 The next part of our program is one in which I will invite Dean Holly Humphrey, the Dean of the Medical School, and Laura Roberts to come up to the podium. Let me just announce for those who were not here earlier in the day that at the conclusion of Dr. Roberts' talk, you see we're running about 10 or 15 minutes behind, but we'll catch up. I'd like all the fellows and faculty and board of the McLean Center to please come up on the stage because we're going to do our group photograph in the morning rather than in the evening. Good. Let me introduce you to Dean Holly Humphrey. Thank you very much, Mark, and I'd like to extend a warm welcome to all of you here this morning. I see many familiar faces in the audience, many of whom are part of our university community, but a large number of you who have traveled a long way to be with us once again for this annual ethics conference. So I have the great pleasure of introducing to you the 2015 McLean Center Prize winner in clinical ethics and health outcomes. Dr. Laura Roberts is well known to this community, and it is my great pleasure to introduce her as the recipient of this important award. I actually want to begin by welcoming Dr. Roberts back to our campus given that she spent the better part of a decade here before beginning her decorated medical career. In fact, Dr. Roberts came to the University of Chicago in 1978 as an undergraduate student studying social studies of science and medicine. After receiving her bachelor's degree and then a master's degree in philosophy, she matriculated to the Pritzker School of Medicine and earned her M.D. degree in 1988. After graduating from medical school, she was the recipient of a one-year McLean fellowship, and it was during that year that Dr. Roberts and Dr. Mark Siegler developed and collaborated on a paper published in Academic Medicine entitled, Development of a Teaching Program in Clinical Medical Ethics at the University of Chicago. That we are all sitting here today at the McLean Center Conference is an obvious testament to the results of how that paper unfolded. In 1989, Dr. Roberts left Chicago for warmer climates, heading first to the University of New Mexico School of Medicine for her residency in fellowship in psychiatry. From her McLean fellowship onward throughout her time in New Mexico and beyond, Dr. Roberts has continued to study, investigate, and write extensively on medical ethics in mental health care and on incorporating medical ethics into medical education. In fact, she is one of our nation's experts in those conversations. Her CV reads almost as a bibliography of current topics in medical ethics, ranging from informed consent to the use of genetic information to the ethics training for residents to mental illness in trainees and more. On the clinical side, Dr. Roberts has written widely on disparities of health care and psychiatry and stigma of treatment in unique populations. In the realm of medical education, she has explored curricular development and the pedagogy of teaching ethics and professionalism to students and residents. We will hear more about that momentarily. She has published several books, including The Concise Guide to Ethics in Mental Health Care. She continues to publish her work in leading peer-reviewed journals. Indeed, in 2003, Dr. Roberts was appointed the editor-in-chief of the journal Academic Psychiatry, a position she holds to this day. Presently, Dr. Roberts is the chair and McCormick Memorial Professor in the Department of Psychiatry and Behavioral Medicine at the Stanford University School of Medicine and the chief of psychiatry service at Stanford Hospital and Clinics. She serves as a board member of the Bucksbaum Institute, a further testament to her devotion to teaching physicians how to empower patients when making choices in their own medical care. She has received numerous awards for both her clinical work and her scholarly contributions, including both the Distinguished Psychiatrist Award and the Distinguished Service Award from the American Psychiatric Association. She has also received the Lifetime Achievement Award from the Association for Academic Psychiatry. We can now add one more award to her list, the 2015 recipient of the McLean Prize for Clinical Ethics and Health Outcomes. Please join me in congratulating Dr. Laura Roberts. Thank you so much for everything, Dr. Humphrey, and I hope that you and Dr. Siegler, my friends and colleagues at the McLean Center, looks at my deepest thanks for this extraordinary honor. I especially thank Mark Siegler from the bottom of my heart because we have had decades of connection and mentorship across miles and the unfolding of our lives and I'm very grateful. I really want to thank the McLean family too for their generosity in assuring that the McLean Center will continue to support the people and the work of bioethics at the University of Chicago with reach and impact that is across the world and will reach into future generations. So thank you so much. My experiences at the McLean Center defined me as a physician and as a physician scientist and as a teacher and helped me really discern my professional calling in academic medicine what a rare and important gift this Center is. And I want to thank my family and my sweet friends, many of whom are here to share in this day. My career has definitely been a team sport and I have the best team. And yet with all of this, I want to say that I've come to understand that one does not get what one deserves in life, not the good, not the bad. And every physician in this audience knows this because of what we see and what we experience with our patients. They are often dealt a bad hand. They certainly don't deserve it. And this is particularly true for the most vulnerable of our patients. So this is the topic for today, reflecting