 I am pleased to welcome you to the seventh and sadly the final panel of the annual McLean Center conference this year. The seventh panel is entitled, Surgical Ethics. It's my honor to introduce this panel's moderator, Dr. Peter Angelos. Peter Angelos, M-D-P-H-D-F-A-C-S, M-A-M-S-E, is the Linda Kolder Anderson Professor of Surgery and Surgical Ethics, and is the Vice Chair for Ethics and Professional Development and Wellness in the Department of Surgery, is the Chief of Endocrine Surgery, and is the Associate Director of the McLean Center for Clinical Medical Ethics all at the University of Chicago. A native of Plattsburg, New York, where his father was a community general surgeon, Peter Angelos completed his undergraduate degree in medical school and Ph.D. in philosophy at Boston University. He completed his residency in general surgery at Northwestern University and went on to complete fellowship in clinical medical ethics here at the University of Chicago and a fellowship in endocrine surgery at the University of Michigan. Dr. Angelos is a very busy endocrine surgeon who is written widely on improving outcomes of thyroid and parathyroid surgery, on minimally invasive endocrine surgery, and ethical aspects in the care of surgical patients. Dr. Angelos has published over 250 peer-reviewed articles and has authored or co-authored over 50 more book chapters. He edited two editions of the book, Ethical Issues in Cancer Patient Care, and is the co-editor of the American College of Surgery textbook entitled Ethical Issues in Surgical Care, and is co-editor of a forthcoming book entitled Difficult Decisions in Surgical Ethics. Dr. Angelos also was a regular contributor to the American College of Surgeons' Surgery News, where he wrote a column on surgical ethics entitled The Right Choice from 2011 through 2019. He's a governor of the American College of Surgeons, a member of the Academy of Master Surgeon, educators of the American College of Surgeons, and is the past president of the American Association of Endocrine Surgeons. In June 2019, Dr. Angelos began a six-year term as a counselor of the American Board of Surgery. It's a delight to welcome Dr. Peter Angelos to serve as the moderator on this seventh panel entitled Surgical Ethics. Thank you, Mark, very much for that really very kind and way too long introduction. It is a real honor for me to be moderating this last panel for the conference. It's been a great conference. I appreciate everyone who has stuck it out until the end, but we've got a series of excellent talks. And I'm going to start by talking about the value of attending to the ethical dimension of the surgeon-patient relationship. Now I have no disclosures with respect to this presentation, but I do have a few disclaimers and I think it's valuable to at least put them out there at the outset. First of all, when it comes to evidence and ethics, it's a little bit harder to make the case and especially in things where it's a little bit harder to measure these things. And so most of what I'm going to present to you is related to my opinion and therefore I'm absolutely convinced it's true, but you may lack proof and that's okay. But hopefully it'll form some subject for discussion. Lastly, I do want to state that this presentation, for this presentation, I have really focused on surgeons and the experience of surgeons and my own personal experience as a surgeon. Now I do not believe that that experience is unique in providing medical care. And so I would challenge everyone listening who does not identify as a surgeon to see the ways in which there are similarities and differences between the things that I'm suggesting with respect to surgery and other areas of caregiving in medicine. So let me start with a sort of basic question. Why is it good to be ethical? And certainly we know that there's an intrinsic value in acting ethically as a surgeon and as a person. But there's also I would argue an extrinsic value in acting ethically and that is that patients benefit from ethical surgeons, but what I'm going to also suggest is that surgeons also benefit from the attention to the ethical dimension of surgical care. And so in that sense I'm going to be focusing a little bit more on what is the benefit to surgeons more so than what is the benefit to patients, although obviously what's beneficial for patients is equally if not more important. So I'm going to talk a little bit about burnout and in this sense I think I'll be perhaps following some of the similar vein that Bernie Lowe suggested in his excellent presentation about how the tough ethical questions are the ones that keep us up at night but they also help us find meaning in our work and also some of the comments that Farke-Curling made about some of the methods to reduce burnout. So we know that burnout is an important issue for surgeons as well as other caregivers and you know I think that's an open question whether there's an epidemic of burnout or rather there's just a greater awareness of the issue but either way I think it demands attention and we know it's a risk factor for depression and suicide. Estimates are that about 400 physicians per year commit suicide. So that's equivalent to one very large medical school class of physicians per year. So that's a huge and tragic loss. Now there are a number of potential factors that are associated with surgeon burnout and others have commented on these. People suggest that a loss of autonomy is significant, a diminished sense of value in our clinical activities. Some people have pointed to the electronic medical record as being adding to that problem. And some have even suggested that inclusive language may devalue individual physician contributions and so the term provider as opposed to the term my doctor or my surgeon suggests that a provider suggests a cog in the wheel rather than an essential actor and so perhaps that has something to do with these increased feelings of burnout. Now there are of course personal characteristics that have been discussed to reduce the risks of burnout resilience defined as the ability to bounce back from adversity is thought to be an important factor capacity. The ability to bear the many unavoidable irritants of daily life with relative equanimity. These are valuable traits that seemingly would help people to reduce the risk of burnout. There are many others I'm just going to highlight these two because I do think that they're interesting. You know it's this interest and this emphasis on these factors for example resilience that led to a number of interventions. The University of Chicago has a whole resilience week and I thought it was particularly impressive in the winter of 2019. We had a whole series of resilience week lectures presentations these were for residents faculty other caregivers students. Of course if you remember that was also the time of the polar vortex in Chicago so I thought it was with tremendous irony that resilience week was canceled due to extreme cold. It seemed to be to suggest we have a lack of resilience we're in Chicago anyway but nevertheless I digress so what about are there aspects of surgical practice that could increase resistance to burnout and I do believe that emphasizing the ethical dimension of the surgical care of patients that we provide may have benefit to surgeons as well as to our patients. Now what is this ethical dimension of surgical care that I'm talking about well it's the non-technical aspects of surgical care and these are things like communication with patients. They are really focused on the surgeon patient relationship and the importance of the trust that patients place on their surgeons. It is certainly intimately related to shared decision making which we've heard a lot about in the last couple days. Well how might this attention to the ethical dimension affect surgeons? Well I would say regardless of the practice setting the individual relationship of surgeon and a patient is an intensely personal one. We can't or at least I can't have a relationship with just patients in general I have a relationship with each individual patient separately and in fact every time we obtain informed consent for an operation we are asking our patients to trust us individually so I am specifically asking my patient to trust me to do things to them that are potentially very harmful if it doesn't go well. And the responsibility to uphold our patients trust is in fact a central motivator to surgical excellence and I would argue that it's even one of the motivators to continuing medical education in surgery, the desire to keep up with the literature etc. Now what are the reasons why many chose to be surgeons and this is non-scientific. I am relating to you some aspects of my personal life as well as in talking with many friends and colleagues who are surgeons over the years. I think it's the opportunity to use our individual skills and talents to aid another person in need of assistance that's what really I think drives many and for many of us the joy of surgery is in helping our patients and regardless of how devalued we may feel in our jobs for each individual patient who trusts us to lie down in the OR we are highly valued. Now how can we emphasize this ethical dimension in surgical care? Well I think that there are a couple of things that would be helpful. First of all we need to take seriously how well or how poorly we communicate with our patients. We need to emphasize the development of communication skills in optimal surgical education and practice. I think we also need to acknowledge the central role of trust in the surgeon-patient relationship. Now we all know that there are things that we can control and things that we cannot control. And lack of control we know is a major source of frustration that's felt by surgeons and lots of other physicians in large institutional practices today. We know that loss of control is intimately related to increases in the risk of burnout. But I would suggest that in the privacy of the exam room each interaction that we have with our patient is under the control of the surgeon. So I can't control what my patient's going to say but I can certainly control a number of aspects of the way that I explain things, the extent to which I ensure that there's high level communication, that I answer questions, that I spend the right amount of time and that sort of thing. So I do think that we may have time pressures but there's really no administrator who can affect how well or how poorly I engender my patient's trust. Now I do think that we know that there's a tremendous impact of complications on surgeons and multiple studies have pointed out the serious impact on surgeon well-being that complications have. Some have described the surgeon as the second victim of a complication. I'm not sure I like that characterization but nevertheless it's prevalent. Multiple institutions have sought to reduce this impact by peer counseling programs. I think these are worthwhile interventions but I also think that there's something more that we could do and I think that focusing on the ethical dimension of surgical care also might help because by ensuring the adequacy of informed consent from our patients we are actively engaging them in the decision-making process around their operation and such shared decision-making acknowledges that the surgeon does not always know best and that complications can and do occur. And having had these conversations does not diminish the physical impact of a complication on a patient but I do think it may reduce the psychological implications on both the patient and the surgeon. I do think that increasingly we throughout medicine are faced with a dilemma. We are increasingly pushed to measure our outcomes and quantify results and certainly that's valuable. We need to measure outcomes. We need to be very careful in how we do it and we need to pay attention to it. As Lord Kelvin said, if you can't measure it you can't improve it. So there is definitely a value in measuring things so that we can improve them. Unfortunately it's difficult to quantify ethical behavior but we still need to encourage it. And Albert Einstein said it quite nicely, not everything that counts can be counted and not everything that can be counted counts. So I'll leave you with just a few conclusions. First of all I think it's good to be ethical. I think that there is both intrinsic and extrinsic value and I want to go on the record of being strongly in favor of ethical behavior. Secondly, I think attention to the ethical dimension of surgical care reduces the likelihood of surgeons being considered near technicians. And I think this is absolutely critical for the future of the profession of surgery. I think that the emphasis on the relationships that surgeons have with their patients can reduce the risks of burnout. And by emphasizing the importance of patients trust in surgeons, surgeons may be less likely to be negatively affected by complications when they occur. Both patients and surgeons I believe will benefit from the high levels of ethical care that surgeons provide by really paying attention to this ethical dimension and really fully encompassing the ethical dimension in what I would argue is really complete surgical care of our patients. So with that I want to end and thank you for your attention. I also want to thank specifically Mark Siegler for his many years of friendship, mentorship and guidance and for inviting me to be part of this great program today. So thank you. It's now my privilege as the moderator of the session to introduce our next speaker. Julie Kaur, MD-PhD is an associate professor of obstetrics and gynecology in the section of complex family planning and an assistant director of the McLean Center for Clinical Medical Ethics. After completing medical school at the University of Chicago's Pritzker School of Medicine, Dr. Kaur completed her obstetrics and gynecology residency, fellowship in family planning and an MPH at the University of Illinois at Chicago. A dedicated educator, Dr. Kaur serves as the program director for the fellowship in complex family planning, assistant director for the MS3 obstetrics and gynecology clerkship and co-director for the Pritzker School of Medicine's first-year doctor-patient relationship course. Her academic and clinical work focuses on understanding and addressing barriers that