 It is my distinct pleasure to welcome you this morning to a presentation facilitating discussion of ethics dilemmas coordinated by the American Society for Dental Ethics in the American College of Dentistry. This morning we're going to interact with you in a number of ways with a presentation by the speakers noted on the slide as well as engaging you in small group discussions in the middle part of the morning session and then bringing us all back together for a bit of discussion. I'd like to introduce the speakers this morning, Odette O'Garry, Larry Guerrero, and Catherine McGullis. And we hope that you'll find this presentation both helpful and insightful as you think about your day to day activities, whether you are in private practice working in one of the community clinics or teaching dental graduate or dental hygiene students. We have four objectives this morning to think about discerning the ethics dimension in various clinical scenarios, to talk a bit about and help you develop the ability to effectively analyze ethics dilemma cases, and also to understand and apply the principles of facilitation in small group settings. My one comment on that is that we know that often members of the college are invited to participate in ethics courses as part of dental and dental hygiene education, and we want to give you the skillset necessary to facilitate a group discussion. I also want to know that you may want to engage in a small group discussion with your staff in private practice and utilize some of the model that we talk about today as well as the skills that we talk about in facilitation. And then we also want, as part of this presentation on facilitation, to talk about and enhance your expertise in leading ethics dilemma discussions, because as oral health providers, we know that we are often faced with dilemmas in day to day activities as well as part of our clinical provision of care. So the morning schedule is presented to you. We have, are in the session now that deals with introduction. We then will segue into talking about an ethical decision making model that we hope you will find very helpful, followed by a presentation about facilitation skills. We then have scheduled a break that will allow us as just so you understand as presenters to join you in one of the 10 groups that we have divided all the participants into. There will be other members of the college who will be joining us, who will help facilitate those small group discussions, and they will introduce themselves when we are all in the small groups. We'll then, after that break, present a video that's going to be the source of our discussion this morning. It is one of the ethics dilemma videos that the ACD has available to you, and it will be the source of our discussion as well as our application of the ethics decision making model and our utilization of the facilitation skills. And then we'll return back to what we're calling the main room where you are right now and talk a little bit about what happened in those small group discussion and some of the group dynamics, and then follow that up with a conclusion. So we're looking forward to your engagement as part of the small group discussion as well as responding to questions that you might have as a result of our presentation this morning. So just to lay the foundation for a bit of what we'll be talking about later in the morning, we are going to really emphasize the skills necessary for facilitation. Facilitation is the act of making something easier, and often as oral health providers, we are asked to make decisions whether it's in treatment planning, whether it's part of something that we're doing when we're with a patient, perhaps it's part of your role as either an employer or as an employee. But facilitation is a set of skills that will help you guide discussions. Facilitation can be used in academic settings if you're asked to lead a small group, as I've noted earlier, in office settings and in staff training development as part of your role in a dental society meeting because all of us belong to different organizations and professional organizations as well as the American College as part of study clubs, perhaps you're an advisor or a mentor for the student ethics groups. And then other parts of your both professional and personal experiences. And so we will help you with understanding what facilitation is, but we will also provide you with some resources which starts with the next part of our presentation this morning, and that would be the ethics decision making model. We also want to remind you, and many of you, I have had information presented to you, again, as part of your professional education in dental school, or perhaps as part of one of your dental society meeting, a bit of discussion about ethics. It is based on and part of moral principles. It is part of what might guide us as oral health providers in both our character and our conduct. It is very simply, and I enjoy this particular definition of it, the study of what is right and good with respect to what we do. You know, often it's described as what we do when people aren't looking or watching us. It seeks to answer ethics, you know, the principles that will present to you today, what should we do and why we should do it. It emphasizes, you know, the spirit rather than the law because we know we're also guided by regulatory and legal obligations as well that influence us, whether we're part of a province or part of a state. And it also guides us in what we ought to do or ought not to do. So I hope one of these explanations resonates with you as you think about the professional ethics that guide your conduct and guide your activities in your day-to-day activities. The question that you may be asked as a member of the college or perhaps if you're in an educational setting or perhaps as part of your private practices, do ethical questions have answers? Often because of the nature of our work as a professional, we tend to think that there is one way of doing things or maybe a couple way of doing things. And I would suggest and we would suggest today that some choices in responding to an ethics dilemma are better and some are worse. And for those of you in private practice, we know that we're faced with an ethics dilemma or an ethical dilemma almost every day. And we have to sort through how we might respond to that or perhaps one of our employees asks us a question that presents to us an ethics dilemma or perhaps as part of your teaching, you know, students are faced with ethics dilemma and you yourself might reflect on your educational experience and remember something that happened to you while you were in dental school, for example. What we hope to help you think about this morning is how might you make the best choice? How might you make the choice that's based on those ethics principles that we talk about and some of the other guidelines that we're going to suggest to you today provided by the college, provided by the American Dental Association and for others that are part of other oral health care provider associations what those guidelines present to us. And so ethical questions do have answers, but it may not be the same answer based on the circumstances that you find yourselves in. So we find the ethical decision making model a wonderful guide for what you might think about or a framework that you might use in terms of trying to resolve a particular dilemma or guiding a discussion in a dental education setting to help students understand how they might value what they know and then make a decision in terms of what might be the best choice. And so although we could spend a fair amount of time on this, Katherine and I are going to review for you some of the important aspects of this particular model and how you might use it as a framework in your leading a facilitation or facilitating a discussion I should say and or in your day to day activities. So the model is presented here and then we will peel it apart a bit. I speak about it as if it's an onion kind of go through the different layers of it to help you use it and then we will use it as a framework or a template for our discussion in small groups this morning. Just in any kind of ethics decision making, you need to recognize the problem or the concern. You need to think about possible alternatives and notice the plural of that. And by that I mean there should be more than one alternative that's under consideration. It's not just one answer as I pointed out before when we have an ethical dilemma. We want to talk with you today about determining what is professionally at stake. We also want to share with you and remind you that you need to consider what is ethically at stake. And again, we'll describe what we think are some of the professional issues that you need to think about as well as the ethical principles that are applicable. And then we'll talk a bit about how you might determine what ought to be done. And then after you consider what ought to be done, after you think about the alternatives that you have identified and analyze those, what course of action should you take or what course of action would be best to resolve that particular dilemma. So first, the first step in the model is thinking about or defining what the problem or concern is. That may be described as an ethical dilemma, but it is asking you to really focus on what is the problem? What is the trouble that you are sensing? What is your gut telling you? So most likely it's a conflict among ethical principles or values that you feel that there is a tension there. And in situations, it may include more than one concern in a given situation. So there may be multiple concerns. And so it may be that your analysis of that particular situation may have a couple of layers to it. So the first step is to describe or define the problem or concern. The next is to collect relevant information. And so as you think about the dilemmas that you've identified or that have been brought to your attention or are part of a discussion in a class that you have or a small group discussion, you want to encourage the individual experiencing that dilemma to review all the relevant information. And we've outlined that for you, whether it's the patient's record, whether it's the office policy or protocol, whether it's the handbook or the clinic manual in a dental education setting. You may want to discuss with your colleagues or your peers. And you also always want to refer to evidence-based science, because this may not be a clinical dilemma. We're talking about other kinds of dilemmas. So it's not choosing a treatment plan option, but it is other factors that are causing the dilemma or a concern in a particular situation. We also want to think about what are the values of the parties involved. The parents are the guardian, the patient, the family, your colleagues, your staff. And so collecting relevant information is a very important aspect of the particular model. We then want you or those that are involved in discussing this particular concern to think about possible alternatives. And so this means more than one. This means that you're not going to say, well, I know how to solve this. This is the direction that we should take. This is the decision that should be made. So it is a plural with good reason, because we want you to discern a little bit to think about how might I solve? How might my staff solve this? What do the dental or residents need to think about when they're trying to solve the dilemma that we have chosen to discuss? Just like we're going to ask you this morning to think about alternatives in resolving the dilemma or the concern that's presented in the video. And as you think about those alternatives, you need to start thinking about what are both the potential risks and consequences to those alternatives or the advantages to certain alternatives. So what are the alternatives that could help an individual or you resolve a particular concern or a particular issue? I'm going to turn over to my colleague in a minute a discussion. Catherine will talk about central values, because one of the things that we want you to recognize is there are multiple factors that are professionally at stake. And these particular values that we'll present to you today are recognized as very important to the practice of dentistry. And they're also ranked to assist you as a provider or as a facilitator in a discussion to walk through those that are discussing this particular concern. What is most important and what is least important? But we also, and we base these on a model that's presented in dental ethics at Chairside, which is a textbook that's been written by our colleagues, David Ozar, David Sokol, and Don Patoff. And so that is one of the resources that we'll identify at the end of our presentation. And we may be very useful to you to give you more information about the model that we're talking about. So I'm