 Thanks, it's a treat to be here. I hope you'll find this presentation provocative. This is a photograph taken by a colleague in Pontiac, Michigan at St. Joseph's Mercy Health Center. Her name is Peg Nelson. And this photograph is remarkable for a number of reasons. One is that there are a lot of health professionals clustered around the patient's bed. The other one is that the patient's bed is actually occupied by two people. And the other peculiar feature is the health professionals are not focused on the patient. The patient is one of a number of observers. And I find this image revealing and thought provoking around what we count today in healthcare. So to me, this is a remarkable image. I'm a person who makes my living partly through interpretation of images. And I'd like to share with you an interpretation of this image. The patient is a 57 year old woman with advanced patriotic cancer. And her prognosis is dismal. Like most people who are facing the end of her life, she's troubled by some things. One is she's been quite concerned that she's going to die in pain. And her terrific palliative care team has managed to at least substantially allay her fears in that regard. Her second big fear is that she will die alone. And again, the palliative care team in concert with the patient's family, I think have managed to reassure her that they will do their level best to make sure someone is with her in the final hours of her life. Her third fear was a little bit more difficult to respond to. Her first grandchild would be born in the coming couple of months. And our patient was quite concerned that she would die having never had met her first grandchild. And a race against time. One week passed, two weeks, a third week. It became apparent that the patient would very likely expire before the birth of her grandchild. And this presented a big problem, a big challenge to the people involved in her care, including her family. So in my experience, something rather remarkable happened. Some health professionals consulted each other about a very unusual problem and came up with a rather unusual solution. And you see that solution in action in this image. Namely, the patient, the 57 year old advanced pancreatic cancer patient's daughter came into her room and lied down supine next to her mother in the hospital bed. And an ultrasound machine was rolled up to bedside. And a technologist spent about 35 minutes at the bedside giving this patient an opportunity to meet her unborn but named grandson. His name would be Aidan. So our patient lying there in bed had a little bit over a half an hour to see her unborn grandson's heart beating. She had an opportunity to count his 10 fingers and his 10 toes. Now rather unexplicably, at one point her grandson actually gave her the thumbs up sign. We don't know what that means but it happened and we captured the image. We have a static sonogram showing her grandson giving what appears to be the thumbs up. Does that count? No formal request was entered for that exam. An ultrasound machine from a busy ultrasound clinic was rolled away from the clinic and up to this patient's room. That meant first that that piece of equipment could not contribute to the productivity of the department to which it was assigned. And secondarily, patients waiting for exams had to wait longer because that machine had been taken out of service for upwards of an hour. Is there, you may know, ICD-10, the International Classification of Diseases includes something like 70,000 diagnostic options. Is there an ICD-10 code for this exam? A major source of revenue for the American Medical Association, CPT codes, right? Current procedural terminology. Now in its 10th edition, is there a CPT code that can be applied to this exam? Not that I'm aware of. Did this exam contribute to throughput? If anything, its impact was negative. Was any revenue generated from this exam? No, in fact, revenue was lost or at least delayed patient satisfaction scores may have in fact suffered because this exam was, because in a sense there's no patient in this room at least in terms of the utilization of that precious healthcare resource, an ultrasound machine and an ultrasound technologist. Are there any entries in any medical record? No. In terms of the ontology of contemporary healthcare, this exam does not exist. It never happened. It doesn't count. And to me, an exam like this is a powerful reminder that sometimes the things that count for the most simply aren't counted and in some cases may in fact be uncountable. There's a quote often misattributed to Albert Einstein, it goes like this. Not everything that counts can be counted and not everything that can be counted counts. In our current zest for quantification, we sometimes lose sight of the fact that some of the things that count for the most are in fact uncountable. Suppose I made the bold assertion that your marriage or your relationship with your most significant other stinks. Your marriage is lousy. Suppose you were to set about disproving my assertion. You can bring any evidence you want, but it has to be quantitative. Show me the numbers that prove that your marriage is of high quality. Well, you know, what would you talk about? Well, you know, my spouse's BMI, you know, is a very svelte 22. You know, my spouse has an IQ of, you know, 130. My spouse has expected lifetime earnings, you know, we're on the order of, on an average day, we speak X number of words to each other. X number of expressions of affection per week, you know. Would that tell the story of your marriage? I think we are living and practicing in an era of healthcare where we desperately need advocates for what really counts, despite the fact that it can't be counted. And I like to think that the McLean Center is one of the bastions, one of the places where our sensitivity, our perceptiveness, our gut feeling for what really makes a good health professional, a good doctor, good care for a patient is nurtured and developed because I exist much of the day in an environment where if I can't produce data, what I have to say is sometimes considered not worth listening to. By the way, I'm not suggesting we should cease collecting or analyzing data, particularly coming on the heels of a moving presentation about carol stocking, but that being said, the social sciences, the biological and physical and chemical sciences do not have a monopoly on truth and surely it's incumbent upon ethicists above all. People whose very being stems from character, human character, what makes someone admirable, compassionate, wise, conscientious, not necessarily something we can quantify, but I think something that's vital and real and desperately needs advocates in the current healthcare environment. So I wanna pass on that misattributed statement by Albert Einstein again. By the way, Einstein, of course, surely the most important physicist of the 20th century, in fact, Time Magazine's person of the century, Einstein didn't work mathematically. He worked in thought experiments that could be conceived as far more, far less like a mathematical equation and far more like something like a narrative, right? He figured out the story and then he found the math to help describe it. Perhaps that's a paradigm that we need to adopt as medical ethicists. So that misattributed quote, not everything that can be counted really counts and everything that counts cannot be counted. So thank you very much.