adolescents and young adults face in seeking and obtaining reproductive health care. She is the co-editor of the recently published book entitled, Reproductive Ethics in Clinical Practice. So welcome, Dr. Kaur. Thank you so much. Thanks, Julie. That was just fantastic, and I do think it does seem to me that there are going to be some wonderful themes emerging from this series of presentations. I know that several people have put in questions already, but for those of you who are thinking of them, please go ahead and put them in so that they can be ranked by the other participants. So it is a pleasure for me to introduce the next speaker, Dr. Norman Hogikian, who is professor and associate chairman of Otolaryngology Head and Neck Surgery at the University of Michigan Medical School, professor of music in the UM School of Music, Theater and Dance, and faculty in the University of Michigan Center for Bioethics and Social Sciences and Medicine. He serves as chief of the division of laryngology and general otolaryngology, director of the University of Michigan Vocal Health Center, and faculty ethicists with the Michigan Medicine Clinical Ethics Service. Dr. Hogikian received his bachelor of science degree in cellular and molecular biology from the University of Michigan Magna Cum Laude and Phi Beta Kappa in 1982. He went on to graduate from the University of Michigan Medical School, was AOA with distinction in research in 1988. While in medical school, he received the Howard Hughes Medical Institute, National Institutes of Health Research Fellowship, spent a year at the NIH. He had a residency in otolaryngology, had a neck surgery at Wash U in St. Louis, and then a fellowship in laryngology at Loyola University of Chicago under Dr. Robert Bastien. Dr. Hogikian joined the University of Michigan faculty in 1995. He's a graduate of the Clinical Medical Ethics Fellowship at the McLean Center. His laryngologic research interests include measurement of voice-related quality of life, laryngeal paralysis, subglottic stenosis. His ethics-related research interests include the doctor-patient relationship, trust in the surgeon-patient relationship, and ethical considerations for patients with communication disorders. Dr. Hogikian will be speaking on trust in the surgeon-patient relationship today. Thank you very much, Peter, for that very kind introduction. And thank you to Dr. Siegler and the McLean Center for the opportunity to participate in this year's conference. I'm going to talk about trust, something that's important in any relationship, is particularly important in the doctor-patient relationship. And my presentation is going to focus on how trust develops between a surgeon and their patient. I have no relevant disclosures. And I'm going to start with some background material on trust and call it food for thought. Although I could have done no better job than Peter has already done with his presentation in getting us into a mindset thinking about trust. Following that, I'll present some of our own research on patient perceptions of how trust develops between a surgeon and a patient, and then I'll briefly touch on future directions. Pause for a moment and consider undergoing surgery by a surgeon you trust. Well, it's a stressful, anxious circumstance. There's uncertainty. There's vulnerability. But those things can be buffered by the guardrails of the trust that you have in your surgeon. Now pause and contemplate having surgery by a surgeon whom you've not had the opportunity to establish trust with or whom you do not trust. That's a completely different proposition, isn't it? A quick true story from this week. On Monday I operated for a patient with a paralyzed vocal cord doing an operation where we expose the larynx and I actually drill an opening in the laryngeal cartilage in order to expose the underlying vocal fold and then adjust the position of it in order to enhance the patient's voice. And this operation is necessarily done under local anesthesia with light sedation because we have to actually listen to the patient's voice in order to adjust the position. And so they're away with their neck open in the oar. The next morning I was rounding on this patient and I said to her, boy I'm certain it must be a very difficult thing to participate in your own surgery like that and thank you. For that it's an important part of the outcome of this operation. And she said to me, you know, Dr. Hogekin I could feel my anxiety starting to well up at several points in the operation because I could hear what was going on and I was at a picturing it in my mind. And it was the trust I had in you, her choice of words. It was the trust I had in you that allowed me to contain the anxiety during the surgery. Now reflect on the other side of that trusting relationship as a clinician upon how it feels to establish trust with a patient. Well, it feels pretty good, right? There's certainly a responsibility associated with that, but it feels good to have that trusting relationship. Now reflect as a clinician or as simply a human being on how it feels to not be trusted or to not have trust in someone else. It doesn't feel very good. I submit these two phrases to you that the joy and meaning in being a physician are to be found in the doctor-patient relationship and that trust and trustworthiness are critical elements of this relationship. This was an interesting paper from a few years back that proposed foundational characteristics of being a physician. And in order to be foundational, they felt that the characteristics should be timeless and real, yet aspirational. And by that, they meant that these aren't things that you ever finish doing. You don't say, okay, I've accomplished that. I'll move on to the next task. Rather, these are things that we constantly aspire to. Practical wisdom, obligation of self to other, and compassion. And while it's not strictly listed here, I would submit to you that trust is operating in each of these. In one of Dr. Siegler's many classic papers, he proposed the physician-patient accommodation model of the doctor-patient relationship. And in the paper, he explores unilateral models and then presents this model that retains mutual autonomy and that it involves shared decision-making. And through this, he said that earned trust develops through dialogue. And this is how we determine what is right and good for a particular patient in a particular situation. Two of my colleagues have written about trust. Peter, in some of his work on informed consent, had noted that the informed consent process seems to be about establishment of trust rather than purely information transfer. Alex Langerman published a paper recently about trust as a predictor of patient perceptions of trainee independence and surgery. This is an interesting paper, and I would say this tells a cautionary tale. It's co-authored by the Dalai Lama, and I would say that it might be on all of our bucket lists to co-author an ethics paper with the Dalai Lama. The cautionary tale is that they state that current health care delivery models limit the development of compassionate engagement, and I would say compassionate trusting engagement. Time spent with patients. There's more and more emphasis on spending less time with a given patient in order to see more patients or continuity of care, and there are certain surgical care models that seek to minimize or even eliminate a surgeon's role in nonoperative evaluation and care of a patient. Promoting the notion of surgeon as purely technician, something which I roundly reject for the concept of surgeon as a complete physician. This cautionary tale really resonates with me as a 60-year-old physician. So what is trust? You know it when you feel it. You appreciate it when someone bestows their trust upon you, but what is trust? Well, there are a variety of definitions, and many include the phrase the optimistic acceptance of vulnerability. Think about that for a minute. That's a really powerful phrase, isn't it? It's very thought provoking. Some elements of trust in physicians that have been acknowledged to recognize their interpersonal communication, technical competency, and agency, or loyalty, fidelity. And trust is born of conditions characterized by risk, uncertainty, and vulnerability. And that sounds a lot like surgery to me. This photo is me with a patient with a complex laryngeal tracheal stenosis, whom I've cared for for more than a quarter of a century. And our relationship is very much built upon trust, and she was thrilled to know that I would include a photo of her in this talk today. So how does trust develop between a surgeon and a patient? We published this paper earlier this year on patient perceptions of exactly that. And my co-authors are Lulia Khanna, who is our pre-doctoral ethics fellow at Michigan at the time. She's now a resident in otolaryngology. Andy Schumann, who's a head next surgeon and co-chair of our clinical ethics program. And Janice Fern, who is a PhD bioethicist and social worker, who is a principal clinical ethicist with our program, and she's an expert in qualitative research. The nuts and bolts of this study are that it was qualitative and interview based. Subjects were recruited at the time of surgery scheduling using convenience sampling. What that means is following an outpatient clinic visit, when a patient made a decision to have surgery, they were asked if they were interested in participating in the study. If so, they were subsequently contacted, underwent an interview that was recorded and transcribed. And these were thematically analyzed using an inductive open coding strategy, employing reflexivity to try and limit bias. The convenience sampling led to these descriptive statistics. There was uniformity of race. Gender mix was equal. Most of the patients had had surgery previously. A few, small percentage, had had surgery by the current surgeon before, many not. And the subspecialties listed there reflect and a subspecialties in an otolaryngology had next surgery clinic. And data from this study led to three themes. And I'm going to review each of those themes now. The first was trust across various contexts. And trust in a surgeon was felt to have exceptional weight and consequences compared to other contexts. People mentioned that the gravity of the circumstances and the extreme vulnerability, the nature of trust itself seems to operate similarly to other contexts. That is, when people noted differences, it would go back to the exceptional of the weight and consequences or the gravity of the circumstance. And people noted that inherent trust or distrust in physicians may exist. And a few supportive quotes. Surgery or trust in the context of surgery is quite a bit different. You're going to be unconscious. You're going to be essentially helpless, unable to advocate for yourself. Trust is the same compared to trust in other doctors. I feel confident with them. So, inherent trust in physicians. Then going on to say, I think it's very important trust in surgery because your life could be in balance or something could go wrong. So you need to have real complete trust. Again, going back to the gravity of the circumstances when characterizing a difference for trust in a surgeon. The second theme was the impact of prior knowledge upon trust. That's prior knowledge before the clinical encounter. And this was felt to set the stage for development of trust if it was present. And not everyone had prior knowledge before they met their surgeon, prior knowledge of the surgeon. Sources of prior knowledge include online sources, word of mouth, family, friends, or other providers. Also, some people had institutional trust. That is, they knew of or had had care at the institution of the provider before. And that set the stage for them to have trust in the individual. Prior experiences with healthcare, good or bad, could also impact trust. Some supporting quotes, I was reading as Google reviews and they were really good. And we're all aware of Google reviews these days and the impact they may have. I was nervous because I never met her before. And someone who had a family member who worked in anesthesiology who had asked about the surgeon that they were going to be seeing. And the anesthesiologist said good things about that doctor and that helped set the stage for developing trust in that surgeon. And then the last quote reflecting institutional trust. Institution has a reputation for being one of the best care centers. And that set the stage for them to develop trust. The third thing which was overwhelmingly the dominant thing was the importance of the interpersonal connection with the surgeon during the clinical encounter. Participants stressed the relational, not the transactional elements of the clinical encounter. They mentioned communication, things like kindness, respect, the knowledge that the surgeon had. And a really interesting finding from this was that observing a surgeon interacting with other team members in the healthcare team also impacted the development of trust in that surgeon. Some supporting quotes. There wasn't anything before I met him. It was just the one-on-one and the way he handled himself. When she came in she was warm and very nice. Looked me straight in the eye. Talked to me, not to the computer. The other surgeon that I actually did not go with walked in, went to the computer, started talking at the computer and didn't even look at. Gosh, I remember he was a very kind-hearted person who seemed to genuinely care about. And then the last one about relationships with other members of the care team. If he seems to have good relationships with other people that work with him rather than being distance, that would be a good sign to me. And again, the data from this study led to these three things. The importance of trust or the significance trust across various contexts where trust in the surgeon was felt to have exceptional weight and consequences. Impact of prior knowledge upon trust, this could set the stage for development of trust if it existed. And then overwhelmingly, the dominant thing was the interpersonal connection with the surgeon during the clinical encounter. Some limitations of this study include the modest sample size and the relative homogeneity of the participants. Some future directions that I would propose. I'd enjoyed if we have some conversation about