on ethics and our work in caring for vulnerable people or rather reflecting on the experience of caring for our patients when they are vulnerable and what this teaches us why this is important. Now the doctors all know this, but I want to say to everybody in the audience that every physician carries around all of our patients with her. We all do. All the patients here, all the doctors here know this, but I want you to know that we remember and we think about our patients, the people who shaped us as physicians, the people we serve every day. Our patients who invite us into their worlds and in so doing, they help us learn about medicine more about life and about humanity. Our patients are people we have suffered with, stood with, not turned away from. And ordinarily, such ties are only those that come by blood, by family. But these are the ties of medicine. These are the ties of the doctor and the patient. So this morning, I want to tell you about three patients. And actually, I fit in a few more. But I mostly want to tell you about three patients. They're very important to me. My first patient is my first patient who died. I was third year medical student, an internal medicine rotation here at University of Chicago. It was November 1986. My patient was an African-American man, not yet 50 years old, with disseminated Otsel carcinoma. Just by the name of it, you know that is bad. It means he has very bad disease, cancer, riddled throughout his entire body. This very ill man from the south side of Chicago was enrolled in a clinical trial that was not going to cure him or even help him. It was a trial to see how much the human body can take. It's what's called a toxicity trial. My patient understood that he was going to die from cancer. He understood that the intent of the clinical trial was not to cure him or even to treat him. His informed consent was impeccably done. The doctors, the lawyers, the IRB would be satisfied. Every box was checked, and the trial itself was well designed. It was necessary to advance the care of cancer in this country. This man was unbelievably stoic. I can see him in my mind's eye laying so still, not moving an inch. His pain was so great. I took care of him every day for weeks. The man got sicker and sicker. He was unable to eat, unable to speak, and in the end unable to breathe due to the pain. On the last day of his life, when we had to transfer him to the ICU to intubate him because he was struggling so much with each breath, he was bleeding from everywhere. His mouth, the tissues of his mouth were so fragile from the chemotherapy. And he had to be transferred from a medical floor to the ICU. But he asked me not to send him to the ICU as if I could make the decision. He knew he would die, though, if I sent him to the ICU. I remember the deep, long look he gave me. I remember very clearly it was wintertime, snowy and cold, right around my birthday, 29 years ago. He then told me that the real reason he had joined the trial was so that he could live until June when his son was to graduate from junior high. I didn't know what to say. It was never going to happen. He was a courageous man with bad disease and rolled in a clinical trial that does not prolong life and often shortens it. And I'm sad to say he did not make it to his son's graduation. His participation in the clinical trial may have helped someone else, may have defined treatment that might have helped another form of cancer, but not his. And this man taught me a lot. He taught me about dying and loss, how finite the efforts of doctors are in the face of serious illness. He taught me that we are all vulnerable in the inevitability and nature of our dying. But he also taught me something else, something that we all know and is important to emphasize. He taught me that what we know rationally and why we actually do things are not the same. The wishes and hopes that we have, sometimes the experiences of desperation that we feel. These are the things that move us in our decisions, subjective things that influence us, such as decisions to sign up for a clinical trial that does not promise what we are looking for. This man, his death, the nature of his death, permanently changed me as a person, as a young physician. He certainly inspired me as a consultation liaison psychiatrist to take care of people, including people as they are dying and how to hold steady with them, not turn away from their suffering. He also inspired me to study end-of-life care from clinical and ethical perspectives. This third-year medical student experience, taking care of him and later others, also inspired me to study decisions in clinical care and human research, essentially what we've been talking about this morning. My first big grant through the NIH examined how health decisions are actually made in the context of serious illness. We examined many, many different issues, but we certainly demonstrated how people are not human calculators, computing benefit and risk trade-offs, but instead that our decisions are influenced by many things, hopes, psychological and situational factors, money, desperation, sometimes things that seem irrational if you don't have an empathic understanding of the person. Learning more about this is so important because when we engage with ill individuals, we need to understand why they are coming to the experience, what they bring to that experience, and so we do not exploit their misplaced hopes and vulnerabilities. One patient, my first patient I lost, he helped me to learn so much, and for my medical students who are here, I want to tell you, one patient can be an entire medical school. They can teach you nearly everything you need to know if you will open yourself to it. I want to tell you about a second patient. This is a few years later. This is a psychiatry