going to turn this over to my colleague, Catherine, who can talk a bit with you about the central values. Catherine? Thank you, Pam. Determining what's professionally at stake may include several things, and we'll start with the central values. And some of them may apply to the case we'll be discussing shortly. It's said that every profession has certain values that are viewed as essential to the proper and appropriate practice of the profession. And we strive to bring these into practice because we value them, but mainly because they are the values to achieve for those that we serve, our patients. So yes, it's an important aspect of the central values that they are ranked in the hierarchy of the highest most important value to be considered. So these are the six values. If you look through them, you may have seen them before. Think for a few seconds which of the values would be highest, which would be ranked of highest importance above all others. The values are aesthetic values, patients' oral health, patients' life and general health, dentist's preferred pattern of practice, patient autonomy, efficiency and use of resources or cost containment. So the highest value is patients' life and general health. It ranks highest in the hierarchy because every treatment must be evaluated on the basis of this. Every treatment that places a patient's life or general health at risk is certainly unethical and unprofessional. And what value would be next? Patients' oral health. Oral health is next in priority. Oral health is defined as appropriate and pain-free oral functioning. While this is a complex topic, it is an obvious value that dental professionals understand and aim to achieve. The value recognizes expertise and experience in maintaining the patient's oral health as well as creating pain-free functioning. But the focus on oral health isn't placed ahead of the patient's life and their general health. So which value would be next? Patient autonomy. The patient's autonomy is the next in the value, the next value in the hierarchy is the patient's right to self-determination, their ability to make their own healthcare decisions that reflect their values and their goals. Whatever the values are to achieve for our patients. As long as the patient's life and general health and their oral health aren't jeopardized, the patient's autonomy, their choice is respected next. The choice may be based on their own values, even if we don't think that it is the best choice or the option that we may choose to do. But a dentist should refuse a patient's choice if it harms their oral health or their general health. And the next in the hierarchy is the dentist's preferred patterns of practice. This value pertains to the dentist's preferences in practice. A dentist practices with a range of what's considered technically competent. It depends on training, knowledge, habits, judgment, and the choices you all make in offices. Operatory setups, instruments, materials to use, techniques, considering time, effort, the degree of comfort and trust in procedures, basically the philosophy of practice, which is in that range of being technically, a broad range of being technically competent. But the fact that the dentist has a habit of practicing in a certain way does not weigh the patient's autonomy and choice, and also the priorities given to general and oral health. The last two are aesthetics. Aesthetics considerations are lower. Aesthetics results shouldn't place the patient's oral health or risk damaging healthy teeth. The patient's ideas of an aesthetic result may differ greatly from the dentist's view. An appropriate contour and shape of restoration tooth is important because it does contribute to oral health. So aesthetic results are placed lower in the hierarchy, lower oral and general health, and the dentist's preferred pattern of practice. And the last value, of course, is efficiency and use of resources. There are not an endless supply of resources available. Resources include materials, staff, not expertise, and also time available to practice. So generally, it's beneficial to practice in ways that preserve the limited resources and allocate them effectively. This also influences our productivity very favorably if we are efficient with the use of resources. But the decision to contain costs shouldn't place the patient's health, patient autonomy, or even achieving aesthetic results ahead. So these are the dentistry's central practice values, ranked in the hierarchy. And they are also included in the facilitator's resource sheet for the course. So next, when considering professional and ethically issues at stake, may also include American Dental Association Principles of Ethics and Code of Professional Conduct, known as the ADA Code. The link to the code is in, document is in also handouts. And the code calls upon dentists to follow high standards of ethics, which place the benefit of our patients as the primary goal. The first code was created in 1866 over 150 years ago. It's an instrument to help a dentist do what is right and good. Adherence to the code is volunteering for ADA memberships, but some states incorporated into the jurisprudence exam and requirements may require compliance with it. Well, it doesn't address every situation. It is an evolving document and was most recently updated during the fall, last fall. The code consists of three parts. The first part are the principles, the principles of ethics. They are five aspirational goals of the profession. They are described as the firm guideposts that provide guidance and offer justification for the code and the advisory opinion. They do differ from the central values because they are not arranged in a hierarchy. Judgment is needed if the principles are in conflict to assess if one principle may take priority in any given dilemma or in decision making. And the principles also may overlap and compete with each other and create these dynamics. The next part are the code is the code of professional conduct. And it describes conduct that is either required or prohibited. And violations of this code may result in disciplinary actions. The third section are the advisory opinions. They're interpretations to some specific situations in the code. So we'll go through the principles. The first principle is patient autonomy, self-governance. A dentist has the duty to respect the patient's rights to both self-determination and to confidentiality. This is treating a patient according to their desires and also within the bounds of what is considered accepted treatment. Patients should be involved in treatment decisions in a meaningful way with consideration given to their needs, desires, and abilities. It also includes safeguarding the patient's privacy, records, and confidentiality. The next two principles are non-maleficence and beneficence. They are sometimes considered two sides of the coin, non-maleficence to do no harm and beneficence to do good. So non-maleficence to do no harm is the duty to refrain from harming the patient. It's a concept to protect the patient from harm by keeping knowledge and skills current, such as taking this continuing education course to continue education and keep skills current, and knowing abilities and one's limitations, and when to refer to a specialist or other professional if it's in the best interest or welfare of the patient. It also includes protecting the patient from harm by knowing when and under what circumstances to delegate procedures and care of the patient to any dental auxiliary, such as the dental assistant or registered dental hygienist. Beneficence is the duty to promote the patient's welfare and act for the benefit of patients. The obligation is service to the patient and the public. The most important aspects of beneficence are the competent and timely delivery of care within the bounds of clinical circumstances of the patient which do consideration given to their needs, desires, and values. The same ethical considerations for any practice arrangement, be it for service, managed care, or other arrangements does not excuse the dentist from the ethical duty to always put the patient's welfare first. The two principles also include several codes and advisory opinions. And some of the details include that non-maleficence says it's unethical for a dentist to practice while abusing a drug or agent that affairs their affiliated practice. That a dentist should not jeopardize a patient's health by discontinuing treatment or abandoning them without giving adequate notice and opportunity to continue care with another dentist. It also includes personal relationships. Unlike other medical professionals, dentists aren't forbidden to engage in what's known as a dual relationship which is when a professional has another relationship before or after they create a doctor-patient relationship with someone such as a dentist treating a family member, a friend, or even the dry cleaner. The code says that a dentist should avoid interpersonal relationships that could impair their judgment to treat the patient or exploit their confidences. Beneficence includes being familiar with the signs of abuse and neglect which a dentist may have a greater opportunity to notice in practice and also reporting it consistent with the laws. Beneficence includes the obligation to promote the professional demeanor in the workplace. So a dentist should support a respectful and collaborative relationship in the office and this includes mutual respect, good communication, and high levels of collaboration with everyone and its goal to provide the best care for the patient. And under this principle of beneficence, it includes a new advisory opinion that was added last fall during the pandemic. So a dentist should balance the obligation towards an individual patient with the obligation to the public. So during a public health care crisis or emergency, a dentist's ethical obligation to the public may supersede an ethical obligation to an individual patient. So it tells us that a dentist may opt to postpone elective or non-emergency care procedures when weighing the risk but also consider the need to treat a patient who has an emergency or urgent need. The next principle is justice. It is a principle of fairness. A dentist has the duty to treat people fairly and deliver dental care without prejudice. The profession should seek allies and activities that help promote access to care for all. Justice includes such things as using reasonable discretion in selecting patients which may include deciding whether or not to accept the family member or a friend in that dual relationship, as we just mentioned, in non-emergency. Services should not be denied because of the patient's race, creed, color, gender, sexual orientation, gender identity, national origin, or disability. And justice also includes a code of conduct about emergency service. So please note that the code says that a dentist shall be obliged to make reasonable arrangements for emergency care of patients of record. And also, dentists are obliged to make reasonable arrangements for those patients who are not of record. So under the code of justice, it specifies reasonable arrangements for patients with emergencies, not necessarily providing the direct care to them. After the emergency, the patient should also be returned back to their regular dentist. Justice also includes justifiable criticism review of that. A patient's oral health status should be communicated to them without making disparaging comments about prior services. An advisory opinion also goes on to say that any comments or reports are made should, we should ensure that they're truthful, informed, which may involve consulting with a previous provider, and also be justifiable. An unjustified comment made by a patient's new dentist is unethical and also can lead to a lot of issues. Justice also includes that a dentist may give expert testimony, but not for a degree fee based on a favorable outcome, and should not accept rebates or split fees. And the fifth principle and final principle is veracity. It's funny, I hear students advising each other when studying for an exam on the ADA principles that we give them to just know the first four principles well, because if you know those, if anything else is asked on the exam, everything else will be under veracity. Because veracity is the principle of truthfulness and probably has the most details with advisory opinions and code. The dentist has the duty to communicate truthfully, to be honest and trustworthy in dealing with people, and includes respecting the position of trust in the doctor-patient relationship, communicating truthfully and without deception, and also maintaining intellectual integrity. So as you can see, it does seem to include the most codes and advisory opinions. Basically, veracity includes that dentists should not represent treatment, care, materials, fees, represent themselves, their credentials, or