that today. I've listed there. And the impact of trusting relationships upon clinician well-being, Peter already, I think, discussed things relevant to that concept. And also trust as a potential quality measure is something that's potentially very interesting to me in the future as well. And I'll close with a quote from our paper that the power of the interpersonal transaction amongst surgeon and patient is at the crux of this reflection. And I think it's incumbent upon us to promote care models and to educate young surgeons in a way that acknowledges this. Lastly, a shout-out to my McLean Center class at the left is our group on our first day in July of 2018 at Wright. Are the surgeons in my cohort together with Peter at our graduation? If any of you happen to be listening, I miss you guys and our Wednesdays in the McLean Library. Thank you very much. Thanks, Norman. That was wonderful. And I agree. I think we all miss the ability to meet in person and looking forward to being able to do that someday soon. So I'll again encourage you. There've been some excellent questions posted. If people have others, please go ahead and put them in. It's really a pleasure to introduce the next speaker. Megan Applewhite, MDMAFACS is an Associate Professor of Surgery and Chair of the Center for Ethics Education and Research at Albany Medical College. She is also a consultant bioethicist for the Department of Defense Medical Ethics Center. Dr. Applewhite is the Director of the Alden-March Bioethics Institute at Albany Medical College and holds the John A. Bayland MD Chair of Medical Ethics in the college. She completed her general surgery residency at Leahy Hospital and Medical Center, and we were fortunate enough to have her as our endocrine surgery fellow at the University of Chicago, where she also completed the McLean Fellowship for Clinical Medical Ethics. Her research interests include surgical ethics, healthcare of the incarcerated patient population, and military medical ethics. Today, she'll be speaking about ethical challenges encountered by third-year medical students in their surgery rotations. Welcome, Megan. Hi, thank you so much for that kind of introduction, and I just want to say thanks again to Dr. Siebler for allowing me to come and talk about our research. I'm really excited today to talk to you all about this project that we've been working on for the last several years, and really we've got a huge support from our leadership in the college to be able to spend a lot of face time with our medical students throughout their four years, and it's really been through the very direct work of Dr. Wayne Shelton, who is a McLean fellow in 1993 and 1994, who is very much with intention decided to study bioethics education in medical students. And particularly as the years progress in the third and fourth years, it can become a little bit more challenging to I guess, create an educational curriculum that is meaningful and impactful, and so he's really made a concerted effort to grow this program, and I have been fortunate enough to work with him on this project. So the course, as it is, is called Healthcare and Society. It is a four-year longitudinal medical school curriculum the first couple of years, and this is not meant for you to read in detail, but just to demonstrate the face time that we're able to get with the students. We have about 50 topics that we cover with them over the first two years of their education, which has now actually been consolidated down to 18 months, probably with most of your medical schools as well, if that hasn't happened already. But the idea is that we have large group discussions during this time. We have small groups. Their small groups are consistent through the first year, and then again through the second year with consistent faculty members leading their small groups of about 10 to 12 students, and so they really get to know one another really well during these first couple of years. The students consistently impress us. They are very vulnerable, they are very vocal, they are very clear-headed, and they get along so well in this type of situation where we can put them in a room to talk about these sensitive topics, and they really do develop an incredible toolbox of vocabulary and of just knowledge of these sort of ethical dimensions of care, as Peter pointed out, the ethical dimensions of surgical care, which is not necessarily which vessel do you ligate and which one do you leave alone, or how do you remove the thyroid and what steps, not particularly clinical things, but more of the human side, more of the personal and social side of medicine and of what they're likely to encounter in their next couple of years. So when we move forward to the third and fourth years, or what is the clinical years, the question is how to maintain that rigor and that kind of environment to foster discussion and lively communication about challenging ethical problems. If we're not there, hands on with them every step of the way. We lose control. We lose control of the curriculum. We lose control of what they learn and what they see. But one thing that we do know that has been shown time and again, and here in this 2011 academic medicine paper, is that empathy declines. So they did a systematic review that investigated the determinants of development of and changes in empathy during medical school and residency. So we'll look at them just the results of the 11 medical school surveys that they did and near the papers they evaluated. And they all used tools for self assessment of empathy. And what they found was that no studies documented an increase in self assessed at the of trainees. The nine of the 11 studies looking at medical student empathy found a significant decline in empathy as training progressed, specifically when entering the clinical setting. So why? What happens? This is the moment that so many of them wait for that they look forward to and that they say, I'm going to start getting to do what I've wanted to do for so long, what I've worked toward for so long. So what happens? Their distress was identified to be a factor that influenced a decline in empathy. And what was distress? How did they qualify distress? Burnout, low sense of well being, reduced quality of life and depression. And these are real things, right? And they start as early as the first clinical experiences that medical students have. So what happens? And how can we better understand it so that we can maybe remedy it going as far out as is the attendings and more senior faculty. The causes of distress in these, these manuscripts were thought to be mistreatment by superiors or mentors, that their values of idealism of their enthusiasm and their values of humanity declined. What they really valued about going into medicine sort of tapered away and was replaced by technology and objectivity. They lost their social support. Many felt that they had social support problems and who knows if it's because they were distant from family for a longer period of time or if it was because they're sort of experiencing this loss of enthusiasm, this loss of idealism and this high value for humanity and just don't have an outlet to talk about it with anyone. They also identified the formal informal curriculum, which they, they, they said was fragmented physician-patient relationships that they witnessed, whether it's, it's turnover of attendings of residents, handoffs, miscommunications, lack of communication. They said it in unsuitable learning environment and inadequate role models. So when we were thinking about how to develop this third and fourth year and when Dr. Shelton was going through and trying to with very clearly, as I said before with intention, think about the best way to understand what happens, thought, well, let's learn about the hidden curriculum. So the hidden curriculum is a set of lessons which are learned, but are not openly intended to be taught in schools. So it's the norms, the values and the beliefs conveyed in the classroom and social environment. So it's not necessarily the medical, the clinical parts of the job. It's not the dosing of, of Tylenol. It's not the, the drip of morphine. It's not the, you know, particular indication for surgery. It's more of the, the, the value-laden sort of take-homes that they, they earn or that they learn. It often refers to knowledge gained usually with a negative connotation, but not always. And in the case of medical students, as we just saw, it's suggested to contribute to the decrease in empathy beginning at the time of training when patient contact starts. So how do we learn to fix it? How do we learn about it so we can fix it if it's hidden? So the idea came to us that we should ask. We should ask the students and we should ask in a safe space. So to allow them to dictate what we talked about, telling us what they learned that maybe we didn't intend for them to learn in the hospital. So it was set up in this way that during the clinical years of medical, medical school, every couple of weeks in this begin, began with internal medicine. And it's been going on for several years in internal medicine. And then we've added surgery, obstetrics and gynecology, pediatrics and psychiatry. And every couple of weeks when the students are on these rotations, they will meet with a bioethics faculty member and or one of the clinicians and one of the clinicians or just the bioethics faculty members. So there's not always a clinician in there. And that's, that's intentional sometimes. And before they come together to talk, each of them is asked to submit a vignette, basically an ethical or value laden encounter or situation they found themselves in that, that has been meaningful to them for some reason, either it's distressing, it's called made them sad or it's, it's confused them, but it's something that is that is one of these, as Dr. Angelou says, you know, one of the ethical dimensions of the care that we give or inpatient, inpatient treatment that we can't necessarily teach in a didactic lecture. So what did they receive that we didn't intend to give them that they wanted to talk about? So they submit a vignette. And accompanying that is a survey that talks about various components of the vignette. And I'll get to that in just a moment. So at the very beginning of this, we submitted an IRB and so that we could collect and catalog all of these things. So the goals of our study are to catalog and understand the untaught events and encounters that influence the ethical, social and professionalism aspects of medical education. It's to encourage a critical and intentional evaluation of the learning environment in an effort to explicitly recognize these value-laden situations that mold students' professional identity development. And ultimately, the goal would be to incorporate the awareness of these findings into trainee and faculty development efforts to increase communication to maintain empathy, ideally, to improve patient care and provider well-being. So for this study of the bigger study, is we just looked at one academic year of these of these vignettes and their accompanying surveys, and basically took every MS3, all of their surveys and vignettes and then broke them up into what we called surgical clerkships, which was surgery and OB and GYN, and non-surgical clerkships, which was internal medicine and pediatrics. We did leave psychiatry out because their data is so interesting, and it sort of compounded the picture in a way, and that's going to be a separate paper because it is, the students are so insightful. It's so remarkable, but that's to talk about another day. So they come and they discuss the cases in the small groups that they're very familiar with, and they're very familiar with the setting, having done it since they were first years, with one to two moderating bioethics faculty. And then what we did was we just analyzed the type of, the type of vignette that they submitted, the outcome, and the impact of the difficult cases, comparing the surgical groups with the non-surgical groups. So here are samples of some of our questions. What does the primary issue or concern in this case mostly pertain to? And they could choose one, and we defined those for them. What was your clinical, who was your clinical mentor at the time that this case occurred and the choices attending or resident? Did you share your concerns about this case with your clinical mentor or team? And if not, why not? Were you worried about how it would impact your evaluation? Were you worried that you would appear naive? Did you not feel there was enough time to discuss it? Did you feel uncomfortable about it? Was there another reason? How would you rate your clinical mentor as a professional role model in the management of the case that you posted? And if you encountered this kind of case or a similar one as a future physician, how closely would you emulate the way that it was managed by your clinical mentor or the other or physician involved? And finally, as a result of your involvement in the case posted, did you experience any moral distress? So we defined the types of concerns very clearly so that they could understand if they were saying it was ethics. It would be qualified as ethics if it were one of these inclusion criteria, professionalism, quality of care, or medical surgical. We also defined moral distress as something that occurs when someone knows the right thing to do, but certain constraints governing the situation one is working within make it nearly impossible to pursue the right course of action. Our hypothesis for this study was that the distribution of case types would differ between the surgical and non-surgical groups, and that as compared to the non-surgical groups, the surgical groups would be less comfortable reporting challenging cases to their mentors. And our results effectively found this. So the case categories differed when comparing the non-surgical clerkships to the surgical clerkships with more ethical cases being categorized in the surgical clerkships and it being split mostly between quality of care and ethics for the non-surgical clerkships. The mentors more likely to be in attending in the non-surgical clerkships. They were more likely to share their concerns with the mentor in the non-surgical clerkships and it's for a variety of reasons. How well the mentor handled the case was thought