resident. This patient was a very special man. He had a doctoral degree in literature, and just as he was finishing his studies, he was diagnosed with schizophrenia. A few decades later, when I met him and took care of him, he worked at a church. He kept care of the church and kept the property clean and good repair, looking after things, and he lived in a small area in the basement. He spent most of his time reading. He was a very gentle soul. I often saw him walking around town. He did not have the life that he was meant to have, but he had a decent life. One night, he came to the emergency room brought by a member of the church who had found him in his room, lying in his bed, mute. He had superglued his eyelids shut. He would not speak, he would not explain why. The staff in the emergency room had tried to talk with him, but he would not say one word. It was clear he understood what was going on, but wouldn't speak. He would shake and become agitated if anyone tried to reach out to touch him, to examine him. But knowing his background and having observed him, knowing a little bit about him from the neighborhood, I didn't ask him to talk to me. I just went on instinct, and instead I simply talked to him. I said, I know you. I know you from the neighborhood. I told him I knew he was a good person, that the only reason he would want to superglue his eyelids shut and not speak and wouldn't want anyone to touch him was because he was afraid that he would hurt them. He was afraid that looking at people, speaking at people, or having any contact would hurt them. And he didn't want to hurt people, I told him. I told him I knew this. He visibly relaxed. He reached out from my hand, still would not speak, but he let me know that we could help him. And that night we were able to give him the medical and psychiatric treatment he needed, and we were able to keep, despair his eyes. But it turned out he did believe that. He believed that he could kill people with just a look, or a touch, or a spoken word. He was desperately afraid of the destructive power that resided within him, a terrible, terrible torturing delusion that went with his illness. Caring for this man and others with schizophrenia at this particular time was very important. It was certainly important to me, as a young psychiatrist, learning how to use myself, feeling my way through the process of becoming a person who uses their intuition, their knowledge, your empathic sense, your skills to be able to help people. But more importantly, this is a time in this country when psychiatric research was being shut down everywhere because of concern that people with mental illness were too vulnerable by definition to participate in research. And I understood this philosophically. Mental illness threatens the ability to make decisions. Mental illness is so severe as even in the story of this man. How can you ever ethically involve anyone with such severe illness in a research study without taking advantage of them? But I found this idea, which would have been the subject of an ethics 101 paper in college, hard for me, once I'd actually taken care of people with schizophrenia. Working with people with schizophrenia day in and day out, I learned all in all these are incredibly courageous people living with hard disease. You cannot imagine what it's like to push through your day, day and night with these painful thoughts and beliefs that go with such a disease. And honestly, we have the same treatments for this condition that we had 25 years ago. And I remember one patient when asked if I thought, if he thought he had schizophrenia. He said, I want to. I desire to. I would rather have a mental illness than what the voices tell me. In all of this work, I learned that schizophrenia is a heterogeneous condition as it's ups and downs. Some people with this illness are really not capable of making complex decisions with real implications for their lives. And yet some are, depending on the kind of decision in the nature of their symptoms. And it is completely wrong to assume the people with schizophrenia do not have the same altruistic motivations as other people who enroll in clinical research. I remember another patient, a veteran who participated in a research study on new anti-psychotic medications at the time. And he said he knew he would never get better. His illness was so severe. But he was grateful to the women who had volunteered to be in clinical trials for breast cancer. And his sister had breast cancer. And he wanted to help other people with schizophrenia. He wanted to serve our country once again as he had in the military. And I just have to say, nobody thinks about that. No one thinks about how there's authentic altruism living in a person with such severe disease. No one thinks of a military man who served our country risking his life who then is willing to then live a greater burden of symptoms in a clinical trial out of respect and with an altruistic heart because of his love of his sister with cancer. Working with people with schizophrenia taught me that. Our intention to protect them may be nobly motivated, grounded in just the right philosophical principles and regulations. But to assume that all people with this condition are incapable of logical and generous-hearted decisions is not correct. And ultimately, it is not respectful. We can invite some, not all, but some people with serious illnesses, just like physical illnesses with HIV and cancer, but also mental illnesses to join with us to answer a question of importance to them and to society and then to respect the decision they make. During this time of caring for people with schizophrenia, I agonized that we did not have better treatments. Not having new ways to treat schizophrenia, which affects 1% of all people, every culture, every nation in the