advertise in any false and misleading manner. This includes such unethical actions as removing an amalgam, and restoration in a non-allergic patient claiming it's a toxic substance, reporting in correct dates of treatment to benefit the patient, and also performing unnecessary services are unethical, also known as overtreatment. It's certainly a significant ethical issue in dentistry. So it's respecting the trust in the doctor-patient relationship, communicating truthfully without deception or being misleading. So that concludes, completes the quick review of the ADA code. Link to the code is provided and also you will find a document called the four-box method in the handout posted. The four-box method poses questions for ethical considerations in patient care to consider when with the principles in decision making. We also wanted to highlight that the American College has core values included in the ethics handbook for dentists length, the ACD core values are a guide for ACD fellows and are, like I said, included in the link to the handout. So I know Pam is going to be continuing on with the additional considerations. So the information that was provided by Katherine is quite rich and it reminds us that the ADA code is very valuable and provides a lot of guidance as we've noted the advisory opinions. And so when we think about what's ethically at stake, both that and the ACD core values are very helpful. We also want to consider when we think what other considerations that need to be included in whether, in our decision making, there are legal implications. And so for many of you, there are state regulations that guide you in your decision making. There may be federal implications. And so a decision to choose a particular alternative may be influenced by that. In some circumstances, this doesn't play as significant as a role as it may in other situations. And so confidentiality informed consent, informed refusal, discrimination or a discriminatory-based decision, the legal principles of negligence, abandonment, consideration of the standard of care, they are important for you to discuss and to be familiar with what is legal or illegal in the particular state that you're practicing in. And also to remind again, whether it's your staff or the dental students that you're working with, that ethics drives much of what we do, but so do legal considerations. And so we have examples of that. If there's a dilemma related to, say, a potential situation of abuse, state jurisdictions require most dental professionals to be mandated reporters, for example. State Dental Practice Acts may have language and are ever-changing. And so for example, I'm from Michigan and we now have, as part of our State Dental Practice Act, an obligation to report suspected human trafficking. And then there are public health codes that may also guide your decision making. And so thinking about this, again, the ethical obligations as well as the other obligations provides for a rich discussion and also for consideration. There are other factors that need to be considered in this model when we talk about what's professionally and ethically at stake. And that is maybe focused on looking inward or it may be focused on looking at the patient. So a language and understanding and health literacy, the decisional capacity of the patient that might be the focus of a particular concern, finances of the patient that we're treating, the family issues or family dynamics in terms of who is the decision maker, cultural and religious factors as we think about the values that are important to that particular patient. Or it could be, again, our staff as well if there's a concern or a dilemma that's been faced because of something that's going on in our clinic or in our private practice. Conflicts of interest, other, and I'd like you to reflect on that in thinking about some dilemmas that you faced, it could be office policies. It could be because of an organization that you're working with or working for as well in terms of their mission, in terms of other things that you need to consider. And so this is all to say that when we're using this model, there's many considerations that need to be brought into the discussion and brought into consideration. So moving on with the model, remember we've talked about identifying what the concern is, collecting information, identifying some alternatives and then really spending time on all the different considerations. How do we determine what ought to be done? And we use the language of ranking and justifying and prioritizing those alternatives, thinking about all the different values, obligations and principles that we discussed a bit earlier. So we suggest that you rank from first to last. In some situations, we may talk about ranking in terms of what is the least aggressive versus what is the most aggressive action. And aggressive is a strong word, but the least aggressive and one that I'm sure many of the folks on this call if you're involved with students is to do nothing. And at least when I teach the students, I say that is my least favorite option and not the one that they should rank as the first. But you wanna justify your ranking in terms of those ethical principles. How can we honor them? How can we take them into consideration so that we do no harm and that we don't violate many of the things that Catherine talked about in terms of what the different layers to that ethical principle involve? And then are there legal obligations that may help us rank things a little bit differently? Or are there other obligations or factors that we talked about in terms of the patient's needs, the patient's values, the patient's personal circumstances? So what might seem like number one to you might be through your lens. And what we're suggesting is that there's other facets to your decision making that you need to consider. And we hope that as we're going through this this morning and as we talk about the case, you'll think about those different aspects. And then we suggest in this model that you have to make a choice. How would your choice? What would you act upon? How would you truly resolve that particular dilemma? So what choice can you live or not live with? There's sometimes when we talk about ethical dilemmas, the driving home test. And as you think about your day and how you decided to resolve a particular concern, and as you're driving home or taking transportation home, how does that make you feel? What choice would be the most just or fair or responsible given the authority that you have? And by that I mean that your dental credentials in your community, in your practice, in an educational setting, as a faculty person, you need to consider all that. What is the most responsible? And what choice would probably have the best overall outcomes because that's really the direction that we're going to at the end of the day. What did we decide to do perhaps to protect that patient, to address that concern, to resolve that particular dilemma? So as you're thinking about the alternatives, it may be that your number one alternative is not the one that you would choose because one and two are close, but there are certain factors influencing your decision making. So what choice would you truly act on and why? That is the question that we want you to consider. And as you think about the why, the answer has to include because it supports these ACD values because it really, I see in the ADA code and as I look through that and as I reflect on what it's saying, it really honors those ethical principles that are not only part of our ethical values and principles, but for all of the professions that we interact with. And what might be the possible outcomes of your decision? And that is when you're talking with dental students or when you're talking with your staff, your choice may be unpopular. Your choice may be one that not everybody agrees with but is ethically sound. Your choice may be one that shows your responsibility as a licensed oral health care provider. And that's the same that's true for other licensed professionals within your practice. The dental hygienist, perhaps the dental assistant in your jurisdiction also carries a license. And so what are the outcomes? And it's not always a popularity contest and it's not always the easiest route to take. And so concerns or ethical dilemmas are not easy and they're not always black and white in terms of this is what I need to do. That is why we're offering you the model so that there's some reflection and some thinking about what you're going to choose to do and what you will actually act upon. Now, the ACD offers this pocket card as it was called or wallet card that's been called in the past. Perhaps I'm dating myself but they also provide a quick model that you might use in terms of ethical decision making. We suggest the model or the framework that we proposed earlier this morning because it has some layers to it that make you pause, that make you encourage discussion, that make you do a little bit of research and evaluation. But this model talks about assessing and includes some of the themes that we talked about. It talks about communicating, interacting with your patient, listening to your staff, listening to others that your colleagues or your peers that are talking with you or helping you review the information that you've collected or what is ethically and professionally at stake. It talks to you about thinking about outcomes as it relates to the alternatives and then also making a decision. And so assess, communicate and decide. So we have a wealth of resources that we are gonna utilize today but if you're not familiar or if you haven't looked at some of the resources available from the college as well as from the American Dental Association and the American Dental Hygienist Association also has a code of ethics that you and your staff can look at. There is the handbook, the videos and we're gonna use one today but there are multiple videos that can be great to use with students as well as with your staff, the ADA principles, the American Student Dental Association has a white paper that speaks to ethical principles as well and some articles that we've cited as well as the textbook that isn't just for school and isn't just for students but is very valuable for providers as well. And so and also why is ethics research and why is it important from the health science area? So many more resources are available but we thought that this would spark some interest on your part and we wanna encourage you to utilize these particular resources. So Catherine and I wanna thank you for your attention. Hopefully this was a review of some of the principles and ideals that you learned as part of your professional education or your professional development but we also want hope we've introduced some new ways of looking at ethical dilemmas. And so we're gonna turn over this presentation to Odette and Larry as our colleagues as we talk a bit about facilitation skills. So again, thank you for your attention and we look forward to applying this model later this morning. Thank you. Well, good morning. I'm pleased to be here as well. I understand we've got a pretty good crew of audience here so that's wonderful. Odette and I are I think both live we're both coming live here in a second and our focus now is on this concept or process of facilitation. And you'll note from the title here that I have listed this as knowledge and process required. So we're gonna talk through each of those here but first let's just do a quick review of the objectives that we've covered. Thank you. So far we have covered talking about your background knowledge about ethics, about ethical principles, central values of dental practice. So we can effectively discern the ethics dimension in clinical scenarios and so that you and your audience members or your participants, your learners can develop the ability to effectively analyze ethics dilemma cases. So on the second part is Larry on the second part of this presentation as Larry mentioned, we will focus more on the objective of understanding and applying the principles of facilitation and small group settings and also in how to develop and enhance your expertise in leading an ethics dilemma discussion. So if we were live and we were doing this all together we'd be asking these questions and then waiting for a response. Clearly we can't do that today and that's just welcome to the life as a virtual presenter here and a virtual audience. But the question is how is a facilitation environment different from that of one of presentation and lecture? What we've been doing right now and I think really easy for you to discern right now that what we've been doing has been this, a very leader centric or teacher centric model where you're hearing from someone you're listening to it again in a situation where we were live you'd be able to respond back to that. I see a