. But as soon as I try to do something about it, put my hand on it or put a bandage, and even though you may say ouch or you may say something and I cannot, I may not even listen to your ouch, I could do what I am. But then afterward, I really, if you have pain, then it's different. So I think these emotional things are very difficult to conclude some major thing about it. Yeah, and I couldn't have said it better. I think that you did a nice distinction in talking about situational aspects of this, but in certain situations, one becomes sort of programmed to do it. The other interesting thing you raised, there is that there seems to be a residual emotion. If you are programmed to keep your emotions under wrap in certain situations, there is a residual to it that after the fact sometimes comes back, or as Tracy was pointing out, that perhaps sometimes unexpectedly will well up and that's a sign that in fact, there's things or there's emotions are still there. You're not insensitive, but that in fact you've formed them in some way so that you're able to execute certain behaviors. So it is a fairly complex dynamic. In the education and medical practice available to a group who previously were not able to get educated and not able to get licensed. So this is a big change. This is the immigrant population that Mark was the first in the country to work on. I'm told now that it's been picked up by a number of California schools and other schools down in the southern tier. But Loyola was the first school to do it. This was a lovely event and thanks so much for coming. Thank you so much. Thank you.