world. It creates profound disability and early death. And not having new ways to treat and help people with this condition is a social injustice. Not doing research on mental illness is the ethical problem. Not doing research on mental illness. Scientific neglect of such a devastating disease is unjust. Scientific neglect is a form of disparity, often guided by prejudice and not fact and not fairness. And if you then view this on the world stage for psychiatric conditions of all kinds, mental illnesses are the leading causes of disability and early death in economically established countries like ours and second leading cause behind only HIV and other infectious diseases throughout the world. These diseases cause such great burden because we do not have adequate treatments and we do not have systems of care or resources for people in need. And I can make the economic case. The cost of undertreating and not treating mental illnesses every year across the world every year is $2.5 trillion. And this is according to the World Economic Forum. And it is hundreds and hundreds of millions of dollars for the businesses of this country. So it's a huge issue. And that's just from depression alone. These conditions hit early and they hit hard. They hit early, the average age of onset of mental disorders is 14 years of age. One in eight children and adolescents has a psychiatric or neurodevelopmental disorder with psychiatric sequelae. Suicide among our country's most advantaged and disadvantaged people is the third leading cause of death for young people. For some young people, such as Native American young men and transgender youth, as we heard about earlier today, the rate of suicide can be 10 times greater than for others in the general population. Nearly one million people die by suicide each year according to the World Health Organization. And it's probably a larger number. In the US, it's about 36,000 people. In our country, suicide is twice the cause of death of homicide. And in the world, suicide is twice the cause of death as occurs in war. Not only do these diseases hit early and hit hard, causing disability and death, neuropsychiatric disorders hit late and hit hard too. Alzheimer's disease, late life, depression, delusional disorder, these are the conditions of elders. And the number of elders is increasing. By 2050, there will be 2 billion elders in the world, more than twice the number on the planet today. Consider further that the most seriously mentally ill are now commonly housed in prisons and jails, rather than health facilities, or are unhoused, living in the streets, living in poverty, more often victims of crime than those who enact crime. Scientific neglect of these conditions is simply untenable from a social policy point of view. Do you know that we really do not understand the mechanisms of these diseases? The treatments we have do make a difference, but they're still based on logic of two and three decades ago. My earliest patients with schizophrenia inspired me to understand all of this. And with a great team, I have done several studies that have helped to define evidence-based supports and ethical boundaries and public policy governing research with vulnerable people, including schizophrenia, cancer, HIV, diabetes, depression, and with healthy people, who in one study we learned actually had greater vulnerabilities than seriously ill people. They did not understand what it would be like to live with a health condition. So let me tell you the story of one more patient. This is a patient I had in New Mexico. I know exactly when, because I saw him in the emergency room when I was hugely pregnant with my second daughter, 20 years ago. I know, because when they called me to come evaluate him, the nurse said, he's suicidal, but don't worry. He left all of the guns and ammo in the truck. So when I went down, being pregnant, I was a little apprehensive. I'm pretty fierce, and I can talk to pretty much anybody, but I was a little worried. So I looked through, peeked through the window, into the room in the ER, and there sat a very dignified Hispanic man, praying the beautiful cowboy hat on, and a beautiful pair of worn cowboy boots on. When I walked in, he was very calm, very respectful. He offered a beautiful blessing to the baby and my tummy, and he thanked me for coming to talk with him. He told me that he had driven 300 miles to be seen after having spent the night in a field the night before. He spent the entire night intending to kill himself. Instead of shooting himself, he would shoot the gun off into the sky over and over, trying to make it through a few minutes, only to do it again. He had many guns, he had a lot of ammunition, and it was a long night. And we talked, and I came to know him. And I learned that he was a person of tremendous stature in his community, responsible for the largest ranch in the area, an elder in his church, and he had a loving family. He told me that in the weeks before he was riding his horse to oversee this big ranch in New Mexico, and he found a body, a man who had fell from a water tower in a remote area on the ranch. And since then, since finding this grizzled body, he'd been having ravaging thoughts, thoughts that he had suppressed from the Vietnam War, memories that came back to him, he couldn't sleep. His war experience was terrible. He felt tortured and inadequate, and he felt inadequate and bad. He felt weak, he started drinking to soothe his nerves. He knew, if anybody knew how weak he was, he would never hold his position in the community. He would lose everything. He would lose his place as his leader. He would lose his job in the ranch. His family, everything he had built. And this is why he spent the night in the field, shooting off all of his guns and his ammunition, feeling that he had lost everything. But