 So I think we're going to go ahead and get started. Happy Valentine's Day to everyone and thanks for spending noon of your Valentine's Day with us at the McLean Center. So it's my pleasure to introduce today's speaker. Catherine Rowland is an assistant professor in the department of surgery section of pediatric surgery here at the University of Chicago. Katie received her Bachelor of Arts as a university scholar with an emphasis in biology and the medical humanities from Baylor University. She went on to receive her MD and master of population health science degrees from Washington University in St. Louis. She has been here at the University of Chicago for the past several years as a pediatric surgeon with a clinical emphasis on minimally invasive techniques. And her research focuses on moral and professional foundation in medical education. Katie is a faculty fellow at the Hyde Park Institute and the course director of the scholars in ethics and medicine program where she teaches medical and undergraduate students in the cultivation of character using a virtual ethics framework to promote flourishing as a physician and in life. And today, Katie will speak on what would a good doctor do an examination of the physician in the patient-physician relationship. So welcome, Katie. Thank you so much for having me today. I'm excited to be here and share some of my thoughts with you. Again today we're going to do an in-depth examination of the physician in the patient-physician relationship. I don't have any financial disclosures, but for those of you who are not aware of the Hyde Park Institute here at the University of Chicago, since I do mention it in my talks, I just want to state that it is a nonprofit that works alongside the university and it helps students alumni and other members of our University of Chicago community sharpen their purpose and strengthen their character to serve the common good. So there's several different things we'll be talking about today. I want to start with first defining the problem and whether it be burnout, moral injury, or a discussion of human flourishing, we'll go through kind of what is the current problem within the medical system today. I'll address briefly Aristotle's virtue theory and how character cultivation for flourishing might apply to medicine, especially its role in restoring the individual physician. I'd then like to talk a little bit about how here at the University of Chicago we've applied Aristotle's theory to medical education and how we are teaching wisdom of our undergraduate students as well as some of our early medical students. And at the end I'd like to conclude with the character of a good doctor and some future directions for growth. So what is the problem. I want to start by showing some of the statistics about our medical students today. Because despite what we all see is probably a growing number of problems within our field students are wanting to go into medicine and higher numbers than we've ever seen before. And in fact, when you look here from early 1980 to the most recent date in the past year we're seeing increasing numbers of students, very bright students applying to medical schools. 52,000 actually. And on this this graph other graph where you can see that the, the y axis has been changed, about half of those students are accepted into medical school. So we've seen an increase in the number of students accepted, but it's still really only about half of the number of students that apply. Those numerical values are depicted here on the top box shows that there were a total in 2023 of 52,000 applicants of which there were essentially 23,000 spots for those applicants. Again, these are really smart students. The mean GPA was 3.77. These are motivated smart students who want to become doctors. And yet something happens through the process of them applying and being accepted into medical school and the time in which they become doctors and the doctors and who they become. And I think some of it has to do with with what their perception of being a doctor is many of them when you ask them want to help people. So they start out applying and starting medical school. See viewing our profession is one in which we are able to help and heal people. And then by the time that they themselves are physicians, they find themselves sitting in front of a computer documenting on an EMR stress by the amount of tasks they have to complete. And the very little time they have to spend at the bedside actually helping heal patients. In fact, the state this these numbers are pre COVID. So I would suspect that these are even higher, but 54% of doctors say they are burned out. 88% are moderately to severely stressed and 59% of doctors wouldn't recommend a career in medicine to their children in ICD 11 burnout actually has its own ICD code. I'm sure that there are people in this room who can empathize with some of the feelings or the description of burnout feelings of energy depletion or exhaustion, increased mental distance from one's job and reduce professional efficacy. I'm a surgeon, so I have surgery highlighted in this graph, but I think what's interesting about this study that looked up burnout and professional fulfillment from a surgical standpoint actually surgery on the the y axis is professional there was a you know relatively high degree of professional fulfillment within my profession. And yet the, the physicians with burnout was still remarkably high. And that's depicted along the the x axis. So really no matter what your specialty is when when questioned as to physicians intention to leave their current institution secondary to burnout. Those numbers range anywhere from 20 to 40% with the, the average being about 30% I again have surgery boxed up there about 30% of surgeons intended within the next two, two years to leave their current institution. And that ranges to tendings that burnout is affecting. And in fact when internal medicine residents were measured on the mazat burnout inventory sale 4.3% at the beginning of their intern year rated as you know qualifying for having burnout so very low numbers. By the end of that same year 55% of those residents met criteria for burnout. Very male forming was happening during the process of their intern year. And in fact, residents in general surgery anesthesiology orthopedics and OBGYN are estimated to have the highest prevalence of burnout. Most likely due to the high stress work environment there in the fact that they deal with life threatening emergencies and overloaded shifts. The studies that have measured it the, the level of burnout changes a little bit depending what study you're looking at, but it's about approximately 40% in general surgery, 63% in internal medicine, 63% in neurology. And we know that burnout has very severe and adverse consequences, both in one's professional life with an increased rate of medical errors, increased depersonalization, reduce