to be better in the non-surgical clerkships and they wish to emulate their mentors more frequently in this case. They experienced more moral distress in the surgical clerkships. So these are just a couple of excerpts from the vignettes that will sort of demonstrate the breadth of different of these sort of value-laden issues that they bring forth. And they're not all bad. Some of them are really good but it's just sort of these you know these less clinical, less profoundly medical questions that people encounter in more of the gray areas of medicine that they're learning. So this first one says regarding denying surgery to a two-pack per day super morbidly obese patient with a reducible ventral hernia. What is the line that we draw of when to operate versus when not to operate? If this patient had been admitted to the emergency department emergently they may have received an operation. This was extremely this was an extremely complex situation to work in and and it was it was fascinating to compare the provider risk and the patient risk and reward. Regarding a 35 year old motor vehicle accident with an irreversible with irreversible injuries our attending explained to us into the family that that care was futile but we decided to do a trach for the patient anyway to help the family better cope with their loss and prepare for their loved ones imminent death. This case made me heavily consider the idea of a peaceful death and how often family will want everything done even when it's not necessarily the best for the patient. I've been surprised by some of the language and comments made by attendings residents in scrub text while in the operating room. This one I'll summarize but it basically talks about how they're asked to put in orders when they're rounding so that the residents can spend more time with the patients and although that makes sense to the student it also makes them feel really uncomfortable. And and finally this one discusses that the residents and the physicians were extremely skilled and knowledgeable but the bedside manner oftentimes these patients very upset the many times the residents would leave in the middle of a conversation and medical students would be left to give answers that were oftentimes not sufficient for patient needs. So these these students as I say are very thoughtful and from the institution administered course evaluation we found that greater than 95% of students either agree or strongly agree that health care in society in their third year decrease their overall stress level and this matters right this matters this is a big deal because if this is the time when empathy begins to decline and we can somehow decrease the burden of stress and depression and you know we I can't say all those things we didn't study whether or not that happens but sort of overall well-being that's that's really meaningful and and hopefully it means that you know we can we can do better and do more. We also find that the faculty participants are enthusiastic about the course that they can sort of review the clinical care through the lens of a student and that enhances their compassion. So points of discussion that that we get into are why are students in the surgical rotations more likely to have moral distress less likely to talk to their mentors? Is it the demands or the pace of the service? Is it the setting of the rotation that there isn't really a forum for thoughtful discussion? Is it the hierarchy of the discipline that the contact time with the attendings is potentially less and there are stereotypes that surgeons aren't approachable or aren't aren't just kind as other physicians and can we prime surgeons and other physicians to be more receptive to these types of concerns? So in conclusion as students evolve and develop their professional identity and moral agency we are finding that we have the opportunity to uncover these value-laden influences that mold them. Having meaningful discussions and open communication at all levels beginning in medical school may allow for maintenance of empathy and compassionate care and so from what we've learned so far is that just acknowledging that the job comes with difficult decisions encounters and outcomes may be therapeutic and it may help to shape the professional identity of trainees and then understanding the untaught for these disciplines can enhance communication and support for each other our trainees and our patients and we have much more to come as we're doing the qualitative analysis of these vignettes and our surveys are improving. I just want to say thank you again for this opportunity and I would look forward to any feedback and your questions. Thank you Megan that was wonderful and I think really gives us a lot to think about you know how we are being perceived by the students who rotate with us. So again I encourage you to put in your questions there are a lot there and go ahead and vote those that you think are most important to address. It's my pleasure to introduce the next speaker Gina Piscitello. MD is an assistant professor of palliative medicine, hospital medicine and an ethics consultant at Rush University Medical Center. Her research interests involve patient family and clinician communication, ethics education for medical trainees and allocation of scarce medical resources. Gina completed her clinical ethics fellowship at the McLean Center and she'll be speaking today about the topic of the ethics of extracorporeal membrane oxygenation in practice. So welcome Gina. All right thank you so much Dr. Angelos and I want to start off by saying thank you to Dr. Siegler for allowing me to speak today. The topic I'm talking about I worked on with a bunch of different people many of them who are past McLean ethics fellows so I just want to say thank you to them right out the bat that includes Renee Vermeer, John Stokes, Whitney Gannon, Anthony Cannellides, Megan Kanaka, Claire Chappelle, Pat Lyons, Laura Frye, Mark Siegler of course and then Will Parker who helps me with most of my ethics projects. So thank you to you all. So today I'm talking about the ethics of extracorporeal membrane oxygenation in practice and so we did a study on the group that I just mentioned and I surveyed seven different hospitals about how do they actually use ECMO in practice. It was a cross-sectional study that was done in January 2021. As you mentioned too I have no financial disclosures. So ECMO this is a picture from Rush Hospital. There's a video online kind of explaining to the community what ECMO is and so this is a very common occurrence in the hospital. This patient he is on ECMO walking around the hospital doing laps. Many of the patients especially if they are able to be mobile this is very important for them to be mobile to help get them off ECMO when they are ready the best way possible. So there's different forms of ECMO. If your heart or your lung has failed that would be the reason for ECMO support. It is an advanced form of life support that can only be done in the hospital setting. So it is unique in that other forms of life support like mechanical ventilation. Those could be done potentially at a long-term acute care hospital if you have a tracheostomy place and you could be discharged or like dialysis care that could be done outside of the hospital. But ECMO currently can only be done in an acute care hospital and with that there's an intense amount of support that's needed for those patients. So those patients often have a one-to-one nurse so a nurse specifically just for them and then an ECMO tech assigned just for them. So you have increased staffing needs. You can see from this picture there's a lot going on with the machine behind them. These patients sometimes they're just on it for like a few hours or days. Sometimes they're on it nine months. And so the hospital costs that are associated with this can add up to over a million dollars if they're on it for that long of a time period too. There's data that shows that the predicted cost per quality of life year for ECMO is about $30,000. And ECMO for some people it's a true miracle. For adult patients there are some people with ECMO they are alive and they are able to survive for a long time period after that because of it. But about 50 percent of patients who are placed on ECMO adult patients do die before discharge. So there's quite a high mortality rate. So I want to start us off with a case here. So this is a hypothetical case but a very similar case of what's actually occurred at multiple hospitals across the country during COVID. So a 30-year-old female with history of a BMI greater than 35 is admitted to the intensive care unit with acute respiratory distress syndrome secondary to COVID pneumonia. They place her on she requires intubation. She's on 100% oxygen nitric oxide but her oxygen levels are still low. So that would be a reason that they would put her on ECMO and they put her on Vinovenous ECMO because only her lungs were failing not her heart. So that was the reason for that. Now fast forward nine months later she's still on ECMO. Awake and alert. She is happy with her quality of life. A little bit of anxiety because she isn't allowed to leave the hospital. With district visitor restrictions her husbands had had trouble coming in to visit her because of those restrictions. The hospital did the best that they could to get her husband in but he also needs to work. And so that's been difficult and then her young children it's been very hard for her to be away from her young children. So she's had a lot of anxiety with that but she goes around the unit with for walks she the nurses love her the team just loves her. But there's thought that her lungs will never improve enough where she can be successfully liberated from ECMO and actually survive it. So this talk we're going to talk about kind of these topics about patients who are on ECMO for a long time but I want to put one more part into the story. And that is that she is a total candidate for a for a lung transplant but she is not considered because she is an undocumented immigrant and has no health insurance in the United States. So this case happened at multiple hospitals across the country where the patient had a true medical indication for lung transplant and were declined at multiple centers solely because of their financial inability to pay. There is data on this that patients who donate organs about 12% of those patients that donate organs from a 2003 study are people without insurance. So people are allowed to donate but then only 0.8% of people who receive organ transplants are without insurance. So they're donating a lot but they're not being able to receive them and that's what this data or what these cases showed us as well. I think the unique case about ECMO is that when patients are on ECMO for this long of a time period their hospital costs are excessive. Would it not be cheaper to pay for a lung transplant and lifelong immunosuppression and get them off ECMO than to continue up them on ECMO long term? And so those are very important ethical issues you know just the cost that's one thing but then there's also that we have our the 1984 National Organ Transplant Act and the organ procurement and transplantation network will say organ transplants must be equitable and they're not equitable and we saw that during the COVID-19 pandemic into this current day. So the topics that we looked at with this survey of the multiple hospitals were looking at exclusion criteria for ECMO, informed consent, and then withdrawal of ECMO. This is just kind of a baseline of who did we survey and so each hospital that we surveyed the seven hospitals every department that placed patients on ECMO they were eligible to be included and we asked one person from each of the hospitals to speak on behalf of their department for how they view ethical concerns with ECMO patients. You can see here most of the respondents that we had were attending physicians. The department that they came from varied quite a bit so we had anesthesia, cardiac surgery, emergency medicine, pulmonary critical care, cardiology. Most of the physicians or the one who was practitioner that responded they were involved in both vino venous and vino arterial ECMO placement and then most of the people that responded were male and so starting off with exclusion criteria. So with exclusion criteria I'm very interested in this topic especially because I think with ventilator allocation we talked about that a lot you know last year and then also this year again you know where ventilator is actually short in the United States like we really didn't hear that information ECMO was truly scarce in the United States. ECMO exclusion criteria were absolutely used in practice and I think it was just the emphasis on ECMO was not as prominent as like the ventilator which was kind of a very like trendy topic. With exclusion criteria so I'm going to show you what they were from the respondents. It's kind of a busy slide and the point is is that it's a busy slide so these exclusion criteria varied quite a bit based on department and based on the hospital. So you can see here 13 of the 14 hospitals had exclusion criteria and what the what they based it on so looking at age so that varied quite a bit. Some hospitals you were over than 60 you just don't get it. Some hospitals if you were 74 you could still get it so age there was quite a difference body mass index and then you can look at the medical comorbidities to that varied quite a bit different. The important thing to notice that this information is not public and so can a patient have you know access you know if a patient had access to this information and they were like 70 you know they could say oh well this hospital might consider me like I'm going in for a lung transplant I might end up on ECMO long term for that period I'd rather go to a hospital where they would consider me for ECMO. You know we saw during the COVID pandemic there was an article on CNN some of you might have saw there was a man in Florida that was had COVID pneumonia was on life support and his wife was looking all around to see would anyone just give him an ECMO circuit that's all he needed and I remember thinking like you know how wonderful this wife is advocating for the patient but like you know there's no chance like this patient's going to get an ECMO circuit there was