somehow, the morning came, he survived the night. He drove 300 miles to the university hospital. We talked, we worked through a plan. And just to tell you the end of the story, he did very well after our encounter in the ER. But I remembered just as I was leaving the room, I turned and I asked him, why did you drive 300 miles? There must have been a clinic closer by. And he sat up tall in his chair, and he was very proud. He said, yes, in fact, I helped to build the clinic. And I said, well, why didn't you go there? And he said, my sister works there. Right? So I'm sure you understand. This wonderful patient inspired me to understand how health, community life, and stigma interact. He taught me that we could put clinics and resources everywhere, but until we address stigma, the health disparities would persist in rural areas, 75% of the land mass of our country. And we would be unable to address life-threatening conditions like post-traumatic stress, depression, anxiety, and alcohol misuse. This wonderful patient taught me everything I need to know to then study invisible barriers to care for stigmatizing conditions, a large project I did in Alaska and New Mexico. And in this project, we found something we didn't expect. We hypothesized that stigma would have the greatest negative impact in the very smallest communities. But instead, we found out that's not true. In the smallest community, everybody knows everybody's business. They know about Uncle Joe's addiction. They know about cousin Mary's sexually transmitted diseases. They know the whole deal. Now, we found that stigma has the greatest negative impact on confidentiality, the therapeutic relationship, adherence to clinical care recommendations, and informed consent in communities where not everybody knows one another. It's just big enough. These are the communities that are fewer medical resources and yet have all of the social pressures that damage the standard of care that we receive, medically and ethically. And with colleagues in subsequent studies, we learned that people go where they're not known, going to another city, going to a public clinic, going somewhere other than to their usual doctor. Even going so far as crossing the border from one country to another when it's dangerous for care of stigmatizing conditions, or they receive no treatment at all, suffering alone. This one patient led me to explore stigma, spending time with dozens of people from many cultures, exploring how stigma affects health and healthcare. I studied the culture of medicine, supported by the Gold Foundation and others. For example, looking at how physicians, medical students, residents, they do not seek care for their health needs for fear of being perceived as less than perfect. Documenting how physicians in training deal with stress, their own mental health issues, including the fact that one in six medical students has contemplated suicide in the prior year, and more than half of students would not intervene with an ill peer. That's the power of stigma. More positively though, when residents and medical students and physicians had the experience of being a patient, it instills compassion and empathy toward others in need, and this is what we need in our doctors. They become better doctors. I studied other cultures, workplace cultures, one study funded by the Department of Energy, learning how employees don't seek care or want their personal health information or genetics known for fear that their employers will learn about their problems. They don't want stigma and they don't want to be vulnerable in the eyes of their coworkers or bosses. I studied stigma in other cultures, Hispanic, Native, Alaska, New Mexico. I kept following the path to find more and more vulnerable people, including the most vulnerable people I've ever encountered, rural runaways, often fluid and questioning gendered people who've been abused, undocumented people exploited for their labor and relative captivity, street people, traumatized veterans of foreign wars who find their ways to the frontier of this country, invisible people. My patient who drove 300 miles to talk to someone also taught me a lot about psychiatry, about how overwhelming distress can emerge in people who have many strengths. They taught me how fluid the psychological state associated with the impulse to end one's life can be and how it isn't necessarily an authentic wish to die, but rather troubled problem solving and how it's commonly related to this experience of trauma and loss, the rupture in the feeling of belonging. In addition to addressing stigma, he taught me that we must devise and share positive strategies for handling overwhelming feelings if we're gonna be successful in addressing mental health issues in our world. And now many years later, this positive work has been a big focus for me. In my role at Stanford, I'm in the fortunate position to be able to advance work that not only addresses serious illness and distress, but helps to prevent people at risk from ever getting there. To give one example, colleagues in my department are doing an amazing project in which we're teaching hundreds of children living in impoverished and violent neighborhoods, techniques of yoga and mindfulness. Being from the Midwest, I gotta say this is totally California, but I will tell you that these kids are doing better in school, they're better with their friendships, their teachers and families are doing better. It's incredible work, work that is creating reservoirs of resilience and joy, strength that these children and families can draw upon in years to come. So today I've mostly talked with you about three patients, these three patients who inspired novel and very unexpected bioethics work. These patients inspired many funded grants and ethics. In fact, early in my career, I