compassion and decreased interaction with patients, as well as personal consequences as well such as substance abuse, strange personal relationships, depression and even suicide. Because most of us who go into medicine are willing to jump through all the hoops, do the many things required of us to get into medical school and then into the specialty that we're in. There has been a shift to use the language instead of burnout to moral injury and I'm sure most of you are aware of this. The focus when we talk about burnout it can be very easy to focus the, the need to improve right to do better to do more yoga outside of work to come back to work fully recharge to fix burnout on an individual level. And moral injury is used to describe really the constraints within our medical system that makes some of these things outside our control. And so moral injury describes the challenge of both knowing what you need to do in order to care for patients but being able to provide that care due to constraints beyond our control. And it helps locate the source of distress on a broken system and not a broken individual. And there are many things that are broken about our system right like the electronic medical records declining reimbursements threats of litigation increasing specialization that we see just the rapid pace of innovation within medicine today. The need for 24 seven care of increasingly sick patients, non adherent patients, and the fact that physician metrics and patient satisfaction, sometimes outrank the actual care provided. And so I would argue that perhaps instead of using the terms moral injury or even burnout, we shift our focus and think about human flourishing human flourishing is the state in which all aspects of a person's life are good. And the way the reason I like to use this to think about the current problems within the medical system is that it gives us a way to acknowledge and appreciate both the role of an individual physician, as well as the role that the system has and the community that we're working on. Tyler Vander wheel who runs the, the Human Flourishing Institute at Harvard talks about the difference between flourishing and well being. And if you're around a hospital these days you've heard a lot about well being and well being initiatives right. And so well being if we think of that as the relative attainment of a state in which all aspects of a person's life are good as they retain to that individual and contrast that to flourishing in which you can attain a state in which all aspects of a person's life are good, but include the context in the community in which one lives. And so you can imagine that one might be able to attain some measure of well being in a very corrupt environment, but one isn't really truly flourishing unless the community itself is good. To speak about flourishing flourishing is not just a wellness initiative I would argue that it's more than that it's also trying to fix some of the problems within the community and the system. It certainly is not a way just to recharge your batteries and come back to the work the next day to be fully charged. It's not an answer to burnout because there are a lot of systems issues that play to. And for you to it's really not about achieving work life balance, because if you're talking about flourishing you're talking about looking at life as a whole, your work and your, your life outside of work are all your life. And so while it's very important to take care of ourselves outside of the hospital. What I'm hoping to focus on today is that what happens inside the hospital is what made us all want to become doctors in the first place. So how can we divert our attention to fixing some of the things so that we have satisfaction with the careers that we've chosen, and that we're happy with the work that we do inside of the hospital. I would argue that flourishing is acknowledging our humanity, acknowledging that our work life and our personal life are all our life. And then some aspects of flourishing will buffer against clinical burnout and be a source of resilience and fulfillment, but that's not the sole purpose of pursuing flourishing. So when we talk about flourishing what we're talking about is a theory of philosophical theory that dates back to the time of Aristotle. Aristotle's virtue theory in which character cultivation and the cultivation of character virtue leads to human flourishing. Again, this is not a new idea this dates back to the time of the ancient Greeks, and the ancient Greeks and Aristotle were concerned with the, the ethics of being of what should I become. So this, when we talk about Aristotle's theories are on the character of human beings, and he proposed that to be a moral person one must develop or cultivate their virtues and demonstrate their virtues and their actions. And by cultivating both intellect as well as moral virtue, one flourishes as a human being. So how do we then develop virtue, our virtues are habits and dispositions of character that can only be acquired through practice. So if one wanted to become a generous person one who would have to practice generous acts till being generous became second nature to become courageous one must practice acts of courage. And within thinking about these different virtues Aristotle proposed the concept of the golden mean. So that in the center right there's a virtue, but you can have a deficiency of the virtue or an excess of the virtue neither which is necessarily good. And so when we talk about courage, you can imagine, especially as a surgeon right then you need to be trained as a surgeon to be to be courageous. And then if you have a deficiency of courage and are cowardly, that's not good for you or your patients, but it's also not good to have an excess of courage right and to run fullheartedly irrationally into an operating room without a solid plan or a good management plan for the patient. And that's true for each of these virtues that are presented here, generosity, ambition, modesty, honesty, friendship, temperance and self control. And you can think of it like this, you know that the virtues sits in the middle, but there's a vice on either side. And so by cultivating virtue one will act well and flourish. And there's been recent empirical evidence that supports that virtue by developing virtue that promotes life satisfaction, well being stronger relationships mental health and an ability to deal with adversity. So what does this look like at the 21st century. Tyler Vander wheel has proposed five different flourishing domains. And I think these are important to just talk about and identify the five domains that lead into the ability to flourish that he proposes our happiness and life satisfaction, physical and mental health, meaning and purpose character and virtue and close social relationships. And then there's an additional domain for financial security which also plays a role in your ability to be