nothing in Florida available it was during the time where Florida hospitals were overwhelmed and then I remember seeing an article like about a month and a half later an update of that patient there was a physician I believe he was in Connecticut who reached out to the family they transported the patient up to Connecticut placed the patient on ECMO he survived and so there are patients that if they had this information like they would absolutely advocate and like try to get to these centers where they would be eligible for ECMO and so do these you know exclusion criteria should they be transparent so people are allowed to do that you know honestly like personally I think that they should be there is so important you know it is important to note are these absolute exclusion criteria so I know that certain centers these are what are written down but they still do place patients on ECMO even if they are on this exclusion list so we can't say for sure in practice that these are absolute exclusion criteria but these are what was given to us in the survey the next slide is looking at what were the exclusion criteria for patients with COVID-19 so the extra corporeal life support organization they actually came up with guidelines for how you should consider excluding patients if they have COVID-19 pneumonia and so they had guidelines but you can see here there's a lot of variety in what hospitals did so these hospitals even with the guidelines did not you know align themselves totally with that guideline from this institution from that support organization I want to mention that also support organization they had it as an absolute exclusion criteria advanced age but they did not define what advanced age is I mean is advanced age 35 there's just there's a lot of concern that like potentially those absolute exclusion criteria could totally withhold ECMO support from certain patients who very well might benefit from it so on this list you can see that age for patients with COVID pneumonia some of the centers significantly decreased the age to be considered for ECMO and then you can see again body mass index the time on the vent they required lower time on the vent for patients with COVID-19 pneumonia and then about half of the centers that we surveyed actually changed their criteria just for the COVID patients so how were decisions made to place patients on ECMO at most of the centers you can see here 10 of the 14 departments responded that it is a group decision we all talk about it and then place a patient in ECMO but you can see that some of the hospitals it's an individual decision that that physician they want they think the patient needs criteria for it they're going to place them on it now talking about informed consent there's a lot of literature about informed consent for ECMO patients is it even possible it's such a complex form of life support is often done in emergent situations so we ask questions about that in this survey as well the most common person that was included in the informed consent process was the attending physician or fellow physician and you can see those are like the darker blue and the orange on the on the graph here the interesting thing is I just wanted to see you know some of these patients are on life support for quite a long time on the ECMO and you know do we ever include people like social work or palliative care just people who might be able to help holistically evaluate a patient's preferences and value for care up front in the informed consent process and you can see palliative care social work that was in the light blue and green categories they were rarely included up front in that informed consent process when informed consent was done my slide can you advance it thank you great um so for patients who we thought the life expectancy was 24 hours or longer the average length of time spent obtaining informed consent was about 25 minutes but when they expected life expectancy of the patient was less than an hour the average time spent concerning the patient was about seven minutes or so so in an emergency situation is there is it possible to consent consent to patient totally you know fully for ECMO I think it'd be a very difficult thing plus for many of these patients are they even awake and alert to consent are you consenting their alternate decision maker instead how long does informed consent last that varies quite a bit based on the clinician that respond to the survey so some informed consent is done once that cannula is put in for the ECMO informed consent is done we must read consent for anything else other people don't believe that informed consent when you consent to ECMO that continues your entire hospital course um now one thing and I think this was something the discussion of a time limited trial I guess initially kind of before the survey I was thinking you know discussion of a time limited trial in that informed consent process that might really help down the road you know in these situations where we have people on life support nine months with that you know considering do we consider withdrawal of ECMO later on down the road so we ask clinicians would you do you think it is important to discuss a time limited trial upfront in this informed consent process and we ask them based on patient diagnosis should it be asked and so you can see here there's certain diagnoses that physicians really agree it should be discussed in the informed consent process so for patients like who have experienced a cardiac arrest or interstitial lung disease those are patients we really should include it up front now even if we included it up front though that informed consent for a time limited trial we say like you know we're going to put you on ECMO and do a full out for 30 days but if you're not improving we are going to remove ECMO even if the patient agreed to that upfront 30 days later if they say well I'm awake and alert my quality of life is great to me I want to spend more time with my family and friends I want to remain on it could we still withdraw it and say like oh well you consented you know 30 days ago to the withdrawal we're still going to withdraw it now I think you know we're finding in practice that would be very difficult to do and actually in like real situations where that has occurred what happened what ended up happening in the situations that I'm aware of is that the decision was actually made the patient says continue we will continue now this is asking it a patient is going to surgery just a generic surgery now is it okay to just place them on ECMO without getting their consent beforehand so if a patient's going to surgery and something unexpected happens do you need to say up in front of the surgical informed consent oh well if something unexpected happens we might place you on ECMO most the clinicians surveyed here say no we do not need to discuss ECMO beforehand if you consented the surgery you're consenting to ECMO even though you don't know even what ECMO is and so there's a certain population that potentially they might end up on ECMO and they don't even know what ECMO is and we had time to consent them and we chose not to this is looking at patient preferences and values for care so the graph on the left is asking do patients and surrogates always have informed consent for ECMO you can see in six of the six of the clinician department respondents said no they do not the graph in the middle are we giving patients and surrogates the option to withdraw ECMO for the department say that we do not offer patients and physicians the option to withdraw ECMO even if they ask for that and personal experience I have seen that that has been thought to be true in practice but then you know the clinician taking care of the patient you know I asked in that situation well did you ask your attending that and then the attending is like no of course you could withdraw ECMO so but that some people do believe that we cannot withdraw ECMO for ECMO patients we we do not offer that option to patients and then the graph on the right is asking for patients and ECMO are we always aware of the preferences and values of care of that patient and ECMO that we're caring for and in six of the centers they responded we do not always know the preferences and values of care of that patient we're caring for an ECMO and so that can lead that people right now could exist on ECMO and they are not okay with it because we do not we have not tried to assess their preferences for care for that patient and now withdrawal of ECMO we asked the question to respondents if a patient's awake and alert on ECMO they have significant lung failure that will never improve they're not a lung transplant candidate they are awake and alert their quality of life is good what should be done in that situation five of the ECMO centers said they said that they should withdraw ECMO six of the ECMO center said that continue ECMO but if they got worse do not escalate support so they had like a pneumonia you wouldn't escalate support one of the ECMO center said continue ECMO escalate support but do not change that circuit or oxygenator and then two of the centers said you know we'll escalate we'll continue ECMO and escalate support they had a pneumonia we're going to treat the pneumonia too the important thing here is how much variety there is between these centers a patient at one hospital might potentially be withdrawn from ECMO who is awake and alert they their quality of life is valuable to them they might be withdrawn because of their own that centers you know beliefs about that or another center might actually continue them on it forever and life expectancy so you know a center potentially a patient might have 30 days to live or another center might be nine months to live and this information is not public it's happening in practice but it's not public so patients wouldn't know how to advocate for it ethics consults with ECMO you can see here about half the centers they say there's been at least one ethics consult on a patient they've cared for an ECMO one of the centers every patient in ECMO gets an ethics ethics consult some of the other reasons for ethics consults would deal with like kind of considering withdrawal of ECMO support and then finally I wanted to mention so allocation during periods of true scarcity you know for me personally if a patient's awake and alert they want to remain on ECMO and ECMO is not scarce I also agree with them remaining on ECMO now is it equitable that we spend a million dollars on one patient like the patient in the transplant and the case that I discussed you know she is undocumented her husband's undocumented we spend a million dollars on her but then her husband can't even afford a basic inhaler as an outpatient that's not equitable care but I don't think we should take from one remove from one of these ECMO patients and then you know to give to another why can't we you know keep the ECMO patient but then also focus on improving the quality of medical care for her husband and other people but on periods of true scarcity I think that kind of changes that we really need to look holistically and have like big centers looking at where ECMO circuits available to try to not ration it in the first place but if they are short you know if we have people on ECMO for a long time period we end up with a first come first serve method where people who got on it first they're allowed to stay but then another patient who might benefit from it doesn't have that same equitable access and then last same and really quick there is talk about a new consideration of a new definition of death for patients on ECMO so we talked yesterday about you know consideration of brain death or higher function death there is now talk that patients who are awakened alert on ECMO are they dead if they can truly not be liberated from it you know the machine is doing all the work are they could that be considered death and if so like that would you know potentially lead to more organ transplantation availability to do organ transplants in those patients so I think that's kind of a controversial topic but it's a very interesting topic and I think there's a lot more to come on that so thank you Gina thank you very much a huge wealth of ethical issues that you've raised and a number of people are asking some good questions related to that so the next speaker is Dr. Alex Langerman who is a head and neck surgeon and researcher at Vanderbilt University Medical Center in Nashville Tennessee. Alex spent his career setting the operating room and the surgical profession through the lenses of ethics and innovation. Most of his training was at the University of Chicago where he also served on the faculty in both otolaryngology and after completing his ethics fellowship at the McLean Center he was also faculty at the McLean Center before he sadly moved off to Vanderbilt. Now at Vanderbilt Dr. Langerman directs the surgical ethics program at the Center for Biomedical Ethics in Society where he focuses on surgical ethics education and on studying the surgeon-patient relationship. Today Alex will be speaking on talking with patients about surgical trainees. Welcome Alex. Peter thank you so much and I miss you too and you know Mark thank you for including me again this wonderful wonderful conference it really the best. One of the most exciting things I think about this year is how surgeons are kind of peppered throughout the agenda in all the different sections and I'm just pleased to see the legacy of Mark and you Peter in engineering surgical ethics as a viable subspecialty within ethics but also seeing how surgeons have an important voice in all aspects of bioethics so thank you and to all my friends I miss you and I wish we were in person perhaps next year so I have no disclosures so surgeon-patient communication is a brief sort of my own outline here what are things that we might talk to patients about the details of their disease options for treatment we conduct informed consent we ideally show empathy and compassion and we also handle as surgeons difficult topics now what does that mean traditionally difficult topics they're things like errors bad news and even more so lately we talk about triage or rationing but that's something that sort of classically was in the purview of surgeons when you think about trauma there's also these controversial difficult