was told don't go into psychiatry, don't go into ethics, those will be career killers and I'm here to say, we had a different outcome. But from these, yeah, right. But from these evidence-based projects came important insights about medicine in our world, about novel, clinical and community-based interventions, recommendations for improved clinical and research practices, education and public policy. These patients and others helped me to establish the Institute for Ethics in New Mexico and more recently at Stanford, the Center for the Prevention of Premature Mortality. And I can tell you more, but it leads me back to the very beginning. We physicians, we carry our patients around with us every moment. I carry hundreds of patients with me. The teenage girl who permitted herself only six grapes each day because her eating disorder ruled her life. The brilliant but depressed surgeon living in Chicago, the Hispanic woman who was an incest survivor living in the Rio Grande Valley, the Iraqi man who was a torture survivor, the Cambodian man who was a torture survivor, the Silicon giant, Silicon Valley giant with alcohol issues and more lives you cannot imagine and lives you can imagine. These are hard stories, hard stories of our patients, people we know and they are our own stories. As a psychiatrist and a physician, I can tell you the hardest stories of the human condition. I can tell you about human vulnerability. But I can also tell you about human courage. I can tell you about strength and resilience. It's like Helen Keller said so simply, the world is full of suffering, it is also full of the overcoming of it. Every physician here can tell you the truth of this, we see it every day. It's like Emily Dickinson said so beautifully in her poem, Life. She said, on the bleakness of my lot, bloom I strove to raise, late my acre of rock has yielded grapes and maize. We see people who grow grapes and maize from bleak, dry, hard stone. And so this brings me to my true message in my talk today and I hope I'm fulfilling the spirit of the McLean Center fully. What role does ethics and professionalism have in caring for the vulnerable? How does an ethical focus make a difference and why does this matter? It matters first and foremost because ethics work, paying attention to the ethical meaning in our experiences with our patients causes us to listen differently. This focus allows us to listen, to be attentive, to be attuned to the experiences of others, to learn and to gain an empathic understanding of the illness and how it is lived. If we listen in this way, if we listen for meaning and we will understand our patients better and we will communicate to them in words and actions that we appreciate what it is they are living through. We will be able to let them know that even if we cannot cure their disease, we will help them bear their suffering by not turning away. Healing involves this attunement, this standing with, so in short, this focus makes us better healers. Attention to ethics and caring for vulnerable people matters also because there are so many vulnerable people and it's under-recognized. Many people are rendered vulnerable by virtue of their illnesses or their circumstances and it's difficult because vulnerable people become invisible. They feel they must hide their suffering or they must hide themselves. A focus on ethics and caring for vulnerable people also matters because individuals and these populations have not received sufficient attention medically or scientifically and as I've tried to illustrate insufficient attention medically and scientifically to vulnerable populations is an important issue of social justice and questions of social justice should move us. A focus on vulnerable populations is also vulnerable because we can make a difference that's important to the health of the public and the health of the world. Just give you one wonderful example. I have an amazing colleague named Jeff Kelly who I believe has done more to prevent illness than anyone I've ever met in my career. He's a clinical psychologist at the Medical College of Wisconsin and he works in the space around HIV prevention in more than 100 countries. Like me, he has drawn to the most vulnerable populations. In one project he performed, he was working with the Roma, the Gypsies. Roma are the largest ethnic minority group in Eastern Europe, received little education, most live in profound poverty, have very little medical attention and the life expectancy for Roma people is decades less than for members of the majority population. This population is amongst the most vulnerable in the world and are extraordinarily difficult to reach. Jeff and his team using a particular approach called opinion leader research, found a way to gain trust of this marginalized population to reduce the spread of HIV and other sexually transmitted diseases by working with the local influence leaders. By not preaching, not intruding or placing external controls, not judging but providing accurate information and support and resources to the individuals who shape the social norms of those communities. The people who model behavior in the community and set the tempo for others. And this opinion leader work makes a difference, reducing the prevalence of illness, reducing the rate of new infections amongst the individuals most at risk. But this work is unlike any other work I have seen because its impact grows over time. With most interventions, it's a little blip. The impact diminishes shortly after the work is done. With opinion leader research, the social norms themselves change and the opinion leaders themselves drive the community to health. Through such efforts that bridge social and medical science, we can change the health of the public even when dealing with the most challenging and stigmatized