able to flourish. So these five domains that are listed though are all nearly universally desired and an end in and of themselves. And so this is the flourishing scale and I recognize that the print is small, but I think it's important to hear some of the questions that that help us measure virtue and so this short scale is 12 different questions because it includes the financial ability. And each one is rated from zero which is poor to 10 which is excellent. And at the end of taking the scale you just take an average of all your numbers and that gives you your flourishing index. But some of the questions that I'd like to point out dealing with meaning and purpose and character and virtue are in the middle there. Overall to what extent do you feel that the things you do in your life are worthwhile. And so this is my purpose in life. I always act to promote good in all circumstances, even in difficult and challenging situations, and I am always able to give up some happiness now for greater happiness later. So when this, when these human flourishing skills are given in the general population this is not specific to medicine this is the general population of the US amongst adults. Typically what's been seen in the past is that people who are early on in life, which would be Gen Z which is the blue area, and then people who are later on in life, typically have the highest flourishing measures. So what's been seen in the past when this has been studies is that flourishing is high at the beginning of adulthood right takes a decline in mid adulthood and then rises again towards the end of life. So this is data post COVID though. And this data is really scary because for the first time we saw the people very young and adulthood right the group that's 18 to 25 had some of the lowest flourishing scores. And that is much different than what we've seen in society before. And so instead of that lowest point of flourishing being kind of at the midpoint in your adulthood in your life we're seeing now that people are starting out. With much lower measures of flourishing than they have in the past. When these scales are applied to residents. This was the scale that's been given to internal medicine as well as psychiatry residents and the results of that study. The mean flourishing index for residents was 6.8. This is lower than the, you know, age matched average in the United States so our residents as compared to kind of their age match controls are not flourishing. Again, this is work from Professor Vander wheel but it shows different pathways that lead to flourishing. And I presented only because it talks about the different things that lead into the domains in which we measure flourishing and family work education and community are the four pathways he proposes that lead into our domains of flourishing. And the reason I'm showing this is because during the time of training as a resident, I think that work and education and in some sense your family and your sense of community are all wrapped up in the hospital. That's part of what residency is and so I think there are people who have still strong family relationships and perhaps strong religious community relationships during the time of residency. But even if just work and education are encompassed in, you know, what they're doing here in the hospital. What we're what we're teaching residents in the hospital and teaching students in the hospital has a major effect on their pathways to be able to flourish. And yet we're not very intentional about what we try and teach them to help them flourish. I also believe that this is extremely important because when you look at the entire flourishing index. The one question that arose from the index that was most predictive of a individuals flourishing in the future was from the character and virtue domain. And so if someone answered very strongly to I always act to promote good in all circumstances, even in difficult and challenging situations that had the most robust association with their subsequent composite flourishing later on in life. So this is a space in which we can act to help promoting people and to develop in people in ways in which they feel like they are able to promote good in all circumstances, and have a huge impact potentially on the rest of their life and their subsequent flourishing. So how does this apply to medicine. All of you I'm sure in the room are are well aware of principal based medical ethics and the the four principles are pillars of autonomy beneficence now Maleficent's injustice. Principal based medical ethics trains physicians to be able to make morally permissible decisions using the principles of biomedical ethics, and for many medical students this is the only exposure that they have to ethics during their medical training. I personally believe that about principal based medical ethics provides a very important standardized framework to approach many of the difficult and complex health care decisions and situations that were put in in the hospital. But the one thing it doesn't apply to as as well is the individual physician who's helping guide or helping families. Sorry, I'm a pediatric surgeon so families are helping patients make some of these difficult decisions. In fact, one of the reasons in which we use principal based medical ethics is so that we make sure that the physicians preferences right are not being put before that of the patient it's really to focus the decision decision that's being made on the decision that the patient would want. Part of the part of doing that, you can err on the fact that it then removes some sense of a responsibility for the physician who's helping guide that decision making process, and it also removes the sense of moral agency for the person who is carrying for those people. I think it may not be as readily applicable to many of the daily ethical decisions that individual physicians are asked to make that are probably happening on a much more routine daily basis than some of the larger ethics consults and clinical situations in which an individual consult is needed, right because on a day to day basis you might be interacting with a family that is angry or upset, you might be in an interaction with a colleague who doesn't agree with the decision or a treatment plan you've made. You might be in a your own personal conflict with something that's going on with your family outside of work and so there are many ways in which virtue ethics applies to things that the principal based medical ethics aren't as well suited to when we're thinking about an individual position. And so virtue ethics gives us an avenue just to start to discuss the character formation of physicians as individuals. This is not a new idea in medical ethics right this was really first introduced by Pellegrino back in the 1980s. This idea of using and applying Aristotle's virtue theory to medical ethics. And so I'd like to talk about a few ways that