couple of questions that have popped up in the Q and A box here that we'll get to at the end those sorts of things but a leader centric environment is exactly what you're experiencing right now what we experience in these big conferences like this. A learner centric environment is more what we're trying to accomplish in a facilitated group. Odette you want to talk about that? Yes, well I was thinking of the previous one if you can see there's not as many directions you know the arrows don't go in as many directions. So that's more of a content delivery whereas on the other model, yes. That one has the content is delivered but there's also the process as the first slide explained. So in this type of environment, both things are happening and this one I think encourages exchange of ideas between the participants. It goes in several directions, encourages, engages all the participants and there's more active learning that happens this way and that leads to a deeper understanding of facts. I was thinking you can- So the goal of the facilitator, I'm sorry, the goal of the facilitator in this environment here is to stimulate all of that cross-arrow stuff that's going on. We're trying to ask questions, create an environment, a safe environment where participants are comfortable talking to each other, not just as a facilitator. So in the leaders- Any further before I move on? Yes, I was thinking you can't ask the audience but I can answer your questions too. But I was thinking, I've heard it referred to as the leader-centric one and I've heard you say this before, it's the sage on the stage, whereas the learner-centric is the guide on the side, where you have a facilitator that is guiding the learners. Excellent. So just to reiterate, in a learner-centered environment which we're trying to accomplish using this technique called facilitation, the goal is to have the learners. And in here I'm speaking mostly about student audiences, those of you that will be facilitating discussion of ethics dilemma cases in a group of third year or fourth year students type thing. The goal is to let the learners do the learning. It's their responsibility here. And the goal of the facilitators is to provide the environment, to work to create a safe environment that allows that to happen. The goal is to remove, to sort of move yourself away from being a sage on the stage to this person that's helping to stimulate a discussion. So more of asking questions and guiding the group and less as an expert, that's just providing the information to the group. So we have a question again, what's the role of the group leader in a learner-centered learning environment? And I think this is what Larry has been alluding to. So the role here is not to present information, not to relay the information to the group as you would do when you are a presenter, but to be the guide, be the person that asks questions, that encourages discussion that helps the learners become responsible for their own learning. They have to find out what they know and what else they need to find out more about. Yes. So Paula Friedman has just made a comment here in the question and answer box. Does the facilitator act as the devil's advocate? Yeah, I mean, that would be one of the strategies for moving the group to consider an idea. We'll talk a little bit more about this coming up here. So what are the possible roles? And this is worth thinking about because there are many for someone in the moderator, leader, whatever environment here that we're gonna focus on in a small group. Certainly the content expertise is one of the things. Those of you that are practitioners, those of you that have experienced practitioners as is the case with most folks in the college, you are content experts about dentistry. We also expect you when you lead a small group here to be a content expert about ethics. And that's what the whole first part of this presentation was. It is important, imperative, that as you act in a moderator facilitator role, that you have that background knowledge in place to be able to bring up issues, to do the devil's advocate thing that Paula was talking about earlier. You're also a resource person in many cases. Now, it says with lots of experience, that means that as you understand and as you delve into the concept of ethics, you understand where you can route people to for more understanding. Again, part of content expertise is knowing what the resources are in a particular field. We've been talking about the facilitator role and helping others think, talk and listen are things that we're gonna continue to talk about here. But even more importantly, and again, this speaks to what your role as a facilitator can be, is your role as a model for how to think about cases? Sometimes in a group where there's not good understanding about how to work through thinking process, you're also gonna model it. And what we're gonna suggest to you here and has already been mentioned by Pam, is that part of your role in modeling how to think about ethics cases is to guide your participants in your group through that ethics decision-making model. All of the facilitating questions are right there for you. And again, we'll practice this as we're moving forward. Some of you in a teaching environment may also be asked to act as an evaluator. You may have to write an evaluation about how students performed in that. And that's another role that we take on when we take on the role of leading the group. Anything else, Odette, on that? Yeah, I was thinking of some things to think about and be careful about when it says content expert and resource person to make sure that, yes, you may be the expert, but you don't want to become the expert during the facilitation session. Because then automatically, all the participants will ask you about all their doubts. They'll ask you the questions and they won't participate between them anymore. So just a balance between that, providing appropriate information at the appropriate time, but not becoming the expert that answers all the questions. And yes, that's all I wanted to add. I know we're gonna talk more about that in practice. And we are. As we get to the group dynamics component of this right after the case, we'll talk a fair amount more about that. That's an important issue. So facilitation, we are making the argument here, making the statement that you have both content and process necessary. Your content is your knowledge of the ethical principles and values, your ability to work through a decision-making model. I think there are four listed in the ACD handbook, different ways of looking at decision-making using ethics as a framework. You can use any of them. We've chosen to use this one that is really, the parent of this one is from Dave Ozar. But that framework allows you to guide people through a case. And it allows you to guide yourself through a case as well. So that's the content piece. The process piece is the guidance, how you will actually do the guidance through a decision-making model. And most of this is through stimulating discussion using open-ended questions. I certainly don't have to tell a clinician about what open-ended questions are and why we use them. It's a crucial part of clinical life here. But we will talk a little bit more about this moving forward. Right, so we're gonna talk about the facilitator rule. So the facilitator, you have to remember that the focus of the facilitator is participant learning. And also that the facilitator's goal is to stimulate discussion. You're not a presenter. You're not there to give them information or to give them the right answer, whatever that may be. So you're there, your focus again is that the participants learn and that they become responsible for their own learning and the goal of your US facilitator is to stimulate their discussion. So you may start by asking participants the kind of questions they should be asking themselves to understand and then address the dilemma. A good question to start with would be, so what do we know about the case? So what are the facts that we know about this case? So you start the discussion by asking the participants these type of questions. So your goal is to move the participants to take this role themselves. And then they can become the active discussers and questioners. So your goal is to become unnecessary as a facilitator. What do facilitators not do? So this is, we just did some do's here. Here's some don'ts. Facilitators, a person who is facilitating does not give participants a lecture or extensive factual information. That's a lecture. They don't announce right, wrong in their thinking. They might use a different strategy for that when you recognize that people are on the wrong track. It might be to ask them another question. And they don't tell learners what they ought to study or read, at least in key. That might be something for a wrap up in a conversation, a suggestion that's made. Now, a lot of times in the discussion of ethics dilemmas we're talking about a single case event. You're together with a group of students. Certainly if you're in an office environment or in a meeting environment, you may have one shot at folks. This isn't easy to do sometimes. And so this takes a little bit of practice to try and open this up to accepting that role as facilitating. We call it taking on the facilitation attitude. Because it is an attitude. It's different than what you think you do as a presenter. Moving on, Odette? Yes, yes. So a facilitator then is a person skilled in helping learners learn. As Larry was saying in the previous slide, a facilitator doesn't do all the talking. A facilitator actually listens, is open to ideas, encourages participants to share their ideas. Now in a perfect world, a facilitator would be a content expert and a process expert. So you would have the expertise in dentistry and ethics and also the expertise in facilitation. Now we don't always get that. And I know Larry will have something to say about that. But what we would like to avoid is to have a content expert that has no facilitation skills. Because then you have somebody that I think will find it hard to resist the temptation of doing all the talking, sharing all the information, giving out the information to the participants and not allowing for an opportunity to share ideas and share information and have everybody participate. We're gonna come to a couple of little tidbits here about how you recognize the role that you're in. And this content expert without facilitation skills, this actually comes from the group dynamics literature. Many years ago, Howard Barrow wrote this. The challenge that you have here, like Odette says, is it's not a facilitated group discussion any longer, it's simply a lecture. And so when someone is unable to take on that attitude, this is what you get. So for those of you that are directing curricula or assigning, selecting people to participate in group discussions with students especially, you have to pay attention to this. Sometimes it's not visible the first time, but it becomes very visible as you see people work. So keep an eye on this. I think my experience in training facilitators is always that you can train somebody, but sometimes they don't realize what they're doing. So this is a, this last avoid thing is really a crucial point here of the talk. So as I mentioned, we talk about attitude, all right? What's that mean? Odette? Well, I think that you have to step into that role and you have to be conscious that you're stepping into that role. You're not a presenter, you're not a teacher, you're not a lecturer anymore. So yes, you will be delivering content the same way you would have done if you were a presenter, but now you're also focused on the process of how learners learn and helping them learn. But you have to think about it, especially for those of us that do teach. Sometimes it is, you have to readjust your attitude and that you're not the expert. You can't have the participants ask you all the questions, you can't be in that role, but you have to reflect the questions back to the group to enhance their discussion. So we'll, again, we'll talk a little bit more about this as we talk about group dynamics, but I do want you to be thinking about this. It's a different attitude. When you move into a role as a facilitator, you have to reset your brain in some way, shape or form to help you remember that you are in a different role now. So we've looked at this already. This was the model that Pam and Catherine presented about a framework for an ethics-to-alignment discussion. There's, this is a natural framework for facilitators. The questions are almost already there. I mean, just look at this. You're presented with a case or you use a case. We're gonna do this in just a few minutes here where we come into a case. The first question the facilitator is likely gonna ask is, so what are the facts of this case and what's the