topics so these are topics where there's a lot of uncommon knowledge so you know in contrast to maybe these traditional topics such as errors I mean if you ask any patient do errors happen in surgery any personal lay public they would know that but there are other things about surgery that curve hidden behind the curtain these are things that the public not not typically be aware of there are topics that are ethically ambivalent so you know uh some people may argue yes we should be talking to patients about x and other people say you know I don't think that's a good idea and I'll get into some reasons why people might not want to talk to patients about these controversial topics and you know to wit these are topics that are not not routinely disclosed some surgeons believe that they should not be talked about or they fall to the wayside in the face of other topics that may be getting more attention so what are some examples here so surgical trainees which I I'll enjoy talking a little bit about today overlapping surgery innovation in new surgery and how do we talk about the fact that this is something I might not have done before or our own experience you know a junior surgeon or a new technique and saying to a patient I you know this might be the first time I'm doing this financial considerations uh you know peer who bell talked about a little bit about this surgeons physicians in general are good at it and um you know that's a tough topic but also the role that it might play in decision making is very controversial a video recording and recording in general in the operating room a topic I care a lot about certainly something that's being introduced and has a lot of controversy surrounding it and then artificial intelligence and its role in surgical decision making and how to discuss this with patients these are all important topics so what do you people say when they argue they shouldn't do it well more harm than good right that's an argument for beneficence over autonomy that you might scare a patient or make them upset rather than you know really being worth it and saying their autonomy isn't as important as making sure that they're they're protected from this bad information they say that patients won't participate so you know you have this idea of um participation in a learning a health system artificial intelligence participation in overlapping surgery in the in the sense of ensuring that a surgeon can care for as many patients as possible in a day or uh you know surgical trainees training the future generation of surgeons people may look at that and say well if I talk too much about this patients are going to say I don't want trainees or they're going to say no you can't I won't let you do an overlapping case with me or I don't want to participate in this in you know in AI data collection so from a communitarian perspective or maybe even a justice perspective you might say that's more important than the autonomy of the patient that's another argument that some people make and then of course there's the last one right no good way to say it these are tough conversations these are hard for people to talk about and so there's like the spilkis right aspect I just it's uncomfortable to me to to talk about this topic and and so those are things that people say now there's another argument right what's the priority of the information that may might be going through these are difficult topics these are topics that might take a while to talk about and there's not usually a ton of time to interact with patients and so you got to focus on your diagnosis your intervention the risk benefits alternative and uh as Dr. Ogikian said earlier and I really love this talk trust building right really really important for the the surgeon-patient relationship so what do you do when you're researching these topics if I may propose that you would determine the priority of a given topic uh relative to the other things you have to talk about with the patient identify what patients think about this and the pitfalls things that they might be really upset about identify the key talking points if you're gonna actually talk about this and develop ultimately some guidelines for handling these discussions so um I'll start with sort of looking at the potential priority of these topics research I did a while ago other people have done similar research but this is patients want knowledge and control over what who does what in the operating room patients are particularly interested if a resident's going to be doing something on them what they're going to be doing and how much autonomy they have and and all of those details and so that becomes an important topic and I'd argue that patients do want to know they think it's important to hear about um we did a study where which I talked about a couple years ago this conference where we showed patients an actual video of two surgeons operating um you know so there's the the two hands in there and I took a screenshot of the video and lo and behold I think the one shot that doesn't show the two hands in there I'm sorry but imagine there are two hands in there operating and the point was we showed this actual video and we asked patients to think about it and then tell us what what how they would describe teamwork you know a resident and then attending operating together how they would describe it to a patient a fellow patient in a reassuring but truthful manner and what we found was um that they identified these sub themes that they you know the thing they think that the surgeon should tell the patient that there is going to be a resident that's important right that it actually is going to happen um talk about the activities the resident's going to do talk about the experience of the resident talk about supervising supervising the resident that the teamwork aspect of it and some kind of reassuring statement um based on this uh uh these themes we came up with this kind of spiel this sort of um statement that a surgeon might say to a patient you know this teaching hospital there's a resident explaining the resident's a doctor explained they'll be assisting and learning and that they'll be doing some of it and I'll be there to make sure of it you know and I'm in charge now one thing that the caveat of course of the statement is this implies the surgeon is going to be there the whole time which is not always the case and you know so there's some nuances uh there that could be addressed in other forms of research but for for the purposes of what we're going to talk about now we'll just kind of assume this is just resident and attending participation together which in fact alone is a controversial topic for patients um so we have this statement and we actually this is work in progress that's the caveat right which is great about this conference you can present work in progress I can change my slides up to three minutes before I talk and and that's okay and that's I love that about this conference so um what we did in this in this uh slide is um this is this is a m-turk so mechanical turks so these are people who just get paid 50 cents to respond to a survey and we we showed them that spiel and we asked them how they felt about residents participating in surgery both before and after the spiel and admittedly a little unexpectedly I think we shifted people to be a little bit less comfortable with residents just a little bit not probably statistically significant this work in progress we we got about 1500 uh surveys probably that we're going to send out so um you know we're not even near where we're going to finish as far as doing statistics on this but the point is just visually you can see that the um the the orange bar um you know gets a little lower in the very comfortable and somewhat comfortable a little higher in uncomfortable range um after that quote which is interesting you know you think about well if we're going to be truthful maybe we're going to make people uncomfortable it's probably more to that and uh look for the paper you know hopefully next year um so then you know so key talking points so there's a little more to this research here so then and here sorry for the busy slide and I'll just a little shout out to peter and rumsfeld for the unknowns unknowns which I love peter's use of that in this so what we did is we dug through uh interviews with patients from some of the other papers that I had done we dug through interviews with surgeons for some of the papers I've done and my student william quatch did all this work and identified every single thing that a patient or a surgeon said would be something you might want to tell a patient about a resin and we collected all those things because the idea was okay we we heard patients say in the previous you know a couple slides what they thought would be a reassuring and truthful thing to tell to another patient but patients don't really know all the things they might get to know and so there's the unknown unknowns and so we said okay well let's let's also present these same patients who did that previous survey you saw with um all of the potential things they could know about a patient you know things about about a resume excuse me so things about the resident themselves you know how much they're doing you know um if they're necessary even for the surgery things about the attending you know and and whether they thought the resident was good things about the hospital um you know and that importance perhaps in the hospital's reputation and then also some distractor questions some things we probably wouldn't ever consider talking about you know if you met the resident you might know this but the resident's gender religion their age things like that that we really consider perhaps distractor questions but are kind of interesting too because you know it gives us a little bit of discomfort when we think about someone making decision based on those things okay so on our first 400 again this is kind of work in progress but um we got you know so we asked not only the the respondents to to identify uh sort of on a on a on a liquid scale how important these things were but then we had them weigh them as like you know their their top five in order of like the most important things and we did some calculations to kind of come up with this list and if you do a little cut off you can see that some of the most important things that really stand out you know here are you know perhaps obvious things right who will be performing the majority of the operation who's actually going to be doing this uh you know um what the attending's opinion of the resident is which is kind of a proxy for you know how good is this person going to be how many times the resident's assisted with the specific surgery how long the resident's been you know performing surgery again proxies right for the big question the big question how will the resident's involvement affect the success and likelihood of complications now interestingly people really their their top weighted thing was you know uh how often how many times is resident done before getting at experience in some way i think is a proxy of of equality but there's more to be done here but the point is we're starting to look at okay let's figure out what the what the bucket is of all the things you could possibly talk about let's kind of narrow down what the what the most important things are so again uh a work in progress and it's an artificial scenario right so we're interviewing we're doing the survey online imagine you need surgery right that's not the same as as uh as actually sitting there contemplating surgery right and you might think that that might make people uh more willing to have a resident than if they're really facing it on the other hand you know in these surveys there's no trusting relationship with the surgeon and I think patients may say oh well if this surgeon's saying this is kind of how they do it or you know reassure in some way it's going to be okay that might be enough as well you know and so that is all worthy for the research but it's also interesting that gives a sense of preconceived notions of the lay public what do they consider important information and ours is you know it's not necessarily what what the surgeons told us was going to be the important information um but but tations actually saying what would they like to hear if we were going to tell them a little bit about this and maybe this gets us ultimately uh as this work progresses into an efficient way to talk about it that addresses most of the concerns is reassuring hopefully in some way and also we can prepare surgeons to handle the typical questions they may get so that we could insert this into a um surgeon patient discussion without overly burdening that discussion um so next step right develop guidelines and um try to find something again that's truthful and reassuring um that's always been my mantra but gosh starting to look at the initial survey results I wonder how the more truthful we get maybe we're going to be a little less reassuring and so that gets back to the original question of autonomy you know versus beneficence and and how is the right way to insert this in there and so I think that's that's what's interesting about this topic that's what's interesting I think in general about controversial topics and that's why we need to keep doing this work um and early with you know just my goal for the conference uh and I'm honestly impressed because we're running completely on time so uh goes to the team handling this and thank you for your attention thank you Alex that was great as always and thank you for ending early so we have even more even a little bit more time for discussion so there is still a little bit of time for people to put thanks there there's still a little bit of time for people to put in questions um the the next thing that we're gonna uh go on to is uh I'm just going to introduce very briefly uh for a few minutes uh my colleagues uh Dr. Peggy Kelly and Dr. Vassil Lankina who uh have worked with me on a book project that hopefully um some of you might be interested in uh Peggy is a pediatric otolaryngologist she's currently practicing at Providence St. Vincent Medical Center in Portland Oregon she completed her undergraduate degree at Stanford University with honors and her medical degree from the University of Pittsburgh in 2017 she was