 Ira is the Solon and Betty Gershman professor of colon and rectal surgery at Washington University Medical Center in St. Louis. He's the director of the WashU Center for the Study of Ethics and Human Values. Ira has been a real leader in surgical ethics education throughout the U.S. and has been instrumental in helping over 45 and 45 surgery programs develop teaching in ethics. In addition, he's had leadership roles in numerous colon and rectal surgical societies. He's authored or co-authored over a hundred peer-reviewed manuscripts, book chapters, etc. He will speak to us today about ethical challenges resulting from the stress of a career in surgery. Ira. This is going to be a different kind of talk. We're starting with concerns in the delivery of healthcare, complicated by a system where our patients purchase the cheapest healthcare when they're well, but they use it when they're sick and they want the maximum without regard to time and cost. To summarize, they want to pay for a Kia but drive a Cadillac. No one's ever come in and said, I don't expect you to do everything for mom because I know I bought the cheap policy. The relationship with our patients is changing. It's one from paternalism where everybody said, I'll do whatever you tell me doc, to a more shared decision making to one based on real informed consent. This presents dilemmas, one of which is never written about. We talk a lot about autonomy of the patients, but no one talks about the autonomy that extends to the surgeon as well as the patient. We really should not be forced to perform surgery that we think is scuttle, and yet many of us do. The surgeon stays, I hope, as part of the palliative care team. It's changing because we actually know the patients and the families sometimes more than the primary care because we spend more time with them, especially under stressful conditions. We are the ones who have to guide patients and families to these appropriate decisions in their care, perhaps even for generations if these are genetically based problems that they have. With respect to many of my colleagues, I'd say that no one or few can understand the anxiety of going to bed at night and realizing what we have to do in the morning if we're facing a horrendous life-threatening operation. I do make the point that I don't think anyone can identify with the situation in the operating room when we burn the bridge, and we can't go forward, but we can't go backward, but the end isn't in sight. This is what I think in gender's bad behavior. I think in many cases we're just terrified, and yet we do stand by allowing the community, our students, our non-surgical colleagues to perpetuate the myth that we're only technicians. I'm honored to be back at the McLean Center with Mark and my teachers here. I feel like the oldest student you've ever had standing up in front of you, but they were fun in the early days when I said there were ethical challenges in surgery and eyes would roll back. Then we had the Lantos revelation when John came to visit us and you do ethics pizza rounds for the surgery service. He insisted that the medical house staff be there as well as the surgery house staff. He presented the challenge to the medical house staff first of a patient who comes into the emergency room, severe myocardial infarction, hypotensive, no matter what was done when the patient got to the intensive care unit. He couldn't be saved and he died. How many of you felt responsible? No one. He presented the scenario to the surgery house staff. The patient comes in with a ruptured abdominal aortic aneurysm, hypotensive. You've been in the operating room for six hours trying to save the life. You get the patient to your intensive care unit. You stay up all night with the patient and the patient dies. How many of you feel responsible? Everyone. The difference, the difference was stunning. But now there's a threat to their, our cherished relationship because medicine has become a business. Time is money. Reimbursement is down. So theoretically we need to see more patients to generate the same income. It's frustrating because we can't actually do more now than ever before. So in many cases we try to do it for as many people as possible. Plus too many of my colleagues in surgery, this was alluded to yesterday, respond to the business model. There's a shift in attitude within the profession. Business jargon has become commonplace. Patients are replaced by consumers. Eventually they become customers. Patients were treated like family members. Customers come to your business to purchase health care. And the less time you spend with customers, the better your bottom line. It's difficult to demonstrate that restoring the doctor-patient relationship is going to save money for the business. So who supports the surgeon? Where do we find help? We have our personal values. Our mentor system is corrupted by their reduced working hours and the less time we spend with our mentors. We have advice and stories from respected individuals. And as I'm going to finish the rest of my talk, we go to literature and history. If we were really good, we would create and participate in an effective support system for our trainees and ourselves, but that's for the future. So I'm going to refer to a mentor and teacher, Tom Krizik, who spent much time here at the University of Chicago. And I'm going to his ethics lecture presented to the College of Surgeons in 2001. He starts stating that four surgeons committed suicide in one year. They were