populations. A focus on ethics and vulnerable populations matters because it will allow us to do better science, to test our assumptions and do exceptionally innovative work. It helps us to ask the right questions and also to welcome unexpected answers. Matters also because of what inspire us. I've already told you about my yoga thing, so great. But my department, we have a big focus on caring for vulnerable populations and it inspires us to do great science. In part because we are desperate for solutions, necessities and mother of invention. In my department, we have basic scientists, translational sciences, clinical researchers, community-based researchers who are inspired by neurodevelopmental disorders like autism, fragile acts, serious mental disorders like Alzheimer's disease, bipolar disorder. My people use their creativity and skills to study these serious conditions. I'm gonna go ahead two slides. So let me then tell you about one other study from another program in California that focuses on a considerable vulnerable population which is elders. This project is done by Dilip Jeste at San Diego. And what he's done is he has interviewed people age 21 through 100 and followed them longitudinally. And his focus has not been on disease but on health and resilience, on wisdom and optimism. And he has tested the assumption of whether life gets worse during aging. Instead he has found that people get happier as they age. They gain perspective, self-understanding, self-acceptance, their happiness moreover is independent of physical disability. Unless there is mental illness as we age, we enjoy a better life. So ethical attention to the experiences of vulnerable people matters for so many reasons. It makes us better doctors, helps us to address social injustice and health disparities, helps us to have a positive health impact on the world. It helps us to do better in creative science that brings us better answers and hope. For those of us who work in medical schools, the focus is important because it helps us fulfill our mission. You know, in academic medicine, we play a very special role in society. We are more than any other institution responsible for the future. I'm gonna say it again. More than any institution, we are responsible for the future, the well-being and the health of the population. And it's through this methodology combining interdependent missions of science, clinical innovation, education, community engagement and leadership, plus careful stewardship of resources, human and financial. And through this methodology, we are trying to change what is possible for human health and disease and trying to gain understanding of fundamental science. So attention to ethics makes us better leaders in academic medicine, not only people who seek to do good, but people who can enable good to happen. An ethical focus on vulnerable people helps us to make decisions in a manner that takes more into consideration the needs of invisible populations that shape the health of the world and can have a better, more positive influence now and in the future. Focus on ethics, especially professionalism and vulnerable populations also matters because it helps us to teach. To teach medicine. This work helps us to teach our early career colleagues about the nature and the role of the physician. There's a wonderful Californian poet. She wrote in this wonderful poem called Crown. She said, too much rain loosens trees. In the hills, giant oaks fall upon their knees. You can touch parts you have no right to. Places only birds should fly to. I recite this poem every year to my graduating residents and fellows and I remind them all of the sacred responsibility we carry as physicians. And a psychiatrist in particular as we enter the intimate lives of our patients, something we are permitted to do because they are suffering. They are suffering and this allows us to transgress usual boundaries to go to places and trees where birds should fly to. So finally and most importantly, attunement and focus on vulnerable people as we do in clinical medical ethics helps to keep the patient and his or her life experience at the heart of our work. The moment this is lost, our profession is lost. So indeed today I could have shown you a lot of data, many PowerPoint slides filled with graphs and tables, quantitative results of all these studies, using the skills that actually got here at the McLean Center. But instead I wanted to tell you stories, stories of my patients, stories that are the heart of my professional calling in medicine. My stories are the stories of the people I've cared for, the stories that changed me, the stories that gave meaning to every physician and future physician here, no matter what role they find themselves in, they carry these stories with them. I did it because it's true to my heart, but also because I think it's what's special about the McLean Prize and the McLean Center. So I would encourage every individual in this room to reflect on what each individual human encounter brings, to hold it dear, to put it in an ethical context, to work it, reflect on it, hold yourself open to it, even if it is very hard and to gain all that you can from it. It could be as a healer, a scientist, a teacher, an ethicist, a policymaker, a leader, or all of these, as I know many of you are. So as with Blake, where we have the tiger in the lamb, the sorrow and the joy, the vulnerability and the strength that we find in humanity, both nourish us, inform us, hold our spirit and bring us close to what we were meant to do with our lives. So in closing, I wish to say I'm very honored to receive this award today, but I accept it as an expression of my gratitude for my patients, who are my teachers and have been my companions on this great journey as a physician. Thank you. Thank you very much.