ethical concern? What's the dimension that we see here? What's the dilemma that we see? Okay, now I just did three rapid-fire questions. Don't do that, all right? One question at a time on the table. Facilitation is about clarity as well. And if you throw three questions at somebody, they're still thinking about the first one when you're asking the third one. So put a question on the table and leave it. The second step of that process, all right. So we've identified the dilemma. What do we see as possible options for resolving this pause, long wait? Okay, we'll come to that in a minute too. What's professionally at stake here? Catherine has worked us through the central values and the ADA principles, that's what's mentioned here. What else is ethically at stake? And this kind of facts in relative to the sort of the facts of the case too. Because if we were to look at a case that involved a patient that doesn't speak the same language that you do, there's an inbuilt ethical concern there about getting to inform consent that we have to recognize right up front. So that's the nature of that unique case that's present. In many cases where finances are an issue, finances are one of the largest single autonomy limiters that exist. If the patient's in tremendous pain or if a patient is descending into dementia, their decision making may not be very good. We have to recognize all of these as the unique issues that come into a case that we look at. So that's determining what else is ethically at stake in this model. And then as it's been discussed, what are the pros and cons of the alternatives that were listed? And then of that, making a decision about course of action. Anything to add or debt? I'm gonna move on. I was thinking just from our own teaching experience that sometimes recognizing the problem or concern can be the hardest thing to do. But it is very important to spend enough time doing that so that people, and sometimes it helps to have learners think about what bothers you? So in terms of this, and I wanna come back to that particular thing, we've actually got some data on this from work that we've done at IU, where we were looking at our students across the curriculum. And initially when we first started working through this model, using this model as our competency measure, because this is our competency measure at IU. The students have to be able to do this to be determined as competent in ethics with a case that they haven't seen before. We do that in their third year. That question of what's the problem or concern, if we're looking at a D1 group, a first year group, that is a really tough question for them. They jump immediately to alternatives. They don't start with what's the ethical concern. They jump immediately to alternatives. When I do this with professional audiences, experienced clinicians, guess what? They wanna do the same thing. They wanna jump to options and alternatives. You guys are in problem solving mode. I know that, I understand that. But there's a step before here that allows us to actually better understand this case. If we step back and say, okay, what's actually the issue that's present here? We verbalize that. So again, we'll come back to this a little bit. That's part of the facilitation environment that you'll be guided through today. Okay, I am back. Facilitator skills. So, and I know we have addressed some of these already, but it is doing a very active listening, listening to your audience, your participants, your learners and stimulating them. That is one of the primary skills that you wanna develop. So there's a not talking much, the 2080 rule. When you are a presenter, you will be doing the opposite. You know, 80% telling and presenting information and 20% listening. When you are a facilitator, you have to flip that. So then you do 20% telling and 80% listening. You keep your messages brief. You have to remember that talking is not your job. Your job is listening, encouraging participants to share their ideas. You have to get other people to talk. That is what your job is, not talking, doing all the talking. Using open-ended questions, and I know that has come up before. So questions that cannot be answered with yes, no. You know, all of, I think most of you are familiar and that's coming in a later slide, but using open-ended questions, you know, such as, so what facts do we know about the case? And then that'll encourage people to start sharing. And don't tell many war stories. It's tempting when you're looking at a case, you know, that triggers some personal experiences. It would be tempting to talk about a similar case that you saw in your office or in your experience. And you can do that, but just don't make that the focus of the discussion. And you have to observe the process, watch for patterns. That will allow you to, for example, one of the participants is being very quiet. You know, if you are noticing that, then you can think of ways to bring that person into the discussion. You observe if somebody is dominating discussion and needs to give other people a chance to participate. You notice if there was a good idea that came up and then the group sort of, you know, moved away from it, but it's worth bringing back. So all of that you can do if you are being an active listener and paying attention to the group dynamics. Well, we'll talk about group dynamics in a session right after we do the case. And we'll focus in those patterns that Odette just talked about. We're gonna focus in on each of those because they're important. There's a different strategy for facilitating each of those patterns that we'll talk about. This is the challenge again of trying to do this as a virtual presentation versus a live event where you'd actually be able to watch this happening. When we trained facilitators at IU, I mean, this was not a three hour process. It was a three day process. We put people into groups. We gave them feedback about it. So this is an exposure to this concept at this point in time. You have to practice it to get good at it. And you have to have some mentorship from it. I think it's really, really useful to have somebody in with you and watch your strategy and give you feedback about these things to become an expert facilitator. It's a skill just like anything else. So one of the goals here, your role, and again, just mentioned, you have to help people articulate what they're thinking. The exploration, the unpacking part of what you're thinking is part of what stimulates a discussion. It's not just listening. It's also participating. So the active listening part is a facilitator, certainly. We want to guide our students to be active listeners as well. But we also want them to explore, to lay out what they're thinking about, what's on their mind. For some people, this is a stream of consciousness issue and they do it very easily. For other folks, it is very difficult for them to interject what they're thinking about. And they may have some really important thoughts about this. So again, a goal as a facilitator is to draw people into the conversation. Again, we'll talk about that when we get to group dynamics a little bit. Our goal, and one of the things that you can use as a assessment as to whether or not your facilitation is being successful is are the learners talking to each other? Is there discussion going on that's not simply directed to you that's being directed across the table to other folks? You saw that early diagram where the arrows were going every which way. That's what we're trying to get at here. So the how question, again, if we were live together, we would push that out as a question and pause for that. Here's how. So you restate things. That is one good way to do that. And an example here, and it sounds like you think one option is, for example, call the patient at home. How do you feel about that? So notice, again, the open-ended questions. What are the advantages and disadvantages of this? So you restate, sometimes you paraphrase, you're open to the ideas. You can also say, I hear you say that this, this, this, is true, does everybody agree with that? So you are paraphrasing, restating, reinforcing. I'm getting ahead of myself with the reinforcing. I know that's coming up. That's okay. It's okay. It's all parts of the same thing. It's hard to talk about these. Yes, it's hard to isolate them because they're all, you know, become part of the facilitator skills. So another skill that you can have is, yeah, another skill you can have is to summarize. We, you know, here's the sort of the statement. So we've looked at this and we've talked about that. Okay, fill in the blank there. And so far it seems the group is thinking the best option is X, Y, and Z. Thoughts? That's the question that I'd lay on the table. And you'll notice the question was not. So do you feel X, Y, Z is the best option? One is an open-ended question. That second one is a closed question. What you get when you ask that question is yes. You will always get yes, unless it's just ludicrous, then you might get a no. But most of the time you get yes. So you can't ask it that way. You have to ask it as, you know, it sounds like the group thinks X, Y, Z is the best option. Thoughts? Lay it on the table. I know we have gone over this, you know, the asking open-ended questions. But I think it's worth stressing this. It is, sometimes you do have to think about this and make sure that you're not asking a close-ended question. So what other options might be present given the situation? So again, your focus and your goal is to have people participate and share more of their ideas. I may spend some time talking about this when we get to group dynamics a little bit. What happens with, and this is the second step of the model, right? What are the options that happen? Or what options are present? That what happens here is people give you an option that's what they would do. And they aren't thinking about other options. So sometimes we have to back people up and we have to say, okay, what's the least severe thing that you can do given the case environment in terms of responding to the situation? And then what's the most severe, most aggressive thing that you could do? Those are the two bookends. They're at either end of the spectrum. Then it becomes easier for people to fill in the blanks in the middle, fill in other options in the middle. One of the strategies here in thinking about ethics dilemma case is to lay things on the table that you might not do simply as a way of getting them on the table. So you'll end up with a series of options that are permissible and options that are impermissible, appropriate and inappropriate. It allows you to see the scope, the range of things that you could possibly do. I'm going to move on here. Yes, important to draw people out. We talked about if, as a good facilitator, you notice that somebody is very quiet. It is part of your job to draw them out. Maybe mentioning, Mary, it looks like your wheels are turning. What are your thoughts about this case? That could be a way to bring somebody out in a non-threatening way, not putting somebody on the spot, but just allowing them to share their ideas. We didn't say, Mary, you haven't said anything this whole session. What are you thinking about? You want to shut somebody up that's already reticent to talk? That's a way to do it. So it's a guiding process. You've got to make it a safe environment to get people to talk. And again, Mary, in this particular instance, will talk about a person like Mary when we talk about group dynamics coming up after the case session. So give learners time to think and to respond. I mentioned earlier, we don't ask three rapid-fire questions in a row. Ask a question and then wait. And we use something in this. Actually, there's literature on this. It's called the Eight Second Rule. The Eight Second Rule is lay a question on the table and pause. Count to eight in your head. It's hard. It feels like forever to have that kind of silence. A really good facilitator can count to 12, okay? Can wait them out. But this silence is perfectly okay. People are thinking during this time. It's not that they're not going to say anything. Somebody will say something. And it is sometimes not easy, but you have to just embrace the silence and resist the temptation. Resist the temptation to say something. Right. You also, as a facilitator, reinforce the points that you know are important. So you can say something like, that seems like an important point. And this becomes even more important when the group has moved maybe away from that important point. So it's very good for you to restate it and reinforce it. This also can help the group stay on topic, you know, stay on track. Typically, you will have the time limitation to the discussion. So you will have to have a balance between moving forward the depth of discussion and also addressing the points that you know are important to advance people's