I think virtue ethics is is unique and reasons maybe it should be taught alongside principal based medical ethics and ways in which it's applicable in our daily lives as physicians. And one is because our character really determines our response in times of stress. So I look at this picture as a pediatric surgeon this is a trauma Bay after traumas come through and this is probably was a pretty stressful trauma right. And on the floor there's equipment strewn everywhere I see. You know we probably line kits or other you know maybe a thoracostomy tray. There's lots of equipment that has been opened around the room and left and disarray. And so how do you respond in situations like this in high stress environments. One of the reasons that surgeons and an emergency medicine physicians are taught a TLS are given a very strong guideline of how to approach a stressful situation like this is so that you have an internal guide right you focus on airway breathing circulation primary survey secondary survey. Those of us who have been through surgical residency could probably do that and recite that in our sleep you know what to do when you come into the trauma Bay. You know what your job is, and it's well embedded in you you don't have to stop and think about it or weigh what to do in this situation you know what you need to do. And character is much the same way character is how you're going to respond in times of stress it's what's going to come out when you don't have time to think about much else. And yet we spend very little time trying to prepare medical students in the character that they'll need to respond to the stresses that we put them in in the hospital. We kind of assume we can teach them all the intellect and the technical skills that they know to be a doctor, but the stuff about their character or how to relate to patients or how to deal with controversy they'll figure that out or they've already learned how to figure that out we don't really actively invest in teaching them some of those things. And I think for two ethics is so important is because as we've discussed, we'll react within our habits there aren't always times to think, you don't always know when you're going to walk into a situation that's going to challenge your character your ethics. In fact, sometimes you knock on the door and walk in a patient room and walk into a patient who's very upset or angry. And sometimes you have warning, but sometimes you have no warning for about what you're going to walk into. You don't have the chance to say okay I got to leave the room for about 10 minutes and think about how I want to respond to you and come back. I mean you can, if you need to but also your first response is going to be the response of your character, what's been built into you. Character also informs our response to human suffering. Again, I think this is another thing we just expect students to know. We expect students to know how to to respond to people who are hurt or suffering. And as doctors were trained right to alleviate suffering so our first thought is how can I how can I make the suffering better. We don't talk necessarily or train people necessarily how to sit with suffering how to be around someone who's suffering, how to hear them how to listen to them how to show them love through the attention that we give them. And how to figure out sometimes their goals in response to suffering. And I would also argue that virtue ethics well it's applicable to patient encounters I hinted at this early earlier it's also applicable to the way in which we interact with our colleagues. We know in medicine we work very strongly in multidisciplinary teams and with other groups of people, and the way in which you treat the people that you work with I think very much as a mark of your character. And that's not something that we really always talk about within the medical education system how to, when there's a disagreement in the right, you know care for a patient how to resolve those conflicts, how to resolve conflicts when there's conflicts with the call schedule right how to respond to somebody when they say have had a bad outcome. All these things we can, we can talk about and address when we talk about how we cultivate character. And finally, we know that from from worked on that the virtue ethics is directly linked to personal flourishing and I would propose that it is probably linked to our professional flourishing as well. Medicine today is increasingly less focused on individuals. And I would argue that virtue ethics gives us a way to start thinking about medicine as an individual physician and an individual patient again. And none of these things up here are bad things right like evidence based medicine is wonderful as is quality improvement. But the one thing that evidence based medicine is done right you the assumption is that any physician who's looking at the same patient and following the evidence based guidelines would come to the same conclusion right and so it's removed a little bit of that individual autonomy that we have as physicians so it's a quality improvement for for some in some aspects the way in which you know we have to cover shift work and call coverage. None of these are bad things we're dealing with an increasingly sick system that's running 24 hours a day so we can't be on call all the time. But how do we still maintain those individual relationships we have in light of that. Even the introduction of using provider at some institutions instead of physician that you know any provider is applicable you know round peg that can be moved around and fits nicely and you know in the pegboard there. And so I believe some of this has led to the active decay of the physician in the patient physician relationship. Perhaps many of the reasons that students who go into medicine become doctors who are disillusioned with medicine is I believe many of our students. As are many of our physicians are more much more intrinsically motivated individuals and extrinsically motivated. And so medicine appeals to them because they see as an opportunity for mastery for having a meaning and purpose for having a sense of autonomy and what you do. Especially when they become physician all of a sudden all these extrinsic motivation measures are placed upon you right your salary your RVU your quality improvement you know points where you stand on patient metrics for patient satisfaction. These are all extrinsic things that we're trying to imply in and motivate people with who are naturally most likely much more intrinsically motivated individuals. Next when it was has been looked at this is a paper from John Yoon that was that was published recently. When you look at the intrinsic motivator of salary it wasn't really associated at all with physician meaning and commitment. But when we look at intrinsic motivators so a sense of calling calling was associated with highlight meeting and commitment to direct