all fellows of the college. They were all involved in academic medicine and were considered successful. How utterly complete was their impairment? That surgery itself might be an impairing profession is a troubling thought. And he made the point we may not be as supportive of each other as we think we are. Perhaps the very profession of surgery may be impaired. He defines impairment as an impaired surgeon is one who for physical or psychological reasons is no longer capable of performing in a professionally safe fashion. Our standards are high. Injuries and age related problems may be a little consequence and non-surgical specialties, but can significantly impair and incapacitate surges. Significantly, we tolerate such problems poorly. Our bar of safety for surgical performance is set high. Complications and problems are easily identified. We work in a very public environment. Accusations are too easily made. The challenge is to measure and evaluate competence before preventable complications occur. He goes on to say impairment is a secret sickness. Impairment from alcohol and drugs associated with higher incidents of mental illness, divorce, accidents, premature mortality and suicide, as he states among his four friends. Are we in a impaired profession? It's one whose virtues of courage, veracity, fidelity, dedication, including the social virtue of caring are threatened by external goods of power, prestige and money and whose identified purpose fails to unite its members. He states of surgeons don't function with a unity of vision or spirit of caring for each other. The profession is fostering the growth of impairment. In the 50s and 60s, it got worse with third parties and Medicare as they established an unfortunate expectation of fee for service. Dr. Chris makes the point, how does an individual or society value the special skills available nowhere else that make the difference in life and death? And yet we run the risk of exchanging virtue and respect for money. The most impairing facts of our profession, he says, have become that we've become rich. We expect to be rich in society does not highly regard the rich, unless you're a sports figure or a rock star. He faces the crisis of decreasing compensation and inflating expectations. The major battle has become financial. If you look at the life, the productive life of a surgeon, we can practice at age 30 to 35 years and we quit 22 years later, a tragic waste of resources for society and for surgery. External goods threaten virtuous and caring behavior. He makes the strong point academic surgery is dog eat dog. But he clarifies it that private practice is the opposite. He goes on to imply that the seeds of impairment are sown in the educational process. When we seek surgeons, we look for those with intensity and drive but not too intense and not too much drive and not too ingratiating. It's difficult to predict who will handle the potentially impairing stress surgery is supposed to be different. There's problems with workload changes in the doctor patient relationship and diminishing reimbursement. Still, the excitement of surgery and performing operations seems to be no less intense. He claims it can even be seductive. He goes on to describe the good role model our mentors who stresses the ability to be humane as a key of the profession of surgery. They teach us to handle the experiences that change us. None are abusive or harassing or impaired or impairing. But yet if you look at the negative role model, this person may be abusive, harassing or themselves exhibit a form of behavior or personality impairment. The result in a hostile working environment inside and outside the operating room. Particularly true when there's a power differential and when women trainees are placed at risk. And yet others see these as often hyper forming, competitive, successful in academic and financial areas and in fact can be seen by others as entertaining and charismatic. He finishes by saying the mistakes are impairing. There's no greater challenge to us than how we handle mistakes. Public disclosure is a serious ethical issue. Anticipation of silence, disapproval or litigation precludes wide disclosure and truth telling. It's profoundly human to seek forgiveness. And yet too often in our profession, there's no place where we can actually ask for forgiveness. If you look at the support systems, usually there's 20 people for the average person in society, friends, relatives and neighbors. It drops critically in the first year of surgery residency. There's a nonhuman part of the time, usually a cat or a goldfish. It never returns to the level that many people in the rest of society enjoy. Surgery is competitive and can be a very solitary profession. Unidentified colleagues are presumed to be sharks until proven otherwise. We're advised not to bleed because it attracts sharks and we're advised to get out of the water if someone else is bleeding. He finishes by suggesting that perhaps we should choose the middle path as taught by Buddha. Like the Buddha, we are early exposed to old age, illness, poverty, blood, pain and death. And we can never go home again once we've seen these images. We become joined with humanity in ways that others cannot be. To find the way one must be guided by a master, by our mentors. Just as we learn virtue and caring, we can learn how to apply ethics and morality to the practice of surgery. He finishes, surgery may be an impairing profession in many ways, but it doesn't have to be. Thank you.