understanding of the case. Another skill is refocusing the group to keep the discussion on track. And again, what's that sound like in an environment? This is what Odette was just talking about. You know, the statement from a facilitator might be, you know, that seems like an important point. What about the question of? All right. Again, an open-ended question here. The stimulus here or the intent here, the attitude here is to try and keep the group focused on the case that's happening if they start to sidetrack. And again, that first statement, that seems like an important point. That's kind of a, it's kind of a acknowledgement of what they're talking about. But that next statement, that question is, what about the question of? That's the refocusing statement. So the goal of facilitation then in summaries to develop participants who can actively and independently step through a decision-making model, such as the one that we've been addressing, to look at an ethical dilemma scenario, to be able to work through the different stages of thinking through an ethics dilemma scenario. So you, as a facilitator, will not be telling them what to do, what to think, what's, what are all the answers, so to speak? What are the options? What are the ethical principles? But you are encouraging and allowing the participants to actively and independently do this. And then with your skills, if something doesn't come up that you feel should come up, again, refocus the group, what about the question of? That question that pops up. So that's the initial part of our presentation here. There's a couple of questions that have arisen that I see in the Q&A box that I'm going to talk about just briefly here. We've got a couple of minutes left on this segment before we move into the next section, which is a break, believe it or not. Lance has asked, you know, on the long, I'm reading the question here, on the long wait open question strategies, how do you avoid the rapid response of the same rapid responders each time? You've facilitated groups before, Lance. There's no question about that. Some people are so comfortable just doing stream of consciousness that you get an immediate response from folks, and it's not fought out. It's coming, again, they're using a talk out loud strategy. Again, we'll talk about this with group dynamics, because it's an interesting person. One of the things that you can do with a person like that is don't look at them. Look at the other people in the group. And then some of the other things that you can do with a person like that is, and I'm going to model this here. John, hold that thought for just a second. The question that I asked was, okay, that stops it right there. So there are different strategies that you can use with those folks. Again, we'll talk a bit more about this in the group dynamics piece. Larry Lawton, the facilitator skills that we're talking about apply to a flipped classroom concept rather than the lecture format, 100%. A flipped classroom is simply a large group facilitation environment that the instructor, the person that's upfront, really is working in the mode to stimulate discussion across that class. Again, that's a pedagogical tool here. I wish we had more time to talk about this. It's a lot of fun to talk about flipped classroom. If you haven't ever heard that word before, you might use Dr. Google here and just take a look about that, because it is a fascinating way to teach. I moved in my own life. I moved away from the pure lecture environment years ago because, frankly, the flipped classroom environment is a lot more fun. It's just a lot more engaging as a teacher to do that. I think that's all I have. Again, Odette, any wrap-up comments here before I move to this next slide that talks about the break and such? I think that just to assure participants that all these concepts are going to all come together. I think once we do the activity of looking at a case and analyzing, and then I think we're going to have even more questions, or the participants are going to have more questions about facilitation, because it's different when you see it in action, and it is a lot of fun for us to enjoy the dialogue and enjoy the discussion. So again, we're going to talk about logistics just a little bit as we go into the break here. We're going to do a break. You guys are on Eastern time there, so that break is going to be from 9.25 to 9.35, a 10-minute break. Then we're going to come back, and we're going to watch the case together as a large group. I'm probably going to show the scenario. By the way, this is the newest of the ACD videos. We filmed it about three weeks ago, so you're the first group to see this. The title is The Emergency Patient, and if it's not up on the ACD website yet, it will be shortly. After we watch the case, I may show it twice, just because we probably will have some stragglers coming in and out of the break a little late. I'll show it twice. We'll move into the breakout groups. And you guys on your screen, you have some, I think, instructions on your screen. There should be a little button there that says breakout. I think there is a Q&A. If you look in, let's see, let's see. I have to ask this question. I can't ask the question. So here's just some feedback here. We had some feedback from a participant earlier. There are 10 breakout rooms, okay? If when you click on that button to go to your small group, if you're only seeing five, our tech folks have advised us to tell you to refresh your screen. And you do that on a PC. If you're on a PC, it's Control-R. If you're on a Mac, it's Command-R. And that will refresh your screen, and then all 10 groups should show up. Let me just say that if that doesn't work, it should, but if that doesn't work, come out of the presentation and go back in. Come out of your view and go back in. Quit and come back in. That will bring up all the groups. Once you're in your small group, before, excuse me, before you go into your small groups, make sure your microphone and camera are active so that your small group participants can see and hear you. And please click. If your name is not showing up, give permission. There's a button there. Give permission for your name to show up. And so after this, after we watch the videos, we'll go to the Assigned Group. So at this point, we're going to go to break. We've got, I want to have you back here at 9.35, please. Thank you. All right. Coming back live here to talk through this again, I'm seeing a couple of messages about folks knowing what breakout room they're in. You should have gotten an email message. And if that, if, if you did get an email message, your breakout room number is in there. If you didn't, I'm going to show a slide in a minute that shows, shows the groups. And we'll leave that up for just a couple of minutes here. In fact, before I play the video, let me show that right now. And then I'll come back to the, I'll come back to the video here at one sec. Let me get that up. There you go. So you should be seeing a list of names in rooms here right now. So see if you can find your name. If you don't, it says to hold for room number. You might just let me know if you're still not seeing your names. I see a couple of people here. If any of you are not finding your names here, please, please let me know. All right, I'm going to leave this up for one more minute and then we're going to go back and we're going to watch the video. Watching the Q and A box here is we're coming out of break here. If there's any other questions, you know, please go ahead and type them in there. I am, I'm seeing a couple of messages pop up, understand that, that some of you may only be able to join by audio. And I got that, not, not a problem. I'm, I'm seeing a few, I'm seeing a few folks here that are still not seeing their own names. Group four has one less participant than, than some of the other groups. So let's see, why don't we say Andrew? Why don't you head, go ahead and go in group four. And then the rest of you pick a group and just go into it. If you're not seeing your name up there, the groups are a max of 15 people. I don't think we have that many people. You should be able to get in without, without trouble. If it tells you the group has reached maximum, pick a different group. And that's just the way we'll do that. All right, I'm going to go ahead and come off of this slide. I'm going to show you the video. And we'll run through the video twice, like I said earlier, but we will take a look at it here. We're going to look at the first few minutes of this scenario. There is more to the video that is text-based and focused on options and, and contributing factors as to why you might choose an options. That's really for use when you're showing the entire video to a group and you want to actually present the options. What we're going to do in this case session is we're going to show you the video and you're going to have to discern what's going on in the case and then just, and then make a decision about what your options are. And again, what I want you to be thinking about here is what's the least severe thing you can do, least aggressive thing you can do, and what's the most aggressive thing you could possibly do. And then what's in the middle of those? That's a way to think about options. So here we go with the case. Dr. Amy Meru has been in practice about five years since graduating from dental school, first associating and then opening her own practice in a downtown area of the city. As is the case for many of her classmates, she's taken on a substantial bank loan to open the practice and to pay for essential equipment, her staff, and even painting her office. She also continues to make sizable monthly payments to cover her student loans. Despite this, Dr. Meru is busy and is determined to make her practice profitable. Right now, she is in the middle of an appointment, placing veneers on her patient, Mr. McCoy, aware that she has a full schedule for the rest of the day. You doing okay? Uh-huh. We shouldn't be too much longer. Dr. Meru, I am so sorry to interrupt. Can it wait, Kirk? Mr. McCoy and I are a bit busy. I'm sorry. It is really hard to understand. I'm sorry. It is really urgent. I'm really sorry. I'm going to have to step out, but hopefully this will only take a minute. I'm terribly sorry to step in like that, but this guy had just come in. He's holding his jaw. He says he's in pain and he's adamant about seeing somebody right now. Good morning. What can I help you? Man, I don't have an appointment. I just need to see the dentist now. What's your name? Have you seen Dr. Meru before? No, I just called him. I haven't. It's the first place I saw. Listen, if you've never been here before, you'll have to fill out our new patient paperwork, sir. You've left out all your payment information. Do you have insurance? I've got 40 bucks on me. If I get paid on Friday, can I please just see the dentist? Look, she's with a patient right now and it's probably going to be a little while. Listen, there's a low-cost dental clinic just down the road. A few blocks south of the Dunn Expressway. Maybe you could just take me. I was just there. They said they filled all their emergency appointments for today. I'm really hurting. Hang on a minute. I'll go talk with the doctor. He seems kind of like a low life to me anyways. Okay. Let me go speak with him. Hi. Are you the doctor? Come away. This one tooth is killing me. I think you got to get it out of there. What are the ethical and professional issues raised by this scenario? You may pause. So there's the case. I'm going to run it one more time and then we're going to break into small groups. And as I mentioned to you before, if you did not see your name on that list, you will simply go ahead and select a group. If you can't get into that group because it's reached maximum, select a different group. That'll be fine. Dr. Amy Maru has been in practice about five years since graduating from dental school, first associating and then opening her own practice in a downtown area of the city. As is the case for many of her classmates, she's taken on a substantial bank loan to open the practice and to pay for essential equipment, her staff, and even painting her office. She also continues to make sizable monthly payments to cover her student loan. Despite this, Dr. Maru is busy and is determined to make her practice profitable. Right now she is in the middle of an appointment, placing veneers on her patient, Mr. McCoy, aware that she has a full schedule for the rest of the day. You did okay? Uh-huh. We shouldn't be too much longer. Dr. Maru, I am so sorry to interrupt. Can it wait, Kirk? Mr. McCoy and I are good busy. I'm sorry. It is really urgent. I'm really sorry. I'm going to have to step out, but hopefully this will only take a minute. I'm terribly sorry to step in like that, but this guy had just come in. He's holding his jaw. He says he's in pain and he's