patient care. Personally rewarding hours per day were associated with career satisfaction, life satisfaction and commitment to clinical practice and having long term relationships with patients was associated with career and life satisfaction and highlight meaning. And so virtue ethics allows us to address some of these things and talk about the investment in the character of physicians embracing our privilege privilege in the patient physician relationship. Reestablishing a sense of community within the medical field and recognizing our single goal of providing the best care for patients. And so perhaps instead of being just around peg. Virtue ethics allows us a way to look at each other as larger pieces and unique pieces of a puzzle. And so I've talked a lot about how virtue ethics may apply within medicine. But the big question out there is, is can you actually teach someone character is there any data to support that right. It sounds great but can you actually teach someone character. I would argue yes you can. What are we teaching now by not intentionally trying to develop character, we're actually malforming patients right because there is a hidden curriculum that's recognized within medicine. Certainly a very small percentage of that that green little piece of the pie is positive. The rest of the hidden curriculum that that's not really publicized or widely knowledge is vulnerability privileged dehumanization hierarchy and navigation and negotiation. And so it's not surprising in light of all that that medical students in the US during the course of their training, show that they decline in empathy, decline in moral judgment and have this increase in burnout and depression. Patients have picked up on on what is happening within the medical field as well. 74% of patients had a mostly positive view of their doctor. 57% so really only a little more than half of all patients believe their doctor cared about their best interest the patient's best interest, all or most of the time. A little more than half think that physicians who went into the medicine to help take care of patients actually have the impression that patients have that that physicians care about their best interest. And only 12% thought that their doctors could admit a mistake or take responsibility. I think this might be data that you guys saw before but one of the things that I thought would always be the saving grace of our profession our ability to show empathy. It's now being shown that perhaps chat GPT is more empathetic than we as as individual physicians are. And so when patients are asked what is your ideal physician, they say that somebody who is competent empathetic humane personal forthright respectful and thorough. That's the same question to doctors when medical students residents and physicians were asked to describe a person who's a good doctor they said that that person was fair, honest, kind, a leader, a good team player and a person with good judgment. But sadly they were much more likely to report that a good doctor should be a leader and a person with good judgment, then they were to think that they possess those skills. They were not practicing physicians right as well as residents, but they recognize that a good doctor needed the skills of leadership and good judgment, but they felt like they did not possess those skills themselves. And when medical students were asked can a person can a person still be a good physician, even if they're not a very good person, the majority disagreed that you could be a good physician and not a good person. Character matter character is fundamental, especially important in helping us maintain constancy in the face of contingencies, ensuring that we stay true to our guiding values and purpose when outside events or pressures tempt us to abandon what we hold most year. I think this describes residency today but I also think this describes the experience of being an attending physician as well. And again, whether we're intentional about it or not. This character formation is happening. And I think we must agree that medical educators should be responsible for helping train medical students to have good character. So how do we cultivate and teach this can this be taught on the Oxford character initiative was one of the first programs to examine whether character cultivation could still occur in a graduate population of students and are able to demonstrate over the course of the year that for their graduate students that had enrolled within this initiative course that they demonstrated an increase in service and gratitude through the course of their their year of teaching. And they describe seven practices to cultivate character including habituation through practice so as we talked about earlier if you want to be a courageous person you practice courageous acts reflection on personal experience engagement with virtuous exemplars using dialogue that increases your virtue literacy, being aware of situation variables cultural influences and institutional incentives, having moral reminders and friendships of mutual accountability. So how does this apply for physicians. Here at the University of Chicago, we instituted the scholars and ethics and medicine course about six years ago now. It's an innovative curriculum that's really hasn't been is not done anywhere else in the country. And we bring together both pre medical students, as well as some of our MS ones and a few MS to students. The goal of the course is to help train future physicians for not only the medical knowledge in the care, but for the character traits as well that they will need to flourish in medicine and in life. And so one of the questions that I always start out our course asking students is what kind of doctor do you want to be. And as you go through medical school, you get asked this question a lot right, and usually the correct response at least if you're going into surgeries I want to be a surgeon. But it depends you students will answer this in many different ways. But the first thing we think about when we hear this question is what kind of specialty do you want to go into right. We don't stop and think about like what kind of doctor do you actually want to be not so much your, your resume virtue doctor right, but your eulogy virtue doctor like I want to be a kind and compassionate doctor. Through teaching this course we've come up with this constellation of virtues that describes different virtues or character traits that are applicable to flourishing as a physician. And we group these into three different categories. And a lot of these virtues actually you could argue could be put in different categories. But the way in which we've arranged things is to look at both the ways in which your character or virtue affects your personal infrastructure, the ways in which your characters are relationship supportive, and the ways in which character and virtue can be patient