an American College of Surgeons McLean Center surgical ethics fellow and I'll just also introduce Vassil who is a cardiac surgeon and cardiac critical care specialist he was on the faculty of the University of Chicago for many years I'm also a graduate of the McLean Center for Clinical Medical Ethics Fellowship since retiring from the University of Chicago he's been instrumental in developing the ethics curriculum for the medical school at the University of Ukraine and I know that Vassil is on and I'm not sure if Peggy is but I'll turn it over to you both hi thanks Peter unfortunately I think Peggy's having technical difficulties from Oregon and so the presentation that she prepared I will sub in for her if I can have the first slide so as Peter said uh we we have been working for the last two years on this book um it's called Difficult Decisions in Surgical Ethics and it is a book that is in a series of books next slide please a series of books which is called Difficult Decisions in Surgery an evidence-based approach uh the series editor is Mark Ferguson of the University of Chicago and over I think over 10 years or more it started off with thoracic surgery and then multiple other specialties have uh produced similar volumes over the last 10 12 years for total 11 volumes this is the 11th volume in this series uh it is multi-authored uh is devoted to you know these books are devoted to specific surgical questions whether it's uh endocrine surgery or bariatric surgery or trauma and uh liver hepatobiliary etc uh next slide please and the these are two of the books that the the current editors have published one is an endocrine surgery and one is in cardiothoracic critical care surgery next slide the the birth of this idea came about at this conference two years ago the last conference where we all met together and during lunch we sat down the three of us and we talked about how great it would be to produce a book by uh by basically fellows and graduates of the McLean Center uh who are surgeons a surgical thematic uh book and so we we jotted down a number of uh subjects and uh headings that we want to explore and then we said let's uh let's listen to information let's talk to our graduates at that point uh in 2019 there were 84 graduates that were surgeons of the McLean Fellowship and so we sent out letters uh to all of them uh soliciting information first of all they interested in in contributing a chapter and what kind of topics are dear to their heart we got back a fair number of great ideas and about 25 people initially responded and we we ran with that we um we then next slide we then sat down and made a uh made our uh sections figured out uh which which authors are going to contribute to what and and this is what we came up with basically about 11 subsections in this book uh we were very fortunate to have Dr. Mark Siegler uh Dr. Bernie Lowe and also Dr. Robert State to contribute introductory chapters for instance Mark is talking about the importance of formal education in medical ethics in the 21st century uh Robert State is talking about what makes surgical ethics unique uh and then the editors themselves have put together a chapter called notable ethical surgeons in which we talked about each of us picked a few surgeons that we thought exemplified in our eyes what an ethical surgeon uh is and and and how that influenced our own practice so the various other uh chapters and sections that we have deals with for instance communication and Alex Langerman contributed a chapter called transparency in surgery we have one on informed consent is it truly informed levels of care and high risk surgery uh how to deliver bad news we call it a family postmortem and then what on surgical empathy uh further we uh we're all educators and so we have a section of surgical education teaching surgical ethics training residents disclosure to patients um communication during a week surgery uh can professionalism be taught during residency and similar to what we've talked about today informed consent of patients regarding training participation uh we've also taught medical error and medical discrepancy surgical disclosure of errors disclosing errors of others uh Dr Pogikian contributed that chapter uh expert witnesses testifying against uh uh against colleagues so uh we also have a chapter on cultural uh and religious diversity uh and I think one of the one of the very interesting chapters is what about the Moors of the Navajo Nation we had uh a surgeon who works with the Navajo Indians and also a native Navajo resident in ENT who put together a very detailed chapter on uh the history of the Navajo Nation their Moors how you speak to them uh how you deal with them and et cetera so that that I think is a very very interesting chapter including some videos on the Navajo Nation we do talk about the surgery on the incarcerated patient which Megan Applewhite has kindly contributed uh and then we talked about dilemmas in adult patients uh surgical buy-in for major surgical procedures ethics of caesarean section on maternal requests uh fertility sparing surgery instead of definitive cancer resections uh anal sparing surgery and then we also have a section on pediatrics and their family uh we have contributions by Catherine Hunter on balance and benefits of pediatric ECMO we talk about brain death in NICU we talk about the ethics of pediatric bariatric surgery uh critical care how do we deal with with families that their loved ones have severe brain injury uh and then burn patients that burn via recognition the ethics of their care and rationing ventilators when you run out another section on do not resuscitate palliative care end of life uh periodical DNR goals of care of palliative surgery and conflicts with surgical decision makers an interesting section is one on global surgery so we had a pro and con section uh that we should be doing medical missions uh pro and a con view and then also a commentary from one of our surgeons a graduate of the mcclain fellowship who herself uh is uh uh a medical missionary in in africa and late taking care of nika um who commentant on on the on the medical missions uh in in that part of the world now because uh as we started uh developing our um our strategy and our topics uh COVID hit and so we had to add a section on COVID and so we we have uh Boris Lushniak who's uh uh former deputy surgeon general talked about COVID-19 gave us an overview of the of the entire disease and how it taught the world and prepared and then we talked about uh the hot zones new york city uh italy and we have authors talking about uh how they cope with uh the COVID especially in those early uh months uh when there was ravaging those two areas uh finally and innovative research uh we talked about surgical ethics of surgical of surgical trials uh introducing new techniques again alex langerman contributed that a very nice chapter on uterine transplant by Angie wall and then talked about uh very uh innovative and uh experimental treatment for prostate cancer that's limited by the ability to pay so again an ethical dilemma next slide please so uh we uh we started off at the at the meeting um uh we sent out the letters we got uh a lot of interest from our fellow surgeons uh and in in april we got a formal uh contract from springer after we submitted our topics uh that we were going to prepare uh we sent out uh the official letters to the authors they contributed uh and of course uh you know we had certain deadlines uh and you know deadline is only good for a short while and it keeps getting extended at any rate we finally put it together and it was due to come out this week but due to some technical glitches at springer it'll be out in february so we look forward to to presenting this book to the community and i hope that we find interest amongst our members next slide we have uh over 730 pages uh 39 out of the 51 chapters are written by 37 McLean surgeons and fellows and 12 are written by invited experts in their field next slide we talked about some of the several chapters uh that um uh that are included in the book and finally and peter i want you to join in on this next slide uh so we often we editors are dedicating this book to mark and anna siegler your guidance of hundreds of clinical ethical fellows through their time at the McLean center for clinical medical ethics and your collective enthusiasm warmth and dedication to the study of clinical medical ethics have inspired this book and that's it thank you thank you very much faciel i think that that very last slide is perhaps the most important one of everything that you said uh and so uh uh we we do want to end the panel with those special thanks to mark and anna we do have now time for a little bit of question and answer and there have been a number of questions that have been raised by the by the participants and so i'm going to go ahead and try to ask a few questions of the panelists and um if you would like you know it's a little bit difficult in this environment for us to engage in a conversation without all talking at the same time so i'll try to ask people for comments um but if you would like to make a comment about something that someone else is saying please you know signal to me wave and then i'll be sure to call on you so that we can be sure that we have a little bit of conversation um so uh let's uh start with uh and and i hope i don't offend anyone we're going to use first names for the panel okay so it's late in the day it's a saturday we're going to use first names so uh so is so is not to offend anyone everyone gets their first name so uh julie um somebody asked a question of whether um separate consent was obtained for prostate exams under anesthesia by urology and that was answered by dr park moady who said no uh at least you know not routinely um here so i guess my question for you based on that interaction is in what ways do you see pelvic exams is different and perhaps um requiring a separate informed consent yeah thank you for that question um so i do think that that's public exams fit under the larger rubric of intimate exams and i was actually communicating with lori bruce um from yale about this and kind of the the larger topic of intimate exams um you know i will say that i think if we ask patients um and in fact when you ask patients um many do perceive the pelvic examination as being distinct from other exams now i i do also think that um there should be more explicit conversation around other intimate exams um but my focus is really you know i don't do any work around prostate um uh so clearly my work is really focused on the pelvic examination um but i guess my answer to that question is ask the patients and patients very much feel that this examination is distinct from other examinations that are out there um thank you very much um so so i've got a question uh for norm um and uh uh this was uh asked very nicely i'm going to paraphrase um how can a patient develop trust in a surgeon whose philosophy or world view um is significantly different from the surgeon um yeah thank you for that question i guess my my fundamental answer would be i i don't think that should matter um that the surgeon patient relationship the doctor patient relationship should not be limited or encumbered by a world view difference or frankly any other individual characteristics of of the surgeon or the patient um you know i'd be interested maybe kind of fleshing that out maybe a little bit more so i understand it uh or making sure that i am understanding it but i would i would say i don't think it should matter what the world view is thanks uh uh you know i'm uh since there's a lot of questions and uh there's a lot of panelists i i'm gonna go on then to um ask uh maybe a couple people ask about some nuts and bolts about the study that you uh have done of the third year students and their reflections on the ethical issues and so a couple of them were uh and i'll just ask them together and let you answer them all at once um first of all did students consent to participate could they opt out uh and uh do you share their reflections if you know positive or negative with the faculty and residents um we were exempt from the irb for the need to get a consent that's a really good question um we anonymize all the data um so we don't know who submitted it we don't know uh we know the rotation that they were on but we don't know anything else about the individual person we don't know anything about the services that they were on in particular within um that rotation um so it's all anonymized data um and so they don't need to consent for it um what was the second part of that question i'm so sorry oh could they opt out no no so it's i mean the the whole longitudinal curriculum is a mandatory class it's mandatory attendance in person when it's in person or remotely when it's remote so it's not like other courses where they can watch the recordings if if they want to or just read about in the book if they want to the the whole four years is a mandatory course and so uh they do need to submit vignettes and they do need to submit the surveys that accompany the vignettes uh for each one got it thank you um so uh jeena i've got a question for you um and uh and you know it is i guess i'll ask two of them together um uh someone asked will the ECMO patient without insurance be able to be on a transplant list in their country of origin and then uh in addition i guess i would ask the more general question is there any screening of eligibility for transplant prior to putting someone on ECMO or is or is are these completely separate and independent discussions do you think yeah i think like with the time like how urgent these patients especially with COVID pneumonia were placed on it i think there's not enough time to talk about that beforehand for many of the patients so that's an issue um i was just googling before this um so a multiple of the patients that i'm aware of across the country um they were of Mexican origin and just looking that up um there's one for this article i found there's one active transplant center in Mexico and they did shut down for a bit because of the COVID pandemic and so for her that um for the patients that i'm aware of that likely wouldn't have been an option to send them back home um so i think they're ideally there's a lot of things that we should ask up front about um an informed