adamant about seeing somebody right now. Good morning. What can I help you? Man, I don't have an appointment. I just need to see the dentist now. What's your name? Have you seen Dr. Maru before? No, I just told him. I haven't. It's the first place I saw. Listen, if you've never been here before, you'll have to fill out our new patient paperwork, sir. You've left out all your payment information. Do you have insurance? I've got 40 bucks on me and I get paid on Friday. Can I please just see the dentist? Look, she's with a patient right now and it's probably going to be a little while. Listen, there's a low-cost dental clinic just down the road a few blocks. It's south of the Dunn Expressway. Maybe you could just take me. I was just there. They said they filled all their emergency appointments for today. I'm really hurting. Um, hang on a minute. I'll go talk with the doctor. He seems kind of like a low life to me anyways. Okay. Let me go speak with him. Hi. Are you a doctor? I'm waiting. This one tooth is killing me. I think you gotta get it out of there. What are the ethical and professional issues raised by this scenario? You may pause the video. Right, everybody. Um, we're going to go ahead and move into the small groups at this point in time. Those groups will start at 9, uh, 9.55. Um, looking at messages here to see if there's anything I need to remind you about. Um, remember that when the small group is finished, you're going to come back to the main session and we'll talk through, um, the group dynamics piece and then move into a, uh, period of time. After that, about a 10-minute presentation we'll move into a period of time where we're going to talk about, um, just open, open time for discussion. There'll be 20 minutes at the end for open time for discussion. We can see the Q&A field. Again, I wish we could talk to you directly. We can't, but we certainly can see the Q&A field. For those of you that, um, were, are, uh, not able to find your name on this, uh, slide showing the, oops, hang on a sec. I'm putting the wrong slide up. For those of you that are not able to see your names on this, uh, on this, on this slide here, that should be showing up now, then again, join one of the groups and we'll, and we'll get you in. All right, see you in the group in a minute. I can hear you typing, Larry, so. Oh, hey, you're back. Okay. I am guessing that other people are hearing this as well. So we have, um, we're, we're at, uh, what, 1035 year time there and we are going to come back into the main group. We're, excuse me, at 1029, we're going to come back at 1030. So I'm going to start, start talking at, thereabouts at 1030. All right, everybody, I am hoping that people are coming back in from the breakout rooms and we have, uh, actually have an audience back present in the, uh, in the large room at this point in time. We're going to wait just a minute here. Looks like people are coming back in. So from what I can tell. So I'm going to get started here, um, on the group dynamics part. Odette, are you back in yet? Are you, are you with us yet? My, my colleague, uh, maybe trying to come back in, uh, for those of you that don't realize this, those of us that we're presenting had to actually log out of the presentation and log into a different website to, uh, to get into the small group. So there's a bit of, uh, a bit of, uh, a technical challenge just getting that all, getting that all done. So I'm hoping, I'm hoping people will be back in a minute. I'm going to get started here on the group dynamics side. And I'm already seeing a couple of questions that have arisen here that we'll, that we'll talk about, uh, on the, on the group dynamics piece. When we're talking about a group dynamics, component, there's a entire literature on group dynamics. It's a fascinating literature for those of you that are participating in not just, uh, not just small group activities, but in large lecture activities as well. Larry Lottin's comment early, early on, um, before we, before we broke for, for a group and such, Larry Lottin's comment about the flipped classroom is an example where the group dynamic shifts dramatically in, in terms of how we think about, interacting in a, in a large group environment. So the statement here, everyone influences each other. And the process is the teacher. That's a, that is a, I'm looking for the word here. I'm sorry. That is a innate fact of a small group environment where we're trying to include, where we're, where discussion is the main focus of that thing. It's not just a seminar with a presenter presenting. It's not a, it's not a, uh, leader-centric group. It's a, it's a learner-centric group. And so we showed this, this slide earlier today when we were talking about learner-centric where the discussion goes on back and forth. Now, what I just experienced in my, in my small group was, this is really tough to do in a virtual environment. We mostly had people responding to a question that the facilitator asked. So we didn't get to many of these cross arrows participant to participant. We saw them briefly in the, situation again in the group that I had, we saw them briefly where someone would comment on a, an option or a thought about the, the ethic, the ethical principles or something like that that another, that another group member would have raised. And what I can say to you is that, hang in there. This develops over time. It doesn't develop initially, especially in those of us that have been conditioned to be in presentation mode the whole time, either as a listener or as a presenter. It takes a little bit of time to develop this, but you continue to work at it. The pausing of questions, the asking a question and pausing is one of the most important things that you do because it requires other people to respond. So as a facilitator, that's a very, very important tool. I'm going to spend a little bit of time on this, on this slide. This is a, for those of you that remember your biology, this is a Punnett square. And the two variables here are level of participation, high or low, and level of influence that a member might have in a group, high or low. So let's zoom in on the concordant behavior to begin with, this plus plus behavior here. What's that phenotype actually look like here? Well, we've all experienced this, and in fact in a group of ACD fellows, lots of people are in this category. They're willing to participate, they participate a lot, so they speak frequently. And what they say has high influence in the group. It is something that is their important thoughts. The group accepts them as important thoughts. So that's the phenotype of a high participation, high influence member in the group is one of strength really. Let's look at the opposite. The non-participant or low participant and low influence group. Phenotype, low influence phenotype. So the most common thing in a student environment that we see with this is a student who is simply unprepared. They haven't done the preparation work and their level of influence is low simply because they have nothing to contribute and their level of participation is low because they have nothing to contribute as well. This is a tough category to facilitate through. And again, something that we would spend time talking about if we had more time. It's these discordant or the heterozygotes here, if you will, that are fascinating to me. And I'm going to start with this one over here. The high participator who has no influence in the group. We commonly see this as a person who talks all the time and says absolutely nothing. They yak. And so this is a, I mean it's a fact of groups. You see these kinds of folks. The question is how do you deal with them? And so as opposed to the high participator that has high influence, I don't have to, as a facilitator, I don't even have to look at this person as they're speaking. They're going to speak to the group no matter what. With this person over here, the high, the high participator, low influence person, the person that's talking and not saying anything. This is the one time that I might interrupt somebody. I might say, I'm sorry, hold on to that for just a second. Ben, what were you saying? What were your thoughts about this? I might interrupt. And that's the only time, the only phenotype that I'm going to interrupt here. Now let's contrast that to this phenotype here. The low participator that has high influence. This is a fascinating category. Again, it's one that every group experiences. This is a person who is a deep thinker, has really important things to say, but it's very difficult for them to initiate a statement. And so this is the, if you recall back to the slide that Odette talked about, Mary, it looks like your wheels are spinning. What are you thinking? This is giving, it's a, in putting this in quotes, it's a giving permission. It's an encouragement. It's a stimulus to enable that person to speak. And if my yacker over here, my high participator with low influence is speaking, I might, again, I might interrupt, saying something like, hold that thought, Ben. Mary, I can see your wheels are spinning. What are you thinking? Do you see what I'm doing there from a facilitation perspective? I'm redirecting the conversation and identifying the phenotype of the people that you have in your group. And again, to Larry's question about a large class, a flipped classroom environment, you still do this there as well. In a large classroom environment, 100 students, 10% of those people are going to be talking. And so the goal is, is how do you draw the other 90%? Maybe it's 20% that talks. How do you draw the other 90% in? So how do we do that? Well, one, the open-ended question piece. I think I hope you heard all the facilitators try and use open-ended questioning during that session with them. You know, do you think the doctor should be doing treatment for that? Do you think the doctor should be doing the treatment for that that the patient's asking for? That's a closed question. What are your thoughts about that doctor's treatment decisions? That's an open-ended question that leads to discussion. Here's a value question. Did the doctor do the right thing? Yeah, how about, what do you think about Dr. Too's decision? Okay, those are two different strategies. The open-ended question leads to discussion. The closed question leads to silence in the group with intermittent yeses or noes. And that's it. So open-ended questions are crucial importance, of crucial importance. We talk about facilitators being metacognitive. And metacognitive, the simple definition for that, is thinking about thinking, right? So the goal of the facilitator is to get people, the participants, to think about, okay, what's going on? Do I understand the scenario? Have I thought about the possibilities? All these questions that you see on the screen here right now. And the goal of the facilitator is to ask a question that stimulates the participant to, that stimulates the participant to ask a question to ask that question themselves. Stimulates the question about, is there another way to think about this problem? As a facilitator, I asked that question. I asked, so of the options that are on the table, are there others that you might think about? Of the option that we're talking about, is there another way to think about that option? Okay, that's a way of getting people to do that. Again, our goal is to make ourselves as facilitators unneeded as the presentation, as the group progresses through the thing. So we encourage comments between among participants. We absolutely encourage discussions that are moving in the right path. As a facilitator, you should know what the right path is. We encourage critique. Here's an option that's on the table. Someone else says, that's a possible option, but the concern that I've got is that's a great discussions. We encourage consensual decision making by the group in that last step before coming to conclusion about which option to take. One of the questions might be of the options on the table, which are simply inappropriate options. They're impermissible. We wouldn't do them. Versus, now let's focus on the ones that we would consider. And let's rank those. Let's look at pros and cons. What does the most good and the least harm? I hear some typing, and I'm not sure where it's coming from there. The other steps of this thing here, discussion of disagreement, summarization, and the goal to have all members participate. We challenge, are you sure about that? I'm wondering if we all understand that the same way. How do we feel about that decision? And one of the things that I would encourage you to do is to ask questions like that of a group as a facilitator, whether they're on the right track or the wrong track from your perspective as the expert in dealing with this case. And why do I say that? Because otherwise, as soon as you ask that question, if you're only asking that question when you know they're