responsive. And so the goal really with our course is to try and cultivate students to think about and cultivate virtue now prior to them having really any true clinical rotations in hopes that they will be better physicians in the future. Again, it's a year long course for the undergraduate students here at University of Chicago they get course credit for this. So it shows up on their formal transcripts they get credit for having participated. The first cohort was in 2017. Initially, you know part of the purpose of this group is to create community in a space for reflection. So initially we had capped the applicants or the cohort of 25 students. Over the past few years we've seen an increasing number of students who want to be involved in this course and it's very hard to turn away anyone who wants to cultivate character. We've had 87 students supply the year before that we had close to I think 84. So this past year we've admitted 40 students 17 of which are medical students and 23 of those students are our pre med students here. And during the year long course we teach Aristotle's theory of virtue ethics, in order to provide a framework and a language to talk about cultivating character. We bring in different positions both locally here from University of Chicago as well as from across the country, so that the students have a chance to engage with physician exemplars, as well as mentors we bring back. Fourth year medical students as well as some of the residents and fellows here who serve as mentors to the younger students in the course. We try and create a sense of community and so when I show you the schedule some of the events that we host are purely social events I'll have the students over at my house just for a chance for us to get and talk and see each other kind of outside of the lecture hall or seminar. We explore the characteristics of foster humanistic medical care and try and offer students at a time in which they have space and time for reflection. This is just a sample schedule for for the year I feel like every year we add a little more I don't think I could fit this year's course schedule on here. But we have two large seminars so to Saturday seminars one in the fall and one in the winter in which we spend about five hours together. We're talking through various lectures having small group discussions, we then meet about once to twice a month throughout the the rest of the year. In which during which time we have again both local University of Chicago physicians as well as those who travel from other institutions come and talk to the students. We share a meal over dinner and then we open up for an hour long Q&A and a chance for the students to ask these physicians questions and and get to know each other better. During the course of the year we talk about different situations that call for virtue, as well as approaches and effective practices to help cultivate character and virtue. So you can say it is this effective we actually have been measuring this since the start of the cohort. And the way in which we're measuring what we're doing is using what's called the situated wise reasoning scale, which is able to assess five different aspects of wise reasoning. So basically one's ability to look at things from another's perspective, consider and change the consider how there are multiple ways in which one situation may unfold. Show intellectual humility and a recognition of your own limits of knowledge, search for compromise and view the event through the vantage point of an outsider. We have our data here. And when you look the blue is the students who participated in the course, the reds are controls so those are students here at University of Chicago who don't participate in the course. And so what we see is after a year long participation in the course that the students who are in our course show an increase in their ability to have wise reasoning, right, their blue line goes up. So students who have not participated in this course actually show that their wise reasoning deforms during the course of the year. So not only do they not increase in their wise reasoning they actually become less able to reason wisely and see another person person's perspectives. So in our in our last two minutes, I would like to talk about perhaps how this applies to which virtues might be most compelling for physicians which which are these virtues if we look at these as being important for physicians to potentially target and teach and make a true impact in. And I would like to propose that maybe the case for that in terms of the virtue to focus on as we move into the future as humility. But first I'd like to also just say that we can teach character we should be teaching character, and we can do it through intentional curricular developments, but it does involve time, attention and energy, which is something that students do in residence and so translating this into, you know, a program for residents is more challenging, just because I know for myself as a surgical resident when I was at the end of my day I barely had time to reflect on the case I did that morning and technically how I could have improved what I did in in caring for that patient much less have the space and time to reflect upon my character or much larger aspects of who I was becoming. But it is important that we create the space and time for students as well as residents, and we do that through fostering relationships, demonstrating our own vulnerability and creating a culture that both recognizes and awards character and giving people a time to think about who am I becoming through this process, and why am I doing this. So one of the new initiatives that are on the horizon. The Hyde Park Institute we're hoping to launch as extracurricular mini series this spring right after match day for the fourth year students. This is the first time we're doing this so it'll be three, you know, seminars over over a dinner and talking about with residents after they've matched and have or sorry with medical students after they've matched and have residency on their mind. It's going to be a good resident, how to have difficult conversations and deal with mistakes and bad outcomes. And then the last one what to do with your pay when your pager goes off a user's guide to maintaining compassion and caring as a resident. You guys, you may also have seen advertisements for the meaning and purpose and medicine series this also is sponsored by the, the biological science division office or faculty affairs as well as the Hyde Park Institute. And this we're hoping to try and change a little bit of institutional culture to talk about recognizing and cultivating characters really at all levels and investing in intending physicians and what it means to really have a clear sense of meaning and purpose and what you do. So I would ask as you're out there in the audience thinking about how all this applies and ties together to think