consent process but i think a lot of it we don't have time to or the patient can't consent themselves because they're not awake or alert thank you um definitely a challenging group of uh patients without question um so i'm gonna ask the the next question of um uh alex first and then i'll ask norm for you to to weigh in afterwards so uh alex to what extent do you believe that uh full explanation of trainee involvement might significantly cause a decrease in the trust that the patients place in their surgeons well you know i think i don't think that that that would be the case i do think that i um that it may make the patients more worried or more concerned about the training involvement i think there's a potential for that i think that is the challenge that that you face and i suppose there's an element of if a patient were to refuse trainee involvement which is a subtopic you know worth more conversation but something that we've studied uh how surgeons respond to that you know i mean if you're like well you know forget you like get out of here i mean that that wouldn't in general a lot of trust of course versus um you know a discussion about the reasons why trainings are important or or other you know you can't do the surgery without the training other things that hopefully would build some trust so i actually don't think that an explicit discussion would harm trust specifically and in fact i think it bolsters trust because the more open and transparent you are in communication the the there's no sense that you're hiding something now what really damages trust and we saw this with the overlapping surgery you know sort of um uh expose and the Boston Globe and why the patients were off were very upset the ones that they interviewed and was that that they didn't know that that was happening versus you know a situation where you might tell a patient ahead of time an uncomfortable truth about well you know this is kind of how we logistically make it happen and this is something i do practice what i preach i talk to my patients about trainees and when i'm overlapping i talk to them about that um and i don't think that that's anything that they're like yeah yeah you know that's what they really want but at the same time i think that they appreciate that i am being forthcoming with them and the the thing i'd really not want to do is to have that be a situation that they don't know about and then after the fact be like oh you know hey i i never really told you about this but this this you know this was kind of how your surgery was conducted i think that's the real undermining of trust thanks norm thoughts yeah great great question and i think um or i know alex is helping us all learn about this through his research i didn't mention we we published an additional thematic analysis study which was around the question of trust in trainees and three themes came out from that which were that trust in trainees was bounded by what the trainee would do trust in the attending surgeon and institutional trust so those were the three themes that came through when we query patients or in interviews where they discuss trust in trainees um i i i do believe in the obligation to to discuss the roles that trainees are going to have in surgery and i would advocate for you know informed by knowing that interpersonal relationship is an important part of developing trust in the attending surgeon and i would advocate for us making a point of discussing our our training programs when we're consenting patients for surgery on the morning of surgery right it's often a team that patient has not met before uh and that the attending should introduce if possible you know together with them or if not when the attending is talking to the patient uh ahead of time uh mentioned who's going to be there uh you know what what their uh what what role they play in the team and then you know as far as you know deciding what what nuts and bolts is for who will do what i think there probably is a level of too much information but i will say i will be teaching throughout the operation throughout the operation i am there either guiding the hands or working together with one of our trainees or i'm doing things with my own hands with them observing but i'll be teaching throughout the operation so the answer their question i i don't i don't think so and also i think we have an obligation to talk about it and so if it does under my trust we need to figure out how to do a better job thanks norm um julie i can't help but reflect on the parallels between this question of you know should we talk about the extent to which uh trainees are involved you know as alex pointed out somewhat of an uncomfortable position uh to have that discussion and yet um you know pelvic exams under anesthesia certainly something that i think in the past many people would have preferred to not discuss so can you you know reflect on what um you know what what your study has uh has taught us and you know how we might approach these things like discussing trainee involvement yeah i mean i think that my goal um i was so eager to do a chart review um to show the prevalence of accepting a public examination under anesthesia with trainees because just in my everyday conversations with patients um i felt confident that having an open discussion about this um patients for the most part would be accepting um and the idea of not having a discussion because you're afraid that a patient would say no i don't want the trainee involved in this part of care to me was so abhorrent because that meant that people would be then doing this procedure doing this the examination under anesthesia without having asked that question knowing that a certain percentage of people would not want that trainee involved um and so my my goal my primary goal if nothing else with the chart review was just to show people that the vast majority of our patients are fully accepting of having trainees involved and these conversations actually are not that hard um that's something that came out of the interviews with um residents fellows and attendings um they're really not that hard and when you explain to patients the importance of um uh incorporating trainees in this part of the procedure um again patients are very welcoming of this so um you know this is a very focused procedure um but i would say that um it can be a very you know i think daunting discussion at the outset but in reality um it seems to engender trust and um i think makes it a much more positive experience for patients and uh physicians and trainees in particular thank you um so i heard some uh interference sorry i thought someone wanted to make a comment megan let me ask you um given i was a little bit disturbed by the fact that if i understood your data correctly there's a higher level of moral distress by uh students on surgical rotation than on other rotations uh and so is there uh a plan to change the surgical curriculum in any way or counsel surgeons on uh you know how to minimize the moral distress i think you're muted i'm not it's okay sorry um i think i'm okay so um yeah i mean one of the things when i'm trying to figure out that's how the difference is between the medical rotations and the surgical rotations is um maybe FaceTime with attendings might make a big difference in order to be able to um sort of have the capability to ask these difficult questions or to to raise concerns or to say this was hard to work through can can we talk about it and i don't know if it's because we don't have dedicated sit downtime with the medical students um or if we seem unapproachable or always angry throwing things you know a reputation uh raging but um but but really truly i do think that it's just going to become um a more natural sort of um uh discussion to have once we recognize that it helps medical students work through these problems that it decreases um sort of their uh decreasing quality of life so so rather it improves their quality of life through medical school it it decreases the decline in empathy um if we can prove that that happens which i think we're hopefully in the early stages of looking into trying to to prove um maybe it's just enough that we talk about the problems that we talk about these sort of value laden um situations that students find themselves in which which beforehand were just sort of possibilities that were just lectures that were just small group discussions based on a case study right and now they're very very physically and personally involved with these patients um you know one other thing is that when when patients and when students are thrown into surgical rotations it's frequently a very fast-paced environment so you see the number one reason why they didn't report their their distress to their mentors the number one reason is that they didn't have time um and i think that this is really um this is really telling and it's probably also partly due to the fact that their residents were most frequently mentors who also don't have time um so i guess that's my best my best answer to that i think we need to and we need to take our time when we can to recognize that that talking about it is is helpful that matters thanks probably good advice for all of us in multiple circumstances uh jeana let me um let me just read to you one of the questions that was raised and ask you you know your thoughts on it as someone who has a lot more expertise in this uh area so the question was i struggle on our ECMO allocation team with how to justly balance an adequate trial given uncertainty versus the large number of patients dying daily on our wait list thoughts yes um and that is so important i think the first thing is if we have open circuit somewhere else we need to get those patients to that other place you know i heard in chicago a hospital was saying how well they're not referring to their patients anywhere because no one's accepting well i knew personally internally at rush they were accepting so we have no institution like we have no organizational structure to allocate open circuits to people who are in need so that's number one is just get the circuits like if someone's in need get them to the right place but then if we truly do need to allocate like what timeline i think it's going to depend on patient diagnosis all these that patients are put on ECMO for they're going to have a different likelihood of getting off you know there is some data like after 30 40 days the mortality rate starts to plateau so could that be considered that's one idea but then you hear these stories about like people being on it nine months that are finally liberated and now living on their own so i think it's going to be like kind of a very big discussion but like some triage committee is going to need to be involved in that um in in you know conjunction with the the primary doctors but the triage team will have to make that ultimate decision and the timeline i think it's going to have to depend on patient diagnosis and i don't know if we're ever going to be able to come up with the true number it's always going to be subjective very good thank you well i do want to thank you all very much for your uh outstanding uh participation your presentations very very thought-provoking it's time now for us to turn things back over to our fearless leader dr mark sigler good afternoon i just wanted to tell you how delighted and honored i am that so many of you have attended this conference of the mclean center as you know it's the 33rd annual conference um and um it's uh in a way the most exciting one of all um i i i very much loved uh dean polanski's introduction of dr bernard lowe and um and it was a spectacular uh review of of dr lowe's work and then dr lowe's superb talk for the mclean prize presentation this year very very wonderful and very moving in terms of the tradition and background of clinical medical ethics and also the future of ethics as we go forward uh medically uh and and ethically i also uh wanted to express my my great thanks to the seven moderators uh who were with us to yesterday and today we started with dr monica peak and then we went on to dr john lanterns who is remember assisted at the end with dr william parker and then dr amily landon was the moderator of the third panel uh susan toll of the fourth panel and today dr lanie ross moderated the first panel on pediatrics and family ethics and lexie torkey uh moderated these panel six on the field of clinical medical ethics and peter angelo's moderated the final panel number seven on the surgical ethics let me just extend the idea of the moderators who are also wonderful fabulous speakers uh today i just wanted to say that that they were among the 40 people who spoke eloquently and and profoundly um on aspects of medicine medical ethics clinical medical ethics and and the whole range of matters uh i was deeply moved by by the talks today and uh i did and yesterday and and i just wanted to emphasize my my delight at finding such wonderful talks being presented at this conference i just thought it was outstanding and i want to thank the speaker so much but i also while i'm at this i want to say my dear thanks to the mclean centers advisors and assistants kimberley connor who is the administrative director of the mclean center has been very important in developing this program has have been the research assistants um with elena stan kaitis uh in particular have also glenus harris um and ranana dine and then some of the students who have begun to work with us jenna wong juliana khalil um it's been great to have them with us um i let me just conclude by saying that um that i am indebted tremendously uh to barry mclean and the mclean family which started as as dean volanski said with darith eugene mclean barry's mother um back back in the early 1980s and um we've it's been a very moving experience to work with darithy mclean and barry mclean and uh and all of barry's family over the years and then i i do want to acknowledge rachel coder who's been the chair of the board of the mclean center for the last four or five years and want to thank rachel and her husband marco plamesian for their involvement in our progress and work so with that as my background i want to thank all of you for being here today and especially what we'll want to once again acknowledge bernard lowe as the winner of this year's mclean center prides thank you so much