 So, our next speaker is a good friend and colleague, Ira Kodner, who has been a real moving force in surgical ethics nationally as well as within the American College of Surgeons. Ira is an emeritus professor of surgery at Washington University in St. Louis. He is the past president of the American Society of Colonorectal Surgery and the American Board of Colonorectal Surgery and past director of the American Board of Surgery, founding director of the Washington University Center for the Study of Ethics and Human Values, co-editor of the ACS web portal, Community on Ethics, and the author of about 150 papers, book chapters, etc., on colon and rectal surgery as well as surgical ethics. He also has an unbelievable orchid collection, which if you ever have the opportunity, it's wonderful. Ira is going to be speaking today on practicing safe surgery, the impact of ethical teaching. Thanks, Peter. It's a little bit of a typo. It's actually the impact of ethical thinking. Our teaching, I hope, is at least ethical. Congratulations to the claim. Definite feeling of coming home in 25 years is spectacular. Big Pharma has not yet discovered the advantages of buying off ethicists, so I have no relevant financial conflicts. It's, as Peter said, my title has changed because I am now emeritus professor of surgery. I didn't know what that meant. We don't have many emeritus professors of surgery at Washington University, and I really didn't know what was in store for me at this stage of my career. I would like to think that I'm going to have some permanent, unique legacy that I would have created when I became emeritus. Well, here's what they do. They hang you when you become emeritus. But if you look really closely, I do have a unique claim to fame. This is the only picture that's ever been hung of a surgeon holding a textbook on clinical medical ethics. We go down in posterity, Mark. So this is a strange talk. You have to assume for a moment that I'm talking to you all as surgeons. Don't let it bother you. It'll go away in just a few minutes. These are aphorisms from a senior surgeon, or the dinosaur speaks. This is what I've always wanted to say to groups of surgeons. These are views derived from my own mistakes. Those of my colleagues observe complication from decades of being at what I call the end of the road and hundreds of malpractice cases that I've reviewed. In order to get to the perfect operation with the best outcome, three components, the system and services, the patient and family, and the surgeon. So I broke these down so I could discuss them and criticize them. If we look at systems and services, most of these are beyond the control of the surgeon. And we have to settle for what is provided, or at best, for what we can get. For example, specify your choice of anesthesia. Don't say anesthesia of choice, and then when something doesn't go right, criticize anesthesia. Don't let outside non-surgeons decide the procedure or conditions under which you operate. You can't damage yourself in doing this, however. So it's a judgment call how far you can push the system, but you have to realize that there's a variety of gatekeepers, none of whom will share liability with you if something doesn't go well. Contrary to belief of administrators and many other non-surgeons, not every surgeon can do every surgical procedure. This is a recurring theme that I want you to know. The impact of expanding concept of generic medicine and surgery is now the norm. And I fear that it's corrupting a lot of what we do and how we think. This area is where surgeons, ego and or arrogance can become dangerous. So this concept, well, if I don't do it, they'll go somewhere else in town and they're not as good as I am, so I guess I should go ahead and do this procedure. Surgeons have to establish an operating room environment conducive to cooperation, advice and criticism from all components of the team. My line for years was if something isn't right, tell me now, not at the morbidity mortality conference. It's important for you as surgeons now today to declare the anticipated critical times of the procedure. So that isn't the choice of time for lunch and for various rest breaks from the team, but you have to do it in advance. That's often the source of misbehavior in the operating room. If you think about it, where you work, who on your team can criticize or advise you? More so, who knows you and your results well enough to let you know if you're really in trouble or actually impaired? Think about that. New ethical challenges, we have to learn and apply the principles of truth telling and informed consent. We have to communicate completely and compassionately about the disease, the treatment options and the long range plans. In addition, now we need to reevaluate patients' rights and confidentiality in the face of high speed communication via the internet. We've heard that recurrent theme for the whole two day session. My feeling is that you surgeons must lead and not leave decisions to those not actually involved with the surgical care of the patient. Mistaken perceptions of the role of the surgeons and this is, we're the ones to blame for this, I'm only available for cure. That's the easy way out. When we say I'm sorry, there's nothing more I can do for you. Especially with the generic aspects of primary care medicine, I think the surgeon should be a permanent part of the care team even if cure is no longer the goal and there is a lot of activity. Peter gets a lot of credit for coordinating this in the aspects of surgical palliative care. Special dilemmas, we talk a lot about the principle of autonomy in the last two days. No one has discussed the fact that this autonomy extends to the surgeon as well as to the patient. We shouldn't feel forced to perform surgery that we feel is futile or wrong. In addition, the surgeon is part of the care team. Actually now there's been a turnaround. We may have better knowledge of the patients and the families, especially if we've operated or cared for them under previous stressful conditions. A good part of my career involved patients with inflammatory bowel disease, especially Crohn's disease. I knew the patient and the family for generations, whereas there was really no home based quarterback primary care physician. So this is creating an interesting new area for us as surgeons. I love following Gretchen because I don't need to say much about surgical buy-in because she already did. But this article by Pauline Chin in the New York Times discussing the work of Gretchen was very interesting. I pulled a few points from it. Ethicist and social scientist try to explain surgeon's paradoxical behavior with post-operative patients. Some of these lines are terrific. One is a claim self-protection, the surgical imperative to do everything possible. It protects us against the emotional distress of failure. At least I did all that I could possibly do. Very, very real concept. This one's a little better. The surgeon-patient relationship is similar to the biblical covenant between God and his people. I will not abandon you and I will battle to