of someone a physician that you know that you consider wise. And why do you consider them wise? Is it because of the reviews that they bring in? Is it, you know, a surgery, a technical skill that they have? The number of publications or how long their CV is? Do you consider them a wise person because of their clinical acumen? They always know what's happening on rounds. Or do they hold a position of leadership that makes you view them as a wise person? I would guess that many of the things that actually make you consider that person wise in addition to some of those extrinsic things or visible things are actually more character traits that that person has. And so as we think about how we can create wise physicians for the future, I think we really need to focus on how we intentionally create and cultivate character in our trainings. And one area in which we really have focused little attention on is the character trait of humility. And in fact, many people see humility as a sign of weakness. But the word humility comes from the Latin and actually means grounded or from the earth. And so you can think of it almost like a tree that is strongly rooted within the earth. Humility in medicine is fostering a culture of continuous learning and collaboration and patient centered and team based care. And it includes accurate self assessment, a recognition of one's limits, a low self focus and an appreciation of others and an awareness of being part of a larger system and universe. Humble physicians are more likely to seek out information and get feedback to listen attentively to their colleagues and stay on top of the latest research. They're more effective in multidisciplinary collaboration. They recognize and value others contributions. They respect the patient experience and they're much more likely to gain patients trust and adherence, and they mitigate errors and uncertainty they're able to seek out others insights. They acknowledge their own limitations and they learn from their missteps. And so instead of humility really being the vice of defective pride or arrogance. I would argue that humility is the golden mean humility is the state of self competence and self awareness. The device of that defect would be being under confident or timid or self conscious but humility is actually the golden mean between those two and what we should all aim and strive for. In surgery, I think this is very important and this is my own definition of surgical humility. But I think it includes confidence in one's technical abilities, a recognition of one's limits of expertise and experience, then acknowledgement that surgical outcomes are dependent upon a team approach, an expression of gratitude for all those that participate in a patient's care, recognition that the patient preferences, their support and their social consideration are very important factors in their care, a reflection on the process and the outcome of the care provided, and finally taking joy in the good one is doing while striving to continuously improve. And so character character cultivation starts very early. That's one of the reasons that I am working with the undergraduate students and the early medical students. I really believe that that provides an opportunity to build into people before they're even exposed to the hidden curriculum within within a medical center. But I don't believe it's ever too late to start thinking about character cultivation. It does take time it takes energy and it takes a lot of attention to be purposeful about cultivating character. It does also needs to be modeled at all levels and both recognized and applauded. And then really it's a conscious decision to invest in our trainees and who they are becoming to show a genuine interest in them as human beings and focus their training not just on the technical or the academic skills that they need, but really on the character traits that they need to be a good doctor in the future. And I believe that by helping people cultivate helping aspiring physicians cultivate their character, we can help lead them to a sense of professional and personal flourishing. So I conclude with with what kind of doctor do you want to be and maybe since many of us in the room have already declared what specialty we're going into perhaps now is the time where you can stop and think about what you want to be known for in your career. In terms of the type of doctor that you are. I have to give a huge thanks to my colleagues at the Hyde Park Institute who have worked closely with me and the scholars and that that's a medicine course and really have made that that course happen. I also would like to give a thanks to Jessica candell, who was the head of pediatric surgery when I started this academic pursuit as well as all of my partners within the section of pediatric surgery that allow me the time and the space to go teach the undergraduate students and accommodate the call schedule so that I can be there in the classroom with them. Things are going on. So, thank you so much for hosting me I hope this is challenged a little bit maybe how we typically think of ethics in medicine. Any questions yeah. Yeah. And I think that's very true and I think that's one of the reasons why when we talk about well being it almost makes people cringe right to a little extent because the way in which it's being done is maybe not the best way to be doing it. There's very important systems aspects to some of this the EMR being one of them and completing charts there's ways in which we could use AI or the benefits of technology to take away some of those things that remove us from the patient's bedside because again, when we think about motivation I think for people going to medicine the intrinsic motivation was was to take care of patients. And charting is important but charting is mostly linked to RV use and find you know like the hospital getting money right and that's not what necessarily motivates most of us who have become physicians. Not that it's not important but it's not the true motivator and I think that's really a pause for a lot of distress that that physicians and their trainees are feeling within medicine, because the motivation to go into medicine and help take those practices, not the same motivations being applied to them once they actually become a physician. There's data and there's certainly practices you know behind evidence based medicine but one, not every patient fits into that perfect mold either that qualified for that if you're lucky in cardiology that RCT right and surgery we don't even have RCT is fueling most of these things. Again, evidence based medicine in of itself isn't a bad thing but I feel like it does take away some of that aspect of having a relationship with your patient that you're able to know things I had a patient return to my clinic the other week with hydrodinitis now hydrodinitis there's not a lot of evidence based medicine. This patient