on the wrong track, they're going to know they're on the wrong track. Groups do this. So all we're trying to do is we're trying to get them to ask those questions, are we sure? Do we understand this the same way? How do we feel about that? We're trying to get them to do that. So we've said this before, our goal as a facilitator is to absolutely make ourselves unnecessary. That's the whole goal of an environment like this. It's to get a discussion going where the facilitator is not needed. All right, we have time now. We've got 15 minutes left here, what, 18 minutes left here, but I'd like to open this up to addressing some comments and questions. And I'd ask all of my co-presenters to come back on in video and in sound, please. I can see Pam, Odette, and Catherine. Please come back in. I thought I was back in. Oh, maybe you are. And maybe I'm just not seeing you. That's fine. Okay, okay. It might be on screen here. There you are. I got you now. Catherine, I see you now too. All right. Of the things that we were just talking about in that wrap-up on group dynamics, I'm going to ask just those of you that were facilitating to comment, experiences that you had within group, and then we're going to get to some of the questions and answers that are in the Q&A. Who wants to lead off here? Okay, I won't make you wait the eight seconds. I was fortunate. I had a group with pretty high participation, and each member was high influence. The participants had a lot of experience to apply to the case and bring to a discussion. What strategies did you use with a group like that that had high influence? How did you spread out the wealth? They were actually very good, and it actually brings up an interesting point that is a question. Some of the topics brought up interesting side discussions that weren't related to the case. Because everyone had a lot of experience and interesting to discuss and work through, how to get the responses back to the case at hand versus the benefit of discussing all of these side issues that also come up when you're discussing and meeting with such a group such experienced participants. Thank you, Catherine. Just to pick up on a couple of themes that happened there, it's always a fascinating thing to act as a facilitator for a group like a group of fellows here where you've got a lot of experience present. Again, I would argue that the phenotype that is most present in this group is that plus-plus category here. I note from a comment that you just made about getting people to explore here. I see a comment from Regina Messer from Augusta also commenting, difficult to bring the group back to the facts and values. Most of the conversation was what to do. Welcome to a group of facilitators, welcome facilitators to trying to facilitate a group of experienced clinicians. You guys are so focused on what to do because it's what you have to do every day in practice. I got that and this is important to recognize when you're dealing with students. They want to talk about this kind of stuff too but we've got to facilitate them to step back and say what are actually the facts that are present here and what are the ethical issues that are concerned? This is a facilitation of a discussion of an ethical dilemma and unless you name the dilemma, it's not present. It's simply invisible. We've got to name it. Pam or Odette, thoughts on this? Larry, this is Pam. I don't know that I have thoughts on that. You were asking, I think our discussion though led itself where we quickly identified the dilemma in terms of you have the emergency patient and the patient in the chair but then as we kept going through the discussion in the short time, we had just kind of different nuances to that or different layers to that. One thing, for example, that came up was the concern about the safety of individuals in the practice because this was the emergency patient was upset and so again, trying to balance that concern or was that a dilemma? How can I keep my practice safe? And so that was something that I know we as presenters didn't discuss in great detail. So I think you're right to begin the discussion and focus it using the framework you need to identify the dilemma. But it was interesting that that came up as kind of a third dilemma in terms of what would we do about that? Yeah, good, very important comment. Odette, your thoughts from your experience in group? I find it fascinating to hear about the different things that naturally different groups focused on. My group had a very good discussion about professionalism and what was ethically the right thing to do. I thought it was a very good discussion, lots of options that came up to address the dilemma. Okay, one of the things that I'll comment on after having done these cases many, many times is options are never a problem. The challenge with options are getting people to think more broadly because everybody focuses in on things that they would do. And sometimes the things that they wouldn't do are important to get on the table. And that's why I present that strategy about talking about what's the least aggressive thing that you can do, what's the most aggressive thing that you can do, and then fill in the middle here. The goal, especially with the student audience that aren't experienced clinicians, the goal is to get them to consider things that they might not consider otherwise. And it actually turns much easier to raise issues about the ethical principles when you say, well, our option is to do nothing. Just tell the patient that we're full up today and sorry. Okay, well, what are the ethical principles and values that that's violated that particular thing? So what renders that option impermissible in the language of ethics here, if I'm using that language? I noticed, and I'm reading through the questions and answers and things here, I noticed that there were situations where finances simply didn't come up with the discussion. Well, okay, that's an opportunity for a facilitator to raise that. Again, the challenge that we have in this virtual environment is one of time, first of all, very in 30 minutes, it's gonna be pretty tough to get through all of the issues that were present in that case. That very simple case, it wasn't so simple, there's a lot there. So routinely, just for those of you that are gonna try and facilitate discussion on either of these video cases or of paper cases, you're looking at about an hour to get through them to get through them and done well. I'm gonna mute for just a second here because I'm getting ready to sneeze, excuse me. Sorry about that. Other comments, Pam, Catherine, Odette, other comments, I'm reading through the list here. So other thoughts based on what I just said. Well, I was still thinking about when you were talking about the options, I think that another thing that's important to do is to bring back the discussion from discussing options from an ethics perspective because sometimes participants tend to think of the clinical options. You know, I can do an extraction, I can do a root canal, I can, so they are options, but they are clinical. So to bring it back to discussing the ethics side of it. So I'm guessing other facilitators, Pam, Catherine, I'm guessing, I certainly experienced this as well. I'm guessing you guys did that. How did you manage that when you have that or not enough time to manage? We got fairly through the model actually. And then again, as part of the discussion, some other alternatives came up, but we actually ended up thinking about and melding an alternative to some degree in my mind in terms of dealing with, if we didn't go to the treatment options so much as more discussion about it maybe, so I'll share it because perhaps other groups, and it's unfortunate we can't all contribute only the four of us can. That we would perhaps examine the patient just to see what the emergency looked like to de-escalate the situation because again, we talked a little bit more about concern about safety and to show some empathy and understanding and then make a decision as to whether referral was appropriate or treatment was appropriate and then talked a bit about that. So it wasn't so much treatment, it was more of thinking about how the alternative that we chose would best serve a couple of the issues that were raised. That's the best way. Yeah, good points. Catherine, anything to contribute there? Yeah, our group talked about the need for more information about the case. They wanted to know, for example, how large the office was. It was there an empty operatory that the patient could be brought in with staff to help and facilitate seeing the patient as well. So there's more information, I think, that was requested to even make what the appropriate decisions were. So this is a really important comment and I want to think about this for just a second because you will have this come up and the fact of the matter is, whether it's a paper case scenario or a video scenario, that's all the information you have. So this is the opportunity as a facilitator to use the wonderful suppose. Well, let's suppose this is a two-practitioner office with three hygienists and a staff of five. Well, suppose this is a large group practice. So what I'm doing there is I'm raising possibilities here to say, all right, if the thinking is this way, then how might we handle that if the thinking is the other way? How might we handle that? That's an opportunity to use suppose, all right? The other thing that I see mentioned in the chat here that relates to this and it was related to something that both Pam and Odette alluded to, what was the condition of this patient? And so Terry Norris there in Kentucky, in the group that he facilitated, the issue came up as to whether or not from a clinical perspective, how serious was this situation? And could it be to the point where there is really emergent care necessary here as a result of a threat to general life and health if I were to put it into the context of the central value? And so that decision seems to be one of the first decisions that almost needs to be made here before one moves down the pathway of making an assessment of the options that's present. So again, this is a situation where experienced groups of clinicians see things and think about things that are quite different than what an inexperienced group of students are gonna see. So you have to facilitate differently in a group of third-year students that haven't seen a severe infection like that and know what they might know from a pedagogical perspective, they might know they've been told in lecture that these things can lead to very serious issues, but they may not have experienced before. That's an opportunity to facilitate that discussion. If we saw a patient like this, what might you be concerned about health-wise? Again, open-ended question that might lead to a discussion about these things. Other thoughts or comments? We also talked a bit about drug shopping. We didn't want to go off on different tangents, but how you can incorporate to your point, depending on the year. Now, ACD has another video that addresses that a bit, but this is another way of weaving in different things. I think the safety and so forth, just some good discussion about that. And I'm sure we would have liked to talk about the staff member, too. That was part of it, having escalated the situation. So that came into our discussion. So I'm going to wrap this up in the two minutes that we've got left. Thank you, Pam. Important comment. I'm going to wrap this up with a couple of things here. These video cases, there are 16 of them. They're all available to you without charge. The ACD has been amazing in providing the funds to film these things, and they're all available on the ACD's website. They cover a massive range of issues, but they're all issues. The one thing that we chose in filming these things, they had to be issues that were not zebras, they're horses, to use that clinical phrase. They're all common things that happen. And so, whether or not you choose to facilitate a case that is a video case or a paper case that you might have, there's myriad issues in these things. And they take a while to discuss and present. And again, we're working, the American Society for Dental Ethics that has sponsored this program is working on creating a series of facilitator guides, the first of which I'm going to send you by email. You'll get it from Susan at the college. We'll be a brief facilitator's guide to this particular case that our facilitator's used in looking at it. So, I want to thank everybody very much for participating today. I wish we were live. It's so much more fun doing this live than it is doing it on camera. I want to thank my co-presenters, Pam Tzarkowski from Detroit, Catherine Gallis from Tufts, and Aded Aguirre, my colleague in crime at Indiana University. Thank you all for your time today, and I hope this was of some value to you. Best wishes.