the death for you. This is probably the sexist part of it that was just mentioned. The concept of responding to business models to me is probably the most repugnant of all. The shift in attitude where we try to use business jargon as we talk about the practice of surgery. Patients are replaced by consumers. Eventually they become customers. Patients were treated like family members. Customers come to your business to purchase healthcare. The less time you spend with customers, the better will be your financial bottom line. Apology and medical practice, I think we should. Patients and families usually understand an unfortunate but honest medical error and take no legal action. I'm trying to get out of this legal consulting business because it's getting really unpleasant. Patients are less likely to sue when doctors apologize for their mistakes that's been published data. Many hospitals and state laws actually encourage doctors to provide and provide legal immunity for an actual apology. Interestingly, most patients will forgive their doctor for an error of the head, but rarely for one of the heart. And that's where when we shift into arrogance, we become our worst enemies. The surgeon, this is contrary to the teaching, but I believe this after many years. The surgeon-patient relationship is based on trust, which must be established in a very short time. We meet the patient. Frequently they don't know the whole story of the bad news that they have. We have to deliver the bad news. On that first visit, I think our whole job is to establish trust. This becomes the basis for what Gretchen describes so phenomenally as buy-in from the patient and the family. I use the first visit to establish truth telling and trust and that's the major accomplishment. I use a subsequent visit to cover potential complications and alternative procedures. This isn't what expert communicators, non-surgeons, lawyers, and some ethicists advise. I'm a little snarky here because they've never seen a patient overwhelmed with too much information. Then I've concluded after 30 years working with the same nurse that this was the advantage of having a great nurse on the team. The nurse goes back and communicates with the patient. So disheartening in the operating room after a big operation because my ego was getting the better of me and the patient never wanted to talk to me, they wanted to talk to the nurse. So obtaining real consent and buy-in from the patient and the family for your procedure is critical including the alternatives and potential complications. Write it in your record as a pre-op note dealing with these issues. I can tell you it doesn't stand up in court to say that's my usual explanation that I give, I always do the right thing, I just don't have to write it down. Remember, and Gretchen alluded to this, many of the words we use routinely are impossible for a lay person to understand. The examples I've seen too often, you may need a temporary stoma of the anastomosis leaks. Who's gonna understand what that really means? Or better yet, this operation may have some effect on your sexual function, end of discussion. Try to clarify issues of the surgical buy-in during the process of obtaining informed consent. Have the permission to deal with complications before they occur. More, quote, successful legal action derives from abandonment, arrogance, and deception from the admitted errors or poor outcome after doing the correct surgery. Rarely is there successful litigation for practicing good medicine or surgery even if the outcome is not as expected. The surgeon, no one accept your capabilities. Have a mechanism for objective evaluation of results. I'm somewhat concerned about what's measured now with the official programs. They don't really deal with the recurrence of Crohn's disease or the need for stomas or even the cure rate for cancer. We fall down in the quest for more productivity and better gimmicks. We often lose sight of the fact that not all surgeons can or should do everything. Don't do complex procedures that you don't do often. It may not have the support not only to do the procedure, but to deliver the best post-operative care, including serious complications from the various specialties that you'll need for backup. Confront the truth, laparotomy is not a diagnostic test. Almost never have I been able to write down that I was going to do an exploratory laparotomy. Part of this is because of my mentor Rupert Turnbull whose ghost haunted me every time I thought of writing it down. Adhesions don't cause pain and repeated operations don't make them go away. Delaying surgery until the patient loses weight and or stops smoking is wishful thinking and usually won't happen and you know it. Never hesitate to get consultation or refer to the place which will give the patient the best chance. If you don't know what that place is, think of it as the place where you will send the patient when you can no longer manage the post-operative complications. Beware of the path diagnosis. This has brought me down more than once. Every liable experts review outside pathology and radiology reports. It's much easier to dictate an addendum to a report and say I'm sorry than to try to undo an incorrect surgical procedure. Beware of who reads your x-rays in the middle of the night and record by whom and when you receive the reading that necessitated your urgent surgery. In your institution, if your institution can't provide the best pathology and radiology, consider getting another opinion or referring the patient. Be aware of litigation issues on surgery. If we as surgeons don't participate in the legal process, then it's hard to criticize a non-expert who testifies against you in court, which is usually the way it goes. There's almost never legal action because you did the right thing and got less than perfect results. Most often something really wrong was done and the surgeon wasn't completely truthful or was abrupt or arrogant to the patient or the family. Everyone that I've seen goes that way. Sound clinical decision-making is dependent on four elements. I quote David Rothenberger, my colleague in colon and rectal surgery. Clinical experience and expertise above all else. The relevant knowledge base and access to up-to-date evidence. Communication skills, as we've heard now in two or three days, are critically important and interesting personality characteristics that collectively contribute to good clinical judgment. These personality characteristics of the best decision-makers include the ability to live with ambiguity, not knowing for certain that a decision is correct but knowing that a decision must be made. It's kind of a special surgical thing. The ability to be self-critical. Learn from and accept responsibility for our own less than perfect decisions. Reach the balance between psychic self-protection and insensitivity to our shortcomings and the ability to collaborate. Decision-making is dependent on a team effort. So I leave you with a quote from C. Barber Miller, one of my own mentors whom I respect and love and I thank you all to talk to you today. Thanks.