had bad disease and I had started her on doxycycline because I was really the first person to diagnose her. And she presented a week early for her three month follow up with an abscess and called and you know can I get into the clinic right away. And you know I asked her like okay well how is the medicine been you know like are you taking the medicine, and her mom said we can't afford the medicine doxycycline they can't afford it so she wasn't taking it and now she had an abscess and it actually had to be brought into the hospital it was bad for herself we had because she had induration and cellulite as of her entire arm from an axillary abscess we had to bring her into the hospital on IV antibiotics. And, you know, I, I, I miss that when I first met them and talk to them you know like, we, we obviously had a, we weren't on the same page and I think that happened so many times where we prescribe patients these things but we miss the other aspects of their life that are preventing them from actually being adherent with that medication. With that treatment. Yeah. And I don't think it's just empathy I think we do a bad job though, modeling how to help even distinguish between hurt and suffering and find out where a patient might be and what they might want what they might prefer right. Like, the, the teaching the hidden curriculum within medicine almost is just to get in and out of a room where they're suffering as quick as possible. And there are exceptions to that. There are doctors who do a very good job with was sitting with people who are suffering and figuring out ways to help them but there are a lot of times when there's a suffering patient on the floor the, the, the amount of time that the physicians actually spend in the room is less than the other patients they're caring for on the floor. People don't like to be, not all people like to be around suffering and so by, by not really providing any guidance or training as to how to think about this when you're a student or a trainee I feel like we're doing them a disservice. And I do not mean to imply in any ways that humility is the only virtue. I think that part of the constellation there I think all of those aspects of the constellations of virtues to think about our important traits for physicians and we're not trying to make us into round pegs. I appreciate that each of us will have our own character traits and will be stronger in some characteristics than others and that's part of which what makes us able to provide care to so many different people right like we don't want just one. In fact or one clone of one person running around and treating everybody I think there's something unique about the fact that we all have different character traits. Humility is one I think that we as physicians do a bad job at and in fact if anything, the training has been to be less humble to almost beat that out of people people who may come in with humility that's something that's almost by by the unintentional curriculum that that is happening is being forced out of people. And that's the reason I bring attention to that one because I think that's one where we could try and teach and make a true difference in the kind of the in product of residents but I don't by any means. I think that the only character trait that positions should have is humility I think there's a wide array of different characteristics that positions need to be able to treat the the wide array of characteristics that is within humanity. Yeah, Megan. So character cultivation and the path to flourishing is is a lifelong process so you can still cultivate later on in life but you're right. There is a certain age. I, I am not a psychologist so you know do not quote me on this but usually it's around the age of like 26 to 30 in which the character that you have becomes more firmly cemented, which is one of the reasons to to, you know, try and reach students where they've reached that age in which some of those character traits become not necessarily that you can't cause a change but you can't cause as large of a change they have formed their sense of identity. That might be delayed no one's ever studied it in physicians right there's a lot of things that's delayed about the process of going through medical education. And that's in terms of personal development and so maybe there's that opportunity for character development through residency as well, but it's going to become harder. And that's part of the reasons for creating a very intentional change of culture that's modeled from the leadership down, but that really takes being intentional about things because a lot of these things that we're talking about are not traditionally surgeons or physicians were awarded or recognized for, you know, there's not an award for humility that the University of Chicago awards to a physician every year. And so thinking about ways in which we can show to the younger generation that these are things that we actually value and do matter and matter more than just, you know, an email that says these are our, these are our core values, but one that we live out and show. But you know, one of the things when I went into surgery. People said that told me to my face I was too nice to be a surgeon, and I never understood why like why could you not have someone who is technically good and also technically and also has a good bedside manner. Like why do patients have to choose why should they have to choose. Why couldn't you be a nice person or a good person and also be a good technical surgeon. I don't think that we should make patients you know have to choose or compromise between having someone who is technically good and having someone who is a good person. But I those those stereotypes about different fields you know are still alive and wild today. decision making model. There's a decision making feel like I'm not yet at a point where I can actually exercise decision making. Whereas if the focus is on the focus, then even throughout the ones in decision making, even when we're not able to actually make this decision, we are able to listen to the exercise on the part. Yeah. When I have talked about this in an ideal world and I've talked to medical ethicists that are passionate about virtue ethics and teaching that I think the ideal way would be to introduce students to virtue ethics first. Because it gives them kind of an expanded view of what ethics can be, and then provide them the education and the teaching about principle ethic the principle based ethics, because if you teach principle based ethics first to medical students and almost narrows their ability to see what what the rest of ethics could be. And so I believe both are very important to be taught, but there is something to be said about teaching the character aspects first, and then providing them later on with the principle based framework to think through complex situations that they would be in. Thank you. Thank you.